Sunday, December 3, 2023

Lactulose Dosing For Hepatic Encephalopathy

What Is Lactulose And How Does It Work

Lactulose Solution – for Constipation and Hepatic encephalopathy

Lactulose is a prescription drug used by mouth or rectally to treat or prevent complications of liver disease . It does not cure the problem, but may help to improve mental status. Lactulose is a colonic acidifier that works by decreasing the amount of ammonia in the blood. It is a man-made sugar solution.

How To Use Lactulose Solution

If you are taking this medication by mouth for liver disease, take it usually 3-4 times a day or as directed by your doctor. To improve the taste, you may mix it into fruit juice, water, milk, or a soft dessert. The goal is to have 2-3 soft stools each day. Dosage is based on your medical condition and response to therapy .

If you are taking this medication by mouth for constipation, take it usually once daily or as directed by your doctor.

This medication can also be given rectally as an enema for liver disease. Mix the recommended amount of lactulose with 700 milliliters of water or normal saline. Give the solution into the rectum and keep the liquid inside for 30-60 minutes as directed by your doctor. If you keep the enema inside for less than 30 minutes, repeat the dose unless directed otherwise.

Use this medication regularly in order to get the most benefit from it. Remember to use it at the same time each day.

When this drug is given rectally for liver disease, an improvement in your mental status may occur in as little as 2 hours, but if you are taking this medication by mouth, it may take up to 24 to 48 hours. If you are using this medication for constipation, it may take up to 48 hours to have a bowel movement. Inform your doctor if your condition persists or worsens.

Comparison Of Treatment Groups

The 2 groups were similar with respect to demographics and clinical features . The precipitants of HE included a total of 80 potential contributing factors identified in 50 patients . Admission laboratory data were also similar in the 2 groups , with the exception of blood urea nitrogen level, which was higher in the PEG group . Admission ammonia levels were elevated in both groups . Nineteen patients in the lactulose group and 18 patients in the PEG group underwent head computed tomography scanning. No acute CT findings were identified in any patient.

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Lactulose 33g/5ml Oral Solution

This information is intended for use by health professionals

Laevolac 3.3 g/5ml Oral Solution

Lactulose 3.3 g/5ml Oral Solution

5 ml contain 3.3 g lactulose

For a full list of excipients, see section 6.1.

Clear colourless to pale brownish yellow, viscous solution

Treatment of portal systemic encephalopathy


The posology should be adjusted according to the individual needs of the patient. The starting dose can be adjusted after adequate treatment effect individually . Several days of treatment may be needed in some patients before adequate treatment effect occurs. In case of single daily dose, this should be taken at the same time of the day, e.g. during breakfast. During the therapy with laxatives it is recommended to drink sufficient amounts of fluids .


corresponding to 10-30 g lactulose

15-30 ml

corresponding to 10-20 g lactulose

Paediatric population

corresponding to 10-30 g lactulose

15-30 ml

corresponding to 10-20 g lactulose


corresponding to 10 g lactulose

10-15 ml

corresponding to 7-10 g lactulose


corresponding to 3-7 g lactulose


corresponding to up to 3 g lactulose

If diarrhoea occurs, the dosing regimen should be reduced.

Treatment of portal systemic encephalopathy – for adults only:

Beginning with 30 – 50 ml 3 times daily . The dosage has to be adopted to get 2-3 soft stools daily, pH of the stools should be between 5.0 to 5.5.

Paediatric population

Method of administration

Use in patients with galactosaemia.

What Other Information Should I Know

Lactoxx Lactulose 200 Ml Syrup

Keep all appointments with your doctor.

To improve the taste of lactulose, mix your dose with one-half glass of water, milk, or fruit juice.

Do not let anyone else take your medicine. Ask your pharmacist any questions you have about refilling your prescription.

It is important for you to keep a written list of all of the prescription and nonprescription medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.

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Enhancing Healthcare Team Outcomes

In the context of hepatic encephalopathy management, there are multiple decision-making steps involved to ensure the best form of patient care. These would range from the mode of administration of lactulose , the monitoring of the number of bowel movements to achieve the required frequency of 2-3 stools per day.

Communication between the physicians, pharmacists, and the nursing staff is of paramount importance to monitor frequent changes in mental status and accurately measure stool output. In certain situations, dose titration of the lactulose may also be required to prevent dehydration, diarrhea, and excoriation of the anal skin, requiring pharmaceutical intervention. Patients in the ICU who would require lactulose administered via an NG tube would need physical positioning designed to decrease the odds of aspiration.

Optic Nerve Sheath Diameter Sonography

The retrobulbar segment of the optic nerve is surrounded by meninges. The subarachnoid space surrounding the nerve sheath can expand when ICP is elevated and ultrasound measurements of optic nerve sheath diameter can therefore give an estimation of ICP. Optic nerve sheath diameter has been used to estimate ICP in pediatric acute liver failure patients . A diameter > 5 mm has a 88 %96 % sensitivity, 93 %94 % sensitivity to detect an ICP > 20 mm Hg . Like TCD, optic nerve sheath sonography does not provide a continuous measure of ICP, but rather a stochastic estimate.

Standard procedure :

The optic nerve sheath is insonated with a linear array probe in the transverse position in the superior lateral portion of the globe over the closed eyelid. The measurement is taken 3 mm behind the globe encompassing the width of the entire nerve from the margins of the dura mater on either side. Hypoechoic shadowing behind the globe can sometimes obscure the margins of the optic nerve sheath and care must be taken to avoid this artifact .

Contraindications :

Equipment and technical expertise are expensive, but each individual examination is relatively inexpensive.

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How To Use Lactulose For Hepatic Encephalopathy

There are two ways to use lactulose for H.E. You can either use it by mouth or rectally. However, we must clarify that lactulose is not a cure for H.E, but it can only improve your mental status.

Lactulose is an artificial sugar solution and an acidifier of the colon. It decreases how much ammonia can pass into your blood from your colon. But Lactulose has many uses. H.E is not the only condition that lactulose treats. So how you would use it will rely on what you are using it to treat.

If you are using lactulose to treat liver disease, you would have to take it like 3 to 4 times daily. But if your doctor recommends otherwise, follow his directions.

Lactulose may not have so much of a great taste. But you can improve its taste by mixing the drug into fruit juice, soft dessert, or even just water. The goal of using lactulose is for you to have about two to three soft stools daily.

Sometimes, your doctor will adjust your dosage with how you are responding to the therapy. This is determined by how many soft stools you are passing each day.

You can use lactulose as an enema to treat H.E or any other liver disease. You would mix the recommended amount with 24 ounces of normal saline or water. Then, you can pass the liquid into your rectum. Keep the solution inside for about 30 to 60 minutes, except your doctor directs otherwise.

How Should This Medicine Be Used

Use of Lactulose Solutions/Syrup in constipation and Hepatic Coma/Encephalopathy

Lactulose comes as liquid to take by mouth. It usually is taken once a day for treatment of constipation and three or four times a day for liver disease. Your prescription label tells you how much medicine to take at each dose. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take lactulose exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

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Treatments To Improve Sleep Disturbances

Sleep disturbances are more common in patients with cirrhosis than in control subjects. Whether or not this relates to hepatic encephalopathy is unclear. A trial compared the histamine H1 blocker hydroxyzine with placebo in patients with cirrhosis and minimal hepatic encephalopathy. Sleep efficiency and the patients’ subjective quality of sleep improved in patients receiving hydroxyzine at bedtime. However, there was no accompanying improvement in cognition, as measured by neurophysiologic tests. The authors urged caution when prescribing hydroxyzine, on account of the risk of worsening encephalopathy in some patients.

Treatment And Prevention Of Ohe

The initial treatment of OHE is non-absorbable disaccharides like lactulose. The dosing of lactulose should be initiated with 25mL of lactulose every 12hours and the dose should be titrated to achieve two soft or loose bowel movements per day. The working mechanism of lactulose is not fully understood, but it is assumed that the prebiotic effects and acidifying nature of lactulose have an additional benefit beyond the laxative effect.

There is currently no treatment registered for primary prevention of HE. Secondary prevention of HE can be achieved by combination therapy of lactulose with rifaximin, a poorly absorbed antibiotic. In the Netherlands, rifaximin has been approved since 2016 and will be reimbursed only to prevent a third episode of OHE.

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Lactulose May Interact With Other Medications

Lactulose oral solution can interact with other medications, vitamins, or herbs you may be taking. An interaction is when a substance changes the way a drug works. This can be harmful or prevent the drug from working well.

To help avoid interactions, your doctor should manage all of your medications carefully. Be sure to tell your doctor about all medications, vitamins, or herbs youre taking. To find out how this drug might interact with something else youre taking, talk to your doctor or pharmacist.

Examples of drugs that can cause interactions with lactulose are listed below.

History Signs And Symptoms

Lactoxx Lactulose 200 Ml Syrup

Patients with HE usually have advanced chronic liver disease and thus have many of the physical and laboratory stigmata associated with severe hepatic dysfunction.

The history may reveal a precipitating cause. These include:
Rarely, hepatocellular carcinoma and/or vascular occlusion

Disturbance in the diurnal sleep pattern is common, and typically precedes overt neurologic signs. More advanced neurologic features include bradykinesia, asterixis . Hyperactive deep tendon reflexes are common seizures and hallucinations and transient decerebrate posturing may also be seen occasionally.

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If You Forget To Take It

If you forget a dose of lactulose, just skip the missed dose and take your next dose at the usual time.

Never take 2 doses at the same time. Never take an extra dose to make up for a forgotten one.

If your doctor has told you to take lactulose every day and you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

Pathophysiology Of Hepatic Encephalopathy

HE is thought to be primarily because of ammonia-induced neurotoxicity and excessive GABAnergic inhibitory neurotransmitter activity. Ammonia produced either by catabolism of nitrogenous sources or by glutamine metabolism at a mitochondrial level, has been shown to lead to astrocyte swelling and dysfunction . Metabolism of glutamine into ammonia and glutamate may additionally cause stimulation of N-methyl-D-aspartate receptor receptors triggering nitric oxide release and subsequent vasodilation. This vasodilation may lead to hyperemia and cerebral edema . In addition, cerebral autoregulation has been found to be impaired in patients with acute hepatic failure . A variety of other mechanisms may be involved in the pathogenesis of HE including catecholamine and other neurotransmitter abnormalities, and activation of the aquaporin-4 water channel protein on astrocytes. Inflammation may also play a role because elevated TNFa levels have been documented in patients with elevated ICP compared with those without .

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What Are Warnings And Precautions For Lactulose


  • This medication contains lactulose. Do not take Enulose, Kristalose, Constulose or Generlac, if you are allergic to lactulose or any ingredients contained in this drug.
  • Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center immediately.


Effects of Drug Abuse

  • See “What Are Side Effects Associated with Using Lactulose?”

Long-Term Effects

  • See “What Are Side Effects Associated with Using Lactulose?”


  • Diabetes
  • Monitor for electrolyte imbalance when the drug is used for longer than 6 months or in patients predisposed to electrolyte abnormalities
  • Avoid using other laxatives concomitantly
  • Inadequate response possible when taken concomitantly with anti-infective

Pregnancy and Lactation

  • Lactulose use during pregnancy may be acceptable. Either animal studies show no risk, or human studies are not available or animal studies showed minor risks, and human studies were done and showed no risk
  • It is unknown if lactulose is distributed into breast milk use with caution

Side Effects Of Lactulose

Lactulose for constipation || Hepatic encephalopathy || Indicat and uses of laxative

Bloating, gas, nausea, stomach pain, cramps, and burping may happen. If they persist or gradually worsen please notify a pharmacist or doctor immediately.

Remember that the doctor prescribed this drug after weighing the pros and cons and judged that there are higher chances of a benefit than developing side effects. The majority of the people who used this lactulose medication do not experience its side effect so the chances are slim.

However, if you notice any of the following severe side effects seek urgent medical attention. The symptoms are vomiting, diarrhea, seizures, irregular heartbeat, muscle weakness and cramps, and mood changes.

Developing severe allergy is highly unlikely but if it does happen then run to a doctor. The symptoms of a severe allergic reaction are itching/swelling, severe dizziness, rash, difficulty in breathing.

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Clinical Scales For Grading He

A number of scales have been devised for the diagnosis of HE the first of its kind was proposed by Parsonsmith and colleagues in 1957. For patients with moderate to severe HE, the Glasgow Coma scale can also be employed.

Table 1: West-Haven Criteria for Hepatic Encephalopathy

Normal examination if impaired psychomotor testing, consider MHE
1 Impaired addition or subtraction mild asterixis or tremor

MHE, minimal hepatic encephalopathy.

The West-Haven Classification Table

Stage 0. MHE . Lack of detectable changes in personality or behavior. Minimal changes in memory, concentration, intellectual function, and coordination. Asterixis is absent.

Stage 1. Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria, depression, or irritability. Mild confusion. Slowing of ability to perform mental tasks. Asterixis can be detected.

Stage 2. Lethargy or apathy. Minimal disorientation. Inappropriate behavior. Slurred speech. Obvious asterixis. Drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time.

Stage 3. Somnolent but can be aroused, unable to perform mental tasks, gross disorientation about time and place, marked confusion, amnesia, occasional fits of rage, present but incomprehensible speech.

Clinical Features Of Hepatic Encephalopathy

Two broad categories of hepatic encephalopathy are covert and overt hepatic encephalopathy. CHE is particularly associated with poor outcomes.

Grading of the symptoms of hepatic encephalopathy is performed according to the so-called West Haven classification system, as follows :

  • Grade 0 – Minimal hepatic encephalopathy lack of detectable changes in personality or behavior minimal changes in memory, concentration, intellectual function, and coordination asterixis is absent.

  • Grade 1 – Trivial lack of awareness shortened attention span impaired addition or subtraction hypersomnia, insomnia, or inversion of sleep pattern euphoria, depression, or irritability mild confusion slowing of ability to perform mental tasks

  • Grade 2 – Lethargy or apathy disorientation inappropriate behavior slurred speech obvious asterixis drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time

  • Grade 3 – Somnolent but can be aroused unable to perform mental tasks disorientation about time and place marked confusion amnesia occasional fits of rage present but incomprehensible speech

  • Grade 4 – Coma with or without response to painful stimuli

In terms of the physical examination finding of asterixis, it must be emphasized that the flapping tremor of the extremities is also observed in patients with uremia, pulmonary insufficiency, and barbiturate toxicity.

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Hepatic Encephalopathy Nursing Care Plan 5

Nursing Diagnosis: Risk for Injury related to cognition changes, hypoxia, toxin accumulation, and physical impediments secondary to hepatic encephalopathy.

Desired Outcomes:

  • The patient will identify causes that may potentially increase the risk of injury and demonstrate behaviors that avoid injury within 8 hours of nursing diagnosis and treatment.
  • The patient will demonstrate absence of injuries within 4 hours of nursing diagnosis and treatment.

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