Who should attend:

• Clinical faculty from the University of Pittsburgh School of Pharmacy
• Clinical staff pharmacists employed by the University of Pittsburgh Medical Center and deployed throughout the hospital campus in unit based roles and centrally in the department of pharmacy's main pharmacy
• Student pharmacy interns currently working within the department of pharmacy
• Certified Pharmacy Technicians

Hepatic encephalopathy is a spectrum of neuropsychiatric abnormalities that occur as the result of both chronic and acute liver dysfunction. When present in both disease states, it is associated with poor prognosis and higher costs to the health care system. Hepatic encephalopathy is classified based on underlying disease, severity of manifestation, time course, and existence of precipitating factors. While the pathophysiology is not fully understood, ammonia is thought to play a key role in the development of hepatic encephalopathy. Lactulose is commonly used to treat hepatic encephalopathy by helping to lower ammonia levels in the body by multiple different proposed mechanisms including excretion via feces. It has been postulated that another laxative, polyethylene glycol, may work better to lower ammonia levels in this disorder due to it’s more power cathartic effects. Polyethylene glycol electrolyte solution has been studied at larger doses of two to four liters (236 grams to 472 grams) in cirrhotic patients presenting with hepatic encephalopathy. When compared to lactulose alone, polyethylene glycol resulted in a larger change in grade of hepatic encephalopathy at 24 hours without a significant difference in side effects and electrolyte abnormalities in patients with cirrhosis. No literature is currently published regarding the use of polyethylene glycol at lower doses or in patients with acute liver failure.

Upon successful completion of this continuing pharmacy education program, the participant should be able to:

• Describe hepatic encephalopathy including epidemiology, precipitating factors, diagnosis, and categorizations.
• Review the current guideline recommendations and agents used to treat and prevent hepatic encephalopathy
• Discuss the role of polyethylene glycol 3350 in hepatic encephalopathy and available data to support its use.

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2. Elsaid MI, Rustgi VK. Epidemiology of Hepatic Encephalopathy. Clin Liver Dis. 2020;24(2):157-174.
3. Vilstrup H, Amodio P, Bajaj J, et al. Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice Guideline by AASLD and EASL. Published online 2014. https://www.aasld.org/sites/default/files/2019-06/141022_AASLD_Guideline_Encephalopathy_4UFd_2015.pdf.
4. Lee W, Larson A, Stravitz T. The Management of Acute Liver Failure: Update 2011. Published online 2011. http://www.aasld.org/sites/default/files/2019-06/AcuteLiverFailureUpdate201journalformat1.pdf
5. Elsaid MI, Rustgi VK. Epidemiology of Hepatic Encephalopathy. Clin Liver Dis. 2020;24(2):157-174.
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7. Patidar KR, Bajaj JS. Covert and Overt Hepatic Encephalopathy: Diagnosis and Management. Clin Gastroenterol Hepatol. 2015;13(12):2048-2061.
8. Lactulose. In: AltMedDex® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically. Accessed 3/28/2022.
9. Bothe MK, Maathuis AJH, Bellmann S, van der Vossen JMBM, Berressem D, Koehler A, et al. Dose-Dependent Prebiotic Effect of Lactulose in a Computer-Controlled In Vitro Model of the Human Large Intestine. Nutrients. 2017;9(7):767.
10. Rifaximin. In: AltMedDex® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically. Accessed 3/28/2022.
11. Horsmans Y, Solbreux PM, Daenens C, Desager JP, Geubel AP. Lactulose improves psychometric testing in cirrhotic patients with subclinical encephalopathy. Aliment Pharmacol Ther. 1997;11(1):165-70.
12. Watanabe A, Sakai T, Sato S, Imai F, Ohto M, Arakawa Y, et al. Clinical efficacy of lactulose in cirrhotic patients with and without subclinical hepatic encephalopathy. Hepatology. 1997;26(6):1410-4.

Joint Accreditation Statement - this statement supersedes any other statement on this page

In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Pharmacy (CPE)

This knowledge-based activity provides 1.0 contact hours of continuing pharmacy education credit.

Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.