Use of Rifaximin for Treatment of HE in Primary Care

Arun B. Jesudian, MD: When we focus on patients who are going home from the hospital after an episode of OHE [overt hepatic encephalopathy], sometimes we’re not the first provider to see them. Sometimes they’re going to see their primary care provider first. Are there any tips or suggestions you would give them for when they’re managing a patient like this who’s clearly sick and has cirrhosis? Are there things they can do to assess them? Is there any comfort level you can give them when it comes to the HE [hepatic encephalopathy] therapies so that if they needed to provide a refill, they’d feel OK doing so?

Kimberly A. Brown, MD: There’s a lot to unpack with that. I just had a phone discussion about the disconnect between inpatient and outpatient. You’re at a big transplant center, and we’re a big transplant center. Many of the patients we start on these medications we’ve never seen before and may never see again. They get discharged to their primary care physician. There have been some data collected to suggest that the biggest reason individuals mark for not writing rifaximin is that they’re not the primary doctor responsible. So who’s responsible? We’re all responsible. I don’t think a primary care physician should avoid keeping a patient on medication in hopes that you or I is going to capture that patient, keep them on, or give them refills without seeing them.

The good news about rifaximin is that it’s very safe. That’s often the biggest concern that clinicians have when using a medication they’re not familiar with. Are they going to hurt someone? The answer is no; rifaximin is very safe. But that’s the struggle: making that connection from inpatient to outpatient. If I’ve written the prescription as an outpatient, they get refills, but once they get discharged, there’s a disconnect. We’ve started to think about ways we might be able to develop something like a cirrhosis toolbox to send to the primary care clinician with the patient to try to help them understand what’s going on, why they’re on these medications, and how important it is to stay on them.

Arun B. Jesudian, MD: We should emphasize how safe a medication rifaximin really is. If you’re not as familiar with it, sometimes there’s a question whether we be breeding antibiotic resistance. This is an antibiotic, so should there be a stop date on it? In reality, it’s a poorly absorbed or nonabsorbed antibiotic that we haven’t observed resistance issues with, and we’ve been using it on label for many years. Even in the studies, which were rigorous, discontinuing rifaximin for any adverse event was very rare and not any more frequent than with the placebo. It’s an uphill battle to get that message out, but it’s worth fighting so that every provider would feel comfortable prescribing these essential medications that could be the difference between a patient with decompensated cirrhosis not being readmitted shortly after their HE admission or being back in the hospital within a week or 2.

Kimberly A. Brown, MD: Right.

Transcript edited for clarity