What are the recommended first-line treatments for managing acute hepatic encephalopathy in primary care?

In primary care, the recommended first-line management of acute hepatic encephalopathy focuses on identifying and treating precipitating factors, providing supportive care, and initiating specific therapies to reduce ammonia levels and prevent neurological deterioration. First, ensure prompt referral to secondary care for comprehensive assessment and management, as acute hepatic encephalopathy often requires specialist input. Initial treatment includes correcting precipitating causes such as infections, gastrointestinal bleeding, electrolyte imbalances, or constipation. Pharmacologically, lactulose is the first-line treatment to reduce ammonia absorption by acidifying the gut and promoting ammonia excretion. It should be started promptly and titrated to achieve 2–3 soft stools per day.

In addition, rifaximin may be considered as an adjunct to lactulose in recurrent or persistent cases, although its initiation is typically under specialist guidance.

Supportive measures include ensuring adequate nutrition and hydration, and monitoring for complications such as Wernicke's encephalopathy, for which parenteral thiamine should be administered if suspected or if the patient is malnourished or at risk.

In primary care, the emphasis is on early recognition, supportive care, and urgent referral rather than definitive management, which requires hospital-based interventions.

This approach aligns with NICE guidelines on cirrhosis and alcohol-related liver disease, which highlight the importance of managing precipitating factors, using lactulose as first-line therapy, and providing thiamine to prevent Wernicke's encephalopathy ¹,². Literature also supports the critical role of ammonia-lowering treatments like lactulose in the pretransplant setting to improve outcomes (Teperman and Peyregne, 2010).