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  • Polyethylene glycol versus lactulose in the treatment of hepatic encephalopathy: a systematic review and meta-analysis

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Hepatology
Polyethylene glycol versus lactulose in the treatment of hepatic encephalopathy: a systematic review and meta-analysis
  1. Gilles Jadd Hoilat1,
  2. Mohamad Fekredeen Ayas2,
  3. Judie Noemie Hoilat3,
  4. Ahmed Abu-Zaid4,
  5. Ceren Durer1,
  6. Seren Durer1,
  7. Talal Adhami5,
  8. Savio John6
  1. 1Internal Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
  2. 2Internal Medicine, Ascension St John Hospital, Detroit, Michigan, USA
  3. 3Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
  4. 4Pharmacology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
  5. 5Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
  6. 6Gastroenterology, SUNY Upstate Medical University, Syracuse, New York, USA
  1. Correspondence to Dr Gilles Jadd Hoilat; hoilatg{at}upstate.edu

Abstract

Background Hepatic encephalopathy (HE) is defined as brain dysfunction that occurs because of acute liver failure or liver cirrhosis and is associated with significant morbidity and mortality. Lactulose is the standard of care till this date; however, polyethylene glycol (PEG) has gained the attention of multiple investigators.

Methods We screened five databases namely PubMed, Scopus, Web of Science, Cochrane Library and Embase from inception to 10 February 2021. Dichotomous and continuous data were analysed using the Mantel-Haenszel and inverse variance methods, respectively, which yielded a meta-analysis comparing PEG versus lactulose in the treatment of HE.

Results Four trials with 229 patients were included. Compared with lactulose, the pooled effect size demonstrated a significantly lower average HE Scoring Algorithm (HESA) Score at 24 hours (Mean difference (MD)=−0.68, 95% CI (−1.05 to –0.31), p<0.001), a higher proportion of patients with reduction of HESA Score by ≥1 grade at 24 hours (risk ratio (RR)=1.40, 95% CI (1.17 to 1.67), p<0.001), a higher proportion of patients with a HESA Score of grade 0 at 24 hours (RR=4.33, 95% CI (2.27 to 8.28), p<0.0010) and a shorter time to resolution of HE group (MD=−1.45, 95% CI (−1.72 to –1.18), p<0.001) in favour of patients treated with PEG.

Conclusion PEG leads to a higher drop in the HESA Score and thus leads to a faster resolution of HE compared with lactulose.

  • hepatic encephalopathy
  • lactulose
  • cirrhosis

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

http://dx.doi.org/10.1136/bmjgast-2021-000648

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Contributors GJH: study conception and design, acquisition of data, statistical analysis, interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content and submission of the manuscript. MFA: drafting of the manuscript and critical revision of the manuscript for important intellectual content. JNH: data analysis, interpretation of data, drafting of the manuscript and critical revision of the manuscript for important intellectual content. AA-Z: acquisition of data, interpretation of data, statistical analysis, drafting of the manuscript and critical revision of the manuscript for important intellectual content. CD and SD: acquisition of data and drafting of the manuscript. TA: critical revision of the manuscript for important intellectual content. SJ: critical revision of the manuscript for important intellectual content, statistical analysis and study supervision and is also responsible for the overall work as a guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.