The University of Toledo Translation Journal of Medical Sciences 
Gastroenterology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e2 

Comparative Efficacy of Treatment Options for 
Prevention of Post-TIPS Hepatic Encephalopathy: A 
Systematic Review and Network Meta-analysis 

Anas Renno1*, Zohaib Ahmed, MD1, Syeda Faiza Arif, MD1, Muhammad Aziz, 
MD1, Umair Iqbal, MD, Ahmad Nawaz, MD1 Wade Lee-Smith, MLIS2, Joyce Badal, 
MD1, Toseef Javaid, MD1, Ali Nawras, MD1, Mona Hassan, MD1, Sammy Saab, 
MD1

1Division of Gastroetnerology and Hepatology, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
2Department of University Libraries, The University of Toledo, Toledo, OH 43614 

*Corresponding author: anas.renno@utoledo.edu

Published: 05 May 2023 

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is commonly used to treat 
complications of portal hypertension including refractory ascites, as well as secondary prophylaxis of 
variceal bleeding in patients with liver cirrhosis. Unfortunately, 35-50% of patients develop overt 
hepatic encephalopathy (HE) after TIPS. However, data on the utility of lactulose and rifaximin to 
prevent post-TIPS HE are limited. Therefore, we conducted a network meta-analysis to investigate the 
efficacy of multiple pharmacological regimens in preventing post-TIPS HE.   

Methods:  A comprehensive search strategy to identify reports of studies of rifaximin use and post-TIPS 
hepatic encephalopathy was developed in Embase (Embase.com, Elsevier) by an experienced health 
sciences librarian [WL-S], using truncated keywords, phrases, and subject headings. This strategy was 
translated to MEDLINE (PubMed platform, NCBI), Cochrane Central Register of Controlled Trials 
(CochraneLibrary.com, Wiley), and the Web of Science Core Collection (Web of Science platform, 
Clarivate) with all searches performed on 10 February 2022 (see Supplementary Information for detailed 
search strategies). No publication date or language limits were used.   

Results:  The results of this meta-analysis demonstrate no benefit from prophylactic administration of 
either a non-absorbable disaccharide (lactulose/lactitol) alone or a non-absorbable antibiotic (rifaximin) 
alone compared to placebo/no prophylaxis for the prevention of post-TIPS HE. However, there is weak 
evidence supporting the combination of lactulose and rifaximin in preventing post-TIPS HE based on the 
P-score rankings in our network meta-analysis.

https://dx.doi.org/10.46570/utjms.vol11-2023-684 

https://dx.doi.org/10.46570/utjms.vol11-2023-684
mailto:anas.renno@utoledo.edu


https://dx.doi.org/10.46570/utjms.vol11-2023-684 UTJMS 11(1):e1-e2 

https://dx.doi.org/10.46570/utjms.vol11-2023-684 2 ©2023 UTJMS 

Conclusion:  In conclusion, lactulose/lactitol or rifaximin alone did not prevent post-TIPS HE. Despite 
this, there is weak evidence that the combination of lactulose and rifaximin is superior at preventing 
post-TIPS HE. Further research is warranted to determine if there is an ideal time for therapy initiation 
and duration of treatment in order to appreciate significant benefit of administering pharmacological 
prophylaxis to prevent post-TIPS HE. 

https://dx.doi.org/10.46570/utjms.vol11-2023-684
https://dx.doi.org/10.46570/utjms.vol11-2023-684