Using Diagnostic Tests for Minimal HE

EP: 1.Overview of Hepatic Encephalopathy (HE)

EP: 2.Classifying and Grading Severity of HE

EP: 3.Pathophysiology of HE

EP: 4.Natural Progression of HE

EP: 5.Outpatient vs Inpatient Care of HE

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EP: 6.Using Diagnostic Tests for Minimal HE

EP: 7.Differential Diagnosis of HE

EP: 8.Use of Lactulose and Rifaximin in HE Treatment

EP: 9.Clinical Trial Data for Rifaximin in Treatment of HE

EP: 10.Use of Rifaximin for Treatment of HE in Primary Care

EP: 11.Patient Education of HE

EP: 12.Counseling Patients on Managing Medication in HE

Arun B. Jesudian, MD: Do you utilize any of the tools you mentioned, say the Stroop test or any minimal or covert HE [hepatic encephalopathy] testing that can pick up this more subtle cognitive impairment?

Kimberly A. Brown, MD: We have not routinely. In reading Jazz’s literature, the critical flicker frequency seems to be the most reliable in terms of picking up subtle issues. He has developed the Stroop test. But I was in a meeting recently, as you were, and I think Nancy S. Reau [MD] said she fails the Stroop test occasionally as well. I don’t know how accurate that is.

Arun B. Jesudian, MD: I agree.

Kimberly A. Brown, MD: So I don’t. I wish we had something that was easy to administer in the outpatient setting. I think some of the testing that we have is kind of cumbersome in a 20-minute visit.

Arun B. Jesudian, MD: I feel the same way. Either you need some piece of technology, a tablet, or a phone, and you need additional time. You also need to be able to observe them to see how reliable the result is. So we are the same in that we haven’t really been utilizing that routinely in practice. But I do ask those questions you mentioned about mental fogginess or rely on caregiver’s and loved ones to really provide some insight into whether they could be subtly impaired. Oftentimes, if I think there is some subtle impairment, then we’ll just try treating and see if they feel better. That’s probably how I assess for more covert HE in practice.

Kimberly A. Brown, MD: I don’t know if you have noticed this, but I noticed that patients who have had jobs or functions that really required those very high-level brain functions, calculations, decision-making, those types of functions notice it very quickly. So patients who are accountants or lawyers or teachers where they’re having to use those faculties on a daily basis or use to it, they notice that they’re not quite as able to come up with the right answer or as quickly as they were before. So it’s easy in those patients because they tell me, I think.

Arun B. Jesudian, MD: Yes. I’ve had the same experience. It in some ways makes our job easier in identifying it and in some ways more difficult because they want more than anything to return to their cognitive baseline. Certainly, you want to treat them early in that particular situation.

Transcript edited for clarity