Efficacy of L-Ornithine L-Aspartate in Acute Hepatic Encephalopathy.

The Infusion of L-Ornithine L-aspart is as Effective as Nonabsorbable Disaccharides in the Management of Acute Hepatic Encephalopathy.

Hepatic encephalopathy is caused by the effects on the brain of substances that under normal circumstances are efficiently metabolized in the liver. The hyperammonemia is the main factor responsible for the development of hepatic encephalopathy. In patients with cirrhosis, the reduction in hepatocellular function and generation of portosystemic shunts contribute to increase serum ammonium. The current therapeutic approaches, are aimed at reducing blood ammonium levels.

Administration of the non-absorbable disaccharides, have become standard treatment of hepatic encephalopathy.There are no adequate clinical trials comparing the efficacy of L-Ornithine-L-Aspartate (LOLA) infusion against lactose enemas in the treatment of acute hepatic encephalopathy.

Study Overview

• Status: Completed
• Conditions: Hepatic Encephalopathy
• Intervention / Treatment: Drug: L-ornithine-L-aspartate; Drug: Lactose

Detailed Description

The main impact of hepatic encephalopathy in patients with cirrhosis is not related to costs, but its association with decreased survival and quality of life and should therefore clearly established the effectiveness of therapeutic interventions used in this disorder.

At the end of the nineteenth century to the ammonium was identified as the main agent responsible for the development of the syndrome of hepatic encephalopathy. Since then, reduced nitrogen compounds from the intestine are considered the main therapeutic measure. On this conceptual base, nonabsorbable disaccharides are the first line therapy in hepatic encephalopathy.

Current knowledge indicates that other organs such as muscle, brain and kidney are involved in the generation of ammonium, which has set the pace for the development of new treatments, able to act systemically in metabolism and elimination of ammonia . L-ornithine L-aspartate (LOLA) lowers ammonium concentrations in animal and humans models with hyperammonemia. There are no adequate clinical trials comparing the efficacy of LOLA infusion against lactose enemas in the treatment of acute hepatic encephalopathy.

• Study Type: Interventional
• Enrollment (Actual): 30
• Phase: Phase 4

Contacts and Locations

Study Locations

• Mexico
  • Nuevo León
    • Monterrey, Nuevo León, Mexico, 64460
      • Hospital Universitario "José Eleuterio González"

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 75 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients with cirrhosis of any etiology, diagnosed by ultrasound,clinical and / or histologic criteria
• Patients over 18 years and under 75
• Patients with hepatic encephalopathy grade 3-4 according to the criteria of West Haven
• Patients with hyperammonemia >10 µmol/l

Exclusion Criteria:

• Evidence of neurological or psychiatric illness
• Use of drugs affecting the central nervous system
• Withdrawal Syndrome
• Anorectal disease that interferes with the administration of enemas

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intravenous infusion of L- Ornithine L- Aspartate; a) 20 g L-ornithine-L-aspartate	Drug: L-ornithine-L-aspartate; a) Intravenous infusion of 20 g L-ornithine-L-aspartate (4 ampules of 10 mL each) in 250 mL sodium chloride solution administered daily in 4 hours for 3 consecutive days, plus the placebo b) Water enemas, 1000 mL of water and given as retention enema every 12 hours for 3 consecutive days.; Other Names: LOLA
Active Comparator: Lactose enemas; b) 20% Lactose enemas	Drug: Lactose; a) 20% Lactose enemas, 200 g Lactose diluted with 700 mL of water and given as retention enema every 12 hours for 3 consecutive days, plus intravenous placebo b)250 mL sodium chloride solution, infusion for 4 hours for 3 consecutive days.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Improvement of at least one grade in mental state based on the West Haven Criteria	Improvement was assessed at 0, 24, 48 and 72 hours. The mental state was scored from trivial lack of awareness to deep coma from grade 1 to grade 4.	72 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Improvement of at least one grade in mental state assessed by the Glasgow Coma Scale	Improvement was assessed at 0, 24, 48 and 72 hours. The Glasgow Coma Scale assesses three aspects of responsiveness: eye-opening, motor, and verbal responses. The eye-opening was quantified from 1 to 4 points, the motor response from 1 to 6 points and the verbal response from 1 to 5 points.	72 hours
Improvement of at least one grade in mental state assessed by the Clinical Hepatic Encephalopathy Staging Scale (CHESS)	Improvement was assessed at 0, 24, 48 and 72 hours. The CHESS scale has 9 dichotomous questions that assess mental state, intellectual function, behavior, verbal and motor response and orientation. It was quantified from 0 to 9 points.	72 hours
Improvement of asterixis grade	Improvement was assessed at 0, 24, 48 and 72 hours. Asterixis was graded as follows: Grade 0 = without flapping motion, Grade 1 ≤ 5 flaps per minute, Grade 2 = 6 to 10 flaps per minute, Grade 3 = 11 to 20 flaps per minute and Grade 4, continuous flap or patient in coma unable to maintain wrist dorsiflexion. Asterixis grade was evaluated at 0. 24, 48 and 72 hours.	72 hours
Improvement in electroencephalographic tracing grade	Improvement was assessed at 0 and 72 hours. EEG tracing was graduated from 0 to 4: Grade 0 = normal alpha rhythm, Grade 1 =7 to 8 cycles per second, Grade 2= 5 to 6 cycles per second, Grade 3 = 3 to 4.5 cycles per second and Grade 4 < than 3 cycles per second or delta rhythm. EEG was assessed at 0 and 72 hours.	72 hours
Improvement in serum ammonia	Ammonia determination was performed at 0, 24, 48 and 72 hours.	72 hours
Improvement in Number connection tests	The mental state of the patients included in the study did not allow them to perform the number connection test, therefore, they were all assigned to the worst score (Grade 4)	72 hours
Improvement in Portosystemic Encephalopathy Index.	Improvement was assessed at 0 and 72 hours. The PSE Index was calculated by multiplying the grade of mental state by a factor of 3; and the grades of asterixis, number connection tests, serum ammonia and EEG were multiplied times a factor of 1. The results were divided by the maximal possible PSE sum.	72 hours

Collaborators and Investigators

• Sponsor: Centro Regional para el Estudio de las Enfermedades Digestivas
• Collaborators: MERZ PHARMA
• Investigators: Study Director: Francisco J Bosques, MD, PhD, Centro Regional para el Estudio de las Enfermedades Digestivas; Principal Investigator: Claudia Isabel Blanco Vela, MD, Hospital Juarez de Mexico

Study record dates

Study Major Dates

• Study Start (Actual): November 1, 2009
• Primary Completion (Actual): June 1, 2011
• Study Completion (Actual): June 1, 2011

Study Registration Dates

• First Submitted: December 31, 2009
• First Submitted That Met QC Criteria: December 31, 2009
• First Posted (Estimate): January 1, 2010

Study Record Updates

• Last Update Posted (Actual): May 10, 2021
• Last Update Submitted That Met QC Criteria: May 6, 2021
• Last Verified: May 1, 2021

More Information

Terms related to this study

• Keywords: Cirrhosis; Encephalopathy
• Additional Relevant MeSH Terms: Digestive System Diseases; Liver Failure; Hepatic Insufficiency; Metabolic Diseases; Central Nervous System Diseases; Nervous System Diseases; Liver Diseases; Brain Diseases, Metabolic; Hepatic Encephalopathy; Brain Diseases; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Excitatory Amino Acid Agents; Excitatory Amino Acid Agonists; N-Methylaspartate
• Other Study ID Numbers: MI09-002