Hepatic Encephalopathy Hepa-Merz® Hepatic Encephalopathy

Hepatic Encephalopathy (HE) - Definition Hepatic Encephalopathy (HE) is a Metabolically induced Potentially reversible Functional disturbance of the brain Occurring with various degrees of severity secondarily Grade 0-4 Occurring in both acute and chronic liver diseases. ie. 70% in cirrhotic patient The mainly cause is a metabolic disturbance eg. Hyperammonemia

Cirrhosis origins Hepatic Encephalopathy ~80% of patients with cirrhosis may suffer from Minimal HE Chronic liver disease Cirrhosis Minimal HE Manifest HE (Pre)Coma ~50% of patients with Minimal HE will progress towards manifest HE within the next 6 months There are some 20 million people with chronic liver disease worldwide. According to a WHO report published in 2004, liver diseases rank among the ten most common causes of death. Around 14 million people have cirrhosis of the liver. This is the fifth commonest cause of death in the 45-64 age group, and a more common cause of death than ischemic heart disease in the 20-40 age group. On average up to 40% of patients develop manifest hepatic encephalopathy in the course of cirrhosis of the liver. The probability of 5 years’ survival for cirrhosis patients with HE is very low (16-22%) compared to that of cirrhosis patients without HE. The frequency of latent hepatic encephalopathy is between 30 and 70%. Latent hepatic encephalopathy (minimal HE) often goes unrecognized because “verbal intelligence” is not affected. Using the results of psychometric tests, Schomerus et al. showed that 50% of patients with latent hepatic encephalopathy are not fit to drive a motor vehicle. The fitness to drive of a further 25% was questionable (Schomerus et al., Dig. Dis. Sci., 26, 7: 622-30, 1981). Ref. Schomerus et al., Dig. Dis. Sci., 26, 7: 622-30, 1981

Hepatic encephalopathy (HE) - Pathogenesis 1. Ammonia 2. Neurotransmitters hypothesis 2.1 Gamma-aminobutyric acid (GABA) 2.2 Catecholamines and false neurotransmitters 3. Aromatic-branched chain amino acid imbalance 4. Short-chain fatty acids 5. Manganese There are some 20 million people with chronic liver disease worldwide. According to a WHO report published in 2004, liver diseases rank among the ten most common causes of death. Around 14 million people have cirrhosis of the liver. This is the fifth commonest cause of death in the 45-64 age group, and a more common cause of death than ischemic heart disease in the 20-40 age group. On average up to 40% of patients develop manifest hepatic encephalopathy in the course of cirrhosis of the liver. The probability of 5 years’ survival for cirrhosis patients with HE is very low (16-22%) compared to that of cirrhosis patients without HE. The frequency of latent hepatic encephalopathy is between 30 and 70%. Latent hepatic encephalopathy (minimal HE) often goes unrecognized because “verbal intelligence” is not affected. Using the results of psychometric tests, Schomerus et al. showed that 50% of patients with latent hepatic encephalopathy are not fit to drive a motor vehicle. The fitness to drive of a further 25% was questionable (Schomerus et al., Dig. Dis. Sci., 26, 7: 622-30, 1981).

Development of hyperammonemia Normal state Hemodynamic causes Metabolic causes Urea Glutamine Urea Glutamine Urea Glutamine NH + 4 NH + 4 NH + 4 In the liver, ammonia is detoxified mainly by the synthesis of urea and glutamine. These two detoxification pathways are arranged complementarily and sequentially in the liver acini. Whilst periportal hepatocytes have only a low affinity for ammonia detoxification through urea synthesis, glutamine synthesis occurs exclusively in a small (around 5-10% of all liver parenchyma cells), highly specialized cell population at the perivenous end of the liver acini. These cells (perivenous scavenger cells) are of particular importance for maintaining ammonium homeostasis, as they have high affinity for removing ammonia through glutamine synthesis and therefore serve as a collection system for ammonia that has not been detoxified via upstream urea synthesis. In patients with cirrhosis of the liver two factors impair ammonia detoxification, resulting in hyperammonemia: - Ammonia formed in the intestine is channeled past the liver by portosystemic collateral circulation. - The urea-synthesizing capacity of the cirrhotic liver is reduced by over 80%. The same applies to its glutamine-synthesizing capacity, as cirrhosis patients have a severe scavenger-cell deficiency. Impaired detoxification of ammonia in the liver is partly compensated by increased ammonia uptake in muscles, the muscles’ capacity for ammonia elimination correlating with the muscle mass available. Ref. Häussinger D. und Gerok W. in: Hepatologie (Hrsg. Gerok W. und Blum H.E.), S. 847,1995.

Detoxification of ammonia in the liver The glutaminase reaction and urea synthesis take place in periportal hepatocytes, whilst glutamine synthesis takes place in a small population of perivenous hepatocytes (scavenger cells) surrounding the central vein. Glutaminase is activated by ammonia and makes ammonia available in the mitochondria, pH- and hormone-dependently, for activation of the urea cycle. This remarkable property of glutaminase, namely its activation by its own product ammonia, makes glutaminase a pH- and hormone-regulated booster of ammonia. Adequate activation of urea synthesis in the periportal hepatocytes is only possible because of this booster effect. In the periportal-hepatocyte compartment, ammonia is detoxified by a system having a high capacity but low affinity for ammonia. When sufficient quantities of ammonia and ornithine are present, ammonia and HCO3- in the presence of the enzyme carbamoyl phosphate synthetase give a reactive form, carbamoyl phosphate. Carbamoyl phosphate and ornithine form the amino acid citrulline with the aid of the enzyme carbamoyl phosphate transferase. Citrulline is then converted into arginine, and urea splits off with re-formation of ornithine. Ammonia not detoxified in the urea cycle is detoxified in the perivenous hepatocytes, also known as scavenger cells, through glutamine synthesis. These cells scavenge ammonium ions which have escaped detoxification by urea synthesis, with high affinity (scavenger cells). With the aid of the enzyme glutamine synthetase, glutamate is converted into nontoxic glutamine by coupling with ammonia. The glutamine formed compensates for the consumption of glutamine needed periportally for the activation of the urea cycle. Overall, glutamine is not used up in detoxification of ammonia (intracellular glutamine cycle). Häussinger, D., Biochem. J. 267: 281–290, 1990

Diagnostic possibilities in HE Evaluation of the clinical picture using West Haven criteria Flicker frequency analysis (critical flicker frequency, CFF) Determination of mental status: Psychometric tests (e.g. ZVT, LNT, ZST, handwriting) Neurological investigations: EEG, MRI, Evoked potentials (eg. Asterixis) Differential diagnosis Laboratory diagnostics to identify triggering factors: Blood count, Transaminases, Venous acid-base status, Urea, Creatinine

HE severity according to West Haven criteria grade State of consciousness Behavior Neuromuscular symptoms latent / minimal Clinically unremarkable but psychometric tests pathological Clinically unremarkable, but psychometric tests pathological Fine-motor impairment I Impaired concentration and impaired reaction speed disturbances, tiredness (decreased vigilance) Changes in personality Fine-motor impairment II Slowing, lethargy Conspicuous changes in personality, temporal disorientation Asterixis, slurred speech III Disorientation, somnolence, stupor Bizarre behavior, delusions Hyperreflexia and hypo- reflexia, asterixis, spasms Under the West Haven criteria, hepatic encephalopathy is divided into five grades of severity on the basis of clinical symptoms and signs and psychometric test findings. The classification is based primarily on the patient’s mental status. The grades run from HE grade 0, in which there is no impairment of consciousness, to HE grade IV, in which there is severe coma. IV Coma Abolished Areflexia, loss of tone Modified from the original in Conn H. O. and Bircher J. in: Hepatic encephalopathy: Syndromes and Therapies, 13-26, 1994

Child-Pugh classification of the stages of cirrhosis Parameter Number of points 1 2 3 Encephalopathy Grade 0 Grade I/II Grade III/IV Billirubin (mg/dl) or 2 2-3 >3 Billirubin (µmol/l) (≤ 34) (34-51) (>51) Albumin (g/dl) > 3.5 2.8-3.5 < 2.8 Prothrombin time (seconds above norm) 1-3 4-6 > 6 or INR < 1.7 1.8-2.3 > 2.3 The Child-Turcotte criteria, modified from Pugh. The points are added to arrive at the Child-Pugh stage: A (5-6 points), B (7-9), or C (10-15).

Number Connection Test (NCT) Grade 0 15–30 seconds Grade 1 31–50 seconds Grade 2 51–80 seconds Grade 3 81–120 seconds Grade 4 >120 (test cannot be carried out)

Critical Flicker Frequency device (CFF) Close correlation between CFF and severity of HE Statistically significant correlation between CFF and psychometric tests Good correlation between CFF and arterial ammonia concentration Results not dependent on patient’s educational level; no training effects

Treatment of Hepatic Encephalopathy options Evaluate dietary protein Eliminating or remove precipitating factors Drug therapy Non-absorbable disaccharides (eg. Lactulose, Lactitol) L-ornithine-L-aspartate (LOLA) Branched-chain amino acid (BCAA) Oral antibiotics Flumazenil Probiotics Zinc Liver transplant

Non-absorbable disaccharides Lactulose Dose: 45-90 g/d Titrate to achieve 2-3 soft stool per day or stool pH < 6 Route: oral or enema* (the comparison of efficacy is unclear) Efficacy: 70-80% Tolerability: good Side effects: cramping, diarrhea, flatulence Ferenci P, Herneth, A, Steindl, P. Semin Liver Dis 1996; 16:329 Conn, HO, et al. Gastroenterology 1977; 72:573

Non-absorbable disaccharides Cochrane meta-analysis 2004 Thirty randomized trials No effect on mortality; RR 0.41(0.02-8.68, 4 trials) Improvement of HE; RR 0.62 (0.46-0.84, 6 trials) No improvement of HE; RR 0-92 (0.42-2.04, 2 high quality trials) No significant difference between lactulose and lactitol on mortality (2 trials) or improvement of HE (4 trials) but lactitol had fewer side effects Inferior to antibiotics on improvement of HE; RR 1.24 (1.02-1.50,10 trials)

Oral antibiotics ATB Trials Dose Efficacy AE Neomycin Lactulose, Placebo 50-100 mg/kg/d ?, - Ototoxicity and Nephrotoxicity Metronidazole 400 mg bid = Peripheral neuropathy Vancomycin Lactulose 250 mg qid = / + none Paramomycin 4 g/d Rifaximin Lactulose, Lactitol 1,200-2,400 mg/d Strauss E, et al. Hepatogastroenterology 1992; 39:542.  Tarao, K, et al. Gut 1990; 31:702. Bucci, L, Palmieri, GC. Curr Med Res Opin 1993; 13:109.  Williams, R, et al. Eur J Gastroenterol Hepatol 2000; 12:203.

Branched-chain amino acid Meta-analysis 2004 More rapid mental recovery Unclear result on mortality All studies were short duration Should not consider standard treatment Naylor, CD, et al. A meta- analysis. Gastroenterology 1989; 97:1033

Probiotics One RCT, N=97, minimal HE (MHE) Probiotic vs Fermentable fiber vs Placebo Probiotic significant increased the fecal content of non-urease-producing Lactobacillus species, reduce blood ammonia and reverse mHE about 50%

Therapeutic principle

Introducing (L-ornithine-L-aspartate) Hepa-Merz ®

Hepa-Merz® Granules

Hepa-Merz® Infusion Concentrate

Pharmacokinetics L-Ornithine-L-Aspartate is rapidly absorbed and cleavelaged into L-Ornithine and L-Aspartate Elimination half life of each amino acid is short approximately 40 min Bioavailability is 82.2  28% after Infusion or oral administration Some L-Aspartate appear unchanged in the urine.

Effect of ornithine on urea synthesis: Substrate of urea synthesis in urea cycle Activator of carbamoyl phosphate synthetase

Effect of aspartate on glutamine synthesis Substrate in glutamine synthesis Combining of Citrulline to Arginino-Succinate in Urea Cycle

Action mechanism of L-ornithine L-aspartate (OA) Activated Häussinger, D., Biochem. J. 267: 281–290, 1990

(Represent in some of published clinical studies) The role of L-ornithine-L-aspartate (Hepa-Merz®) in the treatment of HE (Represent in some of published clinical studies)

Clinical data of Infusion Lowering of ammonia by OA infusion Administration of 20 g OA i.v. (5 g/h) 100 p < 0.02 83 81 77 80 Fasting ammonia levels μmol N=126 63 = LOLA 63 = Placebo 64 60 L-ornithine L-aspartate Placebo 40 Day 0 Day 7 Kircheis G., Nilius R., Held C. et al., Hepatology 25: 1351–1360, 1997

Clinical data of Infusion Improvement in HE as a result of OA infusion Kircheis G., Nilius R., Held C. et al., Hepatology 25: 1351–1360, 1997

Clinical data of Granules Lowering of ammonia by OA granules Administration of 3 x 6 g OA granules 100 p < 0.01 93 82 82 80 N=66 34 = LOLA 32 = Placebo Fasting ammonia levels (µmol/l) 60 L-ornithine L-aspartate 52 Placebo 40 Day 0 Day 14 Stauch S., Kircheis G., Adler G. et al., Hepatology 28: 856–864, (1998)

Decreased of Serum ammonia Oral LOLA Vs lactulose LOLA versus Lactulose Only LOLA group Has better improvement in Mental status NCT Asterixis EEG LOLA Lactulose Decreased of Serum ammonia JL Poo; J Góngora; F Sánchez-Ávila et al. Annals of Hepatology 5(4) 2006: 281-288

Summary Therapeutic administration of L-ornithine L-aspartate (Hepa-Merz®) increases ammonia detoxification in two ways: Activation of the urea cycle in the liver, through provision of the metabolic substrates ornithine and aspartate. The substrates ornithine and aspartate promote glutamine formation, thereby stimulating ammonia detoxification via glutamine synthesis in the liver, in the brain, and in muscle.

Hepa-Merz® General Information's

Indication of Hepa-Merz For the treatment of hyperammonemia as a result of acute and chronic liver diseases such as liver cirrhosis, fatty liver, hepatitis; Especially for the treatment of incipient disturbances of consciousness (pre-coma) or neurological complications (hepatic encephalopathy) Product Insert

Indications and Dosage Granules: Treatment in mHE, sHE, HE I , HE II, III Containing L-ornithine-L-aspartate 3.0g / 5g / Sachet 1-2 Sachets up to 3 times a day (upon severity of symptom) Dissolve granules in 1 glass of water, tea of juice and drink after meal

Indications and Dosage Infusion Concentrate: HE III, HE IV, Pre Coma, Coma Containing L-ornithine-L-aspartate 5.0g / 10ml / Ampoule Dosage 1-4 Amp per day Pre-coma and Coma Up to 8 Amp within 24 Hrs depend on the severity of the condition Max infusion Rate = 5 Gm/ Hour Max Conc. = 6 Amp/ 500 ml Infusion solutions to Mix up; Normal saline, Dextrose, Lactate ringer, Sucrose. etc.

Toxicology Toxicological tests of L-Ornithine-L-Aspartate on rats and dogs following single and repeated dose of infusion over 4 week gave no effect at level of approx. 1,500 mg/ kg Reproduction studies on mutagenicity found no abnormalities. There is no need to suspect any carcinogenic potential

Safety and Tolerability No case of serious adverse drug reaction 5% of mild gastro-intestinal disturbance i.e, (nausea vomiting) with infusion therapy Nausea is occasional occurred on infusion therapy, with vomiting rarely Symptoms are transient and reversible with reduction of dose or rate of infusion Max rate of infusion is 5 gm (1 Amp) of Hepa-Merz® inf. concentrate per hour is recommended

Hepa-Merz Contra-indication Due to Hepa-Merz® mechanism-increase formation of Urea and eliminate by kidney Hepa-Merz® is not recommended for patient with severe renal function Severe renal function = Creatinine level > 3 mg / dl

Interaction with Other Medications None Known

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