Lactulose

Constipation

Lactulose is used in the treatment of chronic constipation in patients of all ages as a long-term treatment. Lactulose is used for chronic idiopathic constipation, i.e. chronic constipation occurring without any identifiable cause. Lactulose may be used to counter the constipating effects of opioids, and in the symptomatic treatment of hemorrhoids as a stool softener.

The dosage of lactulose for chronic idiopathic constipation is adjusted depending on the constipation severity and desired effect, from a mild stool softener to causing diarrhea. Dosage is reduced in case of galactosemia as most preparations contain the monosaccharide galactose due to its synthesis process.

Hyperammonemia

Lactulose is useful in treating hyperammonemia (high blood ammonia), which can lead to hepatic encephalopathy. Lactulose helps trap the ammonia (NH₃) in the colon and bind to it. It does this by using gut flora to acidify the colon, transforming the freely diffusible ammonia into ammonium (NH+
4) which can no longer diffuse back into the blood. It is also useful for preventing hyperammonemia caused as a side effect of administration of valproic acid.

Lactulose for hepatic encephalopathy generally requires relatively large oral dosages three or four times a day with episodic diarrhea and constant flatulence almost a certain side effect. People who take lactulose at this level of dosage generally end up wearing an adult diaper and plastic pants for any activities away from home or at night (with a chux pad for the bed) because the diarrhea can occur swiftly and without much warning.

Small intestine bacterial overgrowth

Lactulose is used as a test of small intestine bacterial overgrowth (SIBO). Recently the reliability of it for diagnosing SIBO has been seriously questioned. A large amount of it is given with subsequent testing of molecular hydrogen gas in the breath. The test is positive if an increase in exhaled hydrogen occurs before that which would be expected by normal colonocyte digestion. An earlier result has been hypothesized to indicate digestion occurring within the small intestine. An alternate explanation for differences in results is the variance in small bowel transit time among tested subjects.

Special populations

No evidence of harm to the baby has been found when used during pregnancy. It is generally regarded as safe during breastfeeding.

Side effects

Common side effects of lactulose are abdominal cramping, borborygmus and flatulence. In normal individuals, overdose is considered uncomfortable, but not life-threatening. Uncommon side effects are nausea and vomiting. In sensitive individuals, such as the elderly or people with reduced kidney function, excess lactulose dosage can result in dehydration and electrolyte disturbances such as low magnesium levels. Ingestion of lactulose does not cause a weight gain because it is a non-digestible with no nutritional value. Although lactulose is less likely to cause dental caries than sucrose, as a sugar there is potential for this. This should be taken into consideration when taken by people with a high susceptibility to this condition.

Mechanism of action

It is a disaccharide (double-sugar) formed from one molecule each of the simple sugars (monosaccharides) fructose and galactose. Lactulose is not normally present in raw milk but is a product of heat-processes: the greater the heat, the greater amount of this substance (from 3.5 mg/L in low temperature pasteurized milk to 744 mg/L in in-container sterilized milk). It is produced commercially by isomerization of lactose.

Lactulose is not absorbed in the small intestine nor broken down by human enzymes, thus stays in the digestive bolus through most of its course, causing retention of water through osmosis leading to softer, easier to pass stool. It has a secondary laxative effect in the colon, where it is fermented by the gut flora, producing metabolites which have osmotic powers and peristalsis-stimulating effects (such as acetate), but also methane associated with flatulence.

Lactulose is metabolized in the colon by bacterial flora to short chain fatty acids including lactic acid and acetic acid. These partially dissociate, acidifying the colonic contents (increasing the H⁺ concentration in the gut). This favors the formation of the nonabsorbable NH+
4 from NH₃, trapping NH₃ in the colon and effectively reducing plasma NH₃ concentrations.

The effectiveness of lactulose in treating hepatic encephalopathy is somewhat controversial. However, lactulose can effectively be used as secondary prophylaxis of hepatic encephalopathy in patients with cirrhosis. Moreover, recent studies showed improved cognitive functions of cirrhotic patients with minimal hepatic encephalopathy treated with lactulose.

Name

Lactulose is the international nonproprietary name(INN).

Cost

It is available as a generic medication. The wholesale price is about US$0.18 per dose. In the United States 30 doses of the liquid is about US$20.

Availability

Lactulose is available without prescription in most countries. However, a prescription is required in the United States and Austria mainly over unfounded fears that it could be harmful to diabetics. Even though it is approved in most countries as a food additive, it is not allowed in the United States because it is viewed there as a pharmaceutical drug.

Food additive

Lactulose is commonly used as a food additive to improve taste and promote intestinal transit time.