Assessing the Self-Rating Scale Item as a Measure for Lactulose Adherence


  • Stacey Tam Indiana University School of Medicine
  • Nicole Garcia Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine
  • Eric Orman, MD Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine



Hepatic encephalopathy (HE) is a defining complication of end-stage liver disease. The standard treatment is lactulose, but adherence is difficult due to complex dosing regimens and side effects. We adapted a single item self-reported adherence measure - the Self Rating Scale Item (SRSI) - for lactulose use and examined its relationship with clinical events, cognition, and quality of life.

We performed a cross-sectional study of patients with cirrhosis and HE seen at Indiana University Hospital 5/31/2023-7/14/2023. Clinical history and demographic information were collected through electronic health records and patient interviews. Patients provided the SRSI, which reflects their self-perceived ability to take lactulose, bowel movement frequency, perception of missing doses, and quality of life (PROMIS-29+2). Cognition was measured using the Animal Naming Test (ANT). The relationship between the SRSI and other measures was assessed.

42 patients met eligibility criteria and enrolled. The median age was 59, and 55% were female. Patients were divided across SRSI categories: ≤good, very good, and excellent. Patients with better adherence were more likely to have ascites, but other demographics were similar between groups. Ascites was present in 43%, 64%, and 93% of ≤good, very good, and excellent categories, respectively. A higher SRSI score was associated with fewer missed doses and more days achieving bowel movement targets. 79% in the ≤good category skipped lactulose doses compared to 29% and 21% in very good and excellent groups. SRSI was not associated with HE-related hospitalizations or ANT. Higher SRSI was associated with improved sleep and cognitive function, with a trend towards decreased fatigue and pain.

Conclusion/Potential Impact:
The SRSI is associated with other measures of lactulose adherence and quality of life and may be a promising tool to measure lactulose adherence. Adopting the SRSI may be a useful way to improve lactulose dosing, adherence, and health outcomes.