Hepatic encephalopathy: Part 4, driving in the UK

Hepatic encephalopathy (HE) encompasses a wide spectrum of non-specific neurological and psychiatric manifestations in patients with cirrhosis. Overt HE (OHE) is an event that defines decompensation in such patients. Though not as conspicuous, minimal HE (MHE) can be similarly debilitating. As well as prognosticating the subsequent development of overt encephalopathy, MHE carries a significant burden of disease. It has been estimated that 30–45% of patients with cirrhosis will decompensate with OHE during their clinical course, while up to 80% of patients with cirrhosis will have evidence of MHE detected only on psychometric testing of higher executive functions. The ability to drive safely requires cognitive, visual and motor skills, all of which can be impaired in HE. Although studies in driving with HE predominantly involve small groups of patients with varying methodology to diagnose MHE, most of the evidence suggests that the presence of MHE impairs patients’ ability to drive safely. Critically, patients with MHE may lack insight into their compromised driving abilities. However, in patients with MHE who can drive safely, preventing them from doing so could unnecessarily reduce their independence and impair their quality of life. Thus, a fine balance exists between the diagnosis of MHE and subsequent advice given not to drive. Based on published literature, guidance from the UK Driver and Vehicle Licensing Agency and the General Medical Council, we herein review the literature, with proposals to manage issues around driving with HE .