Rifaximin and sarcopenia in cirrhosis: Commentary on a promising but complex relationship

We commend Worland et al for their work associating rifaximin-α use with improved muscle mass in individuals with liver cirrhosis. This observation adds momentum to the evolving gut-liver-muscle axis hypothesis. However, the retrospective design and lack of functional outcomes invite caution in interpretation. Mechanistically, rifaximin may exert benefit beyond ammonia reduction through modulation of systemic inflammation, tumor necrosis factor alpha suppression, and restoration of myocyte integrity. Additionally, concerns about long-term antimicrobial resistance must be acknowledged. Overall, this study represents a valuable first step, but its implications require validation in future, prospective, mechanistically informed clinical trials.