From the Guidelines
For a patient with suspected viral chronic liver disease, initial diagnostic testing should include a comprehensive viral hepatitis panel with serologies for hepatitis A, B, and C, as well as complete blood count, liver function tests, coagulation studies, and a comprehensive metabolic panel, as recommended by the most recent guidelines 1.
Initial Diagnostic Testing
The initial evaluation of a patient with suspected viral chronic liver disease should include:
- A comprehensive viral hepatitis panel with serologies for:
- Hepatitis A (anti-HAV IgM and IgG)
- Hepatitis B (HBsAg, anti-HBs, anti-HBc IgM and IgG, HBeAg, anti-HBe)
- Hepatitis C (anti-HCV antibody with reflex to HCV RNA if positive)
- Complete blood count
- Liver function tests (ALT, AST, alkaline phosphatase, GGT, bilirubin, albumin)
- Coagulation studies (PT/INR)
- A comprehensive metabolic panel
Additional Testing
Additional testing may include:
- HIV screening
- Autoimmune markers (ANA, ASMA, AMA)
- Tests for less common viruses like hepatitis D, E, or CMV depending on risk factors
Imaging and Initial Management
Imaging with abdominal ultrasound should be performed to assess liver morphology, rule out complications like portal hypertension, and screen for hepatocellular carcinoma. Initial management includes:
- Abstinence from alcohol
- Avoiding hepatotoxic medications
- Vaccination against hepatitis A and B if not immune
- Nutritional support
Specific Antiviral Therapy
Specific antiviral therapy depends on the identified virus:
- For hepatitis B, medications like entecavir (0.5mg daily) or tenofovir (300mg daily) may be indicated
- For hepatitis C, direct-acting antiviral regimens are determined based on genotype, prior treatment history, and presence of cirrhosis Early referral to a hepatologist is recommended for treatment initiation, monitoring for complications, and consideration of liver biopsy to assess disease severity if indicated, as suggested by the guidelines 1.
From the FDA Drug Label
Test all patients for evidence of current or prior HBV infection by measuring hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) before initiating HCV treatment with SOVALDI [see Warnings and Precautions (5.1)] . Test all patients for HBV infection by measuring HBsAg and anti-HBc. ( 2. 1)
The initial management for a patient with suspected viral chronic liver disease should include diagnostic tests such as:
- Hepatitis B surface antigen (HBsAg)
- Hepatitis B core antibody (anti-HBc) These tests are necessary to determine the presence of a current or prior HBV infection, which is crucial in guiding the treatment regimen for HCV. 2 2
From the Research
Diagnostic Tests for Suspected Viral Chronic Liver Disease
- To diagnose viral hepatitis, specific viral markers should be determined, including HBsAg, anti-HBs, HBeAg, anti-HBe, anti-HBc, IgM anti-HBc, and HBV DNA for HBV infection 3
- For HCV infection, anti-HCV and HCV RNA should be tested, with confirmation of ELISA positivity using techniques such as western blot or immunoblot 3
- HCV genotyping is also recommended, as different viral genotypes respond differently to therapy 3
- In cases where the interpretation of HBV and HCV markers is difficult, consideration should be given to simultaneous infection with other hepatitis viruses or viruses like HIV 3
Initial Management
- A timely, accurate, and comprehensive screening is essential to combat viral hepatitis, including maximum population coverage 4
- Guideline-defined risk scenarios, such as immigration, infection in household, and male gender for HBV, and IV drug use, blood transfusion before 1992, and immigration for HCV, can help identify previously undiagnosed patients 5
- Elevated ALT values can also be used to identify patients at risk of viral hepatitis, with 82% of previously undiagnosed HBV patients and 83% of previously undiagnosed HCV-RNA positive cases identified by screening only 26% of the population 5
- Patients with anti-HBc alone serological status require further investigation, including measurement of serum anti-HBs responses after HBV vaccination, and may not require pre-emptive antiviral therapy but should be followed up on a monthly basis for alanine aminotransferase 6
- Nucleoside analogue prophylaxis is recommended in anti-HBc-positive liver allograft recipients and anti-HBc alone individuals who receive chemotherapy or biological therapy 6
Predictive Value of Serum Hepatitis B Core Antibody
- Serum hepatitis B core antibody (anti-HBc) level can be used as a promising marker for selecting HBeAg-negative CHB patients who are more likely to respond to Peg-IFN-based therapy 7
- Patients with lower anti-HBc levels at week 12 showed a more significant decline in HBsAg levels during treatment, and combination of anti-HBc at week 12 and baseline HBsAg could identify over 70% of patients who achieved HBsAg clearance after 48 weeks of treatment 7