What are the steps for a hepatitis workup and subsequent treatment?

From the Guidelines

A hepatitis workup begins with comprehensive blood tests including liver function tests (ALT, AST, bilirubin), hepatitis viral serologies (A, B, C, D, E), and tests for autoimmune markers if viral causes are negative, as recommended by 1. Imaging such as ultrasound, CT, or MRI may be ordered to assess liver structure. Treatment depends on the specific type of hepatitis identified. For hepatitis A and E, supportive care is typically sufficient as these are self-limiting. For chronic hepatitis B, treatment options include entecavir (0.5-1mg daily) or tenofovir (300mg daily) as first-line therapies, potentially for years or lifelong, as stated in 1 and 1. Hepatitis C is now highly curable with direct-acting antivirals like Epclusa (sofosbuvir 400mg/velpatasvir 100mg) once daily for 12 weeks, or Mavyret (glecaprevir 300mg/pibrentasvir 120mg) once daily for 8-12 weeks, with cure rates exceeding 95%. Autoimmune hepatitis requires immunosuppression with prednisone (starting at 30-60mg daily and tapering) plus azathioprine (50-150mg daily). Alcoholic hepatitis necessitates complete alcohol cessation and may require nutritional support or steroids in severe cases. Throughout treatment, patients need regular monitoring of liver function, viral loads when applicable, and assessment for complications like cirrhosis or hepatocellular carcinoma, as emphasized in 1 and 1. Vaccination against hepatitis A and B is recommended for susceptible individuals to prevent future infection. Key considerations in the management of chronic hepatitis B include the assessment of liver disease severity, the detection and measurement of HBV DNA levels, and the evaluation of other causes of chronic liver disease, as outlined in 1. The treatment goals for hepatitis B are to decrease mortality and increase survival by alleviating hepatic inflammation and preventing fibrosis, ultimately reducing the progression to liver cirrhosis or hepatocellular carcinoma, as noted in 1 and 1. Regular monitoring and adjustment of treatment strategies are crucial for optimal patient outcomes.

From the FDA Drug Label

Testing prior to the initiation of therapy: Test all patients for HBV infection by measuring HBsAg and anti-HBc. Testing Prior to the Initiation of Therapy: Test all patients for HBV infection by measuring HBsAg and anti-HBc.

The steps for a hepatitis workup include testing for HBV infection by measuring HBsAg and anti-HBc 2, 3.

• Key steps:
  • Test all patients for HBV infection
  • Measure HBsAg and anti-HBc Subsequent treatment may involve ledipasvir and sofosbuvir for certain patient populations, such as those with genotype 1,4,5, or 6 infection without cirrhosis or with compensated cirrhosis 2.
• Treatment considerations:
  • Ledipasvir and sofosbuvir for genotype 1,4,5, or 6 infection
  • Treatment regimen and duration based on patient population and genotype However, the specific treatment regimen and duration will depend on the individual patient's characteristics, such as genotype, presence of cirrhosis, and prior treatment experience.

From the Research

Hepatitis Workup Steps

• The initial evaluation of a patient with hepatitis B virus infection should attempt to assess the disease activity and stage, as well as properly assess the needs for treatment and surveillance 4.
• The initial evaluation usually requires serological, biochemical, and virological tests to confirm the diagnosis, as well as an imaging study to establish a baseline for future monitoring 4.
• A liver biopsy is generally not needed but can provide useful information on prognosis, need for surveillance for hepatocellular carcinoma (HCC), and whether to recommend therapy 4.

Diagnostic Tools

• Serological markers, such as anti-HAV, anti-HBc, anti-HDV, and anti-HEV IgM antibodies, can provide a clear indication of an infection caused by HAV, HBV, HDV, or HEV 5.
• Anti-HCV antibodies and HGV/RNA are used for the diagnosis of HCV and HGV infections 5.
• Excellent serologic and nucleic acid detection methods are available for determining the precise cause and, in some cases, the duration of infection 6.

Treatment and Monitoring

• Follow-up monitoring is aimed at determining disease progression, development of complications, and reassessing the need for treatment 4.
• Monitoring frequency should be determined based on the activity and stage of disease 4.
• Initiation of screening for HCC should be based on age, race, sex, family history, and stage and duration of disease 4.
• The current recommended method of screening and surveillance for HCC is by ultrasonography and alpha-fetoprotein measurements every 6-12 months 4.

Laboratory Diagnosis and Monitoring

• Many microbes, toxins, autoimmune diseases, and neoplastic diseases may cause liver inflammation, but 5 viruses whose main pathogenesis is liver disease are referred to as hepatitis A, B, C, D, and E viruses 6.
• Diagnostics are critical for identifying individuals needing treatment and for monitoring the treatment success 6.
• The routine use of serum biochemical tests allows for the detection of acute and chronic liver injury before the onset of symptoms 7.
• Noninvasive tests for assessment of liver fibrosis are promising tools for diagnosis and prognosis of patients with chronic liver disease 7.