What is the best treatment plan for a patient with elevated liver enzymes and chest pain, suspected of having viral hepatitis?

From the Guidelines

The best treatment plan for a patient with elevated liver enzymes and chest pain suspected of having viral hepatitis is to initiate antiviral therapy with entecavir or tenofovir if chronic HBV is confirmed, alongside supportive care and cardiac evaluation to address chest pain. Initial management should focus on confirming the diagnosis through serological testing for hepatitis viruses (HAV, HBV, HCV, HEV), liver function tests, and cardiac evaluation to rule out cardiac causes of chest pain 1. Supportive care is the mainstay of treatment, including adequate rest, hydration, and a nutritious diet low in fat. Acetaminophen can be used cautiously for pain at reduced doses (no more than 2 grams daily) to avoid further liver stress. Alcohol and hepatotoxic medications should be strictly avoided. The chest pain requires separate evaluation with ECG, cardiac enzymes, and possibly imaging to distinguish between cardiac causes and pain from liver inflammation stretching the liver capsule. For patients with HBeAg-positive or -negative CHB and elevated ALT levels, an HBV DNA level of 2000 IU/mL or higher is a reasonable threshold for determining candidates for treatment, with entecavir, tenofovir, or peginterferon alfa-2a preferred as first-line treatments 1. Most acute viral hepatitis cases resolve spontaneously with supportive care, but close monitoring of liver function and symptoms is essential, with follow-up testing every 1-2 weeks initially. Hospitalization may be necessary if there are signs of liver failure such as coagulopathy, encephalopathy, or severe jaundice. Key considerations in choosing antiviral therapy include efficacy, safety, resistance, and method of administration, with entecavir and tenofovir offering high potency and a favorable safety profile 1.

Some key points to consider in the treatment plan include:

• Confirming the diagnosis of viral hepatitis through serological testing and liver function tests
• Initiating antiviral therapy with entecavir or tenofovir for chronic HBV
• Providing supportive care, including rest, hydration, and a nutritious diet
• Avoiding alcohol and hepatotoxic medications
• Evaluating and managing chest pain separately
• Monitoring liver function and symptoms closely, with follow-up testing every 1-2 weeks initially.

Given the most recent and highest quality evidence, entecavir or tenofovir are the preferred first-line treatments for CHB, due to their high efficacy and favorable safety profile 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Plan for Viral Hepatitis

The patient's symptoms of elevated liver enzymes and chest pain, suspected of having viral hepatitis, require a comprehensive treatment plan.

• The mainstay of treatment for acute viral hepatitis is supportive care, as most cases are self-limited 2.
• General measures in all types of acute viral hepatitis include bedrest if the patient is very symptomatic, a high-calorie diet, avoidance of hepatotoxic medications, and abstinence from alcohol 2.
• In severe cases, hospitalization may be necessary for intravenous rehydration if the patient is unable to maintain adequate oral intake due to nausea and vomiting or if there is any alteration of mental status to suggest evolving fulminant hepatic failure 2.

Antiviral Treatment

• Antiviral treatment is the only option to prevent or defer the occurrence of hepatocellular carcinoma (HCC) in patients chronically infected with hepatitis B virus (HBV) or hepatitis C virus (HCV) 3.
• The approved medication for the treatment of chronic HBV infection is interferon-α (IFNα) and nucleos(t)ide analogues (NAs), including lamivudine, adefovir dipivoxil, telbivudine, entecavir, and tenofovir disoproxil fumarate 3.
• IFNα treatment significantly decreases the overall incidence of HBV-related HCC in sustained responders, but side effects may limit its long-term clinical application 3.
• Orally administered NAs are typically implemented for patients with more advanced liver diseases, and NA treatment significantly reduces disease progression of cirrhosis and therefore HCC incidence, especially in HBV e antigen-positive patients 3.

Management of Antiviral Drug Resistance

• Preventing HBV antiviral drug resistance to nucleoside/nucleotide analogues and appropriate management when resistance occurs has become a major focus in the management of chronic hepatitis B 4.
• HBV antiviral drug resistance may be best prevented by using an agent or combination of agents with a high genetic barrier to resistance 4.
• Frequent assessment of quantitative serum HBV DNA remains the best approach to early detection of resistance, and antiviral therapy should be modified as soon as resistance is detected 4.
• Results from several clinical trials have shown that the addition or substitution of newer antiviral agents can restore suppression of viral replication, normalize alanine aminotransferase levels, and reverse histologic progression in patients with resistance to lamivudine 4.

Treatment Duration and Monitoring

• Treatment of chronic hepatitis B with entecavir or tenofovir leads to viral suppression in almost all patients, but prolonged or lifelong treatment is necessary 5.
• Virological relapse has been well documented in patients with chronic hepatitis B who stop treatment, and relapse rate is particularly high in patients who are HBeAg-negative when treatment begins 5.
• Hepatic decompensation, jaundice, and death have been described in patients with cirrhosis after treatment discontinuation, and there is no robust evidence to support treatment discontinuation in most patients 5.