From the Guidelines
The initial workup for hepatitis should include a comprehensive history and physical examination, followed by laboratory tests to determine the cause and severity, with treatment depending on the underlying cause, and for chronic hepatitis B, antiviral medications such as entecavir 0.5mg daily or tenofovir 300mg daily are recommended for patients with HBV DNA > 20,000 IU/ml and elevated ALT levels 1. The initial evaluation of patients with hepatitis should include a thorough history and physical examination, with special emphasis on risk factors for coinfection, alcohol use, and family history of liver disease and liver cancer. Laboratory tests should include assessment of liver disease, markers of viral replication, and tests for coinfection with other viruses.
- The laboratory tests should include:
- Liver function tests (ALT, AST, bilirubin, alkaline phosphatase)
- Complete blood count
- Coagulation studies
- Serological markers for viral hepatitis (HAV IgM, HBsAg, anti-HBc IgM, anti-HCV)
- Tests for HBV replication—HBeAg/anti-HBe, HBV DNA
- Tests to rule out viral coinfections—anti-HCV, anti-HDV, and anti-HIV in those at risk
- Additional testing may include:
- Autoimmune markers
- Ceruloplasmin
- Iron studies
- Abdominal imaging such as ultrasound
- Treatment depends on the underlying cause, and the goals of therapy for chronic hepatitis B are to eliminate or significantly suppress HBV replication, prevent progression of liver disease, and promote histologic improvement and ALT normalization 1.
- For viral hepatitis A and E, supportive care is recommended with rest, hydration, and avoiding hepatotoxic substances like alcohol.
- Acute hepatitis B typically requires only supportive care, but chronic cases may need antiviral medications such as entecavir 0.5mg daily or tenofovir 300mg daily 1.
- Hepatitis C treatment involves direct-acting antivirals like sofosbuvir/velpatasvir (Epclusa) 400mg/100mg once daily for 12 weeks.
- Autoimmune hepatitis requires immunosuppression with prednisone 30-60mg daily initially, often with azathioprine 50-150mg daily.
- Alcoholic hepatitis necessitates alcohol cessation and nutritional support, with severe cases potentially benefiting from prednisolone 40mg daily for 28 days.
- Drug-induced hepatitis requires immediate discontinuation of the offending agent.
- Patients with signs of liver failure (encephalopathy, coagulopathy) should be referred urgently to a liver specialist for possible transplant evaluation 1.
From the FDA Drug Label
Test all patients for evidence of current or prior hepatitis B virus (HBV) infection before initiating treatment with ledipasvir and sofosbuvir Test all patients for evidence of current or prior HBV infection by measuring HBsAg and anti-HBc before initiating HCV treatment with ledipasvir and sofosbuvir
The initial workup for hepatitis includes testing for HBV infection by measuring:
- HBsAg (hepatitis B surface antigen)
- anti-HBc (hepatitis B core antibody) This is necessary to assess the risk of HBV reactivation in patients coinfected with HCV and HBV before initiating treatment with ledipasvir and sofosbuvir 2.
From the Research
Initial Workup for Hepatitis
- The initial workup for hepatitis typically involves a carefully taken history, thorough physical examination, and standard laboratory tests 3
- Additional studies may be required, such as a viral hepatitis panel, serologic tests for autoimmune markers, tests for antimitochondrial antibodies, measurement of serum iron and ceruloplasmin levels, liver biopsy, and imaging studies of the extra-hepatic bile ducts 3
Treatment for Hepatitis
- The treatment for hepatitis depends on the type and severity of the disease
- For chronic hepatitis C, the combination of ledipasvir and sofosbuvir has been shown to be highly effective in achieving sustained virologic response (SVR) 4, 5
- The addition of ribavirin to ledipasvir and sofosbuvir may be beneficial for certain patients, such as those with cirrhosis or severe hepatic impairment 4
- For acute hepatitis B, the use of nucleoside analogues such as lamivudine and entecavir has been studied, but the evidence is limited and inconclusive 6
Factors Associated with Treatment Outcome
- Factors that predict SVR in patients treated with ledipasvir and sofosbuvir include higher albumin levels, lower total bilirubin levels, absence of cirrhosis, and absence of proton pump inhibitor use 5
- The duration of treatment with ledipasvir and sofosbuvir may also impact treatment outcome, with 8-week regimens being effective for certain patients 5