What is the management of acute hepatitis?

Management of Acute Hepatitis

The management of acute hepatitis primarily involves supportive care, with specific interventions based on the etiology, with antiviral therapy recommended only in select cases such as acute hepatitis C where PegIFN-α monotherapy for 12 weeks is recommended. 1

General Management Principles

• Supportive care is the cornerstone of management for most cases of acute viral hepatitis
• Monitoring: Regular assessment of clinical status and liver function tests
• Rest: Bedrest only if severely symptomatic; prolonged strict bedrest is no longer recommended 2
• Nutrition: Normal palatable nutrition is adequate; no special "liver diet" required 2
• Avoid hepatotoxins: Discontinue all potentially hepatotoxic medications
• Alcohol abstinence: Complete abstinence from alcohol during the acute phase 3

Etiology-Specific Management

Acute Hepatitis C

1. Initial approach:

   • Consider delaying treatment for 8-12 weeks after onset to allow for potential spontaneous clearance 1
   • Monitor for spontaneous viral clearance for at least 6 months if treatment delay is acceptable 1

2. Treatment recommendations:

   • First-line: PegIFN-α monotherapy for 12 weeks achieves SVR in >90% of patients 1
   • Alternative: PegIFN-α2a (180 μg/week) or PegIFN-α2b (1.5 μg/kg/week) for 24 weeks 1
   • Ribavirin combination does not increase SVR rates in acute hepatitis C 1

3. Follow-up:

   • Patients failing to respond should be retreated according to chronic hepatitis C guidelines 1
   • If using DAA-containing regimens, follow recommendations for chronic infection 1

Acute Hepatitis B

• Majority of cases resolve spontaneously without specific antiviral therapy 4
• Consider antiviral therapy (nucleos(t)ide analogues) only if:
  • Patient is developing severe acute hepatitis or acute liver failure 4
  • High HBV DNA levels (>2 × 10^4 IU/ml) with signs of underlying liver disease 5

Acute Alcoholic Hepatitis

For severe alcoholic hepatitis:

1. Assessment of severity:

   • Calculate prognostic scores: Maddrey discriminant function (MDF), MELD, ABIC, or Glasgow score 1
   • MDF >32 or MELD >20 indicates high mortality risk 1

2. Management:

   • Abstinence from alcohol
   • Nutritional support
   • Consider glucocorticoids for severe cases
   • N-acetylcysteine (NAC) may be beneficial as adjunctive therapy 1

Monitoring During Treatment

• Regular follow-up visits to assess:
  • Clinical symptoms
  • Liver function tests
  • Viral load (for viral hepatitis)
  • Adherence to therapy
  • Management of side effects 1

Management of Complications

Acute Liver Failure

• Transfer to ICU or specialized liver unit
• Consider referral to a transplant center early 6
• Supportive care including:
  • Intravenous hydration
  • Management of coagulopathy
  • Prevention and treatment of infections
  • Monitoring for and management of hepatic encephalopathy 7
• Liver transplantation may be life-saving in selected cases 3

Prevention

• HCV-infected individuals should not donate blood, organs, tissues, or semen 1
• Avoid sharing personal hygiene items (toothbrushes, razors, nail clippers) 1
• Proper disinfection and cleaning of materials in medical and invasive procedures 1
• Hepatitis B vaccination for susceptible individuals 4

Prognosis

• Most cases of acute viral hepatitis resolve spontaneously
• Spontaneous recovery from acute hepatitis C occurs in 20-50% of cases 1
• Factors associated with spontaneous clearance of HCV include:
  • Symptomatic disease with jaundice
  • Female gender
  • Low viral load
  • Genotype 3
  • Favorable IL28B genotype 1

The management of acute hepatitis should focus on supportive care while monitoring for complications, with specific antiviral therapy reserved for select cases based on etiology, severity, and risk of progression to chronic disease.