What is the treatment approach for a patient with hepatitis?

Treatment Approach for Hepatitis

The treatment approach for hepatitis depends on the specific viral etiology, with direct-acting antivirals (DAAs) being the standard of care for hepatitis C, nucleos(t)ide analogues for hepatitis B, and interferon-based therapy for acute hepatitis. 1, 2

Hepatitis C Treatment

Chronic Hepatitis C

• First-line therapy: Direct-acting antivirals (DAAs) based on genotype
  • Genotype 1,4,5, or 6:
    • Without cirrhosis: Ledipasvir/sofosbuvir for 12 weeks 3
    • With compensated cirrhosis: Ledipasvir/sofosbuvir for 12-24 weeks 3
    • With decompensated cirrhosis: Ledipasvir/sofosbuvir + ribavirin for 12 weeks 3
  • Treatment duration may be shortened to 8 weeks in treatment-naïve genotype 1 patients without cirrhosis who have HCV RNA <6 million IU/mL 3

Acute Hepatitis C

• Consider delaying treatment for 8-12 weeks to allow for potential spontaneous clearance (occurs in 20-50% of cases) 2
• If treatment is initiated:
  • PegIFN-α monotherapy for 12 weeks (achieves >90% SVR) 2
  • Alternative: Direct-acting antivirals following chronic hepatitis C guidelines 2

Hepatitis B Treatment

Treatment Indications

• Treatment is indicated for patients with:
  • HBV DNA >2000 IU/mL, elevated ALT and/or moderate histological lesions 1, 4
  • All cirrhotic patients with detectable HBV DNA 1, 4
  • HBeAg-positive patients with HBV DNA >20,000 IU/mL and age >30 years 4

Treatment Options

• First-line therapy: Nucleos(t)ide analogues (NAs) 1
• Treatment goals:
  • Long-term suppression of HBV DNA levels 1
  • HBeAg loss/seroconversion in HBeAg-positive patients 1
  • ALT normalization 1
  • HBsAg loss (optimal but rare endpoint) 1

Special Populations

• Pregnant women with high viremia: Treatment in last trimester to prevent vertical transmission 4
• Patients receiving immunosuppression/chemotherapy: Prophylactic treatment to prevent HBV reactivation 4
• Children: Same principles as adults, but not recommended for children <3 years 1

Hepatitis D Treatment

• Limited treatment options 5
• Pegylated interferon-alpha shows efficacy with 25-30% sustained virological response 5
• For HBV DNA-positive co-infected patients: Add HBV polymerase inhibitors 5

Special Considerations

Patients with Substance Use Disorders

• Therapy is recommended for recovered drug users, including those on methadone maintenance 1
• Case-by-case review for active drug users, especially when in conjunction with drug treatment programs 1
• Abstinence from alcohol recommended before and during antiviral treatment 1

Patients with Renal Disease

• For hepatitis C: Dose adjustments may be required
  • For PEG-IFN alfa-2a: Reduce dose from 180 to 135 μg in renal failure 1
  • Ribavirin is contraindicated in patients with renal failure, though clinical trials are evaluating low-dose options 1

Patients with HCC

• For HBV-associated HCC: Start nucleoside analogues prior to treating HCC to prevent further liver injury and reduce recurrence risk 6
• For HCV-associated HCC: Treat HCC first, then address HCV with DAAs after HCC treatment 6

Monitoring During Treatment

• Monitor HBV/HCV coinfected patients for hepatitis flare or HBV reactivation during HCV treatment 3
• Test all patients for evidence of current or prior HBV infection before initiating HCV treatment 3
• For patients on amiodarone receiving ledipasvir/sofosbuvir: Monitor for symptomatic bradycardia 3

Prevention Strategies

• HBV vaccination is highly effective in preventing hepatitis B and subsequent HCC 1
• Universal vaccination of newborns has shown a decrease in HCC rates in endemic regions 1
• HCV-infected individuals should not donate blood, organs, tissues, or semen 2

The treatment landscape for viral hepatitis has dramatically improved with the development of highly effective antiviral therapies, significantly reducing morbidity and mortality when properly implemented according to current guidelines.