Treatment of Hepatitis
The treatment of hepatitis depends on the specific viral type, with direct-acting antivirals being the mainstay of therapy for hepatitis C, nucleos(t)ide analogues or peginterferon for hepatitis B, and bulevirtide for hepatitis D. The approach varies significantly based on the viral etiology, disease stage, and patient characteristics.
Hepatitis C Treatment
Acute Hepatitis C
- For acute hepatitis C, treatment should be initiated with a combination of sofosbuvir and an NS5A inhibitor for 8 weeks without ribavirin 1
- Options include:
- Sofosbuvir/ledipasvir (genotypes 1,4,5, and 6)
- Sofosbuvir/velpatasvir (all genotypes)
- Sofosbuvir/daclatasvir (all genotypes)
- For patients with HIV coinfection or high baseline HCV RNA (>1 million IU/mL), treatment duration may need to be extended to 12 weeks 1
- SVR should be assessed at both 12 and 24 weeks post-treatment due to possibility of late relapses 1
Chronic Hepatitis C
- All patients with chronic HCV infection without contraindications should be considered for treatment 1
- Priority should be given to patients with:
- Advanced fibrosis (≥F3) including compensated and decompensated cirrhosis
- Pre- or post-liver transplant setting
- Severe extrahepatic manifestations (cryoglobulinemia, glomerulonephritis)
- Treatment regimens are genotype-specific:
- Genotype 1: Sofosbuvir/ledipasvir or sofosbuvir/velpatasvir for 12 weeks 2
- Genotype 2: Sofosbuvir/velpatasvir for 12 weeks 2
- Genotype 3: Sofosbuvir/velpatasvir for 12 weeks (consider adding ribavirin for patients with NS5A RAS Y93H) 2
- Genotypes 4-6: Sofosbuvir/ledipasvir or sofosbuvir/velpatasvir for 12 weeks 2
Hepatitis B Treatment
Chronic Hepatitis B
Treatment is indicated for patients with:
First-line treatment options:
- Entecavir
- Tenofovir (disoproxil fumarate or alafenamide)
- Peginterferon-α
Tenofovir has demonstrated excellent long-term efficacy:
Treatment goals:
- Suppress HBV DNA to undetectable levels
- Normalize ALT
- Improve liver histology
- Prevent progression to cirrhosis and HCC
- HBeAg seroconversion (in HBeAg-positive patients)
- HBsAg loss (ideal but rare outcome)
Special Populations
Decompensated Cirrhosis
- For HBV: Entecavir or tenofovir is recommended with close monitoring 4
- For HCV: Direct-acting antivirals without interferon are preferred 1
- Caution: Paritaprevir, dasabuvir, and asunaprevir are contraindicated in decompensated cirrhosis 1
Renal Impairment
- For HBV: Dose adjustment may be needed for nucleos(t)ide analogues 1
- For HCV: Sofosbuvir is contraindicated in severe renal impairment (GFR <30 mL/min) 1
HIV Coinfection
- For HBV: Tenofovir-based regimens are preferred due to dual activity 1
- For HCV: Same regimens as monoinfected patients, with attention to drug interactions 2
Monitoring and Follow-up
- For hepatitis C: SVR should be assessed at 12 and 24 weeks post-treatment 1
- For hepatitis B on nucleos(t)ide analogues: Regular monitoring of HBV DNA, ALT, and renal function
- For patients with advanced fibrosis (F3) or cirrhosis: HCC surveillance every 6 months must be continued indefinitely, even after successful treatment 1
Common Pitfalls to Avoid
- Discontinuing HBV treatment prematurely, which can lead to severe flares
- Failing to screen for HBV before starting HCV treatment (risk of HBV reactivation)
- Not monitoring for drug resistance in patients on long-term nucleos(t)ide therapy
- Overlooking the need for continued HCC surveillance in patients with advanced fibrosis, even after viral clearance
- Inadequate monitoring of renal function in patients on tenofovir
The landscape of hepatitis treatment continues to evolve rapidly, particularly for hepatitis C, with newer regimens showing improved efficacy and safety profiles.