What is the best treatment for hepatitis?

Best Treatment of Hepatitis

The best treatment for hepatitis depends on the specific viral type, with direct-acting antivirals (DAAs) being the standard of care for hepatitis C, nucleos(t)ide analogues for hepatitis B, and pegylated interferon-based regimens for hepatitis D. Treatment decisions should be guided by viral genotype, disease severity, prior treatment history, and presence of comorbidities.

Hepatitis C Treatment

First-line Treatment

• For all HCV genotypes: IFN-free regimens are now the standard of care 1
• Treatment options by genotype:
  • Genotype 1: Sofosbuvir plus ledipasvir, sofosbuvir plus velpatasvir, or other DAA combinations 1
  • Genotypes 2-3: Sofosbuvir plus velpatasvir or sofosbuvir plus daclatasvir 1
  • Genotypes 4-6: Sofosbuvir plus ledipasvir or sofosbuvir plus velpatasvir 1

Treatment Duration

• Standard duration: 12 weeks for most patients
• Can be shortened to 8 weeks in treatment-naïve non-cirrhotic genotype 1 patients with low viral load 1
• Extended to 24 weeks in certain difficult-to-treat populations (cirrhosis, prior treatment failure)

Patient Prioritization

• Highest priority: Patients with significant fibrosis or cirrhosis (METAVIR F3-F4) 1
• High priority: Patients with HIV/HBV coinfection, pre/post-liver transplant, significant extrahepatic manifestations, or debilitating fatigue 1
• Also prioritized: Individuals at risk of transmitting HCV (active injection drug users, men who have sex with men with high-risk practices, women planning pregnancy) 1

Hepatitis B Treatment

Treatment Indications

• Patients with HBV DNA >2000 IU/mL, elevated ALT and/or moderate histological lesions 2
• All patients with cirrhosis and detectable HBV DNA 2
• Patients with HBV DNA >20,000 IU/mL and ALT >2x upper limit of normal 2
• HBeAg-positive patients >30 years old with HBV DNA >20,000 IU/mL 2

First-line Treatment Options

• Nucleos(t)ide analogues (NAs): Long-term therapy with entecavir or tenofovir 3
  • Preferred for patients with decompensated cirrhosis 3
  • Tenofovir requires monitoring for renal impairment and bone mineral density loss 4
• Pegylated interferon-α: Alternative for selected patients, finite treatment course 1

Special Populations

• Decompensated cirrhosis: Initiate NAs as early as possible 3
• HBV reactivation/acute-on-chronic liver failure: Start NAs immediately 3
• Pregnant women with high viremia: Treatment in last trimester to prevent vertical transmission 2
• Immunosuppressed patients: Prophylactic treatment to prevent HBV reactivation 2

Hepatitis D Treatment

• Most challenging form of viral hepatitis to treat 5
• Pegylated interferon-α remains the backbone of therapy, though response rates are suboptimal 5, 6
• Novel therapies are emerging but still show less favorable outcomes compared to treatments for HBV and HCV 5

Acute Hepatitis C Treatment

• For acute HCV infection: Treat with sofosbuvir plus ledipasvir, sofosbuvir plus velpatasvir, or sofosbuvir plus daclatasvir for 8 weeks without ribavirin 1
• Consider 12 weeks of therapy for HIV-coinfected patients or those with high baseline HCV RNA levels 1

Monitoring During and After Treatment

• Regular assessment of viral load, liver function tests, and side effects
• For HCV: Check HCV RNA at weeks 4,12,24, end of treatment, and 12-24 weeks post-treatment 1
• For HBV: Ongoing monitoring of HBV DNA levels, liver function, and surveillance for hepatocellular carcinoma 3

Important Considerations

• Drug-drug interactions must be carefully evaluated, especially in HIV-coinfected patients 1
• Patient education on adherence is critical for treatment success 1
• HCC surveillance every 6 months must continue indefinitely in patients with advanced fibrosis (F3) and cirrhosis 1
• Avoid unregulated herbal supplements due to potential hepatotoxicity 3

The landscape of hepatitis treatment has evolved dramatically, with highly effective therapies now available for most forms of viral hepatitis, particularly HCV where cure rates exceed 95% with current DAA regimens.