What are the treatment options for managing hepatitis?

Treatment Options for Managing Hepatitis

The treatment of hepatitis should be based on the specific viral type, with nucleos(t)ide analogues (NAs) with high genetic barrier to resistance, such as entecavir, tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide fumarate (TAF) being the first-line treatment for chronic hepatitis B, while direct-acting antivirals (DAAs) are the standard of care for hepatitis C. 1, 2

Hepatitis B Management

Classification and Diagnosis

• Chronic HBV infection can be classified into five phases: (I) HBeAg-positive chronic infection, (II) HBeAg-positive chronic hepatitis, (III) HBeAg-negative chronic infection, (IV) HBeAg-negative chronic hepatitis, and (V) HBsAg-negative phase 1
• Diagnosis requires evaluation of serum HBV DNA, ALT, HBeAg, and anti-HBe levels with regular monitoring 2
• Monitoring frequency should be every 3-6 months for liver function tests and HBV DNA in compensated patients, and more frequently in patients with uncertain treatment indications (every 1-3 months) 1

Treatment Indications

• Treatment is indicated for patients with HBV DNA ≥2,000 IU/mL, elevated ALT and/or at least moderate histological lesions 2
• All patients with cirrhosis and detectable HBV DNA should receive treatment, regardless of ALT levels 1, 2
• Patients with severe acute hepatitis B (coagulopathy, protracted course, or signs of acute liver failure) should receive antiviral treatment 3

First-Line Treatment Options

• Nucleos(t)ide analogues (NAs) with high genetic barrier to resistance are the treatment of choice: 2
  • Entecavir (0.5 mg daily for treatment-naïve, 1 mg daily for lamivudine-resistant patients)
  • Tenofovir disoproxil fumarate (TDF) (300 mg daily)
  • Tenofovir alafenamide fumarate (TAF) (25 mg daily)
• Peginterferon alfa can be considered for a finite duration in selected patients with mild to moderate chronic hepatitis B, offering immune-mediated control and possibility of sustained off-treatment response 1

Treatment Duration and Monitoring

• Long-term, potentially indefinite treatment is typically required with NAs, with HBsAg loss considered the optimal endpoint 2
• Regular monitoring of HBV DNA levels, liver function tests, and serological markers is essential to assess treatment response 1, 2
• For patients not indicated for treatment, ALT and HBV DNA should be monitored every 3-6 months, and HBeAg/anti-HBe every 6-12 months 1

Hepatitis C Management

Diagnosis and Assessment

• Diagnosis requires confirmation with nucleic acid testing (NAT) and assessment of liver fibrosis using non-invasive methods 4
• Initial assessment should include evaluation of genotype, viral load, and liver disease severity 1

Treatment Options

• Direct-acting antivirals (DAAs) are the standard of care for hepatitis C treatment 1
• Recommended regimens based on genotype include: 1
  • Genotype 1,4,5,6: Ledipasvir/sofosbuvir (12 weeks) 5
  • Genotype 2,3: Sofosbuvir/velpatasvir (12 weeks) or Daclatasvir+sofosbuvir (12 weeks) 1
  • For decompensated cirrhosis: Ledipasvir/sofosbuvir+ribavirin or Sofosbuvir/velpatasvir+ribavirin (12-24 weeks) 1
• Ribavirin should be given at a weight-based dose of 15 mg/kg per day for genotypes 1 and 4-6 and at a flat dose of 800 mg/day for genotypes 2 and 3 1

Special Populations

• For patients with renal impairment, treatment should be individualized based on GFR, with Glecaprevir/Pibrentasvir (8 weeks) or Grazoprevir/Elbasvir (12 weeks) recommended for those with CKD 4
• For decompensated cirrhosis, sofosbuvir-based regimens with ribavirin are recommended 1

Important Clinical Considerations

Hepatitis B

• Test all patients for evidence of current or prior HBV infection before initiating treatment 5
• Monitor HCV/HBV coinfected patients for hepatitis flare or HBV reactivation during HCV treatment 5
• Avoid discontinuing treatment abruptly as severe acute exacerbations of hepatitis may occur 6
• Recognize that some patients may remain in a "grey area" where treatment indication is uncertain; more frequent monitoring or liver biopsy may be needed in these cases 1

Hepatitis C

• Treatment monitoring should include repeated measurements of HCV RNA levels using a sensitive, accurate assay 1
• Patients should be seen at a minimum of weeks 4 and 12 after initiation of treatment, then every 12 weeks until the end of treatment 1
• Assess for sustained virologic response (SVR) 24 weeks after the end of therapy 1

By following these evidence-based treatment approaches, most patients with viral hepatitis can achieve viral suppression (hepatitis B) or cure (hepatitis C), significantly reducing the risk of disease progression, cirrhosis, and hepatocellular carcinoma.