What is the typical order set for an admitted patient with viral hepatitis?

Standard Order Set for Admitted Patients with Viral Hepatitis

The standard order set for an admitted patient with viral hepatitis should include comprehensive laboratory monitoring, appropriate antiviral therapy based on viral genotype, and supportive care measures to manage symptoms and prevent complications. 1

Initial Laboratory Assessment

• Complete blood count, international normalized ratio (INR) 1
• Hepatic function panel (albumin, total and direct bilirubin, ALT, AST, alkaline phosphatase) 1
• HCV genotype and subtype (for hepatitis C) 1
• Quantitative viral load measurement 1
• Calculated glomerular filtration rate (GFR) to assess renal function 1
• Thyroid-stimulating hormone if interferon therapy is being considered 1
• Assessment of potential drug-drug interactions with concomitant medications 1

Antiviral Therapy Orders

For Hepatitis C

• For genotype 1-6 (pangenotypic approach), preferred regimens include: 1

  • Sofosbuvir (400 mg) and velpatasvir (100 mg) once daily, or
  • Glecaprevir (300 mg) and pibrentasvir (120 mg) once daily with food, or
  • Sofosbuvir (400 mg), velpatasvir (100 mg), and voxilaprevir (100 mg) once daily with food

• For specific genotypes when pangenotypic options are not available: 1

  • Genotype 1b: Grazoprevir (100 mg) and elbasvir (50 mg) once daily
  • Genotype 3: Daclatasvir (60 mg) and sofosbuvir (400 mg) daily for 12 weeks (24 weeks for cirrhotic patients)
  • Genotype 4: Ledipasvir/sofosbuvir or ombitasvir/paritaprevir/ritonavir with ribavirin

For Hepatitis B

• For chronic hepatitis B, preferred first-line agents: 1
  • Entecavir 0.5 mg daily (1 mg for lamivudine-resistant patients)
  • Tenofovir 245 mg daily
  • For patients with decompensated cirrhosis, combination therapy may be considered 2

For Acute Hepatitis C

• Sofosbuvir and ledipasvir (genotypes 1,4,5,6) or sofosbuvir and velpatasvir (all genotypes) for 8 weeks 1
• Extended 12-week regimen for HIV co-infected patients or those with baseline HCV RNA >1 million IU/ml 1

Monitoring Orders

• Liver function tests and viral load assessment at baseline, during treatment, and after treatment completion 1
• For patients on treatment, monitoring schedule: 1, 3
  • Complete blood count, liver function tests, and INR every 2-4 weeks initially
  • More frequent monitoring for patients with advanced liver disease or on specific medications with higher risk of hepatotoxicity

Supportive Care Orders

• Intravenous hydration if patient has poor oral intake 4
• Antiemetics as needed for nausea/vomiting 4
• Pain management with acetaminophen (limited dose to avoid hepatotoxicity) 4
• Nutritional consultation for patients with advanced liver disease 4

Follow-up Orders for Treatment Non-responders

• Disease progression assessment every 6-12 months with hepatic function panel, CBC, and INR 1
• Surveillance for hepatocellular carcinoma with ultrasound every 6 months for patients with advanced fibrosis 1
• Endoscopic surveillance for esophageal varices if cirrhosis is present 1
• Evaluation for retreatment as new effective alternatives become available 1

Special Considerations

• For patients with decompensated cirrhosis, avoid interferon-based regimens 1
• For patients with HIV co-infection, carefully assess for drug-drug interactions between antiretrovirals and hepatitis medications 1
• For patients on opioid substitution therapy (e.g., buprenorphine/naloxone), no dose adjustments are typically needed with modern DAA regimens 5

Common Pitfalls to Avoid

• Failing to screen for hepatitis B before starting treatment for hepatitis C, which can lead to HBV reactivation 3
• Not accounting for drug-drug interactions, particularly with HIV medications or immunosuppressants 1
• Inadequate monitoring of patients with advanced liver disease who may require more intensive surveillance 1
• Using interferon-based regimens in patients with decompensated cirrhosis, which is contraindicated 1

This order set should be tailored based on the specific viral hepatitis type, genotype, presence of cirrhosis, prior treatment history, and comorbidities, with the goal of achieving viral suppression or cure while minimizing complications 6, 7.