What is the treatment for a patient with Hepatitis E (HEV) and elevated liver enzymes?

Management of Hepatitis E with Elevated Liver Enzymes

For patients with Hepatitis E infection and elevated liver enzymes, supportive care is the mainstay of treatment as most cases are self-limiting, but ribavirin may be considered for severe cases or in immunocompromised patients. 1, 2

Diagnosis and Assessment

• All patients with symptoms consistent with acute hepatitis should be tested for hepatitis E, as it is a major cause of acute viral hepatitis in many countries 1
• Monitoring of liver enzymes (ALT, AST), bilirubin, and liver function parameters (albumin, INR) is essential during acute hepatitis E infection 1, 3
• Assess for signs of severe disease including jaundice, fatigue, pruritus, and right upper quadrant pain 4
• Determine whether the patient is immunocompetent or immunocompromised, as this affects treatment approach and prognosis 1

Treatment Approach for Immunocompetent Patients

Mild to Moderate Disease

• Most acute HEV infections in immunocompetent patients are self-limiting and require only supportive care 2, 5
• Monitor liver enzymes every 2-4 weeks until stabilization or normalization occurs 4
• No specific antiviral therapy is typically needed for uncomplicated cases 1, 6

Severe Disease

• For patients with severe acute hepatitis E or acute-on-chronic liver failure, ribavirin treatment may be considered 1, 2
• Ribavirin therapy has been associated with rapid normalization of liver enzymes and clearance of HEV RNA in severe cases 1
• The dose and duration of ribavirin therapy in acute liver failure are not well defined, but case reports show benefit 1

Treatment Approach for Special Populations

Immunocompromised Patients

• Reduce immunosuppressive therapy if possible, especially drugs targeting T-cells, which can achieve viral clearance in nearly one-third of chronically infected solid organ transplant recipients 1
• If immunosuppression cannot be reduced or viral clearance is not achieved, consider a 3-month course of ribavirin monotherapy 1, 7
• Monitor HEV RNA in serum and stool to assess treatment response 1

Patients with Pre-existing Liver Disease

• Acute hepatitis E can cause acute-on-chronic liver failure in patients with underlying liver disease 1
• These patients require close monitoring as they may have a more severe course, particularly elderly patients 1
• Supportive treatment is the foundation, with consideration of ribavirin to prevent progression to liver transplantation 6

Supportive Care Measures

• Ensure adequate hydration and nutrition 6
• For cholestasis, which is common in hepatitis E, consider:
  • Symptomatic treatment for pruritus 6
  • Ursodeoxycholic acid for removing jaundice 6
  • S-adenosylmethionine may be beneficial 6
• For patients with decompensation or liver failure:
  • Albumin and plasma support may be required 6
  • Prevention and treatment of complications are important 6
  • Consider referral to a liver transplant center for patients with severe acute liver failure not responding to supportive measures 6

Monitoring and Follow-up

• For mild elevations of liver enzymes without symptoms, periodic monitoring is recommended 3
• For moderate-severe elevations or symptomatic patients, more frequent monitoring (every 3-7 days) is advised 3
• Patients should be monitored until complete resolution of liver enzyme abnormalities 4

Pitfalls and Caveats

• Ribavirin is contraindicated in pregnancy due to teratogenicity, though the risks of untreated severe HEV to mother and fetus are high and treatment may still be considered in severe cases 7
• Corticosteroids have been used in individual cases of acute liver failure due to HEV, but there is insufficient evidence to support their routine use 1
• Do not confuse drug-induced liver injury with viral hepatitis; a thorough medication review is essential 4
• Remember that HEV infection can have extrahepatic manifestations including neurological and renal disease 5