What is the treatment for acute viral hepatitis?

Treatment of Acute Viral Hepatitis

The treatment of acute viral hepatitis is primarily supportive care for most viral types (HAV, HBV, HCV, HEV), as the majority of cases are self-limited and resolve spontaneously without specific antiviral therapy. 1

General Supportive Management

The cornerstone of treatment across all types of acute viral hepatitis includes:

• Rest, hydration, and symptomatic relief as the primary therapeutic approach 2
• High-calorie diet to support nutritional needs during acute illness 3
• Strict avoidance of hepatotoxic medications (including acetaminophen) and alcohol 1, 3
• Hospitalization for intravenous rehydration if patients cannot maintain adequate oral intake due to nausea/vomiting, or if any mental status changes suggest evolving fulminant hepatic failure 3
• Close monitoring for acute liver failure, which is uncommon but represents a serious complication requiring immediate intervention 1

Virus-Specific Treatment Approaches

Acute Hepatitis A

• No specific antiviral therapy is effective or indicated for hepatitis A 1
• Management is entirely supportive, though 10-15% of patients may experience relapsing illness 2

Acute Hepatitis B

• Supportive care is the standard approach for uncomplicated acute hepatitis B, as 60-70% of cases are asymptomatic 2
• Nucleoside analogs (lamivudine or tenofovir) may be considered in select cases, though controlled trial data is limited 1
• For patients undergoing chemotherapy or immunosuppression with HBsAg positivity, prophylactic nucleoside analog therapy should be initiated and continued for 6 months after completion of immunosuppressive therapy to prevent reactivation 1

Acute Hepatitis C

Treatment should be delayed for 8-12 weeks after onset to allow for spontaneous clearance, which occurs in 20-50% of cases 2, 1

The rationale for delayed treatment:

• A randomized controlled trial demonstrated that delayed treatment (12 weeks) is not inferior to immediate treatment when accounting for spontaneous recovery rates 2
• Anti-HCV antibodies may not appear until 8-12 weeks post-infection, making early diagnosis challenging 2
• Testing for serum HCV RNA is essential when acute hepatitis C is suspected but anti-HCV is negative 2

If HCV persists after the observation period:

• Peginterferon alpha monotherapy for 24 weeks is the preferred treatment, achieving SVR rates of 80-90% 2, 1
• Peginterferon alpha-2a at 180 μg/week OR peginterferon alpha-2b at 1.5 μg/kg/week 1
• Adding ribavirin to peginterferon does not increase SVR rates compared to monotherapy in acute hepatitis C 2
• Monitor HCV RNA levels every 4 weeks and initiate treatment for those still positive at 12 weeks after initial presentation 1

Acute Hepatitis E

• No specific antiviral therapy is indicated for acute hepatitis E 1
• Pregnant women require close monitoring, particularly with genotype 1, as they face higher risk for severe outcomes and fulminant hepatic failure, especially in the second and third trimesters 1

Herpes Virus Hepatitis

• Acyclovir must be initiated promptly for suspected or documented herpes virus hepatitis 1
• Immediate liver transplant listing is required for patients with herpes virus or varicella zoster causing acute liver failure 1

Monitoring and Follow-Up

• Regular assessment of liver function tests to monitor disease progression 1
• For patients without spontaneous recovery, follow-up testing for chronic infection is essential 1
• Untreated patients with chronic hepatitis should be assessed every 1-2 years with non-invasive methods 1

When to Consider Liver Transplantation

Immediate transplant evaluation is indicated for:

• Signs of fulminant hepatic failure (encephalopathy, coagulopathy) 1
• Known or suspected herpes virus or varicella zoster as the cause of acute liver failure 1
• Acute liver failure secondary to mushroom poisoning 1

Special Populations

• Immunocompromised patients may have atypical presentations and higher risk for chronic infection, particularly with HBV and HEV 1
• Pregnant women with hepatitis E face substantially elevated risk and require intensive monitoring 1

Common Pitfalls to Avoid

• Do not rush to treat acute hepatitis C immediately—the 8-12 week observation period allows for spontaneous clearance and avoids unnecessary treatment 2
• Do not add ribavirin to peginterferon for acute hepatitis C—it provides no additional benefit and increases adverse effects 2
• Do not miss herpes virus hepatitis—this requires immediate acyclovir and transplant consideration, unlike other viral hepatitides 1
• Do not overlook pregnant women with hepatitis E—they require heightened surveillance due to increased mortality risk 1