What is the management of acute viral hepatitis?

Management of Acute Viral Hepatitis

The management of acute viral hepatitis is primarily supportive care for most cases, as the majority are self-limited and resolve without specific antiviral therapy, with the critical exception of herpes virus hepatitis which requires immediate acyclovir. 1

General Management Approach

• Supportive care is the cornerstone of treatment for hepatitis A, B, C, and E in most patients, as these infections typically resolve spontaneously 1
• Provide bedrest if the patient is highly symptomatic, ensure high-calorie diet, avoid hepatotoxic medications, and mandate complete alcohol abstinence 2
• Hospitalize patients who cannot maintain oral intake due to nausea/vomiting for intravenous rehydration 2
• Monitor closely for signs of acute liver failure (encephalopathy, coagulopathy), which is uncommon but life-threatening 1
• Assess liver function tests regularly to track disease progression 1

Virus-Specific Management

Hepatitis A

• No specific antiviral therapy is effective or indicated 1
• Management is entirely supportive 1

Hepatitis B

• Uncomplicated acute hepatitis B requires only supportive care 1
• Nucleoside analogs (lamivudine or tenofovir) may be considered, though controlled trial data is limited 1, 2
• For patients undergoing chemotherapy or immunosuppression with HBsAg positivity: initiate prophylactic nucleoside analog therapy and continue for 6 months after completing immunosuppressive therapy to prevent reactivation 1
• Test all patients for current or prior HBV infection (HBsAg and anti-HBc) before initiating any HCV treatment, as HBV reactivation during HCV therapy can cause fulminant hepatitis and death 3

Hepatitis C

• For acute hepatitis C, pegylated interferon-α monotherapy (pegylated IFN-α2a 180 μg/week or pegylated IFN-α2b 1.5 μg/kg/week for 24 weeks) achieves sustained virologic response rates exceeding 90% 1
• Monitor HCV RNA levels every 4 weeks and initiate treatment for patients who remain positive at 12 weeks after initial presentation 1
• For chronic HCV (not acute), direct-acting antivirals like glecaprevir/pibrentasvir are indicated 3

Hepatitis E

• Pregnant women require intensive monitoring, particularly those infected with genotype 1, as they face significantly higher risk for fulminant hepatic failure, especially in the second and third trimesters 1, 4
• Acute infection in immunocompetent patients is managed supportively 5, 4
• Chronic HEV infection in immunosuppressed patients (particularly solid organ transplant recipients) should be treated with ribavirin as first-line therapy 5

Herpes Virus Hepatitis (HSV/VZV)

• Initiate acyclovir immediately for suspected or documented herpes virus hepatitis—this is a medical emergency 1
• Immediately place patients on the liver transplant list if herpes virus or varicella zoster is causing acute liver failure 1

Critical Monitoring and Follow-Up

• For patients who do not recover spontaneously, perform follow-up testing for chronic infection 1
• Untreated patients who develop chronic hepatitis require assessment every 1-2 years with non-invasive methods 1

Special Populations

Immunocompromised Patients

• Expect atypical presentations and higher risk for chronic infection, particularly with HBV and HEV 1
• May require antiviral therapy rather than supportive care alone 1

Pregnant Women

• Hepatitis E poses the greatest concern with higher rates of fulminant hepatic failure 1
• Requires close monitoring throughout pregnancy, especially in second and third trimesters 1

Indications for Liver Transplantation

Immediately consider liver transplantation for:

• Any patient with signs of fulminant hepatic failure (encephalopathy, coagulopathy) 1
• Known or suspected herpes virus or varicella zoster causing acute liver failure—these patients should be immediately listed 1
• Acute liver failure secondary to mushroom poisoning 1

Common Pitfalls to Avoid

• Do not delay acyclovir if herpes virus hepatitis is suspected—waiting for confirmation can be fatal 1
• Do not forget to test for HBV before initiating any HCV treatment, as reactivation can be lethal 3
• Do not underestimate hepatitis E in pregnant women—this requires aggressive monitoring and early transplant evaluation if deterioration occurs 1
• Do not use antiviral therapy routinely for uncomplicated acute hepatitis B—supportive care is sufficient in most cases 1