What is the treatment for acute viral hepatitis?

Treatment of Acute Viral Hepatitis

For acute viral hepatitis, supportive care with rest, hydration, and symptomatic relief is the primary treatment approach, with antiviral therapy reserved only for acute hepatitis C (where immediate treatment is now recommended) and severe/fulminant acute hepatitis B. 1, 2

General Supportive Management (All Types)

The cornerstone of treatment for acute viral hepatitis is supportive care, as most cases are self-limited:

• Provide rest, adequate hydration, and symptomatic relief as needed 1, 2, 3
• Strictly avoid all hepatotoxic medications, particularly acetaminophen, and alcohol 4, 1
• Discontinue all non-essential medications to minimize risk of drug-induced hepatotoxicity 2
• Ensure high-calorie diet to support recovery 3
• Monitor hepatic panels (ALT, AST, bilirubin, INR) every 2-4 weeks until resolution 4
• Hospitalize patients who cannot maintain oral intake due to nausea/vomiting or who show any mental status changes suggesting evolving acute liver failure 2, 3

Virus-Specific Treatment Approaches

Acute Hepatitis A

• No antiviral therapy is indicated - management is entirely supportive 1, 2
• Recovery is typically complete and spontaneous 1

Acute Hepatitis B

For uncomplicated acute hepatitis B, supportive care alone is recommended, as >95% of adults recover spontaneously 4, 1

However, antiviral therapy should be considered in specific circumstances:

• Initiate oral nucleoside analogs (entecavir or tenofovir preferred) for patients with persistent severe hepatitis or acute liver failure 4, 1
• The rationale: While early antiviral therapy may theoretically interfere with protective immune responses, severe acute hepatitis B can progress to fulminant hepatic failure 4, 5
• Do not routinely treat uncomplicated acute hepatitis B, as this may suppress neutralizing antibody production and increase chronicity risk 4

Acute Hepatitis C

This represents a major paradigm shift: immediate treatment upon diagnosis is now recommended without waiting for spontaneous clearance 4

• Initiate direct-acting antiviral (DAA) therapy immediately upon diagnosis of acute HCV with detectable RNA 4
• This "test and treat" strategy is newly recommended based on real-world data showing reduced HCV incidence/prevalence with unrestricted treatment access 4
• The previous approach of waiting 8-12 weeks for spontaneous clearance (which occurs in 20-50% of cases) is no longer recommended, as delays increase loss to follow-up and ongoing transmission risk 4, 1
• Refer patients with injection drug use-related acute HCV to addiction medicine specialists 4
• Counsel patients to avoid sharing injection equipment and consider barrier precautions during sex (even in monogamous relationships during acute phase due to higher transmission risk) 4

Herpes Simplex Virus Hepatitis

• Initiate acyclovir immediately when herpes virus hepatitis is suspected 2
• This is particularly important in pregnant women (especially third trimester) who have increased risk of acute liver failure from herpes virus 2

Management of Severe Complications

Acute Liver Failure

When coagulopathy and any degree of mental alteration develop:

• Transfer immediately to ICU and contact liver transplant center early 2
• Administer N-acetylcysteine regardless of suspected etiology 2
• Avoid benzodiazepines for sedation and nephrotoxic agents 2
• Do not routinely correct coagulation abnormalities unless active bleeding is present 2
• For acute fatty liver of pregnancy or HELLP syndrome, expedite delivery 2
• Liver transplantation may be life-saving in fulminant cases 3, 6

Autoimmune Hepatitis (if suspected)

• Consider liver biopsy to establish diagnosis 2
• Treat with prednisone 40-60 mg/day - do not delay corticosteroid treatment if autoimmune hepatitis is suspected 2

Critical Monitoring Parameters

• Assess for signs of acute liver failure: coagulopathy (prolonged INR), mental status changes, rising bilirubin 4, 2
• Monitor liver function tests regularly to track disease progression 1
• Perform follow-up testing for chronic infection in patients without spontaneous recovery 1

Common Pitfalls to Avoid

• Do not delay transfer to transplant center for patients developing acute liver failure 2
• Do not use acetaminophen or alcohol during acute hepatitis 4, 1
• Do not routinely treat uncomplicated acute hepatitis B with antivirals, as this may impair natural immunity 4
• Do not wait for spontaneous clearance in acute hepatitis C - treat immediately 4
• Do not fail to identify herpes simplex hepatitis, which requires immediate acyclovir 2