What is the treatment approach for a patient with acute hepatitis?

Treatment of Acute Hepatitis

For most cases of acute viral hepatitis (A, B, E), provide supportive care only, as these infections typically resolve spontaneously and antiviral therapy has not proven effective. 1, 2

Initial Assessment and Risk Stratification

Immediately assess for acute liver failure by checking prothrombin time/INR and mental status. If INR ≥1.5 with any mental status change, this constitutes acute liver failure requiring immediate ICU transfer and transplant center contact. 1, 2

Obtain comprehensive laboratory testing including: 2

• Liver enzymes (AST, ALT, alkaline phosphatase, bilirubin)
• Prothrombin time/INR
• Complete blood count
• Comprehensive metabolic panel
• Viral hepatitis serologies (HAV IgM, HBsAg, anti-HBc IgM, HCV antibody with reflex RNA)
• Acetaminophen level and toxicology screen

Obtain detailed medication history for the past year, including all prescription drugs, over-the-counter medications, herbal supplements, and dietary products, as drug-induced hepatotoxicity is a common cause. 1, 2

Etiology-Specific Management

Acute Hepatitis A and E

Provide supportive care only—no antiviral therapy is indicated or effective. 1, 2 These infections resolve spontaneously in >95% of immunocompetent patients. 1

Acute Hepatitis B

For uncomplicated acute hepatitis B, do NOT initiate antiviral therapy, as treatment may interfere with the normal protective immune response and suppress neutralizing antibody production. 1, 2 Over 95% of adults clear acute HBV spontaneously. 1

However, initiate oral nucleoside analogs (entecavir or tenofovir preferred) immediately if: 1, 2

• Persistent severe hepatitis with significantly elevated bilirubin or prolonged INR
• Any signs of acute liver failure (INR ≥1.5 with mental status changes)

Acute Hepatitis C

Initiate direct-acting antiviral (DAA) therapy immediately upon diagnosis with detectable HCV RNA—do not wait for spontaneous clearance. 2 This represents a major shift from older guidelines that recommended waiting 12-16 weeks. 1

Use the same DAA regimens recommended for chronic HCV infection. 2 The immediate treatment approach reduces transmission risk and prevents loss to follow-up. 2

For HIV-coinfected patients specifically, pegylated interferon-α combined with weight-based ribavirin for 24 weeks remains an option if DAAs are unavailable. 1

Herpes Simplex Virus Hepatitis

Initiate acyclovir immediately for suspected or documented HSV hepatitis. 1, 2 This occurs primarily in immunosuppressed patients or pregnant women (especially third trimester), though cases in healthy individuals are reported. 1 Skin lesions are present in only 50% of cases, so maintain high clinical suspicion. 1

Immediately list these patients for liver transplantation, as HSV hepatitis carries high mortality without transplant. 1

Drug-Induced Hepatotoxicity

Discontinue all non-essential medications immediately. 1, 2 Determine the exact ingredients of all non-prescription medications and supplements. 1, 2

Note that medications used continuously for >1-2 years rarely cause de novo liver injury, as most idiosyncratic drug reactions occur within the first 6 months. 1

Autoimmune Hepatitis

Consider liver biopsy for diagnosis when autoimmune markers are present. 2 Initiate corticosteroids (prednisone 40-60 mg/day) promptly—do not delay treatment while awaiting biopsy results if clinical suspicion is high. 2

General Supportive Care (All Etiologies)

Mandate complete abstinence from alcohol and avoidance of all hepatotoxic medications, particularly acetaminophen. 2, 3 Even therapeutic doses of acetaminophen should be avoided during acute hepatitis. 2

Provide high-calorie diet as tolerated. 3 Bed rest is only necessary if the patient is highly symptomatic—rigorous bed rest is not required and does not improve outcomes. 4

Monitor hepatic panels (ALT, AST, bilirubin, INR) every 2-4 weeks until resolution. 2 Watch specifically for signs of progression to acute liver failure: rising bilirubin, prolonging INR, and mental status changes. 2

Management of Acute Liver Failure

If acute liver failure develops (INR ≥1.5 with any mental status alteration): 1, 2

Immediate actions:

• Transfer to ICU immediately 1, 2
• Contact liver transplant center early 1, 2
• Administer N-acetylcysteine regardless of etiology 2

Critical pitfalls to avoid in acute liver failure: 2

• Do not use benzodiazepines for sedation (worsens hepatic encephalopathy)
• Do not administer nephrotoxic agents
• Do not routinely correct coagulation abnormalities without active bleeding

Transmission Prevention and Counseling

For acute hepatitis C patients: 2

• Counsel to avoid sharing injection equipment
• Recommend barrier precautions during sex, even in monogamous relationships during the acute phase (transmission risk is higher with acute infection)
• Refer patients with injection drug use history to addiction medicine specialists

For acute hepatitis B patients, counsel regarding transmission through blood and sexual contact. 2

Special Considerations

Hepatitis B Reactivation

For patients with known HBsAg positivity who require chemotherapy or immunosuppression, initiate prophylactic nucleoside analog therapy before starting immunosuppressive treatment and continue for 6 months after completion. 1 This prevents potentially fatal reactivation. 1

Pregnancy

For acute fatty liver of pregnancy or HELLP syndrome presenting as acute hepatitis, consult obstetrical services and expedite delivery. 2 Pregnant women are at increased risk for severe hepatitis E and HSV hepatitis. 1

Common Critical Pitfalls

• Do not delay ICU transfer for patients with coagulopathy and mental status changes 2
• Do not wait for spontaneous clearance in acute hepatitis C—treat immediately 2
• Do not routinely treat uncomplicated acute hepatitis B with antivirals, as this impairs natural immunity 2
• Do not use acetaminophen or alcohol during any acute hepatitis 2
• Do not delay transplant center contact for any patient with acute liver failure 2