Hepatitis

Medical Treatments for Managing Hepatitis

Treating Viral Hepatitis Infections

Viral hepatitis is defined as liver inflammation caused by viral infection. The most common causes of are five unrelated viruses which specifically target cells of the liver, called hepatocytes. These hepatotropic viruses don't vary by how they are passed from person to person, but rather in the ways they can be prevented or treated.

In some cases, a hepatitis infection can be short-lived—resolving on its own with few, if any, symptoms or consequences.

At other times, it can silently progress over the course of years or even decades, causing a gradual scarring of organ tissue (fibrosis) that can lead to liver damage (​cirrhosis) or liver cancer (​hepatocellular carcinoma).

But, it’s no surprise that the treatment of virus hepatitis is as diverse at the viruses themselves. From hepatitis A to hepatitis E, current treatment recommendations aim to reverse the spread and severity of disease, which today accounts for more than 1.5 million deaths each year.

Hepatitis A

Hepatitis A is caused by the hepatitis A virus (HAV) and is most commonly spread through food or water that has been contaminated with HAV-infected feces. It typically presents as an acute (self-limiting) infection, with symptoms appearing anywhere from two to six weeks following initial exposure. In many cases, it can be entirely asymptomatic, with few, if any, signs that an infection has taken place.

When acute symptoms do appear, they can manifest with jaundice (the yellowing of the skin and eyes), choluria (the darkening of urine), clay-colored stools, and feelings of extreme lethargy or malaise.

There are no specific treatment recommendations for a hepatitis A infection other than to minimize the person’s discomfort and to ensure proper hydration and nutritional support in the event of vomiting or diarrhea. Symptoms tend to fully resolve within two months, although they can last for up to six.​ A vaccine is available to prevent HAV infection, delivered by injection over three courses.

Hepatitis B

Hepatitis B is caused by the hepatitis B virus (HBV) and is commonly spread through infected blood or bodily fluid. Injection drug use and sexual intercourse are common routes of infection as is transmission from mother to child during pregnancy.

As with hepatitis A, hepatitis B can present with acute symptoms, typically within 30 to 80 days of exposure. Once these symptoms resolve, the virus can persist silently for years during the chronic (long-lasting) stage of infection. It is during this stage that persistent inflammation can cause damage to the liver.​ While the majority of people with hepatitis B will spontaneously clear the virus soon after infection, those with chronic infection can be treated to reduce the risk of cirrhosis and liver cancer.

Currently in the U.S., there are seven antiviral drugs approved for use in the treatment of chronic hepatitis B infection. While these medications cannot clear the virus, they can suppress viral replication, thereby reducing inflammation and risk of liver disease.​ The drugs most predominantly used, classified as nucleoside reverse transcriptase inhibitors (NRTIs) are:

  • Epivir (lamivudine)
  • Hespera (adefovir)
  • Viread (tenofovir)
  • Tyzeka (telbivudine)
  • Baraclude (entecavir)

Treatment is typically indicated if you have high viral activity (as measured by the HBV DNA test) and elevated liver enzymes (at least twice the normal level). People diagnosed with cirrhosis are given higher priority. Antiviral therapy may be less effective in those with severe or end-stage liver disease.

The drug Intron A (interferon alpha-2B) is also sometimes used, mainly in younger people or in those anticipating pregnancy. This synthetic form of interferon (a disease-fighting protein) is administered by injection over 24 to 48 weeks.

While the treatment course is shorter than other drug options, side effects can often be profound.​ There is also a vaccine that can prevent HBV infection, as well as a combination vaccine that can prevent both hepatitis A and hepatitis B.

Hepatitis C

Hepatitis C is caused by the hepatitis C virus (HCV) and is spread primarily through injection drug use. Sexual transmission and transmission from mother to child during pregnancy are less common routes. ​Acute symptoms, when present, can appear anywhere from two weeks to five months after initial exposure. While the majority of acutely infected individuals will spontaneously clear the virus with six months of infection, as many as 30 percent of those with chronic infection will progress to cirrhosis.

The treatment of chronic hepatitis infection has been considered something of a success story with newer generation direct acting antivirals (DAAs) able to achieve cure rates of greater than 95 percent in some populations.​ A "cure" is defined as being able to sustain undetectable levels of HCV in your blood (also known as a sustained viral response or SVR) for 24 weeks following the completion of therapy.

Clinical research has shown that 92 percent of people able to achieve this response will remain virus-free for a period of at least five years.

Therapy is dictated by the genetic type (genotype) of virus a person is infected with—classified as genotype 1, 2, 3, 4, 5 or 6—as well as the stage of liver disease. While treatment can be prescribed during acute infection, it is most typically indicated in chronically infected individuals, particularly those with cirrhosis.​ Current therapy options include:

  • Daklinza (daclatasvir): approved for genotype 3
  • Epclusa (sofosbuvir + velpatasvir): approved for genotypes 1, 2, 3, 4, 5 and 6
  • Harvoni (sofusbuvir + ledipasvir): approved for genotype 1
  • Sovaldi (sofusbuvir): approved for genotypes 1, 2, 3 and 4
  • Technivie (ombitasvir + paritaprevir + ritonavir): approved for genotype 4
  • Viekira Pak (ombitasvir + paritaprevir + ritonavir co-packaged with dasabuvir): approved for genotype 1
  • Olysio (simeprevir): approved for genotype 1
  • Zepatier (grazoprevir + elbasvir): approved for genotypes 1, 4 and 6

These DAAs are sometimes used in combination with the drugs peginterferon and/or ribavirin, most often in those who have either failed previous therapy or have been diagnosed with advanced cirrhosis.​ There is currently no vaccine to prevent hepatitis C infection.

Hepatitis D

Hepatitis D is caused by the hepatitis D virus (HDV) and can only occur when a person is co-infected with the hepatitis B virus  It is primarily spread through injection drug use and is seen predominantly in sub-Saharan Africa, the Middle East, and the northern section of South America.​ ​

Treatment options are limited. Acute infections are primarily treated with nutritional support and/or intravenous hydration when needed. Chronic HDV infection tends to be more difficult to treat. While there are currently no FDA-approved therapeutic options, the drug Intron A (interferon alpha-2B) has been shown to achieve sustained viral suppression in 20 to 25 percent of chronically infected individuals. Since HDV can only propagate in the presence of HBV, the hepatitis B vaccine is considered effective in preventing hepatitis D infection.

Hepatitis E

Hepatitis E is caused by the hepatitis E virus (HEV) and is spread primarily through contaminated water in regions with poor sanitation. While most acute infections resolve on their own with little or no medical intervention, people with compromised immune systems (including those with liver transplants or advanced HIV) are more likely to progress to a chronic infection.

As with hepatitis E, treatment options for hepatitis D are limited. There has, however, been some success in achieving viral clearance with the use of the drug ribavirin.​ There is no vaccine available to prevent hepatitis E.

Sources:

American Association for the Study of Liver Disease (AASLD). "Assessing the Global and Regional Burden of Liver Disease." Washington, D.C. Press release issued November 3, 2013.

Centers for Disease Control and Prevention (CDC). “Viral Hepatitis.” Atlanta, Georgia; accessed July 19, 2016.

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