Hepatitis E medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Immunocompetent patients usually do not require any medical therapy. However, patients with pre-existing liver disease, particularly transplanted patients on immunosuppressive therapy, often develop chronic infection and require antiviral therapy. Antiviral therapy may include either Ribavirin monotherapy (first-line), Pegylated interferon-α monotherapy, or a combination of both.

Medical Therapy

As no specific therapy is capable of altering the course of acute hepatitis E infection, prevention is the most effective approach against the disease. Hospitalization is required for fulminant hepatitis and should be considered for infected pregnant women.[1][2][3]

Acute Hepatitis E

The majority of hepatitis E cases in immunocompetent patients are self-limited. Some patients may require symptomatic treatment, however, HEV infection resolves spontaneously in most cases.[4]

Patients with pre-existing liver conditions, may require treatment with ribavirin. A patient who received treatment with ribavirin showed a normalization of bilirubin levels and a decrease in transaminases.[5][6]

Pregnant women with hepatitis E should be treated, however, a specific treatment regimen has not been established. Ribavirin might be indicated for the treatment of these patients. Despite the teratogenic contra-indications of ribavirin, the risks of HEV infection for the mother and fetus may outweigh the teratogenicity risks of the drug.[7]

Chronic Hepatitis E

Chronic HEV infection often occurs in transplanted patients. In this group of patients, viral clearance is the ideal therapeutic target. Three treatment options are available:

Due to the lack of evidence regarding the treatment of chronic hepatitis E, this should be individualized for each patient, according to:

Assessment of a potential reduction of the immunosuppressive therapy, particularly of the T-cell suppression, is the initial approach to treat these patients. 30 % of cases in whom this approach is possible, are cleared from HEV.[8][9]

Patients for whom a reduction of immunosuppression is not possible, and for those who fail to respond to this reduction, antiviral therapy should be considered.[7] This may include pegylated interferon-α monotherapy; ribavirin monotherapy; or a combination of both.[8][10][11][12]

Antiviral Therapy
Drug Characteristics
Ribavirin Monotherapy
  • First treatment option for patients with chronic hepatitis E
  • HEV is often cleared after a few weeks of ribavirin monotherapy
  • Usually prescribed: 600 - 1000 mg/day, during 3 months, however, it must be adjusted to the patient's renal function in order to avoid hemolytic anemia induced by the drug[7]
Pegylated Interferon-α Monotherapy
  • Must be used with caution since it increases the risk of rejection in kidney transplanted patients
  • The duration of treatment may range from 3 to 12 months
  • Due to its severe side-effects and potential organ rejection, it is not indicated in heart or kidney-tranplanted patients

References

  1. "Hepatitis E" (PDF).
  2. Fields, Bernard (2013). Fields virology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 9781451105636.
  3. LastName, FirstName (2011). Lippincott's guide to infectious diseases. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. ISBN 1605479756.
  4. Wedemeyer H, Pischke S, Manns MP (2012). "Pathogenesis and treatment of hepatitis e virus infection". Gastroenterology. 142 (6): 1388–1397.e1. doi:10.1053/j.gastro.2012.02.014. PMID 22537448.
  5. Péron JM, Dalton H, Izopet J, Kamar N (2011). "Acute autochthonous hepatitis E in western patients with underlying chronic liver disease: a role for ribavirin?". J Hepatol. 54 (6): 1323–4, author reply 1324-5. doi:10.1016/j.jhep.2011.01.009. PMID 21281681.
  6. Gerolami R, Borentain P, Raissouni F, Motte A, Solas C, Colson P (2011). "Treatment of severe acute hepatitis E by ribavirin". J Clin Virol. 52 (1): 60–2. doi:10.1016/j.jcv.2011.06.004. PMID 21764632.
  7. 7.0 7.1 7.2 Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, Ijaz S, Izopet J; et al. (2012). "Hepatitis E." Lancet. 379 (9835): 2477–88. doi:10.1016/S0140-6736(11)61849-7. PMID 22549046.
  8. 8.0 8.1 Kamar N, Rostaing L, Abravanel F, Garrouste C, Lhomme S, Esposito L; et al. (2010). "Ribavirin therapy inhibits viral replication on patients with chronic hepatitis e virus infection". Gastroenterology. 139 (5): 1612–8. doi:10.1053/j.gastro.2010.08.002. PMID 20708006.
  9. Kamar N, Abravanel F, Selves J, Garrouste C, Esposito L, Lavayssière L; et al. (2010). "Influence of immunosuppressive therapy on the natural history of genotype 3 hepatitis-E virus infection after organ transplantation". Transplantation. 89 (3): 353–60. doi:10.1097/TP.0b013e3181c4096c. PMID 20145528.
  10. Kamar N, Rostaing L, Abravanel F, Garrouste C, Esposito L, Cardeau-Desangles I; et al. (2010). "Pegylated interferon-alpha for treating chronic hepatitis E virus infection after liver transplantation". Clin Infect Dis. 50 (5): e30–3. doi:10.1086/650488. PMID 20113176.
  11. Haagsma EB, Riezebos-Brilman A, van den Berg AP, Porte RJ, Niesters HG (2010). "Treatment of chronic hepatitis E in liver transplant recipients with pegylated interferon alpha-2b". Liver Transpl. 16 (4): 474–7. doi:10.1002/lt.22014. PMID 20373458.
  12. Dalton HR, Keane FE, Bendall R, Mathew J, Ijaz S (2011). "Treatment of chronic hepatitis E in a patient with HIV infection". Ann Intern Med. 155 (7): 479–80. doi:10.7326/0003-4819-155-7-201110040-00017. PMID 21969351.

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