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{{Hepatitis E}}
{{Hepatitis E}}
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==Overview==
==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==
==Medical Therapy==
Hepatitis E is a viral disease, and as such, antibiotics are of no value in the treatment of the infection. There is no hyperimmune E globulin available for pre- or post-exposure prophylaxis. HEV infections are usually self-limited, and hospitalization is generally not required. No available therapy is capable of altering the course of acute infection.
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.<ref name=WHO>{{cite web | title = Hepatitis E | url = http://www.who.int/csr/disease/hepatitis/HepatitisE_whocdscsredc2001_12.pdf }}</ref><ref>{{cite book | last = Fields | first = Bernard | title = Fields virology | publisher = Wolters Kluwer Health/Lippincott Williams & Wilkins | location = Philadelphia | year = 2013 | isbn = 9781451105636 }}</ref><ref>{{cite book | last = LastName | first = FirstName | title = Lippincott's guide to infectious diseases | publisher = Wolters Kluwer/Lippincott Williams & Wilkins Health | location = Philadelphia | year = 2011 | isbn = 1605479756 }}</ref>
===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.<ref name="pmid22537448">{{cite journal| author=Wedemeyer H, Pischke S, Manns MP| title=Pathogenesis and treatment of hepatitis e virus infection. | journal=Gastroenterology | year= 2012 | volume= 142 | issue= 6 | pages= 1388-1397.e1 | pmid=22537448 | doi=10.1053/j.gastro.2012.02.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22537448  }} </ref>


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.
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]].<ref name="pmid21281681">{{cite journal| author=Péron JM, Dalton H, Izopet J, Kamar N| title=Acute autochthonous hepatitis E in western patients with underlying chronic liver disease: a role for ribavirin? | journal=J Hepatol | year= 2011 | volume= 54 | issue= 6 | pages= 1323-4; author reply 1324-5 | pmid=21281681 | doi=10.1016/j.jhep.2011.01.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21281681  }} </ref><ref name="pmid21764632">{{cite journal| author=Gerolami R, Borentain P, Raissouni F, Motte A, Solas C, Colson P| title=Treatment of severe acute hepatitis E by ribavirin. | journal=J Clin Virol | year= 2011 | volume= 52 | issue= 1 | pages= 60-2 | pmid=21764632 | doi=10.1016/j.jcv.2011.06.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21764632  }} </ref>


===Acute hepatitis E===
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.<ref name="pmid22549046">{{cite journal| author=Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, Ijaz S, Izopet J et al.| title=Hepatitis E. | journal=Lancet | year= 2012 | volume= 379 | issue= 9835 | pages= 2477-88 | pmid=22549046 | doi=10.1016/S0140-6736(11)61849-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22549046  }} </ref>


===Chronic Hepatitis E===
===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:
* Reduction of [[immunosupression]]
* [[Pegylated interferon-α]]
* [[Ribavirin]]
Due to the lack of evidence regarding the treatment of chronic hepatitis E, this should be individualized for each patient, according to:
* Stage of liver disease
* [[Comorbidities]]
* Range of possible reduction of [[immunosuppression]]
* [[Antiviral]] drug side-effects
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]].<ref name="pmid20708006">{{cite journal| author=Kamar N, Rostaing L, Abravanel F, Garrouste C, Lhomme S, Esposito L et al.| title=Ribavirin therapy inhibits viral replication on patients with chronic hepatitis e virus infection. | journal=Gastroenterology | year= 2010 | volume= 139 | issue= 5 | pages= 1612-8 | pmid=20708006 | doi=10.1053/j.gastro.2010.08.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20708006  }} </ref><ref name="pmid20145528">{{cite journal| author=Kamar N, Abravanel F, Selves J, Garrouste C, Esposito L, Lavayssière L et al.| title=Influence of immunosuppressive therapy on the natural history of genotype 3 hepatitis-E virus infection after organ transplantation. | journal=Transplantation | year= 2010 | volume= 89 | issue= 3 | pages= 353-60 | pmid=20145528 | doi=10.1097/TP.0b013e3181c4096c | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20145528  }} </ref>
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.<ref name="pmid22549046">{{cite journal| author=Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, Ijaz S, Izopet J et al.| title=Hepatitis E. | journal=Lancet | year= 2012 | volume= 379 | issue= 9835 | pages= 2477-88 | pmid=22549046 | doi=10.1016/S0140-6736(11)61849-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22549046  }} </ref> This may include [[pegylated interferon-α]] monotherapy; [[ribavirin]] monotherapy; or a combination of both.<ref name="pmid20708006">{{cite journal| author=Kamar N, Rostaing L, Abravanel F, Garrouste C, Lhomme S, Esposito L et al.| title=Ribavirin therapy inhibits viral replication on patients with chronic hepatitis e virus infection. | journal=Gastroenterology | year= 2010 | volume= 139 | issue= 5 | pages= 1612-8 | pmid=20708006 | doi=10.1053/j.gastro.2010.08.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20708006  }} </ref><ref name="pmid20113176">{{cite journal| author=Kamar N, Rostaing L, Abravanel F, Garrouste C, Esposito L, Cardeau-Desangles I et al.| title=Pegylated interferon-alpha for treating chronic hepatitis E virus infection after liver transplantation. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 5 | pages= e30-3 | pmid=20113176 | doi=10.1086/650488 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20113176  }} </ref><ref name="pmid20373458">{{cite journal| author=Haagsma EB, Riezebos-Brilman A, van den Berg AP, Porte RJ, Niesters HG| title=Treatment of chronic hepatitis E in liver transplant recipients with pegylated interferon alpha-2b. | journal=Liver Transpl | year= 2010 | volume= 16 | issue= 4 | pages= 474-7 | pmid=20373458 | doi=10.1002/lt.22014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20373458  }} </ref><ref name="pmid21969351">{{cite journal| author=Dalton HR, Keane FE, Bendall R, Mathew J, Ijaz S| title=Treatment of chronic hepatitis E in a patient with HIV infection. | journal=Ann Intern Med | year= 2011 | volume= 155 | issue= 7 | pages= 479-80 | pmid=21969351 | doi=10.7326/0003-4819-155-7-201110040-00017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21969351  }} </ref> 
{| style="border: 2px solid #DCDCDC; font-size: 90%; width: 50%;"
|+ '''Antiviral Therapy'''
|-
! style="width: 75px; background: #4479BA; text-align: center;"|{{fontcolor|#FFF|Drug}}
! style="width: 200px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Characteristics}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Ribavirin Monotherapy'''
| style="background: #DCDCDC; padding: 5px;"|
* 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<ref name="pmid22549046">{{cite journal| author=Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, Ijaz S, Izopet J et al.| title=Hepatitis E. | journal=Lancet | year= 2012 | volume= 379 | issue= 9835 | pages= 2477-88 | pmid=22549046 | doi=10.1016/S0140-6736(11)61849-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22549046  }} </ref>
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Pegylated Interferon-α Monotherapy'''
| style="background: #DCDCDC; padding: 5px;"|
* Must be used with caution since it increases the risk of rejection in [[kidney transplant]]ed 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==
==References==
{{reflist|2}}
{{reflist|2}}
{{WS}}
{{WH}}


[[Category:Hepatitis|E]]
[[Category:Hepatitis|E]]
[[Category:Viruses]]
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[[Category:Gastroenterology]]
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[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Gastroenterology]]
[[Category:Hepatology]]
 
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Latest revision as of 22:07, 29 July 2020

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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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