Hepatitis E medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Hepatitis E}} | {{Hepatitis E}} | ||
{{CMG}}; {{AE}} {{JS | {{CMG}}; {{AE}} {{JS}} | ||
==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== | ||
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> | |||
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> | |||
=== | 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]] | [[Category:Viruses]] | ||
[[Category:Gastroenterology]] | |||
[[Category:Infectious Disease Project]] | |||
[[Category:Emergency mdicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | [[Category:Infectious disease]] | ||
[[Category: | [[Category:Hepatology]] | ||
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:
- 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.[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]
| Drug | Characteristics |
|---|---|
| Ribavirin Monotherapy |
|
| Pegylated Interferon-α Monotherapy |
|
References
- ↑ "Hepatitis E" (PDF).
- ↑ Fields, Bernard (2013). Fields virology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 9781451105636.
- ↑ LastName, FirstName (2011). Lippincott's guide to infectious diseases. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. ISBN 1605479756.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 7.0 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.
- ↑ 8.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.