eMedicine Specialties > Gastroenterology > Liver
Hepatitis A: Treatment & Medication
Updated: Aug 26, 2008
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Treatment
Medical Care
For acute cases of hepatitis A virus infection, therapy is generally supportive, with no specific treatment of acute uncomplicated illness. Locating the primary source and preventing further outbreaks are paramount. Initial therapy often consists of bed rest. The patient should probably not work during the acute phase of the illness.
- Nausea and vomiting are treated with antiemetics.
- Dehydration may require hospital admission and intravenous fluids.
- In most instances, hospitalization is unnecessary. Most children have minimal symptoms; adults are more likely to require more intensive care, including hospitalization.
- Between 3-8% of cases of fulminant hepatic failure are caused by hepatitis A virus; however, only 1-2% of hepatitis A virus infections in adults lead to fulminant hepatic failure.
- Tylenol may be cautiously administered but is strictly limited to a maximum dose of 3-4 g/d in adults.
- Other treatments are directed by specific complications.
Surgical Care
Consider patients with fulminant hepatic failure for referral for liver transplantation. Recurrent disease after liver transplantation has not been reported. Selection of patients who require liver transplantation may be difficult because 60% of them recover from fulminant hepatic failure without a need for liver transplantation (similar to acetaminophen toxicity), and predicting who needs this life-saving procedure is difficult. Late referral has ominous implications, with the accompanying comorbidities (eg, renal failure, coagulopathy, cerebral edema) and waiting times contributing to poor outcomes.
Consultations
Consider liver transplantation in patients with fulminant hepatic failure. Liver transplantation for chronic relapsing hepatitis A virus infection has occurred in the context of decompensation with good results; however, there is a report of clinical recurrence after liver transplantation.
Diet
Encourage an adequate diet. Patients should avoid alcohol and medications that may accumulate in liver disease. Otherwise, no specific dietary restrictions are necessary.
Activity
Bed rest during the acute illness may be important, although data to support this practice are lacking. Restricting transmission is important, especially in the early phases of the illness. Returning to work should probably be delayed for 10 days after the onset of jaundice.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Analgesic agents
Pain control is essential to quality patient care. Acetaminophen is useful for pain and/or fever.
Acetaminophen (Tylenol, Tempra, Feverall)
Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating. Relieves mild to moderate pain.
Adult
325-650 mg PO q4-6h or 1 g PO tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; caution in G-6-PD deficiency or PKU
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Antiemetics
Used to treat nausea and vomiting.
Metoclopramide (Reglan)
Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, which provides important antiemetic activity.
Adult
5-10 mg PO tid/qid
5-20 mg IV/IM tid
Pediatric
Not established
Anticholinergic agents antagonize effects; opiate analgesics may increase CNS toxicity
Documented hypersensitivity; pheochromocytoma; GI hemorrhage, obstruction, or perforation; history of seizure disorders
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in history of mental illness and Parkinson disease
Vaccines, viral, prevention
Hepatitis A vaccine is used for active immunization against disease caused by hepatitis A virus.
Hepatitis A vaccine, inactivated, and hepatitis B vaccine (Twinrix)
For active immunization of persons >18 years against disease caused by hepatitis A virus and infection by all known subtypes of hepatitis B virus.
Adult
0.5 mL IM; repeat at 1 and 6 mo
Pediatric
Dose is as per that for product Twinrix Junior (half dose of antigen administered)
Immunosuppressants may reduce effectiveness; when concomitant administration of other vaccines or IG required, give different syringes and different injection sites
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in individuals on anticoagulant therapy; may not prevent hepatitis A infection in individuals with unrecognized hepatitis A infection at the time of vaccination; caution when administering to women who are breastfeeding and people with thrombocytopenia or a bleeding disorder as bleeding may occur following IM use; immunosuppressed people or those receiving immunosuppressive therapy may not obtain expected immune response (may require additional doses)
Hepatitis A vaccine, inactivated (Havrix, Vaqta)
May be administered with immunoglobulin injections without affecting efficacy.
Adult
Havrix: 1440 U IM once; booster dose at 6-12 mo
Vaqta: 50 U IM once; booster dose at 6 mo
Pediatric
<2 years: Not recommended
>2 years:
Havrix: 360 U IM days 0 and 30; 360 U booster dose at 6-12 mo; alternatively, 720 U day 0 and 720 U booster dose at 6-12 mo
Vaqta: 25 U IM once; booster dose at 6-18 mo
May decrease effects of immunosuppressive agents
Documented hypersensitivity; IV/SC/ID administration
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in acute infection or febrile illness; duration of effect has not been fully established; efficacy >85%; caution in individuals taking anticoagulant therapy; vaccine does not protect against hepatitis B, C, or E viruses
Immune globulins
Purified preparation of gamma globulin. Derived from large pools of human plasma and is composed of 4 subclasses of antibodies, approximating the distribution of human serum. Used for postexposure prophylaxis or when inadequate time is available for immunization to be effective before potential exposure.
Immune globulin, intramuscular (BayGam 15-18%)
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Effective when administered within 14 d of exposure.
If likely to be returning to areas of high endemicity, concurrent vaccination is recommended. For situations in which exposure is likely to occur before vaccination would be effective, both may be administered without reducing the efficacy of hepatitis A virus vaccine.
Adult
0.02-0.06 mL/kg IM for exposed contacts or individuals traveling to areas for up to 6 mo; use higher dose if subject will be in the area for up to 6 mo (ie, where hepatitis A is common)
0.06 mL/kg IM q4-6mo for travelers staying > 3 mo
Pediatric
Not established
Increases toxicity of live virus vaccine (MMR); do not administer within 3 mo of vaccine
Documented hypersensitivity; IgA deficiency; anti-IgE/IgG antibodies
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
First check serum IgA (use an IgA-depleted product, eg, Gammagard S/D); infusions may increase serum viscosity and thromboembolic events; infusions may increase risk of migraine attacks, aseptic meningitis (10%), urticaria, pruritus, or petechiae (2-5 d postinfusion to 30 d); increases risk of renal tubular necrosis in elderly patients and in patients with diabetes, volume depletion, and preexisting kidney disease; laboratory study result changes associated with infusions include elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk, and apparent hyponatremia
More on Hepatitis A |
| Overview: Hepatitis A |
| Differential Diagnoses & Workup: Hepatitis A |
 Treatment & Medication: Hepatitis A |
| Follow-up: Hepatitis A |
| Multimedia: Hepatitis A |
| References |
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Further Reading
Keywords
hepatitis A, infectious hepatitis, hepatitis A virus, acute hepatitis, hepatitis A vaccine, hepatitis A vaccination, hep A, HAV, HAV infection, fulminant hepatic failure, liver transplant, liver transplantation, hepatomegaly, jaundice, hepatitis B virus, HBV, hepatitis C virus, HCV, hepatitis D virus, HDV, hepatitis E virus, HEV, Picornaviridae
