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Hepatitis E Treatment & Management

  • Author: Prospere Remy, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Jul 14, 2016
 

Medical Management

Prevention

Management should be predominantly preventive, relying on clean drinking water, good sanitation, and proper personal hygiene. Travelers to endemic areas should avoid drinking water or other beverages that may be contaminated and should avoid eating uncooked shellfish. Heating pork to an internal temperature of 71°C for 20 minutes is necessary to completely inactivate the hepatitis E virus (HEV).[47] Care should be taken in the preparation of uncooked fruits or vegetables. Boiling water may prevent infection, but the effectiveness of chlorination is unknown.

Hepatitis E is preventable by vaccination. Studies in Nepal and China had shown 95% efficacy of a recombinant genotype 1 HEV vaccine in preventing infection and clinical disease.[11, 12] Not only did the vaccine prevent the genotype 1 (Hecolin) HEV infection, genotype 4 HEV was also prevented with the vaccination, indicating cross-protection against different HEV genotypes. At this time, the vaccine efficacy against HEV genotype 3 is not known. A vaccine developed from HEV genotype 1 HEV vaccine was approved in China in December 2011. A study showed long-term efficacy of this vaccine, as it induced a sustained level of antibodies and protection against hepatitis E for up to 4.5 years.[48]  

However, further evaluation of these vaccines are required to determine their efficacy in special risk groups, such as patients with end-stage liver disease or immunosuppressed individuals, to define the anti-HEV titers that can be considered protective, and to know the duration of their protective effect.[49]

Treatment of acute HEV infection

Acute hepatitis E in immunocompetent persons usually only requires symptomatic treatment, as almost all of them are able to clear the virus spontaneously. A report showed significant improvement of liver enzymes and functions in a patient with severe acute hepatitis E who was treated with ribavirin for 21 days.[50] Although ribavirin therapy is contraindicated in pregnancy owing to teratogenicity, the risks of untreated HEV to the mother and fetus are high, and trials of antiviral therapy might be worthwhile.[32]

Treatment of chronic HEV infection

In transplant recipients with chronic HEV infection, viral clearance is desirable. The first step is to reduce the immunosuppressive therapy, as reduction of immunosuppression results in viral clearance in 30% of patients.[51, 52] Calcineurin inhibitor (cyclosporine A, tacrolimus) and mTOR inhibitors (rapamycin, everolimus) have an in vitro effect of stimulation of HEV replication.[53] However, mycophenolic acid (including prodrug mycophenolate mofetil) inhibits the HEV replication in vitro.[54] Steroids were found not to influence HEV replication in vitro.[54]

Antiviral therapy should be considered for patients for whom immunosuppressive therapy cannot be reduced and for those who do not achieve viral clearance after reducing immunosuppression. Although data are limited, ribavirin monotherapy (600–1000 mg/day) for at least 3 months seems to be the first treatment option for patients with chronic hepatitis E who are not able to clear HEV after immunosuppression is reduced.[55]  However, the presence of G1634 mutation in the RdRp domain of HEV ORF1 protein was reported to be associated with ribavirin treatment failure.[56]   In this situation, pegylated interferon alfa may be used as an alternative treatment option if there is no contraindication.

Treatment with pegylated interferon alfa for 3-12 months has led to sustained clearance of HEV RNA in patients with chronic hepatitis E who underwent liver transplantations.[57, 58] However, interferon therapy can cause significant adverse effects and organ rejection in transplant recipients, especially those who have undergone heart or kidney transplantation.

 

A study revealed that sofosbuvir, a nucleotide analogue, inhibits RNA replication of HEV genotype 3 in vitro. In addition, sofosbuvir has an additive antiviral effect when it is combined with ribavirin.[59] Although the data appear promising, more data are needed to explore the antiviral potential of sofosbuvir in combination with ribavirin in chronic HEV infection, especially in patients in whom ribavirin monotherapy fails to achieve HEV elimination with.[60]

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Diet and Activity

The acute illness may result in anorexia, nausea, and vomiting, predisposing patients to dehydration. These symptoms tend to be worse in the afternoon or evening. Patients should attempt to ingest significant calories in the morning. As they improve, frequent small meals may be better tolerated. Hospitalization should be considered for patients with dehydration. Neither multivitamins nor specific dietary requirements are required.

Patients should be allowed to function at whatever activity levels they can tolerate. No evidence indicates that bed rest hastens recovery. It actually may retard recovery.

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Contributor Information and Disclosures
Author

Prospere Remy, MD Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center

Prospere Remy, MD is a member of the following medical societies: American College of Physicians, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

David Widjaja, MD Attending Physician, Department of Medicine (Gastroenterology), Bronx Lebanon Hospital Center

David Widjaja, MD is a member of the following medical societies: American College of Physicians, Indonesian Medical Association

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

David Eric Bernstein, MD Director of Hepatology, North Shore University Hospital; Professor of Clinical Medicine, Albert Einstein College of Medicine

David Eric Bernstein, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Kenneth D Flora, MD Adjunct Associate Professor of Medicine, Division of Gastroenterology and Hepatology, Oregon Health Sciences University School of Medicine; Consulting Staff, Department of Gastroenterology, The Oregon Clinic

Kenneth D Flora, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, and American Gastroenterological Association

Disclosure: Nothing to disclose.

Kenneth Ingram, PAC Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health and Science University School of Medicine

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Jonathan M Schwartz, MD Associate Professor, Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health and Sciences University School of Medicine

Jonathan M Schwartz, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and American Hepato-Pancreato-Biliary Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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