eMedicine Specialties > Emergency Medicine > Gastrointestinal
Viral Hepatitis: Treatment & Medication
Updated: Jul 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Viral hepatitis: No specific emergency department treatment is indicated other than supportive care including intravenous rehydration.
- A liver abscess requires intravenous antibiotic therapy directed toward the most likely pathogens and consultation for possible surgical or percutaneous drainage.
Consultations
- Gastroenterologist or hepatologist
- General surgeon
Medication
Certain patients may benefit from pharmacologic therapy. For chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) infections in particular, the goals of therapy are to reduce liver inflammation and fibrosis and to prevent progression to cirrhosis and its complications.
Because the treatment regimens for hepatitis are being actively researched, medication recommendations, indications, and dosages are all subject to change. Make any decision to administer medications in consultation with a gastroenterologist or a hepatologist.
In addition to the medications listed below, the nucleoside analogues lamivudine and adefovir have shown promising results in the treatment of patients with chronic HBV. Other antiviral agents that are being studied for treatment of chronic HBV include entecavir and tenofovir. In addition to being active against HBV, lamivudine, adefovir and tenofovir are also active against human immunodeficiency virus (HIV), making them useful in the treatment of patients who are co-infected with HBV and HIV.
For patients with chronic HCV infection, one current treatment option is combination therapy with pegylated interferon (PEG-IFN) and the antiviral ribavirin. This regimen may be recommended for a certain subset of patients with moderate or severe inflammation and/or fibrosis. The combination of the 2 drugs provides a more sustained clearance of HCV RNA from the serum of infected individuals when compared to monotherapy. Other therapeutic options are being explored for treatment of chronic HCV with the goals of increasing efficacy and decreasing toxicity. These include protease inhibitors, ribozymes, and viral vaccines.
Interferons
These are naturally produced proteins with antiviral, antitumor, and immunomodulatory actions. Alpha, beta, and gamma interferons may be given topically, systemically, and intralesionally.
Interferon alpha-2b (Intron A)
Protein product manufactured by recombinant DNA technology that uses genetically engineered Escherichia coli bacterium.
Mechanisms by which it exerts antiviral activity are not clearly understood; however, modulation of host-immune response may play an important role.
Induces remission in 25-50% of patients with chronic HBV and 40% of patients with chronic HCV and decreases abnormal aminotransferase concentrations in chronic HBV/HCV. Also may play a role in delaying or preventing development of hepatocellular cancer, independent of its antiviral effect, in patients with cirrhosis.
Adult
5 million IU/d or 10 million IU 3 times/wk IM/SC for 16 wk; reduce dose by 50% if severe adverse reactions occur
Pediatric
Not established
Interleukin-2 increases potential risk of renal failure; theophylline may increase toxicity by reducing clearance; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity
Documented hypersensitivity; anaphylactic sensitivity to mouse IgG, egg protein, or neomycin
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
Depression and suicidal ideation may be adverse effects; infrequently, severe or fatal GI hemorrhage reported in association with therapy; prior to initiation of therapy, perform tests to quantitate peripheral blood hemoglobin, platelets, granulocytes, hairy cells, and bone marrow hairy cells; monitor periodically (eg, monthly) during treatment to determine response to treatment; if patient does not respond within 6 mo, discontinue treatment
Antivirals
These agents inhibit viral replication.
Amantadine (Symmetrel)
Antiviral agent that prevents penetration of virus into host by inhibiting uncoating of virus; may be useful in patients with HCV who do not respond to interferon.
Adult
100 mg PO bid for 6 mo
Pediatric
Not established
Drugs with anticholinergic or CNS stimulant activity increase toxicity; hydrochlorothiazide plus triamterene may increase plasma concentrations
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 liver disease, uncontrolled psychosis, eczematoid dermatitis, seizures, and those receiving CNS stimulant drugs; reduce dose in renal disease when treating Parkinson disease; do not discontinue this medication abruptly
Famciclovir (Famvir)
Prodrug that, when biotransformed into active metabolite penciclovir, may inhibit viral DNA synthesis/replication.
Adult
500 mg PO tid
Pediatric
Not established
Probenecid or cimetidine may increase toxicity; increases bioavailability of digoxin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or coadministration of nephrotoxic drugs
Entecavir (Baraclude)
Guanosine nucleoside analogue with activity against HBV polymerase. Competes with natural substrate deoxyguanosine triphosphate to inhibit HBV polymerase activity (ie, reverse transcriptase). Less effective for lamivudine-refractory HBV infection. Indicated for treatment of chronic hepatitis B infection. Available as tab and oral solution (0.05 mg/mL; 0.5 mg = 10 mL).
Adult
Treatment for nucleoside naive: 0.5 mg PO qd 2 h ac or 2 h pc
CrCl 30-49 mL/min: 0.25 mg PO qd
CrCl 10-29 mL/min: 0.15 mg PO qd
CrCl <10 mL/min: 0.05 mg PO qd
Receiving lamivudine or lamivudine resistance: 1 mg PO qd 2 h ac or 2 h pc
CrCl 30-49 mL/min: 0.5 mg PO qd
CrCl 10-29 mL/min: 0.3 mg PO qd
CrCl <10 mL/min: 0.1 mg PO qd
Pediatric
<16 years: Not established
>16 years: Administer as in adults
Not a substrate, inhibitor, or inducer of cytochrome P450; coadministration with drugs that reduce renal function (eg, aminoglycosides, cidofovir, cyclosporine) or that compete for active tubular secretion (eg, probenecid, salicylates) may increase serum concentration of either entecavir or coadministered drug
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
Reduce dose with renal impairment; if on hemodialysis, administer afterwards; common adverse effects include headache, tiredness, dizziness, and nausea; may elevate liver enzyme levels; may cause lactic acidosis; severe acute exacerbations of hepatitis B may occur in patients who discontinue antihepatitis B therapy
Corticosteroids
These agents may be used in cholestatic HAV. A brief course may shorten the illness; however, it may be most effective in a milder disease.
Prednisone (Deltasone, Sterapred, Orasone)
Inactive and must be metabolized to active metabolite prednisolone; conversion may be impaired in patients with liver disease.
Adult
5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Pediatric
4-5 mg/m2/d PO; alternatively, administer 1-2 mg/kg PO qd; taper over 2 wk as symptoms resolve
Estrogens may decrease clearance; concurrent digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur
More on Viral Hepatitis |
| Overview: Viral Hepatitis |
| Differential Diagnoses & Workup: Viral Hepatitis |
 Treatment & Medication: Viral Hepatitis |
| Follow-up: Viral Hepatitis |
| References |
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Further Reading
Keywords
viral hepatitis, viral hepatitis treatment, viral hepatitis causes, viral hepatitis symptoms, hepatitis A, HAV, epidemic hepatitis, infectious hepatitis, short-incubation hepatitis, virus A hepatitis, viral hepatitis type A, hepatitis B, HBV, viral hepatitis type B, long-incubation hepatitis, serum hepatitis, transfusion hepatitis, virus B hepatitis, hepatitis C, HCV, viral hepatitis type C, hepatitis D, viral hepatitis type D, delta hepatitis, hepatitis E, viral hepatitis type E, liver disease, liver, inflammation of the liver, hepatic failure, hepatic disease, infectious hepatitis, noninfectious hepatitis, drug-induced hepatitis, autoimmune hepatitis, liver transplantation, liver transplant
