Acute hepatitis B Treatment

Acute Hepatitis BAcute Hepatitis B

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EpidemiologyEpidemiologyIncidence declined in US from 1990 to Incidence declined in US from 1990 to 20052005

70,000 acute Hepatitis B infections in US 70,000 acute Hepatitis B infections in US in 2005in 2005

Risk factors: sexual exposure, IVDURisk factors: sexual exposure, IVDU

<5% of acute infections in <5% of acute infections in immunocompetent adults progress to immunocompetent adults progress to chronic hepatitis Bchronic hepatitis B


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Clinical ManifestationsClinical ManifestationsIncubation period 1-4 mosIncubation period 1-4 mosProdromal period w/ serum Prodromal period w/ serum sickness like symptomssickness like symptomsThen constitutional sx, Then constitutional sx, anorexia, nausea, jaundice anorexia, nausea, jaundice and RUQ discomfortand RUQ discomfortOnly 30% develop icteric Only 30% develop icteric hepatitis. hepatitis. 70% subclinical or anicteric 70% subclinical or anicteric hepatitis.hepatitis.More severe infections in More severe infections in patients coinfected w/ other patients coinfected w/ other hepatitis viruses or underlying hepatitis viruses or underlying liver diseaseliver disease



DiagnosisDiagnosis

To diagnose acute infection: HBSAg + IgM anti-To diagnose acute infection: HBSAg + IgM anti-HBc (also suggestive is +HBeAg)HBc (also suggestive is +HBeAg)Recovery: Normalization of ALT, disappearance Recovery: Normalization of ALT, disappearance of HBV DNA, transition from HBSAg to anti-HBs of HBV DNA, transition from HBSAg to anti-HBs and transition from IgM anti-HBc to IGGand transition from IgM anti-HBc to IGGChronic: persistence of HBSAg > 6 monthsChronic: persistence of HBSAg > 6 months



DiagnosisDiagnosis



Laboratory TestingLaboratory TestingElevated transaminases-values up to Elevated transaminases-values up to 1000-2000 IU/L with ALT > AST1000-2000 IU/L with ALT > ASTSerum bilirubin may be normalSerum bilirubin may be normalProthrombin time best indicator of Prothrombin time best indicator of prognosisprognosisNormalization of transaminases within 1-4 Normalization of transaminases within 1-4 months in patients who recovermonths in patients who recoverALT elevated > 6 months indicates ALT elevated > 6 months indicates progression to chronic hepatitis progression to chronic hepatitis



Fulminant Hepatic FailureFulminant Hepatic Failurerapid development of severe acute liver rapid development of severe acute liver injury with impaired synthetic function and injury with impaired synthetic function and encephalopathy in a person who encephalopathy in a person who previously had a normal liver or had well-previously had a normal liver or had well-compensated liver diseasecompensated liver diseaseunusual in Hep B infections-occurs in 0.1 unusual in Hep B infections-occurs in 0.1 to 0.5% of ptsto 0.5% of pts due to massive immune-mediated lysis of due to massive immune-mediated lysis of

infected hepatocytesinfected hepatocytes



TreatmentTreatmentmostly supportivemostly supportiveavoid interferon due to increased risk of avoid interferon due to increased risk of hepatic necroinflammationhepatic necroinflammationconsider antiviral therapy with lamivudine, consider antiviral therapy with lamivudine, telbivudine, adefovir, or entecavir as telbivudine, adefovir, or entecavir as monotherapy for short durationmonotherapy for short durationdiscontinue treatment after two consective discontinue treatment after two consective tests 4 weeks apart confirm patient has tests 4 weeks apart confirm patient has cleared HBSAgcleared HBSAg



TreatmentTreatmentRCT of lamivudine to treat acute Hep B:RCT of lamivudine to treat acute Hep B: 71 pts. 31 pts received lamivudine 100 mg 71 pts. 31 pts received lamivudine 100 mg

daily for 3 mo (group 1), 40 received placebo daily for 3 mo (group 1), 40 received placebo (group 2)(group 2)

At wk 4, HBV DNA levels significantly lower in At wk 4, HBV DNA levels significantly lower in treated group (p=0.037), but thereafter levels treated group (p=0.037), but thereafter levels were similarwere similar

Improvement in serum bili, ALT, INR values Improvement in serum bili, ALT, INR values similar in 2 groupssimilar in 2 groups

Hepatology. 2007 Jan;45(1):97-101



TreatmentTreatmentAfter 1yr, 93.5% of pts in lamivudine group and After 1yr, 93.5% of pts in lamivudine group and 96.7% of pts in placebo group lost HBsAg96.7% of pts in placebo group lost HBsAg

After 1yr, 21 pts (67.7%) in treatment group and After 1yr, 21 pts (67.7%) in treatment group and 34 pts (85%) in placebo developed protective 34 pts (85%) in placebo developed protective anti-HBs titersanti-HBs titers

No deaths in either groupNo deaths in either group

Conclusion: No significant biochemical or clinical Conclusion: No significant biochemical or clinical improvement with lamivudine compared to improvement with lamivudine compared to placeboplacebo

Hepatology. 2007 Jan;45(1):97-101



Consider Treatment in: Consider Treatment in: Pts w/ a coagulopathy (INR >1.5) Pts w/ a coagulopathy (INR >1.5) Those w/ a protracted course (persistent Those w/ a protracted course (persistent symptoms or marked jaundice w/ bilirubin >10 symptoms or marked jaundice w/ bilirubin >10 mg/dl for more than four weeks)mg/dl for more than four weeks)Pts with fulminant hepatitis B (to reduce the Pts with fulminant hepatitis B (to reduce the likelihood of reinfection post-liver transplant)likelihood of reinfection post-liver transplant)Immunocompromised patients Immunocompromised patients Those with concomitant infection with hepatitis C Those with concomitant infection with hepatitis C or D virus or preexisting liver diseaseor D virus or preexisting liver diseaseElderly patientsElderly patients



PreventionPreventionHepatitis B Hepatitis B vaccination!vaccination!

Series of three doses Series of three doses at months 0, 1 to 2, at months 0, 1 to 2, and then 6 to 12and then 6 to 12

In US, universal In US, universal vaccination of all vaccination of all newborns is newborns is recommendedrecommended



PreventionPreventionVaccinate high risk Vaccinate high risk adults:adults:

Healthcare workersHealthcare workers IV drug usersIV drug users Household contacts of Household contacts of

people w/ Hep Bpeople w/ Hep B Pts w/ multiple sexual Pts w/ multiple sexual

partnerspartners Men who have sex with Men who have sex with

menmen HD patientsHD patients Pts who require repeated Pts who require repeated

transfusions of blood transfusions of blood productsproducts

Pts w/ chronic liver diseasePts w/ chronic liver disease



EfficacyEfficacypositive immune response is positive immune response is defined as development of defined as development of anti-HBs at a titer of >10 IU/Lanti-HBs at a titer of >10 IU/L95% seroconversion in healthy 95% seroconversion in healthy adultsadultsPost-vaccination testing in Post-vaccination testing in healthcare workers/HD pts/pts healthcare workers/HD pts/pts who are at risk for recurrent who are at risk for recurrent exposure 1-2 mos after exposure 1-2 mos after completion of vaccination.completion of vaccination.Nonresponders complete a Nonresponders complete a second 3-dose vaccination second 3-dose vaccination seriesseries



Health & Medicine

Acute hepatitis B Treatment