management of hepatitis

The management of hepatitis B involves assessing the need for ongoing treatment, which may be initiated in secondary care and continued in primary care under a shared care arrangement ¹. Supportive symptomatic care can include simple measures for itch, such as a cool environment and loose clothing, or chlorphenamine at night, with caution in severe liver impairment ¹. For nausea, metoclopramide or cyclizine may be offered for mild liver disease, but caution is advised with more severe impairment, and metoclopramide should not be used for longer than 5 days due to risks of neurological effects ¹. Potentially hepatotoxic drugs should be withheld, and specialist advice sought if unsure ¹. Referral to a genito-urinary medicine department for STI screening or a drug rehabilitation agency may be appropriate ¹. Patient information on hepatitis B should be provided, and local Health Protection Units notified promptly for surveillance and contact tracing ¹. Close contacts should be offered hepatitis B vaccination and immunoglobulin if indicated ¹. Pregnant women with hepatitis B should be aware that their infant requires immunisation from birth to prevent transmission ¹. Hepatitis A vaccination should be ensured for those with chronic hepatitis B who are not immune ¹. Regular review by a liver specialist is required for all individuals with chronic hepatitis B to monitor serology, screen for complications like hepatocellular cancer, and manage treatment ¹.

For chronic hepatitis B, antiviral treatment is considered for adults aged 30 years and older with HBV DNA > 2000 IU/ml and abnormal ALT on two consecutive tests 3 months apart ³. Younger adults with the same viral load and ALT levels may be treated if there is evidence of necroinflammation or fibrosis ³. Adults with HBV DNA > 20,000 IU/ml and abnormal ALT also warrant antiviral treatment regardless of age or liver disease extent ³. Antiviral treatment is also offered to adults with cirrhosis and detectable HBV DNA, and considered for those with HBV DNA > 2000 IU/ml and evidence of necroinflammation or fibrosis ³. Treatment should be initiated by a specialist ³. For HBeAg-positive chronic hepatitis B with compensated liver disease, a 48-week course of peginterferon alfa-2a is offered as first-line treatment ³. For children and young people with chronic hepatitis B and compensated liver disease, antiviral treatment is offered if there is significant fibrosis or abnormal ALT on two consecutive tests 3 months apart ³. Peginterferon alfa-2a can be considered as first-line treatment, with a nucleoside or nucleotide analogue as second-line ³. Adults with decompensated liver disease require management in conjunction with a liver transplant centre, and entecavir or tenofovir disoproxil may be used as first-line treatment depending on resistance history ³. Tenofovir disoproxil is offered to women in the third trimester with HBV DNA > 10^7 IU/ml to reduce transmission risk to the baby ³.

For acute hepatitis C, spontaneous viral clearance occurs in 15-45% of cases within 6 months without treatment ². If spontaneous resolution does not occur, treatment should be started promptly, as treatment during the acute phase is more effective ². All individuals with chronic hepatitis C infection should be considered for antiviral therapy, initiated by a specialist, with the goal of eradicating the virus and achieving a sustained virological response (SVR), which is considered a cure ². Direct-acting antivirals (DAAs) are the first-line treatment, are well-tolerated, and result in high SVR rates ².