Hepatitis B

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There is usually no need for treatment of an acute infection in adults. With chronic hepatitis B, the goal of treatment is to clear the virus, develop the immune response against future reinfection, and prevent serious complications that may result.

All of the oral medications that have been approved for hepatitis B are very effective at suppressing the virus. However, unless patients develop antibodies against the virus, discontinuation of therapy may lead to recurrence. Some patients develop hepatitis B "mutants" during and after treatment. This illustrates the complexity of treatment for chronic hepatitis B infection and the need for new treatment regimens. A comparison of medications and drug combinations is needed to determine the best long-term treatment strategies. None of these medications offer a "cure," except in rare cases, but they do slow the disease, possibly preventing some life-threatening complications.

Liver transplantation remains an option for those patients who progress to end-stage liver disease, or for those who develop liver cancer. Over time, survival rates have increased and recurrence rates have declined since the institution of long-term hepatitis B immune globulin after liver transplantation. The availability of new drugs may further improve outcomes in the post-transplantation period.

This section contains more on:

  • Medical therapy
  • Treating fulminant hepatitis, a rare complication
  • Treating liver cancer
  • Medical Therapy

    Until 10 years ago, interferon alfa-2b was the only medication approved by the U.S. Food and Drug Administration for treating hepatitis B. Given by injection several times a week for six months to a year, sometimes longer, the drug modulates the immune system against the viral infection. It can cause side effects such as flulike symptoms, depression, and headaches.

    Pegasys, pegylated interferon, is a longer-acting interferon approved for treating adults with chronic hepatitis B in 2005. Given by injection once a week for six months to a year, the drug can cause side effects similar to interferon alfa-2b.

    Epivir, or lamivudine, is a once-a-day pill taken for a year or longer that was approved in 1998. In large placebo-controlled clinical trials, patients treated with lamivudine therapy for 52 weeks had a significantly greater frequency of response compared with a placebo treatment (55 percent vs. 25 percent), in that the drug suppressed the viral load and normalized liver enzymes. However, long-term treatment with lamivudine causes significant viral mutation (up to 70 percent over five years); the effectiveness of other drugs decreases once mutation has occurred.

    Hepsera, or adefovir-dipivoxil, is a pill taken once a day for a year or longer. It was approved for adults in 2002. However, kidney problems can occur while taking the drug.

    Baraclude, or entecavir, a once-a-day pill, seems to have fewer side effects than some other hepatitis B treatments. The drug is a potent antiviral, approved by the FDA in 2005 for adults with chronic hepatitis B.

    Tyzeka, or telbuvidine, is a once-a-day pill approved by the FDA in late 2006 for hepatitis B treatment. In clinical studies, the drug was more potent than lamivudine.

    Viread, or tenofovir, is an antiretroviral drug approved by the FDA in 2008 for adults with chronic hepatitis B.

    Treating Fulminant Hepatitis

    Fulminant hepatitis is a rare syndrome usually associated with hepatitis B and sometimes hepatitis D. It is characterized by a rapid development of jaundice and the onset of brain swelling and nervous system deterioration, likely to have been caused by the buildup of toxins that cannot be removed by the diseased liver. Confusion, disorientation, dementia, and coma may develop within hours in some cases. Areas of liver tissue die, and there is a marked decrease in the size of the organ. Liver failure, vascular bleeding in the brain and elsewhere, infections, and kidney failure may develop.

    Viral hepatitis is the leading cause of fulminant hepatitis throughout the world. An unusually large load of hepatitis A virus and severe infection may result in fulminant hepatitis. Other factors that increase the likelihood of this complication include infection in individuals over 40 years of age, hepatitis A superimposed on pre-existing liver disease, other chronic illnesses, and travel to countries with widespread contamination of food and water with the hepatitis A virus.

    Careful management and painstaking nursing care provide the best hope for recovery from this complication. Regular monitoring of blood glucose levels with constant glucose infusion is essential, because dangerously low blood sugar is a constant threat. Monitoring of weight and serum electrolytes is crucial because reduction in sodium and potassium in the blood can lead to heart irregularities. Early in the course of fulminant hepatitis, potassium supplementation is usually required. Other treatments may be necessary to prevent kidney or other organ failure.

    Intracranial pressure monitoring is frequently useful in fulminant hepatitis. As brain swelling increases, intracranial hypertension becomes a serious problem. The risk of brain damage begins when ICP is too high, and interventional procedures are needed to reduce pressure. Intracranial hypertension management may include head elevation, administration of diuretics, rapid ventilation, reducing core body temperature, and drug-induced coma. Abnormally low blood pressure is also a frequent problem in the management of patients with fulminant hepatic failure. Drugs are often used to maintain blood pressure to sustain life.

    Ultimately, the degree of brain and nervous system deterioration is an indicator of prognosis. Some 80 percent of patients who progress to coma die from this complication. As a result, liver transplantation has become the standard of care in many institutions: It offers a survival rate of close to 90 percent in patients where transplantation appears feasible.

    Treating Liver Cancer

    Chronic hepatitis B infections are an important cause of hepatocellular carcinoma, or primary liver cancer, throughout the world. In parts of China and Taiwan, hepatitis B is the cause of 80 percent of the cases of liver cancer. Hepatocellular carcinoma is responsible for over 12,000 deaths per year in the United States. Worldwide, it causes over a million deaths per year, making it one of the most common malignancies in adults. It is more common in men than women, and in blacks than whites. It is especially prevalent in parts of Asia and Africa.

    In this country, primary liver cancer is often detected during screening for underlying liver disease. Most people with liver cancer have no symptoms until the disease is advanced.

    Most hepatocellular carcinomas are first diagnosed with CT scans, magnetic resonance imaging (MRI), or ultrasound scans. These tests range from 60 to 100 percent accuracy, depending on the size of the tumor, with larger tumors being more visible. About 70 percent of patients with hepatocellular carcinoma have elevated blood concentrations of a tumor marker called alpha-fetoprotein; however, it is not specific for this condition. If there is doubt about the presence of liver cancer, the definitive diagnosis is made by liver biopsy.

    Treatment of liver cancer is based on the size of the tumor, its location, and its spread to blood vessels and nearby or distant organs. Surgery, where a portion of the liver is removed, or "resectioned," offers the only cure for the disease and the best long-term chance of survival. Patients with smaller tumors and without cirrhosis or metastasis to other organs are the best candidates for liver resection. New techniques such as cryosurgery (freezing the tumor and tissue around it), radio frequency ablation (which destroys the tumor inside the liver with a heat probe), and chemoembolization (which destroys the tumor inside the liver with chemoagents) may work for some patients who are not good candidates for liver resection.

    In patients with small tumors but advanced cirrhosis, liver transplantation is the treatment of choice. The tumor must be confined to the liver and without invasion into the surrounding blood vessels. Liver transplant is the only treatment option for patients with tumors that cannot be surgically or medically removed. However, larger or more extensive tumors have a high risk for early recurrence after liver transplantation.

    Traditional chemotherapy and radiation have not been effective for treating liver cancer. The five-year survival rate for patients with liver cancer who have a liver transplant is now about 50 percent.

    Early detection improves the chances of survival after treatment. Certain high-risk people with chronic hepatitis B—Asians and Africans over a certain age, people with cirrhosis, those with a family history of liver cancer, and people over age 40 who have persistently elevated liver enzymes and/or a high level of the hepatitis B virus in their body—should undergo liver cancer screening every six to 12 months with a blood test for tumor markers and a liver ultrasound. Universal hepatitis B vaccination may ultimately reduce the incidence of this often fatal cancer worldwide.

    Last reviewed on 7/23/09

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