Ask the Experts - How Do You Manage the Patient With Hepatitis B and...
Ask the Experts - How Do You Manage the Patient With Hepatitis B and...
I have a patient with hepatitis B (surface antigen-positive; e antigen-negative) and hepatitis C dual infection. Liver transaminases are elevated. Results of hepatitis B DNA and hepatitis C RNA studies are pending. What are your recommendations regarding therapy? Specifically, what interferon regimen (dose, duration) would you suggest, and should I initiate therapy in combination with ribavirin?
The management of patients chronically infected with more than one form of viral hepatitis is sometimes difficult, because each involves a different type of treatment. Thus, chronic hepatitis B is treated with either lamivudine for 12 months or high doses of alfa interferon (either 10 million units 3 times per week or 5 million units daily) for 4 months, whereas chronic hepatitis C is treated with a lower dose of interferon (3 million units 3 times per week) in combination with oral ribavirin (for between 6 and 12 months). Chronic hepatitis D is rare in the United States but requires therapy with large doses of interferon for very prolonged periods, or even indefinitely.
Although there are no guidelines regarding management of patients with dual infection and, in fact, very few data, one commonly used approach is to try and establish which infection is "dominant." Thus, if the patient is hepatitis B e antigen-positive and hepatitis B virus DNA-positive, the hepatitis B may be dominant, whereas if these markers are negative but the hepatitis C virus (HCV) RNA is detectable, one could consider the hepatitis C to be dominant. The clinician then treats the dominant infection with the regimen appropriate for that condition. If this first course of treatment is successful (for example, if there is sustained loss of HCV RNA in a patient with dominant HCV infection), the patient would then need to be reassessed after the regimen is complete to determine whether any further therapy is necessary.
I have a patient with hepatitis B (surface antigen-positive; e antigen-negative) and hepatitis C dual infection. Liver transaminases are elevated. Results of hepatitis B DNA and hepatitis C RNA studies are pending. What are your recommendations regarding therapy? Specifically, what interferon regimen (dose, duration) would you suggest, and should I initiate therapy in combination with ribavirin?
The management of patients chronically infected with more than one form of viral hepatitis is sometimes difficult, because each involves a different type of treatment. Thus, chronic hepatitis B is treated with either lamivudine for 12 months or high doses of alfa interferon (either 10 million units 3 times per week or 5 million units daily) for 4 months, whereas chronic hepatitis C is treated with a lower dose of interferon (3 million units 3 times per week) in combination with oral ribavirin (for between 6 and 12 months). Chronic hepatitis D is rare in the United States but requires therapy with large doses of interferon for very prolonged periods, or even indefinitely.
Although there are no guidelines regarding management of patients with dual infection and, in fact, very few data, one commonly used approach is to try and establish which infection is "dominant." Thus, if the patient is hepatitis B e antigen-positive and hepatitis B virus DNA-positive, the hepatitis B may be dominant, whereas if these markers are negative but the hepatitis C virus (HCV) RNA is detectable, one could consider the hepatitis C to be dominant. The clinician then treats the dominant infection with the regimen appropriate for that condition. If this first course of treatment is successful (for example, if there is sustained loss of HCV RNA in a patient with dominant HCV infection), the patient would then need to be reassessed after the regimen is complete to determine whether any further therapy is necessary.
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