Brief update of viral hepatitis – Notes from the Duke Symposium (9/09)

Hepatitis B virus (HBV) disease – Although the incidence of acute hepatitis B is diminishing (primarily as a result of vaccination) the prevalence of chronic HBV disease seems to be on the rise due to the influx of new immigrants from endemic areas (Asia and Africa).  In addition to interferon, we now have a total of 5 well-tolerated, oral antiviral agents for treatment of this disease.  These monotherapy drugs are potent inhibitors of viral replication and are often administered long term to maximize viral, biochemical and histological remission.  Currently entecavir and tenofovir are least likely to induce resistant mutations of the virus and are typically selected as first line therapies.  Since cure rates are low for HBV, patients with chronic infection need long term surveillance for hepatocellular carcinoma with ultrasound of liver and AFP levels every 6-months.

Hepatitis C virus (HCV) disease remains the most common chronic hepatitis infection in the U.S.  Genotype 1 has the highest prevalence in the population and is the most difficult to eradicate.  One year treatment with combination of injectable interferon and ribovarin has been the mainstay of therapy for nearly a decade (with high incidents of side effects).  The addition of a new oral protease inhibitor, Telaprevir, to the current antiviral regimen has recently been shown to increase cure rates from 41% to 67%.  The medication is expected to be approved by the FDA in 2011.

Many hepatologist have recommended that chemistry laboratories adjust their ALT values with “normal” being less than 30 for men and 19 for women..  Based on these criteria, any patient that is deemed to have elevated LFTs should be screened by serological studies.  Also, any person of Asian descent, offspring or spouse of patients with chronic viral hepatitis, and individuals with high risk lifestyles need serological screening.

I am in the camp that recommends that everyone from newborn to middle age (?50) should be universaly vaccinated against the Hepatitis B virus (or preferably Hepatitis A/B vaccine —- Twinrix)