Hepatitis A, B and C

Hepatitis is a disease of the liver characterized by the presence of inflammatory cells in the tissue of the organ. Hepatitis may occur without symptoms but can lead jaundice(a yellow discoloration of the skin, conjunctiva of mucus and conjunctiva of the eyes), poor appetite, and fatigue. Depending on the cause, hepatitis can manifest either as an acute or as a chronic disease.Acute hepatitis can be self-limiting(resolving on its own), can progress to chronic hepatitis, or can cause acute liver failure in rare instances. Chronic hepatitis may have no symptoms or may progress over time to fibrosis(scarring of the liver) and cirrhosis(chronic liver failure).Cirrhosis of the liver increases the risk of developing hepatocellular carcinoma(a form of liver cancer).

The most prevalent cause in the world is viral hepatitis, which is closely followed by non-alcoholic liver disease and alcoholic liver disease. Hepatitis can also be caused by autoimmune disorders, toxic substances consumed, some medications (like paracetamol), some industrial organic solvents, and certain plants.

PHC Issue

Hepatitis treatment varies depending on the type (chronic versus acute), severity, and underlying cause.

Hepatitis A

In most cases, hepatitis A does not become chronic and does not necessitate hospitalization. Supportive care involves giving intravenous (IV) fluids and keeping a healthy diet.

Rarely, patients with the hepatitis A virus may experience fulminant hepatic failure, a sudden onset of liver failure, especially the elderly and those with a history of liver illness, particularly hepatitis C. Greater age and chronic hepatitis C are risk factors for mortality. In these situations, more extensive supportive care and a liver transplant may be required.

Hepatitis B

Acute

Antiviral therapy is not necessary in healthy patients because 95–99% of them recover without any permanent effects. An illness may last longer and be more severe if you're older and have other health issues. Hospitalization is necessary for some individuals, particularly those who exhibit ascites, peripheral edema, and hepatic encephalopathy clinical signs as well as hypoglycemia, a prolonged prothrombin time, low blood albumin, and extremely high serum bilirubin laboratory signs.

Patients have had success with nucleoside analogs such entecavir or tenofovir, an antiviral medication comparable to that used in cases of chronic hepatitis B, in these uncommon, more severe acute cases. Experts advise saving treatment for severe acute instances rather than mild to moderate ones because there aren't enough clinical trial data and the medications used to treat are prone to developing resistance.

Chronic

The goal of managing chronic hepatitis B is to stop viral replication, which is linked to disease progression. To date, seven drug therapies have received approval in the US:

• The first treatment for chronic hepatitis B was injectable interferon alpha, which has a number of side effects, most of which can be reversed with therapy discontinuation. However, newer treatments, such as long-acting interferon bound to polyethylene glycol (pegylated interferon) and oral nucleoside analogs, have replaced it for this indication.
• Pegylated interferon (PEG IFN) is more practical and efficient than conventional interferon because it only needs to be administered once a week as a subcutaneous injection. It is poorly tolerated and necessitates regular monitoring, despite the fact that it does not build resistance like many oral antivirals do. PEG IFN is expected to cost about $18,000 per year in the US, compared to $2,500 to $8,700 for oral medications; however, its course of treatment is only 48 weeks, as opposed to the oral antivirals, which are typically administered for an indefinite period of time (at least one year) for most patients.] PEG IFN is ineffective in patients with high virus loads and cannot be administered to immunosuppressed or cirrhotic patients.
• The first approved oral nucleoside analog was lamivudine. Although powerful and efficient, lamivudine is no longer advised as the first-line therapy in the Western world due to the development of other, more potent therapies. The usage of newer agents is still prevalent in regions where they are either not authorized or too expensive. The average length of the treatment program is at least one year, plus "consolidation therapy" for at least an additional six months. Some individuals need long-term therapy for an indeterminate amount of time depending on the viral response. Consolidation therapy should be continued for at least a year because Asian people respond less well to it. Every patient should be kept an eye out for viral reactivation because, if it occurs, treatment must be restarted. In general, lamivudine is well-tolerated and safe. Resistance is frequently developed in patients, and longer treatment times are associated with it. If this happens, a further antiviral is added. Since resistance to lamivudine develops quickly, patients who are also HIV-positive should not receive it as a stand-alone treatment. However, lamivudine can be included in a multidrug regimen..
• Although it is no longer advised as first-line therapy, the nucleotide analog adefovir dipivoxil has been used to augment lamivudine in patients who acquire resistance.
• Entecavir is the most effective hepatitis B antiviral drug now available, is safe, well-tolerated, less likely to lead to resistance, and is a first-line therapy option. Patients who are HIV positive and those who are lamivudine-resistant should not use it as monotherapy.
• Because it is less potent and more prone to developing resistance than entecavir, telbivudine is effective but not advised as a first-line treatment.
• Tenofovir is a nucleotide analog and antiretroviral medication that is also used to treat HIV infection. It is preferred to adefovir for both initial treatment and patients who have developed resistance to lamivudine because it is more potent and less likely to do so.

Depending on patient and doctor desire, first-line therapies now utilized include PEG IFN, entecavir, and tenofovir. The American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) have issued recommendations for the initiation of treatment that are based on detectable viral levels, HBeAg positive or negative status, ALT levels, and, in some cases, a family history of HCC and a liver biopsy. Treatment is advised in patients with compensated cirrhosis regardless of HBeAg status or ALT level, but opinions on HBV DNA levels vary. The AASLD advises treatment when DNA levels are detectable above 2x103IU/mL, while the EASL and WHO advise treatment when HBV DNA levels are detectable at any level. If HBV DNA is found in patients with decompensated cirrhosis, therapy and evaluation for liver transplantation are always advised. Since individual treatment with entecavir or tenofovir is now more successful than multidrug therapy in the long run, it is not advised for the treatment of chronic HBV.

Hepatitis C

Compared to hepatitis A and B, chronic hepatitis C development is substantially more frequent. Preventing hepatocellular cancer is the main objective of hepatitis C treatment (HCC). Having a persistent virological response is the greatest method to lower the risk of HCC in the long run (SVR). A cure is indicated by an SVR, which is defined as an undetectable viral load at 12 weeks after the end of treatment. Antiviral medications with direct and indirect actions are currently used as therapies. Pegylated interferon (PEG IFN) and ribavirin (RBV), which have historically been used in tandem as the cornerstone of HCV therapy, are examples of indirect acting antivirals. Based on genotype, these treatments' effectiveness and duration vary. Although they are poorly tolerated, these agents are still used in some areas with limited resources. In high-resource nations, they have been replaced by direct acting antiviral agents, which debuted in 2011. These agents target the three classes of viral replication-related proteins and include:

• NS3/4A protease inhibitors, including telaprevir, boceprevir, simeprevir, and others
• NS5A inhibitors, including ledipasvir, daclatasvir, and others
• NS5B polymerase inhibitors, including sofosbuvir, dasabuvir, and others

Depending on the patient's genotype, these medications are sometimes taken with ribavirin in different dosages (delineated as genotypes 1-6) A direct-acting antiviral regimen can now treat genotype 1 (GT1), which is the most common genotype in the globe and in the United States. For the majority of patients, including those with severe fibrosis or cirrhosis, sofosbuvir and ledipasvir (SOF/LDV) for 12 weeks is the first-line treatment for GT1. Those with advanced fibrosis or cirrhosis who have not responded to past treatment require 24 weeks of treatment, but other individuals with early illness only need 8 weeks of treatment. Cost is still a significant barrier to access for these medications, especially in low-resource countries; the 12-week GT1 regimen (SOF/LDV) is estimated to cost US$94,500.

Except for those with additional chronic medical illnesses that shorten their life expectancy, the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD-IDSA) suggest antiviral treatment for all patients with chronic hepatitis C infection.

REFERENCE

Ambika Rai, Kabita Dahal. Community Health Nursing II. Kathmandu: Makalu Publication House, 2012 (reprint).

Dr.Suwal S.N. & Tuitui R. (2063) A Textbook of Community Health Nursing, 1st edition, Vidyarthi Prakashan (P). Ltd. Kamalpokhari, Kathmandu

HealthLine. 2005. 2017 http://www.healthline.com/health/hepatitis

MedicineNet. 1996. 2017 http://www.medicinenet.com/viral_hepatitis/article.htm

NHS Choice. http://www.nhs.uk/conditions/Hepatitis/Pages/Introduction.aspx

Tuitui, Roshani. Community Health Nursing. Kathmandu: Vidyarthi Prakashan (P.)

Web MD. 2005. 2017 http://www.webmd.com/hepatitis/