Definition
• Chronic hepatitis is the damage and deterioration of the liver parenchyma structure with necrosis and fibrosis as a result of inflammation in the liver lasting longer than six months.
• The most common cause is hepatitis viruses, and many reasons other than viruses can lead to chronic hepatitis.
Etiology
• Viruses: Hepatitis C (most common), B, D
• Non-alcoholic fatty hepatitis (NASH)
• Alcohol
• Drugs: Amiodarone, aspirin, dantrolene, isoniazid, methyl dopa, propylthiouracil, phenytoin, nitrofurantoin, sulfonamide
• Other: Wilson's disease, hemochromatosis, alpha-1 antitrypsin deficiency, autoimmune hepatitis
• Cryptogenic hepatitis (The cause is not clear, it may be NASH or autoimmune.)
• In general, the most common cause of chronic hepatitis in the world is hepatitis C.
Clinic
• Most patients with chronic hepatitis are asymptomatic until advanced stages.
• They are usually noticed due to elevated transaminase levels or positive viral markers detected in tests performed for another reason.
• While weakness and fatigue are common symptoms, jaundice is a common finding in advanced cases.
Chronic Viral Hepatitis Pathology:
• Classification of viral hepatitis according to histopathological activity is made with the Knodell scoring system.
• Inflammation and cell damage in the liver are graded by the histological activity index (HAI) between 0-18 (mild-moderate-severe).
• Fibrosis is divided into stages between 0-6.
• Moderate and severe hepatitis, stage: ?: 2 fibrosis is treated with antivirals, other mild conditions are followed without treatment.
Treatment of Chronic Viral Hepatitis
Chronic hepatitis B treatment
• Treatment Indications:
ALT higher than normal
HBV DNA > 2,000 IU/ml or > 10,000 copies/ml
Moderate/advanced hepatitis or stage >= 2 fibrosis on liver biopsy
• Immunomodulator or antiviral drugs are used in the treatment of hepatitis B.
• Combined drugs are not used in the treatment of hepatitis B.
Immunomodulatory drugs: Interferon (IFN) and pegylated interferon (Peg-IFN).
It is not given in patients with cirrhosis.
Antiviral drugs: Lamivudine, adefovir, telbivudine, entecavir and
is tenofovir.
The resistance development rate is the highest in lamivudine, entecavir and
lowest on tenofovir.
The rate of development of resistance in entecavir is very low, whereas in tenofovir it is G. This
Therefore, these are the 2 most commonly used drugs in the treatment of HBV today.
• Hepatitis B immunoprophylaxis:
A person who has been exposed to hepatitis B virus before may experience viral reactivation later in life under intense immunosuppression.
In case of immunosuppression in hepatitis B carriers, it is recommended to start prophylaxis with an antiviral drug before starting the immunosuppressive.
Even if HbsAg is negative, antiviral prophylaxis is still recommended in very high-risk treatments and procedures in individuals who have had the disease and are anti-Hbc positive. These processes are:
Stem cell transplant B-cell depletion agents: such as rituximab, Ofatumumab.
AntiHbs positivity alone does not require prophylaxis (interpreted as immunization with vaccination).
Chronic Hepatitis C Treatment:
• Treatment is indicated for all chronic hepatitis C patients with HCV RNA positive.
• Sofosbuvir+Ladipasvir is the most widely used treatment for chronic HCV.
is the regime.
• Another widely used treatment today is the combination of Ombitasvir Paritaprevir Ritonavir + Dasabuvir.
• In new treatments, the duration of treatment is 2-3 months, the success rate is 95-100%.
Oral antiviral drugs used in the treatment of HCV according to the mechanism of action
RNA polymerase inhibition: Ribavirin
NS3/4A protease inhibitors (first generation): PREVIR (boceprevir,-telaprevir)
NS3/4A protease inhibitors (second generation): PREVIR (asunaprevir, grazoprevir, paritaprevir, simeprevir)
NS5A inhibitors: ASVIR (daclatasvir, ledipasvir, elbasvir, ombitasvir, velpatasvir)
NS5B inhibitors: BUVIR (sofosbuvir, dasabuvir)
Chronic Hepatitis D Treatment
Treatment is indicated in all patients with chronic active hepatitis D.
High-dose pegylated interferon is the only recommended treatment for at least 1 year. Antiviral agents are not effective.