Liver disease often results from hepatitis that manifests as either an acute event or as a chronic condition, the latter of which can culminate in organ failure, need for transplant, and even death. Hepatitis C virus (HCV) is the most common form of hepatitis, but only one in four patients suffering from it gets diagnosed. The CDC recently recommended that anyone born between 1945 and 1965 receive HCV antibody testing. As many as 1 million new cases of chronic HCV may be uncovered with this dictum.
Nonalcoholic fatty liver disease (NAFLD) is another important cause of hepatitis and is the most common cause of elevated liver function tests. It’s expected to become the most common indication for liver transplantation by 2020. Based on current trends in NAFLD, there is great cause for concern on how best to manage these patients.
Importantly, cirrhosis is a stage of NAFLD that has been associated with hepatic encephalopathy (HE), a condition associated with cognitive impairment that significantly reduces quality of life (QOL). Symptoms of HE range from subtly altered mental status to deep coma. The cyclical nature of the illness can be difficult to break and doesn’t resolve completely until a transplant is received or the patient dies. The direct and indirect costs of managing HE are rising, and admissions for HE have increased significantly over the past 8 years. Additionally, patients suffering from HE tend to relapse, which can further exacerbate problems.
Hepatitis Treatments Becoming More Effective
Neomycin, lactulose, and rifaximin are the only FDA-approved treatments for HE, but the therapeutic paradigm is ever-changing. Historically, treatment for overt HE has begun when symptoms arise, often resulting in hospitalization. Long-term survival is also poor, ranging from 42% over 1 year to 23% over 3 years. Physicians are now striving to recognize HE and treat it earlier. For example, efforts are being made to treat patients diagnosed with cirrhosis prior to the development of subclinical HE. The hope is that we can slow disease progression and reduce hospitalizations while improving our patients’ QOL.
For 30 years, lactulose has been an effective treatment for HE, but this therapy is associated with drug-related side effects, many of which can affect QOL and result in poor disease control due to the need for daily dosage adjustments. This has led to the exploration of less cumbersome treatment options. Rifaximin, the most recently FDA-approved option, offers patients an effective therapy without the side effects that have been linked to other agents. As a result, most patients prefer rifaximin and tend to remain compliant to therapy, reducing the likelihood of hospitalization from remission.
Get an Early Hepatitis Diagnosis
An early diagnosis is pivotal to managing hepatitis and its potential side effects, and treatment options are dictated by the source of the hepatitis. However, most patients with hepatitis remain undiagnosed until cirrhosis develops. This is a point at which treatment is less effective. As awareness of the growing prevalence of chronic liver disease continues, it’s hoped that greater efforts will be made to recognize hepatitis and HE early and that treatments will be provided at a time when they can be most effective.
Readings & Resources (click to view)
National Institute of Diabetes and Digestive and Kidney Disease. Digestive diseases statistics for the United States. Available at: http://digestive.niddk.nih.gov/statistics/statistics.htm#specific. Accessed September 11, 2012.
Bass NM, Mullen KD, Sanyal A, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362:1071-1081.
Bajaj JS, Schubert CM, Heuman DM, et al. Persistence of cognitive impairment after resolution of overt hepatic encephalopathy. Gastroenterology. 2010;138:2332-2340.
Arguedas MR, DeLawrence TG, McGuire BM. Influence of hepatic encephalopathy on health-related quality of life in patients with cirrhosis. Dig Dis Sci. 2003;48:1622-1626.
Munoz SJ. Hepatic encephalopathy. Med Clin North Am. 2008;92:795-812, viii.
Al Sibae MR, McGuire BM. Current trends in the treatment of hepatic encephalopathy. Ther Clin Risk Manag. 2009;5:617-626.
Mullen KD, Ferenci P, Bass NM, Leevy CB, Keeffe EB. An algorithm for the management of hepatic encephalopathy. Semin Liver Dis. 2007;(suppl):32-48.
Bajaj JS, Sanyal AJ, Bell D, Gilles H, Heuman DM. Predictors of the recurrence of hepatic encephalopathy in lactulose-treated patients. Aliment Pharmacol Ther. 2010;31:1012-1017.
Eroglu Y, Byrne WJ. Hepatic encephalopathy. Emerg Med Clin North Am. 2009;27:401-414.
Lawrence KR, Klee JA. Rifaximin for the treatment of hepatic encephalopathy. Pharmacotherapy. 2008;28:1019-1032.