HBV/HCV Co-infection

Management and Treatment

Well established treatment guidelines exist for patients with chronic hepatitis B and chronic hepatitis C; however, there is no currently established standard of care for HBV/HCV co-infected patients.

In general, the same treatment criteria should be applied to patients who are HBV/HCV co-infected as are applied to patients only infected with one of the viruses. Initiation of treatment, as with both HBV and HCV mono-infections, is recommended in patients with active chronic hepatitis or cirrhosis prior to decompensation.

Currently licensed drugs for chronic hepatitis B in the United States include:

Interferon Alpha (Intron A) is given by injection several times a week for six months to a year, or sometimes longer. The drug can cause side effects such as flu-like symptoms, depression, and headaches. Approved 1991 and available for both children and adults.

Pegylated Interferon (Pegasys) is given by injection once a week usually for six months to a year. The drug can cause side effects such as flu-like symptoms and depression. Approved May 2005 and available only for adults.

Lamivudine (Epivir-HBV, Zeffix, or Heptodin) is a pill that is taken once a day, with few side effects, for at least one year or longer. Approved 1998 and available for both children and adults.

Adefovir Dipivoxil (Hepsera) is a pill taken once a day, with few side effects, for at least one year or longer. Approved September 2002 for adults. Pediatric clinical trials are in progress.

Entecavir (Baraclude) is a pill taken once a day, with few side effects, for at least one year or longer. Approved April 2005 for adults. Pediatric clinical trials are in progress.

Telbivudine (Tyzeka, Sebivo) is a pill taken once a day, with few side effects, for at least one year or longer. Approved October 2006 for adults.

Tenofovir (Viread) is a pill taken once a day, with few side effects, for at least one year or longer. Approved August 2008 for adults.

Currently standard treatment for hepatitis C is peginterferon alfa-2a or 2b plus ribavirin. Both hepatitis B and C patients with decompensated liver disease or fulminant hepatitis (rare with acute hepatitis C) are candidates for liver transplantation.

Thorough serologic and virologic testing is required in HBV/HCV co-infected patients prior to consideration of treatment. Assessment of the "dominant" virus is helpful in determining a treatment strategy. Caution must be taken with treatment of coinfected individuals, as increased liver disease after beginning therapy has been described, likely due to loss of viral suppression from the successfully treated dominant virus.

In co-infected patients with HCV dominant disease, interferon (IFN) plus ribavirin treatment has been well studied and has proven efficacy. In patients with HBV dominant disease, IFN with or without lamivudine is a reasonable option. Further studies of other HBV treatment agents such as adefovir and entecavir are needed before these agents can be routinely recommended, though they may be used on a case-by-case basis.

In addition, future studies are needed to assess the effectiveness of peginterferon as well as triple therapy with lamivudine, IFN, and ribavirin in coinfected patients, though peginterferon should generally be used in place of standard interferon in coinfected patients given its proven efficacy in HBV and HCV mono-infected patients.

Resources:

Natural history and treatment of hepatitis B virus and hepatitis C virus coinfection
Seth D Crockett and Emmet B Keeffe

Management of Special Groups: HCV-HBV Coinfection

Page last modified December 14, 2009