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Was ist gesichert in der Therapie der chronischen Virushepatitis?

Which treatment options are validated for chronic viral hepatitis?

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Zusammenfassung

Hintergrund

In den letzten 10 Jahren hat es einen dramatischen Wandel in der Therapie chronischer viraler Hepatitiden gegeben, insbesondere bei der Hepatitis B und C.

Fragestellung

Welche Therapiemöglichkeiten der viralen Hepatitiden sind wissenschaftlich gesichert und können für die Praxis empfohlen werden? Berücksichtigt wurden die aktuellen Studien zur Therapie der viralen Hepatitiden unter Beachtung der aktuellen deutschen und europäischen Leitlinien.

Datenlage

Die Therapie der chronischen Hepatitis B basiert entweder auf einer meist dauerhaften Therapie mit Nukleosid- bzw. Nukleotidanaloga oder einer zeitlich begrenzten Therapie mit pegyliertem Interferon-α (PEG-IFN). Die Hepatitis-D-Infektion setzt eine Infektion mit dem Hepatitis-B-Virus voraus. Eine Therapie erfolgt mit PEG-IFN, jedoch besteht eine hohe Rückfallquote. Die Therapie der chronischen Hepatitis C beruht seit vielen Jahren auf der Kombination von PEG-IFN und Ribavirin (RBV). Für die Therapiedauer und Dosierung ist die Kenntnis von Vortherapien, des Genotyps und des Vorhandenseins einer Leberzirrhose entscheidend. Für den Genotyp 1 sind seit 2011 direkt antivirale Medikamente zugelassen, die den Therapieerfolg deutlich steigern. Ein erneuter starker Wandel der Therapie der Hepatitis C in den nächsten Jahren ist abzusehen. Er wird das Nebenwirkungsprofil verbessern, die Wirksamkeit steigern und einen stärkeren Individualisierungsgrad bei schwer zu therapierenden Patienten ermöglichen. Die akute Hepatitis E verläuft selbstlimitierend, kann jedoch bei immunsupprimierten Patienten, insbesondere nach Organtransplantation chronifizieren. Eine Reduktion der Immunsuppression kann zu einer Ausheilung führen. RBV zeigt antivirale Wirksamkeit.

Schlussfolgerung

Aktuell zur Verfügung stehende Therapien bieten eine hohe Krankheitskontrolle bzw. Ausheilungswahrscheinlichkeit bei der Hepatitis B und C. Bezüglich der Hepatitis C ist abzusehen, dass sich die Therapien zukünftig massiv wandeln werden. Die Hepatitis-D-Koinfektion bleibt weiterhin schwer zu behandeln. Für die chronische Hepatitis E steht mit RBV eine erfolgversprechende Off-label-Behandlungsoption zur Verfügung.

Abstract

Background

In the last 10 years, a dramatic change has occurred in the treatment of chronic viral hepatitis, particularly in the area of hepatitis B and hepatitis C.

Objectives

Which treatment options of viral hepatitis are scientifically validated and can be recommended for practical use in consideration of current studies on the treatment of viral hepatitis and the German and European guidelines, respectively.

Current data

The treatment of chronic hepatitis B continues to be based either on a long-term therapy with nucleos(t)ide analogues or a finite therapy with pegylated interferon alpha (PEG-IFN). Treatment of hepatitis D is also based on PEG-IFN; however, the relapse rate is high. The treatment of hepatitis C is currently based on the combination of PEG-IFN and ribavirin (RBV). To estimate the optimal duration of therapy and dosage, knowledge of previous treatments, genotype, and presence of cirrhosis is crucial. For genotype 1, the first direct acting antiviral drugs were approved in 2011. These drugs led to a significant increase in treatment success. In the upcoming years another dramatic change in the treatment of hepatitis C is anticipated, including an improved side effect profile, increased efficacy, and a greater degree of customization in difficult-to-treat patients. Acute hepatitis E is usually self-limiting, but can become chronic in immunocompromised patients, i.e., after organ transplantation. Reduction of immunosuppression may clear HEV and RBV shows antiviral efficacy.

Conclusion

Currently available therapies have a high disease control or chance for cure in hepatitis B and C. In Hepatitis C treatment, a massive change in future therapies is foreseeable. The hepatitis D co-infection remains difficult to treat. For hepatitis E, RBV is a promising off-label treatment option.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. C. Höner zu Siederdissen: Honorar für Vortragstätigkeit für Merck (MSD). M. Cornberg: Honorare für Vortrags- oder Beratertätigkeiten für Merck (MSD), Roche Pharma, Roche Diagnostics, Gilead, BMS, Novartis und Falk. Forschungsunterstützung durch Merck (MSD), Roche Pharma, Roche Diagnostics und Gilead. M.P. Manns: Honorare für Vortrags- oder Beratertätigkeiten von Roche, Bristol-Myers Squibb, GlaxoSmithKline, Gilead, Merck, Janssen, Boehringer Ingelheim, Novartis, Vertex, Achillion und Idenix. Forschungsunterstützung durch Roche, Gilead, Novartis, Boehringer Ingelheim, BMS, Merck, Janssen und AbbVie. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    C. Höner zu Siederdissen, M.P. Manns &  M. Cornberg

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  1. C. Höner zu Siederdissen
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  2. M.P. Manns
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  3. M. Cornberg
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Correspondence to M. Cornberg.

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Höner zu Siederdissen, C., Manns, M. & Cornberg, M. Was ist gesichert in der Therapie der chronischen Virushepatitis?. Internist 54, 1427–1433 (2013). https://doi.org/10.1007/s00108-013-3319-3

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