Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute HDV infection

1st line – supportive care

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ACUTE
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acute HDV infection
1st line – 

supportive care

Manage patients with acute hepatitis D virus (HDV) infection with supportive care, according to their symptoms (e.g., encouraging the patient to remain hydrated and maintaining nutrition).

  • No antiviral drugs are approved for acute HDV infection.

Note that >95% of immunocompetent adults with simultaneous HDV/hepatitis B virus (HBV) coinfection will spontaneously clear the virus. However, evolution to chronic infection may occur in >90% of patients with superinfection (HDV infection in a person with chronic HBV infection).[34]

Monitor patients for any change in clinical status that indicates progression to a disease state that requires treatment.[2]

Consider – liver transplantation

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ACUTE
|
acute HDV infection
Consider – 

liver transplantation

Treatment recommended for SOME patients in selected patient group

Evaluate patients with fulminant hepatitis for liver transplantation due to the high risk of mortality in this group of patients without transplant.[12]​ See Acute liver failure.

  • Transplantation in eligible patients is associated with an excellent outcome.[55]

ONGOING

chronic HDV infection

1st line – peginterferon alfa

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ONGOING
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chronic HDV infection
|
compensated cirrhosis or no cirrhosis
1st line – 

peginterferon alfa

Offer peginterferon alfa-2a in all eligible patients with chronic hepatitis D virus (HDV) infection with detectable HDV RNA (with or without associated compensated cirrhosis).[1]​ The preferred duration of treatment is 48 weeks.[1][56]​​​​​

  • Note that the National Institute for Health and Care Excellence (NICE) in the UK recommends giving peginterferon alfa-2a to patients with chronic HDV infection only if there is evidence of significant fibrosis (METAVIR stage ≥F2 or Ishak stage ≥3) (see Criteria).[56]

  • Consider personalized treatment durations based on HDV RNA and hepatitis B surface antigen (HBsAg) kinetics and treatment tolerability.[1]

  • Consider stopping treatment if there is no decrease in HDV RNA following 6 or more months of treatment.[56]

  • Stop treatment after HBsAg seroconversion.[56]

  • Treatment success is defined as undetectable HDV RNA 24 weeks after completing treatment.[2]​ One review of 13 studies including 1078 patients demonstrated that the overall virological response (defined as undetectable HDV RNA after 24 weeks following the end of treatment), was 31%.[57]​ However, relapses of HDV RNA occur commonly in the post-treatment phase and have been reported even 5-10 years after the end of treatment.[58]

  • Peginterferon alfa is contraindicated in patients with decompensated cirrhosis.

Evaluate patients with hepatocellular carcinoma for antiviral treatment on an individual basis.[1] See Hepatocellular carcinoma.

Primary options

peginterferon alfa 2a: 180 micrograms subcutaneously once weekly for 48 weeks

Plus – treatment of hepatitis B coinfection

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ONGOING
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chronic HDV infection
|
compensated cirrhosis or no cirrhosis
Plus – 

treatment of hepatitis B coinfection

Treatment recommended for ALL patients in selected patient group

Add a nucleoside/nucleotide analog (e.g., entecavir, tenofovir) in all patients with compensated cirrhosis and detectable hepatitis B virus (HBV) DNA, regardless of HBV DNA levels.[1] Also consider nucleoside/nucleotide analog therapy in patients with persistent HBV infection, especially if HBV DNA levels are close to or higher than 2000 IU/mL.[1][2]​​​ See Hepatitis B.

1st line – treatment of hepatitis B coinfection

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ONGOING
|
chronic HDV infection
|
decompensated cirrhosis
1st line – 

treatment of hepatitis B coinfection

Give a nucleoside/nucleotide analog (e.g., entecavir, tenofovir) to patients with decompensated cirrhosis irrespective of the presence of detectable HBV DNA.[1]

Consider – liver transplantation

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ONGOING
|
chronic HDV infection
|
decompensated cirrhosis
Consider – 

liver transplantation

Treatment recommended for SOME patients in selected patient group

Evaluate patients with decompensated cirrhosis for liver transplantation.[1][2]​​ This may include patients with end-stage liver disease as well as those with fulminant hepatitis.[12]​

  • Transplantation in eligible patients is associated with an excellent outcome.[55]

  • If liver transplantation is not possible, a best-supportive-care strategy is recommended.[1] See Cirrhosis.​

Give patients who have undergone liver transplantation for chronic HDV infection hepatitis B immune globulin combined with a high genetic barrier nucleoside/nucleotide analog after transplantation.[1]

Prioritize optimal treatment for hepatocellular carcinoma (including liver transplantation) in patients with chronic HDV infection and hepatocellular carcinoma.[1] See Hepatocellular carcinoma.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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