First, treatment
1. General treatment:During the active stage, hospitalization and bed rest are required, and easy-to-digest, vitamin-rich, and sufficient-calorie diets should be consumed. After the condition improves, appropriate activities can be performed. Eating too much should be avoided to maintain normal nutritional status and weight. Overeating and lack of movement can lead to obesity and hyperlipidemia, even fatty liver.
2. General treatment:Including liver-protecting drugs, immunosuppressants, and immunomodulators.
(1) Liver-protecting drugs: There are two types, chemical drugs and traditional Chinese medicine preparations.
①Chemical drugs: A large amount of vitamin C, inosine, vitamin B6, and complex phosphatase can be used. For those with long-term elevated transaminases accompanied by disorders of glucose metabolism, insulin-glucose therapy can be tried; for those with disorders of fat metabolism, inositol can be used. Silymarin (Yiganling) 6 tablets per day, taken in three doses, can not only improve liver function but also inhibit liver fibrosis, with good efficacy.
②Herbal medicine preparations: There are many kinds of herbal medicines effective for the treatment of this disease. The following lists several effective preparations:
A. Scutellaria baicalensis tablet: It is a flavonoid effective component extracted from the root of Scutellaria baicalensis, with the effects of clearing heat, detoxifying, anti-inflammatory, and anti-allergic. The side effects are only mild gastrointestinal reactions. 2 tablets each time, 3 times a day, suitable for patients with long-term elevated transaminases with low increase range.
B. Schisandra: It is now known that its effective ingredients are Schisandrin A, B, C, and D, which have a good effect on reducing transaminases, but the long-term efficacy is poor, and there is often a rebound phenomenon in transaminases after discontinuation of the drug. Some patients may experience mild stomachache, acid regurgitation, and discomfort in the upper abdomen after taking the drug, and the addition of alkaline drugs can reduce gastrointestinal reactions. This drug is not suitable for cases of chronic active ulcer and fat metabolism disorder. The dose is 2 capsules of Schisandrin ester twice a day, each containing 2 grains; 3 tablets of Schisandrin tablets each time, 3 times a day.
C. Sediophilus: The active ingredient is Sedophyllin, which has the effects of clearing heat, promoting diuresis, and detoxification. The long-term efficacy of this drug is not ideal, and there may be a rebound phenomenon in transaminases after discontinuation of the drug, so it is necessary to discontinue the drug slowly to avoid the rebound of transaminases. The dose is 2 tablets each time, 3 times a day.
(2) Immunosuppressants:
①Glucocorticoids: Have non-specific anti-inflammatory and immunosuppressive effects. Due to the suppression of antibody production in the body by hormones, it may lead to HBsAg carrier state and other side effects, so it should be strictly controlled. The indications are: A. Negative HBsAg, severe autoimmune response with multiple organ system damage. B. Histologically confirmed chronic active hepatitis with obvious clinical symptoms, continuous elevation of transaminases for 10 weeks and increased gamma globulin. The dose of hormones should generally be small or moderate, 20-40mg of prednisone or prednisolone per day, taken in 3-4 divided doses. After the condition is relieved, the dose can be gradually reduced to maintenance dose. 5-10mg of prednisone or prednisolone per day. A course of treatment is 6 months to 1 year or more.
②Azathioprine: A derivative of mercaptopurine (6-mercaptopurine) with the action of blocking DNA synthesis, thereby inhibiting the proliferation of immunoglobulins and T cells. The indications for the use of this drug are: A. Severe reaction after the use of hormones. B. Concurrent diabetes that is not suitable for the use of hormones. C. Inability to control symptoms with the use of hormones alone. The initial dose is 1.5mg/kg per day, and regular blood counts, liver function, and renal function tests should be performed during the medication period. Currently, it is widely advocated to use it in combination with hormones, with 50mg of azathioprine plus 30mg of prednisolone daily. After the efficacy is shown, prednisolone should be reduced to maintenance dose, 10mg per day, or 50mg of azathioprine plus 10mg of prednisolone, which has the same efficacy as 20mg of prednisolone.
③D-penicillamine: A sulfur-containing amino acid with the function of inhibiting pathological humoral immune response, and can also reduce liver tissue damage caused by immune complexes under the participation of complement. It can be administered by increasing the dose, starting with 100mg each time, 3 times a day, and then gradually increasing the dose, about 300mg per week, until the maximum maintenance dose of 900-1200mg per day. After the liver function improves, the dose can be gradually reduced, 3 times a day, 100-200mg each time, for 6-9 months as a course of treatment.
④ Other: Chloroquine 0.25g per time, 2 times a day, 2-4 weeks as a course of treatment, with poor efficacy and significant side effects.
(3) Immune enhancers: They can restore the body's cellular immune function to normal levels, clear the virus, and thus restore the condition. The existing immune enhancers include immune ribonucleic acid, transfer factor, levamisole, and Yunzhi Gan Tai Granule. They are described as follows:
① Immune ribonucleic acid (abbreviated as IRNA): It is divided into two major categories, specific and non-specific. Specific immune ribonucleic acid is the hepatitis B immune ribonucleic acid prepared from the spleen and lymph nodes of horses and sheep with passive immunity, which mainly acts to transmit specific immune information, that is, to transfer the specific immune function from the immune ribonucleic acid extracted from the immune animals with HBsAg to humans, in order to enhance the specific immune function of humans, enhance the body's immune function, clear HBsAg, and terminate the chronic infection state of hepatitis B. The dosage is 1-2mg per time, injected 1-2 times a week, subcutaneously around the axillary or inguinal lymph nodes, and 4-6 months as a course of treatment. It is reported that the efficacy rate is more than 60%.
The non-specific immunoribonucleic acid extracted from the peripheral leukocytes and spleen leukocytes of normal people has been used to treat chronic active hepatitis with positive HBsAg. After application, more than 80% of patients' lymphocyte transformation test, E-rosette test, skin delayed hypersensitivity test and other cell immune indicators increased, but the rate of HBsAg conversion to negative was low. The dosage is 3mg per time, once a week. It is injected subcutaneously on the inner side of the upper arm below the armpit, and 4-6 months as a course of treatment.
② Transfer factor: It is divided into two types, specific and non-specific. Abroad, the efficacy of specific transfer factor in the treatment of chronic active hepatitis is basically negative. China mostly uses non-specific transfer factor prepared from mixed leukocytes of normal people, and the T cell function of most patients can be increased after application. Some patients may experience transient exacerbation of liver function after taking the medicine, which may be due to the improvement of cellular immunity of the body, indirectly promoting humoral immune function of B cells. If the symptoms are not significantly exacerbated, it can be continued to use, and the liver function can still be normal. The dosage is once a week, 1-2U per time, injected subcutaneously on the inner side of the upper arm, and 20-30 weeks as a course of treatment.
③ Levamisole: It has the effects of promoting macrophage phagocytic function and enhancing T cell immune function. The dosage is 150mg per day, taken twice a day. The efficacy of this drug is not ideal and can be used in combination with hormones. It has good efficacy for chronic active hepatitis with negative HBsAg.
④ Yunzhi Gan Tai Granule: It is a Chinese proprietary medicine with strong immune-enhancing effects. It has good hypolipidemic effects, improves liver function rapidly, and is a non-specific T cell immune enhancer. The dosage is 5g per time, 3 times a day, and a course of treatment lasts for 3 months.
(4) Other: It has been reported abroad that interferon inducers have certain efficacy for chronic active hepatitis with positive HBsAg, and currently in China, polyinosinic acid (PolyI∶C) is mainly used to induce the production of endogenous interferon. Interferon can make virus-infected cells produce antiviral proteins, affect the transcription and translation during virus replication, and inhibit the synthesis of viral proteins. The general dosage is 0.5-1mg each time, twice a week, and two weeks as one course. Two to four courses can be judged for efficacy. Preliminary findings show that HBsAg of patients can turn negative, and transaminases can decrease to normal. The administration of high doses of vitamin C during treatment can enhance the efficacy of interferon inducers by 3 times.
Cyclosporin and tacrolimus have been successfully used in patients who are ineffective to hormone treatment.
(5) Symptomatic treatment: As chronic active hepatitis is a multisystemic disease, in addition to systemic treatment, symptomatic treatment should be carried out in a timely manner when symptoms caused by extrinsic system damage are severe.
① Joint symptoms: Non-hormonal anti-inflammatory analgesics such as aspirin and ibuprofen can be given in appropriate doses, and the dosage should be small.
② When myocarditis is severe, in addition to systemic treatment, appropriate drugs for nourishing the myocardium, such as coenzyme A and adenosine triphosphate, should be given according to circumstances.
③ Chronic renal failure: appropriate antihypertensive treatment should be carried out, and drugs to correct acidosis, reduce blood potassium levels, and promote protein synthesis should be given.
④ When anemia is severe, appropriate blood transfusion and medication to stimulate bone marrow should be given.
⑤ When there is a significant tendency to hemorrhage, a larger dose of vitamin K can be given.
⑥ Other: Once infection occurs, effective anti-infection treatment should be carried out in a timely manner. During the period of immunosuppressive therapy, infections are mostly opportunistic infections, the causative agents are mostly Gram-negative bacilli, so appropriate drugs should be used. In addition, timely and proper treatment is required for hepatic coma.
II. Prognosis
It varies due to different causes and severity of the disease. Mild cases may resolve into chronic persistent hepatitis, severe cases may develop into liver cirrhosis, and liver cancer may occasionally be found. Patients with negative HBsAg after treatment have a good prognosis.
Factors affecting prognosis include alcoholism, heavy physical labor, secondary infection, improper medication, untimely treatment, and incomplete treatment.