The document discusses hepatitis, including its definition, causes, types, transmission, symptoms, diagnosis, management, and prevention. It addresses hepatitis A, B, C, D, and E in detail. Key points include that hepatitis can be caused by viruses, drugs, toxins, and other factors; it often causes inflammation of the liver; and types A, B, and C tend to cause acute or chronic conditions requiring antiviral treatment and lifestyle changes.

1. BY:
Vishnu.R.Nair
Third Year Pharm D
National College of Pharmacy(NCP),
Kerala University of Health Sciences (KUHS), Kerala State

2.  GENERAL ACKNOWLEDGEMENT 
 DEFINITION 
 ETIOLOGY (CAUSES ) OF HEPATITIS 
 EPIDEMIOLOGY 
 MODE OF TRANSMISSION 
 VIRUS DETAILS 
 TYPES OF HEPATITIS 
 PATHOPHYSIOLOGY OF HEPATITIS 
 SIGNS AND SYMPTOMS OF HEPATITIS 
 DIAGNOSIS OF HEPATITIS 
 RISK FACTORS FOR HEPATITIS 
 MANAGEMENT OF HEPATITIS 
 BIBLIOGRAPHY 

3.  To The Almighty, for blessing me to make this ppt , and share it to all
 To my parents, the support of without whom I am nothing
 To my relatives and cousins , for their constant backing and support
 To my friends, well-wishers and loved ones , for their presence, guidance and emotional
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4.  “Inflammation of the liver, due to hepatotropic (liver
preferring) viruses, drugs , or associated
factors……………………..”

5. A. HEPATOTOXINS :
Include :
- Excess alcohol consumption
- Drugs:
1. Isoniazid 2. Nitrofurantoin 3. Methyldopa 4. Acetaminophen
B. METABOLIC DISORDERS:
- Example : Wilson’s Disease
C. BLOOD TRANSFUSIONS
D. AUTOIMMUNITY

6. E. INFECTIOUS AGENTS:
1. Bacteria
2. Viruses:
a. Hepatitis Viruses (HAV, HBV, HCV, HDV, HEV , HGV)
b. Miscellaneous Viruses:
- Adenovirus
- CMV (Cytomegalovirus)
- EBV (Epstein-Barr Virus)
- Herpes Simplex Virus
6. I.V DRUG ABUSE…………………………..

7. 1. As per statistics of CENTRE FOR DISEASE CONTROL AND PREVENTION (CDC):
- For HAV infection : 2,979 cases were reported in 2007
- For HBV infection : 4,519 cases were reported in 2007
- For HCV infection : 849 cases were reported in 2007
2. 3.2 million people in the United States have Chronic Hepatitis
3. 1.4 million infections occur annually
4. HBV is responsible for 1 million deaths annually……………..

8. 1. PARENTERAL ROUTES:
- Injections
- Blood transfusions
- Non-sterilized syringe use
- Tattooing
2. FAECAL, ORAL ROUTE :
- Via contaminated food and water
3. VERTICAL TRANSMISSION (From mother to fetus)
4. SEXUAL TRANSMISSION…………………..

9. 1. HAV (HEPATITIS ‘A’ VIRUS):
- Incubation period : 2-7 weeks (average 28 days)
- Also known as “Infectious Hepatitis “
- Mainly occurs due to UNSANITARY CONDITIONS
- Mode of Transmission :
a. Contaminated food and water
b. Fecal- oral route
c. Sexual route………………………………

10. 2. Hbv (hepatitis ‘b’ virus ):
- Incubation period : 30-180 days (average 75 days )
- Also known as ‘Serum Hepatitis’, since it was found that HBV could be spread only by
blood/ serum
- Now, it is found that HBV can also be spread via:
a. Sexual contact b. Shared needles among drug abusers c. Blood transfusions d.
Hemodialysis e. Vertical transmission f. Tattooing(Body piercing)
- Causes high risk of CHRONIC LIVER CONDITIONS, like :
a. Liver cirrhosis
b. Liver cancer (Hepatocellular carcinoma )
c. Liver failure………………………….

11. 3. HCV (HEPATITIS ‘C’ VIRUS ):
- Incubation period : 50-150 days
- Mode of transmission include :
a. Shared needles among drug abusers
b. Hemodialysis
c. Sexual route (rare)
- Also associated with CHRONIC LIVER CONDITIONS………………………..

12. 4. Hdv (hepatitis ‘d’ virus ):
- Incubation period : 5 weeks
- Also known as “Delta Virus”
- Small virus, that requires concomitant infection with HBV in order to survive
- HBV  Provides surface antigen (envelope protein)  required by HDV for survival
- Mode of Transmission : Same as that of HBV
- (HBV+ HDV) combined infection  difficult to treat………………………….

13. 5. HEV (HEPATITIS ‘E’ VIRUS):
- Incubation period : 2-9 weeks (approximately 45 days)
- Similar to HAV in terms of disease
- Transmitted by contaminated water
- Most common in Asia
6. Hgv (hepatitis ‘g’ virus):
- Resembles HCV
- Not much common………………………………..

14. 1. ACUTE HEPATITIS :
- Mainly caused by HAV
- Seldom causes permanent liver damage, that leads to liver failure
2. CHRONIC HEPATITIS :
- Mainly caused by HBV and HCV
- Leads to CHRONIC LIVER CONDITIONS
- Lasts longer than 6 months
- Viruses live and multiply in liver for years / decades
- For idiopathic reasons  Patient’s immune system is unable to eradicate the virus  leads
to chronic inflammation of the liver  Causes extensive liver scarring, liver cancer and liver
failure………………………

15. 3. ACUTE FULMINANT HEPATITIS :
- Individuals, with acute infections of HAV & HBV  Develop severe inflammation of liver
 Causes liver failure
- Such patients, are highly ill, with symptoms of ACUTE HEPATITIS, along with:
a. Confusion/ coma (due to liver’s failure to detoxify chemicals)
b. Bruising/ bleeding (due to lack of blood clotting factors)…………………………………

16. Here, we will discuss pathophysiology of :
1. HEPATITIS ‘A’
2. HEPATITIS ‘B’

17.  PARENTERAL/ ORAL INOCULATION OF HAV into body  causes accumulation of
INFECTIVE VIRIONS  HAV enters HEPATOCYTES (Liver cells)  HAV replicates
inside Hepatocytes  Leads to 2 conditions :
a. Viral antigen gets shed into bile and through feces (a condition, known as ‘infectivity’)
b. Initiation of host immune response (T-cell activity, monocytes)  release cytokines 
cause hepatocellular injury
• In some cases  Jaundice occurs  Significant liver dysfunction is observed(along with
hepatocellular damage )  convalescence occurs by subsequent therapeutical measures 
recovery
• In most cases  ‘Acute anicteric phase’ is observed  mild symptoms, along with
minimum hepatocellular damage  convalescence occurs by subsequent therapeutical
measures  recovery…………………………..

18. • HBV enters body (through any mode of transmission routes explained earlier )  HBV
enters hepatocytes  HBV replicates inside liver cells  Release 3 types of antigens :
a. Hbc Antigen b. Hbs Antigen c. HbVe Antigen
• The above antigens  expressed on hepatocellular surface  triggers host immune
response  leads to 2 types of immune activities:
a. T-CELL ACTIVATION:
- T-Cell activation  releases cytokines and activates cytotoxic T-cells  Cytokines cause
direct liver cell injury  Cytotoxic T-cells cause lysis of infected hepatic cells  Liver
injury
b. B- CELL ACTIVATION :
- B-Cell activation  produces 3 antibodies ( Anti-Hbs, Anti-HbVe, Anti-Hbc)  cause liver
injury by damaging the liver cell in an attempt to destroy virus………………………….

19.  Can be divided into 3 stages:
1. Prodromal stage :
- Observed 1-2 weeks after viral exposure
- Anorexia - Nausea - Vomiting - Fatigue - Arthralgia - Myalgia
- Headache - Photophobia - Pharyngitis - Fever - Cough - Taste
alterations
2. ICTERIC PHASE :
- Observed 1-2 weeks after PRODROMAL PHASE
- Continues for 2-6 weeks - Clay colored stools
- Yellowish colour of skin, sclera and urine - Hepatomegaly (liver enlargement)

20. 3. Convalescence phase (recovery phase ):
- Resolving of symptoms
- Liver enzyme levels comes to normal
- Hepatomegaly condition still persists
- Lasts for 6-12 weeks……………………………….

21.  Based on symptoms and clinical findings :
- Fatigue - Nausea - Dark urine - Abdominal pain
* Based on blood tests :
- Liver enzyme tests (Elevated ):
a. AST/ SGOT levels will be elevated (normal = 5-40 units of serum)
b. ALT/ SGOT levels will be elevated (normal = 7-56 units of serum)
- Antibodies to Hepatitis virus test
- Viral proteins/ genetic material test
- Antibody to HBV core test :
Here  An antibody is directed against inner core (nucleus ) of virus (core antigen)

22. - Anti-HAV test
- HCV antibody test
- Antibodies to Hepatitis B surface antigen test
- Detection of the following:
a. Hbc Antigen b. Hepatitis B surface antigen c. Hepatitis B DNA d. HbVe Antigen
e. Hepatitis C RNA
• OTHER TESTS :
- Ultrasound scanning (to detect bile duct obstruction , like in gallstones or cancer)
- Liver biopsy……………………………………….

23. 1. Workers in health care profession
2. Asian and Pacific Islanders
3. People , with multiple sex partners
4. Sewage and water treatment workers
5. i.v. drug abusers
6. HIV patients
7. People with Hemophilia, who receive blood clotting factors
8. Chronic alcoholics
9. People, living in unsanitary conditions
10. Hepatotoxic drug overdoses………………………………

24. Includes:
1. GOALS OF THERAPY
2. TREATMENT FOR ACUTE HEPATITIS ‘A’
3. TREATMENT FOR CHRONIC HEPATITIS ‘B’
4. TREATMENT FOR ACUTE HEPATITIS ‘B’
5. TREATMENT FOR CHRONIC HEPATITIS ‘C’
6. TREATMENT FOR ACUTE FULMINANT HEPATITIS
7. NON –PHARMACOTHERAPY / PATIENT COUNSELLING TIPS/ HOME REMEDIES
FOR HEPATITIS
8. PREVENTION OF HEPATITIS…………………………..

25. A. To alleviate signs and symptoms
B. To arrest viral growth and multiplication
C. To avoid progression into complications
D. To reduce morbidity and mortality
E. To ensure patient recovery as soon as possible
F. To improve QOL (Quality Of Life)………………………….

26.  Relive symptoms of nausea, vomiting and abdominal pain
 Focus on supportive care
 No anti-viral therapy available
 For patients, with increased rate of nausea and vomiting  recommend hospitalization 
decreases risk of dehydration
 For patients, with acute liver failure  recommend close monitoring  decreases risk of
Fulminant Hepatic Failure (FHF)
 Give special attention to medicines/ compounds , that cause hepatocellular damage (alcohol,
acetaminophen, etc. )
 Avoid SEDATIVES and TRANQUILIZERS  Decreases risk of Liver failure on brain 
Decreases risk of lethargy and coma
 Provide i.v. fluids  prevents dehydration caused by vomiting…………………..

27. - Involves medications (usually combination therapy) , in order to eradicate the virus
- Quit alcohol , smoking and multiple sex partners
- Medications include :
A. INJECTABLE INTERFERON-ALPHA (INTRON A):
- Synthesized by Recombinant DNA Technology
- MOA: Drug  modulates host immune response  useful in anti-viral therapy
- ADRs:
i. Fatigue ii. Fever iii. Neutropenia iv. Flu-like syndrome v. Myalgia
- Dose : 3 million units s.c. thrice weekly………………………………..

28. B. ORAL LAMIVUDINE (EPIVIR):
- Nucleoside Reverse Transcriptase Inhibitor (NRTI)
- MOA : Drug  Gets phosphorylated Inhibits viral Reverse Transcriptase enzyme 
causes viral DNA chain termination
- ADR :
a. Cough
b. Headache
- Dose :
100 mg P.O every day………………………….

29. C. ORAL ADEFOVIR (HEPSERA):
- Acyclic nucleotide analog
- MOA : Drug  inhibits HBV DNA polymerase  Blocks reverse transcriptase activity 
decreases viral DNA synthesis.
- ADR :
a. Hematuria
b. Diarrhea
- Dose :
10 mg P.O every day………………………

30. D. ORAL TENOVIR (VIREAD):
- Nucleoside reverse transcriptase inhibitor
- 2 forms are used : ‘AF’ and ‘DF’ (prodrugs)
- MOA :
Drug  competes with substrate ‘deoxyadenosine-5’ triphosphate’  incorporates into viral
DNA  DNA chain termination of virus occurs
- Drug  Also inhibits Reverse transcriptase
- ADR :
a. Asthenia b. Diarrhea
- Dose :
300 mg P.O every day……………………………………………

31. E. ORAL ENTECAVIR (BARACLUDE ):
- MOA : Drug  inhibits HBV DNA polymerase  Blocks reverse transcriptase activity 
decreases DNA synthesis
- ADR :
a. Fatigue
b. Headache
- Dose :
1 mg P.O every day…………………………….

32. Focus on supportive care
Focus on the following medications :
a. ADEFOVIR (already explained before )
b. LAMVUDINE (already explained
before)……………………………………

33. - Stop smoking, alcohol , i.v drug abuse , and multiple sex partners
- Involves medications (combination therapy) , to eradicate the virus
- Medications include :
A. INJECTABLE INTERFERONS:
- Already explained above
- Different forms of interferons include :
a. Interferon- Alpha (2b) {INTRON A}
b. Interferon- Alphacon 1 {INFERGEN}
c. Peg Interferon- Alpha (2b) {PEG-INTRON}
d. Pegylated Interferon- Alpha (2a) {PEGASYS}…………………………

34. B. ORAL RIBAVIRIN ( REBETOL, COPEGUS ):
- Anti-viral nucleoside analog
- Chemical name : D-RIBOFURANOSYL, 1,2,4- TRIAZOLE -3- CARBOXAMIDE
- Little effect when given alone  thus given in combination with INTERFERONS
- Dose :
10.6 mg/ kg orally OD, or in 2 divided doses
- ADR:
a. Fatigue
b. Hemolysis
c. Rigors……………………………….

35. C. ORAL BOCEPREVIR (VICTRELIS):
- NS3/4A PROTEASE INHIBITORS
- MOA:
Drug  binds reversibly to non-structural protein (NS3) serine protease  inhibits NS3/4A
serine protease  decreases HCV replication
- Given in combination with PGN-INTERFERON ALPHA and RIBAVIRIN
- ADR:
a. Fatigue
b. Anemia
- Dose:
800 mg orally TID………………………..

36. D. ORAL SIMEPREVIR (OLYSIO):
- MOA :
Drug  inhibits HCV NS3/4A protease  inhibits HCV replication
- ADR :
a. Rash
b. Nausea
- Dose:
150 mg P.O every day, in combination with PGN- INTERFERON ALPHA and
RIBAVIRIN…………………………….

37. E. ORAL TELAPREVIR (INCIVEK):
- MOA:
Drug  inhibits HCV NS3/4A protease  prevents HCV replication
- ADR:
a. Rash
b. Fatigue
- Not used nowadays………………………….

38. Should be done in centers that perform LIVER
TRANSPLANTATION
High mortality rate (80%) associated with Fulminant
hepatitis, without liver transplantation  thus the
procedure is inevitable……………………………

39. A. Avoid exposure to viruses, via :
- Dirty needle exposure
- Unprotected sex
- Body secretions and waste (stools, vomit ,etc.)
B. Immunoglobulin usage :
- Immune serum globulin (ISG) : Human serum , that contains antibodies to Hepatitis A
- Given as prophylaxis to Hepatitis ‘A’
- Immediate onset of action
- Longer duration
- HBIG (BAY HEPATITIS B): Should be given within 10 days of Hepatitis B exposure

40. C. VACCINATIONS:
i. FOR HEPATITIS ‘A’:
- HEPATITIS A Vaccine (HAVRIX , VAQTA)  Contains inactive/ killed Hepatitis ‘A’ virus
- For adults  2 doses are enough
- Mainly recommended for :
a. Travellers to countries with Hepatitis A endemic conditions
b. Homo-sexuals
c. Illegal drug users
d. Clotting factor disorders

41. B. FOR HEPATITIS ‘B’:
- Give harmless Hepatitis B antigen to stimulate antibody production against surface antigens
- Here, Recombinant DNA Technology comes into effect
- Hepatitis B Vaccine ( ENERGIX-B, RECOMBIVAX-HB):
Recommended for :
a. Infants
b. Lab technicians
c. Patients receiving kidney hemodialysis
d. Patients, suffering from hemophilia, who receive blood clotting factors

42. C. FOR HEPATITIS ‘C’ :
- No vaccine available for Hepatitis C
- Researchers claim that according to preliminary search results , a vaccine can be made that
will be effective against HCV antigen
- It is believed that such a vaccine will appear in 2-4 years…………………….

43. D. FOR HEPATITIS ‘D’:
- No vaccine for Hepatitis ‘D’ available
- HBV vaccine  prevents/ protects a person (not affected with HBV ) from contracting
HDV  Since HDV requires HBV to survive and proliferate………………………

44. A. AVOID DEHYDRATION (Have fruit juices, broths ,etc. as far as
possible)
B. DIET (Consume a diet rich in calories and proteins)
C. Avoid alcohol and smoking
D. LICORICE ROOT :
- LICORICE ROOT  Processed into GLYCYRRHETINIC ACID  Has powerful anti-
viral and anti-inflammatory properties  provides relief from hepatitis symptoms 
gives liver a chance to heal and recover
E. MILK THISTLE :
- Common and popular home remedy  plays active role in cell regeneration of liver 
heals and strengthens liver  available as supplements in pills forms

45. F. ST.JOHN’S WORT :
- Take 1 tsp of St. John’s Wort tincture  dissolve in water  consume 3
times a day OR 3 tablets of the above extract each day
- St. John’s Wort  Well known anti-viral compound  helps to prevent
infections caused by Hepatitis viruses
- Available as OTC (OVER-THE-COUNTER) Supplement
also………………………………

46. 1. “PHARMACOTHERAPY: A
PATHOPHYSIOLOGIC APPROACH” ,by
Joseph .T . Dipiro , Barbara. T. Wells
2. http:// www.webmd.com
3. www.healthline. Com
4. emedicine.medscape.com
5. www.medicinenet.com

47. THANK YOU !!!!   
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