Within the alphabet of hepatitis, there is a letter that is not talked about much. We refer to hepatitis D and, despite being considered as ‘forgotten’, its prevalence has increased in recent years. Specifically, it is around 5% in Spain, according to the Spanish Society of Digestive Pathology (SEPD). This disease was believed to be practically extinct in the 1990s, when it affected 20% of patients with chronic hepatitis B virus infection. Precisely, one of the characteristics of this infection, which involves inflammation of the liver caused by the hepatitis delta virus (HDV), is that, for it to replicate, it needs the hepatitis B virus (HBV). According to the World Health Organization (WHO), “co-infection with both viruses is considered the most severe form of chronic viral hepatitis, given its faster progression to hepatocellular carcinoma and death from liver causes.” Federico García, spokesperson for the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), also emphasizes this problem, lamenting that the problem with hepatitis D is that the evolution to cirrhosis or another serious disease is much more accelerated than in the rest of hepatitis. “If a person is infected with hepatitis C, it can take 40 or 50 years before cirrhosis develops, but with hepatitis D, the evolution is faster. Therefore, the patients in these cases are younger,” he notes. The patient profile The profile of the patient infected with hepatitis D has changed over the last decades. In the 1980s and 1990s, most of those affected had used intravenous drugs, as well as hemophiliacs who had received blood transfusions contaminated with the two viruses. However, although there is no vaccine against hepatitis D, there is one for HBV. Therefore, since HDV cannot be produced in the absence of hepatitis B, the vaccine for the latter infection also serves to prevent the former. In this way, thanks to the vaccination programs against the hepatitis B virus at the end of the last century, the prevalence decreased a lot in our country. However, as already mentioned, the number of cases has increased again in recent years, why? García replies that the answer lies in migratory movements: “Normally, they are migrant patients who come from endemic countries in Eastern Europe and sub-Saharan Africa where there is a high prevalence of delta hepatitis.” “These migratory flows come from areas where hepatitis D still has a high prevalence, so experts must be alert and look for HDV in patients with chronic hepatitis B infection,” warned Manuel Rodríguez García, specialist in Apparatus Digestive of the Central University Hospital of Asturias (Oviedo) during the presentation “Hepatitis D, the great unknown”, framed in the LXXXI Congress of the SEPD. What are the treatments available? Experts feel the lack of current therapeutic arsenal to address hepatitis D. Rodríguez clarified that “unlike hepatitis B and C, in D there are no treatment options with an acceptable response rate, which causes the disease to have worse prognosis and patients who suffer from it have a higher risk of suffering from cirrhosis or liver cancer. Specifically, the only treatment available in Spain is interferon, but, as García states, this drug has very little efficacy, since it manages to limit the replication of the virus in only 10 or 20% of those infected. In addition, he adds that “interferon is a molecule that has many side effects and that patients do not usually tolerate well, so they avoid using it.” Fortunately, new pharmacological advances other than interferon have recently appeared with much higher efficacy and tolerance. “Between 50 and 70% of the patients treated with these antivirals manage to reduce the viral load and the replication of the virus”, affirms the SEIMC member. One of these antiviral drugs is bulevirtide, a drug that is already authorized by the European Medicines Agency (EMA) and the American Medicines Agency (FDA), but not yet by the Spanish Agency for Medicines and Health Products (Aemps), although, as García assures, “it is a matter of very little time before they can be used in real life”. For his part, Rodríguez warned that “it is urgently needed that Spain approve new therapeutic options against hepatitis D and that the new generations of gastroenterologists begin to look for it in all patients with B virus infection.”
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