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A - NAPLEX > Chapter 19: Hepatitis & Liver Disease > Flashcards

Chapter 19: Hepatitis & Liver Disease Flashcards

1
Q

How is Hepatitis A transmitted

A

fecal-oral route through improper hand washing after exposure to an infected person or via contaminated food/water

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2
Q

How are Hep B and C transmitted

A

contact with infectious blood or other body fluids

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3
Q

Which type(s) of hepatitis has a vaccine

A

Hep A and B

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4
Q

First-line treatment for Hep A

A

Supportive therapy

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5
Q

First-line treatment for Hep B

A

PEG-INF or NRTI (tenofovir or entecavir)

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6
Q

First-line treatment for Hep C

A

Treatment naiive: DAA combination (2-3 with different mechs)
Other: DAA combination + RBV or DAA combination + RBV + PEG-INF

DAA treatment lasts 8-12 weeks

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7
Q

What is the purpose of ritonavir for HCV

A

used to boost levels of HCV protease inhibitors used with it

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8
Q

T/F: DAAs offer a cure for most patients with HCV

A

True

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9
Q

Which drug class ends in -privir

A

NS3/4A Protease inhibitor (P for PI)

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10
Q

Which drug class ends in -asvir

A

N55A Replication Complex Inhibitor (A for N55A)

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11
Q

Which drug class ends in -buvir

A

N55B Polymerase Inhibitor (B for N55B)

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12
Q

What do the protease inhibitors used for HIV and HCV have in common?

A

They are taken with food

Remember: PIG - Protease Inhibitors & Grub

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13
Q

Boxed warning for all DAAs

A

Risk of reactivating HBV

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14
Q

Warning for sofosbuvir-containing regimens

A

Serious symptomatic bradycardia has been reported when amiodarone is taken with sofosbuvir-containing regimen; do not use together

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15
Q

Sofosbuvir/velpatasvir brand name

A

Epclusa

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16
Q

Glecaprevir/pibrentasvir brand name

A

Mavyret

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17
Q

How are the tablets in Viekira Pak taken

A

2 tabs of paritaprevir/ritonavir/ombitasvir once daily in the morning and 1 dasabuvir tablet twice daily with meals

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18
Q

T/F: Sofosbuvir monotherapy is NOT effective and NOT recommended

A

True

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19
Q

Which HCV drugs must you avoid or minimize acid suppressive therapy with during treatment

A

Epclusa, Harvoni, & Vosevi

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20
Q

Which HCV drugs are pan-genotypic (approved for all 6 HCV genotypes) for treatment naive

A

Epclusa & Mavyret

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21
Q

CI for paritaprevir/ritonavir/ombitasvir (Technivie)

+ dasabuvir (Viekira Pak)

A

3A4 substrates or inducers & use with ethinyl estradiol, lovastatin & simvastatin

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22
Q

Warnings for paritaprevir/ritonavir/ombitasvir (Technivie)

+ dasabuvir (Viekira Pak)

A

Hepatic decompensation/failure in patients with cirrhosis, risk of increased LFTs, significant drug interaction potential

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23
Q

CI for Elbasvir/grazoprevir (Zepatier)

A

3A4 inducers

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24
Q

warnings for Elbasvir/grazoprevir (Zepatier)

A

Risk of increased LFTs, significant drug interaction potential

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25
Q

All DAAs are CI with strong ____

A

inducers of 3A4 (e.g., carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin, and St. John’s Wort)

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26
Q

____, ____ & ____ can decrease concentrations of ledipasvir and velpatasvir

A

Antacids, H2RAs, PPIs

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27
Q

PPIs are not recommended for use with ____

A

Epclusa

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28
Q

Do not use Harvoni with ____

A

Stribild

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29
Q

T/F: Ribavirin CANNOT be used as monotherapy for HCV

A

True - use in combo with other drugs (DAAs and/or interferon alfa)

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30
Q

Aerosolized ribavirin has been used for

A

Respiratory syncytial virus (RSV)

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31
Q

Ribavirin boxed warnings

A

Significant teratogenic effects; hemolytic anemia

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32
Q

Ribavirin CI

A

pregnancy

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33
Q

Ribavirin side effects

A

Hemolytic anemia

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34
Q

When should pregnancy be avoided with Ribavirin

A

during therapy and 6 months after completion; need 2 reliable forms of contraceptives

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35
Q

Which form of INF-alfa prolongs the half-life, reducing the dose to once weekly

A

Pegylated form

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36
Q

Interferon alfas are used for:

Interferon betas are used for:

A

alfa: HBV, HCV, & some cancers
beta: multiple sclerosis

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37
Q

INF-alfa boxed warnings

A

can cause or exacerbate neuropsychiatric, autoimmune, ischemic or infectious disorders; if used with ribavirin, teratogenic/anemia risk

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38
Q

INF-alfa side effects

A

~~~
CNS effects (fatigue, depression)

GI upset

increased LFTs (5-10x ULN during treatment)

myelpsuppression

Flu-like syndrome
fever
chills
HA
malaise

pre-treat with APAP and an antihistamine

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39
Q

T/F: Interferon alfa CANNOT be used as monotherapy

A

FALSE

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40
Q

What is the preferred treatment for HBV

A

INF-alfa

41
Q

MOA of NRTIs

A

Inhibit HBV replication by inhibiting HBV polymerase resulting in DNA chain termination

42
Q

What should be done before a patient can start on an NRTI for HBV

A

All pts should be tested for HIV

43
Q

Why must patients be tested for HIV before starting an NRTI

A

Antivirals used for HBV can have activity against HIV and if a pt is co-infected with both HIV and HBV, it is important that the chosen therapy is appropriate for both viruses to minimize risk of HIB antiviral resistance

44
Q

All HBV NRTIs should have a decreased dose or frequency with CrCl < ____ mL/min

A

50

45
Q

Boxed warnings for all NRTIs

A

Lactic acidosis and severe hepatomegaly with steatosis, which can be fatal
Exacerbations for HBV upon d/c

46
Q

Tenofovir disoproxil brand name

A

Viread

remember - read dis

47
Q

Tenofovir alafenamide brand name

A

Vemlidy

48
Q

Entecavir brand name

A

Baraclutide

49
Q

Lamivudine brand name

A

Epivir HBV

50
Q

Which NRTIs are the preferred therapy in HBV

A

Tenofovir disoproxil
Tenofovir alafenamide
Entecavir

51
Q

Which NRTI should be taken on an empty stomach

A

Entecavir (Baraclutide)

remember - empty and entecavir both start with E

52
Q

Tenofovir disoproxil & Tenofovir alafenamide warnings

A

renal toxicity and/or Fanconi syndrome, osteomalacia, and decreased bone mineral density

53
Q

Tenofovir disoproxil side effects

A

renal impairment, decreased bone mineral density

54
Q

Tenofovir alafenamide side effects

A

nausea

Less renal and bone toxicity

55
Q

Adefovir (Hepsera) boxed warnings

A

Caution in pts with renal impairment or those at risk of renal toxicity (including concurrent nephrotoxic drugs or NSAIDs)

56
Q

Lamivudine boxed warning

A

Do not use Lamivudine HBV for treatment of HIV

57
Q

Lamivudine side effects

A

HA, N/V/D

58
Q

Tenofovir disoproxil & tenofovir alafenamide should not be used with ____ due to increased risk of virologic failure and potential for increased side effects

A

Adefovir

remember this b/c they have the same ending of -fovir

59
Q

Most common causes of cirrhosis

A

Hepatitis C and alcohol consumption

remember this b/c Hep C and cirrhosis

60
Q

Clinical presentation of cirrhosis

A

yellowed skin and yellowed whites of the eyes (jaundice)

61
Q

Albumin will be (high or low) in liver disease

Total bilirubin?

PT?

A

low
High
High

62
Q

Which type of liver disease is associated with:

↑ AST/ALT

A

Acute liver toxicity, including from drugs

63
Q

Which type of liver disease is associated with:
↑ AST/ALT, Alk Phos, Tbili, LDH, PT/INR
↓ Albumin

A

Chronic liver disease (e.g., cirrhosis)

64
Q

Which type of liver disease is associated with:

↑ AST > ↑ ALT (AST will be ~2x ALT), ↑ GGT

A

Alcoholic liver disease

65
Q

Which type of liver disease is associated with:

↑ ammonia

A

Hepatic encephalopathy

66
Q

Which type of liver disease is associated with:

↑ Tbili

A

Jaundice

67
Q

In general, caution is advised when using hepatically cleared drugs in which Child Pugh class

A

Class C (severe liver disease)

68
Q

Which natural product is used for liver disease

A

Milk Thistle

69
Q

Which natural product is a known hepatotoxin

A

Kava

70
Q

Hepatotoxic drugs are typically d/c when the LFTs are > ___ xULN

A

3 times ULN

71
Q

Which class of drugs should be avoided in patients with cirrhosis because they can lead to decompensation, including bleeding

A

NSAIDs

72
Q

Key drugs that have a boxed warning for liver damage

A 
APAP
Amiodarone
Isoniazid
Ketoconazole (oral)
MTX
Nefazodone
Nevirapine
NRTIs
PTU
Tipranavir
Valproic Acid
73
Q

Alcoholic liver disease can include

A

fatty liver, alcoholic hepatitis, and chronic hepatitis

74
Q

chronic alcohol ingestion over a long period of time causes

A

“steatosis” or fatty liver

75
Q

Which drugs are used for relapse in alcoholics

A

Naltrexone
acamprosate
disulfuram

76
Q

Which vitamin is used to prevent and treat Wernicke-Korsakoff syndrome in alcoholics

A

Thiamine (Vitamin B1)

77
Q

Portal hypertension can cause complications including the development and bleeding of

A

esophageal varices (enlarged veins in the lower part of the esophagus)

78
Q

What are recommended first line treatments for bleeding varices

A

Band ligation (putting a band around the vessel) or sclerotherapy (injecting a solution into the vessel to make it collapse and close)

79
Q

Which drug is selective for the splanchnic vessels

A

Octreotide

80
Q

Which drug is non-selective for the splanchnic vessels

A

Vasopressin

81
Q

Which drug class should be added after resolution of variceal bleeding for secondary prevention

A

Non-selective BB

82
Q

Which non-selective BB are used for primary prevention of variceal bleeding

A

Nadolol and propranolol

83
Q

Nadolol brand name

A

Corgard

84
Q

The BB used for portal hypertension is titrated to the max tolerated dose with a target HR between ___ = ___ BPM and continued indefinitely

A

55-60 BPM

85
Q

What are symptoms of hepatic encephalopathy

A

musty odor of breath and/or urine, changes in thinking, confusion, forgetfulness, hand tremor (asterixis)

result from an accumulation of gut-derived nitrogenous substances in the blood such as ammonia

86
Q

Besides drug therapy, how is hepatic encephalopathy treated

A

Reducing blood ammonia levels through the diet (limiting the amount of animal protein)

87
Q

Which drug is first-line for both acute and chronic (prevention) therapy for hepatic encephalopathy

A

Lactulose followed by rifaximin

88
Q

Lactulose works by

A

converting ammonia products by intestinal bacteria to ammonium

89
Q

Lactulose side effects

A

Flatulence, diarrhea, dyspepsia, abdominal discomfort

90
Q

Rifaximin brand name

A

Xifaxan

91
Q

Neomycin boxed warning

A

Neurotoxicity

92
Q

Neomycin SE

A

GI upset

93
Q

Metronidazole should not be used long term d/t

A

peripheral neuropathies

94
Q

What is ascites

A

fluid accumulation within the peritoneal space

95
Q

Patients with ascites d/t portal HTN should restrict ______

A

dietary sodium intake

96
Q

Diuretic therapy for ascites can be initiated with either ______ monotherapy or with a combination of ____ and ____

A

Spironolactone monotherapy

Furosemide and spironolactone

97
Q

When Furosemide and spironolactone are used in combination for ascites, they should be titrated to a max weight loss of 0.5 kg/day with a ratio of ____ mg furosemide to ___ mg spironolactone to maintain K balance

A

40 mg furosemide:100 mg spironolactone

98
Q

Which antibiotic is used for Spontaneous bacterial peritonitis

A

Ceftriaxone to target Steptococci and enteric Gram negative pathogens

A - NAPLEX (83 decks)

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