Chapter 19: Hepatitis & Liver Disease Flashcards by Rohit Sampat

How is Hepatitis A transmitted

fecal-oral route

through improper hand washing after exposure to an infected person

or via contaminated food/water

How well did you know this?

Not at all

Perfectly

How are Hep B and C transmitted

contact with infectious blood or other body fluids

How well did you know this?

Not at all

Perfectly

Which type(s) of hepatitis has a vaccine

Hep A and B

How well did you know this?

Not at all

Perfectly

First-line treatment for Hep A

Supportive therapy

How well did you know this?

Not at all

Perfectly

First-line treatment for Hep B

PEG-INF

NRTI (tenofovir or entecavir)

How well did you know this?

Not at all

Perfectly

First-line treatment for Hep C

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

How well did you know this?

Not at all

Perfectly

What is the purpose of ritonavir for HCV

used to boost levels of HCV protease inhibitors used with it

How well did you know this?

Not at all

Perfectly

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

DAA = direct acting antiviral

True

How well did you know this?

Not at all

Perfectly

Which drug class ends in -privir

NS3/4A Protease inhibitor (P for PI)

How well did you know this?

Not at all

Perfectly

Which drug class ends in -asvir

N55A Replication Complex Inhibitor (A for N55A)

How well did you know this?

Not at all

Perfectly

Which drug class ends in -buvir

N55B Polymerase Inhibitor (B for N55B)

How well did you know this?

Not at all

Perfectly

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

They are taken with food

Remember: PIG - Protease Inhibitors & Grub

How well did you know this?

Not at all

Perfectly

Boxed warning for all DAAs

Risk of reactivating HBV

How well did you know this?

Not at all

Perfectly

Warning for sofosbuvir-containing regimens

Serious symptomatic bradycardia

has been reported when amiodarone is taken with sofosbuvir-containing regimen

do not use together

How well did you know this?

Not at all

Perfectly

Sofosbuvir/velpatasvir brand name

Epclusa

How well did you know this?

Not at all

Perfectly

Glecaprevir/pibrentasvir brand name

Mavyret

How well did you know this?

Not at all

Perfectly

How are the tablets in Viekira Pak taken

2 tabs of paritaprevir/ritonavir/ombitasvir once daily in the morning

and 1 dasabuvir tablet twice daily with meals

How well did you know this?

Not at all

Perfectly

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

True

How well did you know this?

Not at all

Perfectly

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

Epclusa

Harvoni

Vosevi

How well did you know this?

Not at all

Perfectly

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

Epclusa

Mavyret

How well did you know this?

Not at all

Perfectly

CI for paritaprevir/ritonavir/ombitasvir (Technivie)

+ dasabuvir (Viekira Pak)

3A4 substrates or inducers

& use with ethinyl estradiol, lovastatin & simvastatin

How well did you know this?

Not at all

Perfectly

Warnings for paritaprevir/ritonavir/ombitasvir (Technivie)

+ dasabuvir (Viekira Pak)

Hepatic decompensation/failure in patients with cirrhosis

risk of increased LFTs

significant drug interaction potential

How well did you know this?

Not at all

Perfectly

CI for Elbasvir/grazoprevir (Zepatier)

3A4 inducers

How well did you know this?

Not at all

Perfectly

warnings for elbasvir/grazoprevir (Zepatier)

Risk of increased LFTs

significant drug interaction potential

How well did you know this?

Not at all

Perfectly

All DAAs are CI with strong ____

inducers of 3A4 carbamazepine oxcarbazepine phenobarbital phenytoin rifampin rifabutin St. John's Wort

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

Antacids H2RAs PPIs

PPIs are not recommended for use with ____

Epclusa

Do not use harvoni with ____

Stribild

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

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

Aerosolized ribavirin has been used for

Respiratory syncytial virus (RSV)

Ribavirin boxed warnings

Significant teratogenic effects hemolytic anemia

Ribavirin CI

pregnancy

Ribavirin side effects

Hemolytic anemia

When should pregnancy be avoided with Ribavirin

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

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

Pegylated form

Interferon alfas are used for: | Interferon betas are used for:

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

INF-alfa boxed warnings

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

INF-alfa side effects

``` 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

T/F: Interferon alfa CANNOT be used as monotherapy

FALSE

What is the preferred treatment for HBV

INF-alfa

MOA of NRTIs

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

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

All pts should be tested for HIV

Why must patients be tested for HIV before starting an NRTI

Antivirals used for HBV can have activity against HIV 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

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

Boxed warnings for all NRTIs

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

Tenofovir disoproxil brand name

Viread *remember - read dis*

Tenofovir alafenamide brand name

Vemlidy

Entecavir brand name

Baraclutide

Lamivudine brand name

Epivir HBV

Which NRTIs are the preferred therapy in HBV

Tenofovir disoproxil Tenofovir alafenamide Entecavir

Which NRTI should be taken on an empty stomach

entecavir (Baraclutide) *remember - empty and entecavir both start with E*

Tenofovir disoproxil & Tenofovir alafenamide warnings

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

Tenofovir disoproxil side effects

renal impairment decreased bone mineral density

Tenofovir alafenamide side effects

nausea | Less renal and bone toxicity

Adefovir (Hepsera) boxed warnings

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

Lamivudine boxed warning

Do not use Lamivudine HBV for treatment of HIV

lamivudine side effects

HA N/V/D

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

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

Most common causes of cirrhosis

Hepatitis C alcohol consumption | *remember this b/c Hep C and cirrhosis*

Clinical presentation of cirrhosis

yellowed skin and yellowed whites of the eyes (jaundice)

Albumin will be (high or low) in liver disease Total bilirubin? PT?

low High High

Which type of liver disease is associated with: | ↑ AST/ALT

Acute liver toxicity including from drugs

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

Chronic liver disease (e.g., cirrhosis)

Which type of liver disease is associated with: | ↑ AST > ↑ ALT (AST will be ~2x ALT), ↑ GGT

Alcoholic liver disease

Which type of liver disease is associated with: | ↑ ammonia

Hepatic encephalopathy

Which type of liver disease is associated with: | ↑ Tbili

Jaundice

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

Class C (severe liver disease)

Which natural product is used for liver disease

Milk Thistle

Which natural product is a known hepatotoxin

Kava

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

3 times ULN

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

NSAIDs

Key drugs that have a boxed warning for liver damage

``` APAP Amiodarone Isoniazid Ketoconazole (oral) MTX Nefazodone Nevirapine NRTIs PTU Tipranavir Valproic Acid ```

Alcoholic liver disease can include

fatty liver alcoholic hepatitis chronic hepatitis

chronic alcohol ingestion over a long period of time causes

"steatosis" or fatty liver

Which drugs are used for relapse in alcoholics

naltrexone acamprosate disulfuram

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

Thiamine (Vitamin B1)

Portal hypertension can cause complications including the development and bleeding of

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

What are recommended first line treatments for bleeding varices

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

Which drug is selective for the splanchnic vessels

Octreotide

Which drug is non-selective for the splanchnic vessels

vasopressin (Vasoatrict)

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

Non-selective BB

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

nadolol propranolol

Nadolol brand name

Corgard

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

55-60 BPM

What are symptoms of hepatic encephalopathy

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

Besides drug therapy, how is hepatic encephalopathy treated

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

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

Lactulose followed by rifaximin

Lactulose works by

converting ammonia products by intestinal bacteria to ammonium

Lactulose side effects

Flatulence diarrhea dyspepsia abdominal discomfort

rifaximin brand name

Xifaxan

Neomycin boxed warning

Neurotoxicity

Neomycin SE

GI upset

Metronidazole should not be used long term d/t

peripheral neuropathies

What is ascites

fluid accumulation within the peritoneal space

Patients with ascites d/t portal HTN should restrict ______ | d/t = due to

dietary sodium intake

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

Spironolactone monotherapy | Furosemide and spironolactone

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

40 mg furosemide:100 mg spironolactone

Which antibiotic is used for Spontaneous bacterial peritonitis

Ceftriaxone to target Steptococci and enteric Gram negative pathogens

Chapter 19: Hepatitis & Liver Disease Flashcards

(98 cards)