Chronic Viral Hepatitis Flashcards by Jbun L

What are the two types of hepatitis that most commonly transition from acute to chronic?

Hepatitis B
Hepatitis C

How well did you know this?

Not at all

Perfectly

What differentiates acute vs chronic hepatitis infection?

Presence of virus in the blood 6 months after infection

How well did you know this?

Not at all

Perfectly

What biomarkers confirm chronic hepatitis B and hepatitis C infection?

Hepatitis B:
HBsAg

Hepatitis C:
Both anti-HCV and HCV RNA

How well did you know this?

Not at all

Perfectly

What is the consequence of untreated chronic viral hepatitis?

Development of cirrhosis, hepatocellular carcinoma and decompensation with end-stage liver disease

How well did you know this?

Not at all

Perfectly

Chronic hepatitis D is uncommon, but if patient is co-infected with B and D, the liver disease is typically _______ severe and has ________ clinical outcomes.

More
Worse

How well did you know this?

Not at all

Perfectly

Goal of therapy for hepatitis B is to __________.
Goal of therapy for hepatitis C is to __________.

Control viral replication
Cure

How well did you know this?

Not at all

Perfectly

What is defined as sustained viral suppression of hep B?

Undetectable serum HBV DNA (<10-15 units/mL)
Normalization of ALT

How well did you know this?

Not at all

Perfectly

___________ cure of hep B is the most desirable goal of therapy but is rare and not the goal for most treatments

Functional

How well did you know this?

Not at all

Perfectly

What is defined as functional cure of hep B?

HBsAg loss with or without appearance of anti-HBs

How well did you know this?

Not at all

Perfectly

What does it mean when patient develop anti-HBs following loss of HBsAg?

They become immune to hepatitis B. This is rare though.

How well did you know this?

Not at all

Perfectly

The goal of hep C is to cure. How do we define cure?

Sustained virologic response (SVR) which is defined as undetectable serum HCV RNA (<10-15 units/mL) 12 weeks after end of treatment

How well did you know this?

Not at all

Perfectly

Following Hep C cure, can you be re-infected?

Yes

How well did you know this?

Not at all

Perfectly

If patient is suspected to have chronic hepatitis B, how do we manage close contacts?

Test all household members and sexual contacts:
- HBsAg
- Anti-HBs

If contacts are negative for both, offer then hep B vaccine. Retest for anti-HBs 1 month after last dose to ensure response

How well did you know this?

Not at all

Perfectly

If HBV is confirmed, what other viruses should we test for? Why?

HCV and HIV
They have the same transmission route.

How well did you know this?

Not at all

Perfectly

How often should you monitor liver aminotransferases (ALT, AST) and liver function test (total bilirubin, serum albumin, INR) for chronic hep B?

Every 6-12 months

How well did you know this?

Not at all

Perfectly

Is liver biopsy recommended for hepatitis B patients?

No, not recommended.
Non-invasive testing like FibroScan is available.

How well did you know this?

Not at all

Perfectly

When is liver biopsy recommended?

Coexisting liver disease
Discrepancies from FibroScan, imaging and laboratory testing.

How well did you know this?

Not at all

Perfectly

What parameters would warrant treatment?

If there is HBeAg
HBV DNA levels
Persistent elevation of ALT >1 x ULN
Any indication of severe liver disease (biopsy, noninvasive fibrosis markers, imaging and lab tests

How well did you know this?

Not at all

Perfectly

What are some non-pharm we can recommend for patients with chronic hep B?

Advise against alcohol
Encourage smoking cessation
Recommend weight reduction if BMI >30
Blood sugar control if diabetic

How well did you know this?

Not at all

Perfectly

What is the goal of therapy with hepatitis B? Can Hep B be cured?

No cure for hep B.
Control disease by complete suppression of HBV DNA

How well did you know this?

Not at all

Perfectly

How do we avoid HBV reactivation once disease is resolved?

Oral antiviral therapy prophylactically

How well did you know this?

Not at all

Perfectly

What are the three classes of medication for treatment of hepatitis B?

Peginterferon alfa-2a
Nucleoside Analogues
Nucleotide Analogues

How well did you know this?

Not at all

Perfectly

What is the mechanism of action of peginterferon alfa-2a?

Antiviral and immunomodulatory effects promote seroconversion from HBeAg positive to anti-HBe positive

How well did you know this?

Not at all

Perfectly

When do we use peginterferon alfa-2a as treatment?

Chronic hep B patients who are HBeAG positive.
- Have persistently lower HBV DNA levels and elevated serum aminotransferase values

How well did you know this?

Not at all

Perfectly

Who should we avoid peginterferon alfa-2a in?

Acute episodes of Hep B (decompensated cirrhosis) - Increased risk of life threatening infection and worsening hepatic decompensation Immunosuppressed patients with chronic hep B HIV+

What drugs are in the nucleoside analogue drug class?

Lamivudine Entecavir

What drugs are in the nucleotide analogue drug class?

Tenofovir disoproxil fumarate (TDF) Tenofovir alafenamide (TAF) Adefovir

Which nucleos(t)ide analogues are first line?

TDF, TAF, and entecavir

What is the mechanism of action of nucleos(t)ide analogues?

Inhibit replication of HBV in patients who are HBeAg positive or negative

Resistance to therapy was a concern. Which nucleos(t)ide no longer has a concern with resistance?

TDF, TAF, entecavir

Why is lamivudine not a first-line therapy?

Low potency in reducing HBV DNA and high resistance rate.

What is lamivudine's role in chronic hepatitis B?

Prophylaxis to prevent disease reactivation in patients who are on immunosuppressive therapy who are HBsAg negative but anti-HBc positive

______ is a prodrug of _______ meaning it is inactive until metabolized into it's active form.

TAF is a prodrug of TDF

What is TDF active against?

HBV (including lamivudine-resistant HBV) HIV

Is TDF approved for monotherapy of chronic hep B?

Yes

What is TDF active against?

HBV (including lamivudine-resistant HBV) HIV

Is TAF approved for monotherapy of chronic hep B?

Yes

What makes TAF different from TDF, besides the fact that it is a prodrug?

TAF produces higher levels tenofovir diphosphate than TDF and therefore can be given at lower doses (lower toxicity potential).

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg - Anti- HBc + Anti- HBe +/- ALT status normal HBV DNA -

Immune from past exposure No antiviral therapy indicated. Assess for need of prophylaxis if patient receiving immunosuppressive therapy.

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg - Anti- HBc - Anti- HBe +/- ALT status normal HBV DNA -

Resolved infection No antiviral therapy. Monitor ALT and HBV DNA q 3-6 months. Assess for need of antiviral prophylaxis if patient undergoing immunosuppression

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg + Anti- HBc - Anti- HBe +/- ALT status normal HBV DNA often <2000

HBeAg- negative chronic infection No antiviral therapy. Monitor ALT and HBV DNA q3-6 months. Assess for need of prophylaxis therapy if patient is undergoing immunosuppression.

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg + Anti- HBc - Anti- HBe - ALT status normal HBV DNA often > 10 000 000

HBe-Ag positive chronic infection No antiviral therapy. Monitor ALT and HBV DNA q6 months Assess liver fibrosis. Treat only if severe disease suspected.

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg + Anti- HBc - Anti- HBe - ALT status elevated HBV DNA 10 000-10 000 000

HBeAg positive chronic hepatitis Consider therapy with peginterferon or nucelos(t)ide analogues (entecavir, TDF, TAF) if: - ALT is ≥1 × ULN and - viral load is >2000

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg + Anti- HBc - Anti- HBe + ALT status elevated fluctuates HBV DNA 1000 -10 000 000

HBeAg- negative chronic hepatitis Consider long-term therapy with nucleos(t)ide analogues (entecavir, TDF, TAF) if: - ALT is ≥1 × ULN and - viral load is >2000

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg + Anti- HBc - Anti- HBe +/- ALT status elevated HBV DNA >100

Decompensated cirrhosis Nucleos(t)ide analogue therapy lifelong

What is the preferred management for the following patient with chronic hep B? What would you categorize this patient as? HBsAg + Anti- HBc - Anti- HBe +/- ALT status elevated HBV DNA +

Post- liver transplant Nucleos(t)ide analogues plus HBIg

About ___to ___% of acute HCV infections in adults become chronic.

75-85

How is HCV most frequently acquired?

Illicit drug use (snorting cocaine, injecting drugs) Blood transfusions Tattooing Needle-stick injuries

What are risk factors for progressive fibrosis and cirrhosis in patients with chronic hepatitis C?

- Male gender - Being >40 years of age - Duration of infection - Alcohol consumption >50g daily - Co-infection with HIB - Immune suppression - Diabetes - Higher BMI

What makes the hepatitis C antibody (anti-HCV) different from antibodies in Hep A and B?

It's a marker for exposure, not immunity. Therefore an anti-HCV test is used for initial HCV testing

How do we confirm with there is an active infection?

HCV RNA detection by PCR

If patient receives negative anti-HCV test, what is the follow-up procedure?

HCV RNA or follow-up anti-HCV testing should be done if HCV exposure occurred within past 6 months or if patient is immunocompromised

Which patients should be screened for Hep C regardless of risk factors due to their 5x baseline risk?

Patients born between 1945-1975

Following Hep C treatment completion, patient must return ____-____ weeks after for HCV RNA test to determine sustained virologic response (SVR) status.

12-24

What are non-pharms for hepatitis C patients?

- Advise minimal alcohol use - Advise weight loss if patient is obese - Advise glycemic control if patient is diabetic - Avoid herbal products and non prescription liver protective agents

What exams or scans are usually done prior to the start of treatment of HCV?

RNA viral load Genotyping Hepatic fibrosis staging (liver biopsy or FibroScan)

What are the drug of choice for treatment of HCV?

DAA (direct-acting antiviral)

What are the three classes of DAAs?

- NS5B polymerase inhibitors - NS5A inhibitors - NS3/4A protease inhibitors

What drug is under the NS5B polymerase inhibitor class?

Sofosbuvir

Is sofosbuvir usually used as monotherapy?

No, often used in combo with other antiviral agents.

What are the combo products of sofosbuvir?

- Sofosbuvir/Ledipasvir= Harvoni - Sofosbuvir/Velpatasvir= Epclusa - Sofosbuvir/Velpatasivr/Voxilaprevir= Vosevi

Is sofosbuvir a prodrug?

Yes

What are two drug interaction we need to watch out for with sofosbuvir?

Rifampin and sofosbuvir - decreases sofosbuvir concentrations Sofosbuvir, NS5A inhibitor and amiodarone - severe bradycardia

What drugs are part of the NS5A inhibitor drug classes?

Ledispasvir Pibrentasvir Velpatasvir

Are NS5A drugs usually used as monotherapy?

No, typically utilized in combo with other drugs like with the NS5B polymerase inhibitors mentioned prior.

What are NS5A inhibitors all susbtrates of?

CYP3A4

Does that mean they have drug interactions with statins, antituberculosis medications and HIV regimens?

Minimal drug interaction

What is a drug interaction that we do have to watch out for with NS5A inhibitors? Is there specific NS5A inhibitors that are more at risk of this interaction?

Use of PPIs or antacids Ledipasvir Velpatasvir

What drugs are part of the protease inhibitors or NS3 inhibitors drug class?

Glecaprevir Voxilaprevir

Are these protease inhibitors used as monotherapy?

No, typically used in combo with polymerase and NS5A inhibitors.

What is a common drug interaction with protease inhibitors?

Moderate or strong inducers or inhibitors of CYP3A4

Where does ribavirin come into play for Hep C chronic infection?

Only used in combo with other agents for the treatment of HCV

What is an example of immunosuppression in Hep B patients?

Use of immunosuppressive drugs like prednisone - many Hep B carriers experience flare up in later course of tx or withdrawal of immunosuppressive drug

Nucleos(t)ide analogue therapy is usually used as monotherapy for HBV patients. When should we not use monotherapy?

In HBV patients who are also HIV positive patients. - Increased risk of developing resistant HIV strains

Which of the hepatitis viruses is most likely be transmitted in daycare setting?

HAV and HEV, as they're both fecal-oral

What does Epclusa include?

Sofosbuvir and Velpatasvir

What genotypes does Epclusa cover?

1, 2 3, 4, 5, 6

What drugs are in Harvoni?

Ledipasvir and Sofosbuvir

What genotypes does Harvoni cover?

1, 3, 4, 5, 6 (not 2)

What drugs are in Holkira Pak?

Ombitasvir, pariteprevir, ritonavir, dasabuvir

What genotypes does Holkira Pak cover?

1a, 1b, 4

What drugs are in maviret?

Glecaprevir and pibrentasvir

What genotypes does maviret cover?

1, 2, 3, 4, 5, 6

What drugs are in Technivie?

Ombitasvir, paritaprevir, and ritonavir

What genotype does technivie cover?

What drugs are in Vosevi?

Sofosbuvir, velpatasvir, voxilaprevir

What genotypes does vosevi cover?

1, 2, 3, 4, 5, 6

What drugs are in zepatier?

Elbasvir, grazoprevir

What genotypes does zepatier cover?

1a if with ribavirin 1b 3 with sofosbuvir 4

Which of the hepatitis C drugs need to be taken with food?

Vosevi Technivie Holkira

Chronic Viral Hepatitis Flashcards

(90 cards)