Hepatitis Flashcards by Rebecca Adams

How often should people with cirrhosis be monitored for HCC?

6/12 USS

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Differences in hep b natural history with HIV coinfection

Lower rates eAg clearance
Increased HBV VL
More rapid onset of fibrosis, cirrhosis, HCC - old studies

Several HBV drugs also have HIV activity - ? Resistance risk

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HBV/HIV treatment?

TDF/TAF

3TC, adefivir, telbivudine monotherapy not recommended - high risk of resistance

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How long may HEp B viral load take to decline?

Can take longer >48 weeks
Continue therapy if ongoing decline

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Risk with discontinuing HIV tx in HBV coinfection?

Liver flare potentially needing transplant

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What to do for HBV core pos antigen neg having transplant or immunosuppression?

Ensure on tenofovir/entecavir as risk of reactivation

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HBV monitoring

Serology 6/12, hep B dna 6/12
All HIV+ plus hep b and c - 6/12 USS - even if hcv cured or HBV dna suppressed

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Does entecavir have activity against HIV?

Yes but weak, may select m184v
Can only be used with fully active ART

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How to manage hep b co infection if renal impairment?

Switch TDF to TAF
At eGFR <30 switch to entecavir with fully active ART regime
If has HD can go back on tenofovir

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Entecavir dosing?

Depends on renal function
Dose doubled if previous lamivudine resistance documented or suspected (ie if prev 3TC monotherapy for HBV)

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What PrEP should be given to a patient who has HBV monoinfection?

If hepatologist says needs hep B treatment then they start this

If not and only starting PrEP-
Have to be on daily dosing
Counsel on stopping - risk of flare

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Hep C genotypes

1-6
Don’t affect prognosis but do affect drug choice

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In Hep C if antibody positive but RNA negative what does this mean?

Do not have hep C
Do not need further monitoring

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What is sustained virological response in Hep C?

Cure.
If negative hep c RNA 12 weeks after the END of treatment.
(SVR12)

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Reinfecton vs tx failure in hepatitis C

Cannot get late relapse
If negative at SVR 12 and beyond they are cured so if become positive again it’s reinfection

If becomes positive between end of tx and 12 weeks that would be treatment failure

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Who gets hepatitis C treatment?

Everyone.

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Cure rate for hepatitis c?

90-95%

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Do we still use interferons for hep c treatment?

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What do we do if someone fails HCV tx?

Sof/vel if had sof/lip

Sof/vel/vox 12 weeks is mainstay of treatment if failed - contains PI so may have DDI

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HCV protease inhibitors

End in Pravir

Can’t have with HIV PiS, NNRTIs except doravirine
II fine (except elv as requires booster)

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How should acute HCV be treated?

Repeat RNA 4 weeks
If <2 log decrease VL crack on with tx
If >2 log decline then repeat as 12, 24, 48 weeks to ensure cleared

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Baseline hepatitis tests at HIV diagnosis

Hep A IgG
Hep B infection and immunity
Hep c antibody

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Definition of chronic hep B

sAg persisting after 6 months

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What could isolated Hep B core mean?

False positive or previous infection but loss of antibodies or level below detection due to immune dysfunction - may improve with immune reconstitution

Vaccinating can discriminate between the two

V rarely can be after sag gone, before sAb build

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What tests should those with isolated hep bcore pos have?

HBV dna - low would indicate resolving infection Anti hbc IgM to exclude recent infection

How does abacavir affect response to peg IFN/RBV therapy?

Decreased Ribavarin should be dosed >1000mg or >13.2mg/kg

How does HIV impact on Hep B infection?

More likely to progress to chronic HBV Reduced rate of natural clearance of HBeAg Higher HBV VL - associated with faster disease progression - progression to cirrhosis and HCC more rapid in hbv/hiv coinfection

How is chronic hep b infection defined?

Hbsag persisting longer than 6 months

When should hep b resistance be checked?

New diagnosis in someone exposed to ARVs that might have anti hep b activity

Genetic barrier to resistance in previously untreated hep b positive patients

Low with 3TC, ftc, telbivudine, low to intermediate with adefovir, high with entecavir and tenofovir Barrier to entecavir lowered by previous 3TC exposure

Primary non response to NA therapy for HBV

<1 log drop in HBV DNA at 12 weeks

Virological response to HBV tx when NA therapy used

Undetectable HBV DNA at 24 weeks

Partial response to NA therapy in HBV

Fall of > 1 log but not undetectable at 24 weeks

Virological breakthrough HBV

Rise of >1 log HBV dna from nadir level on therapy

Virological response to PEG IFN tx for TB

HBV DNA <2000 after 6 months, at end of therapy and 6 and 12 months after the end of therapy

HBV sustained response to peg IFN therapy

HBV dna <2000 at least 12/12 after end of therapy

How often should hep b dna be measured post treatment in stable patients with HIV?

Annually

Who is recommended to have treatment for HBV?

HBV DNA >2000 regardless of fibrosis score More than minimal fibrosis on biopsy or fibroscan >9 regardless of hbv dna

First line treatment of HBV

Tenofovir containing art Entecavir can be given if TDF/TAF contraindicated but with fully suppressive art as otherwise can select for hiv resistance and only if no prior 3TC exposure

Second line tx HBV

Adefovir or 48 weeks PEG-IFN

Monitoring of HBV therapy

6 monthly hep B dna

In whom is peg-IFN for HBV indicated?

Patients with repeatedly raised ALT, low HBV DNA, minimal fibrosis E antigen pos or neg

Risks of PEG-IFN

Decompensation, worsening of current decompensation and development of liver failure Repeat tests every 3 months to see if seroconverts

Definition of severe acute hep B

Acute HBV with INR >1.5

Definition of fulminant acute hep B

Severe acute hep B plus hepatic encephalopathy

Treatment for acute hep B (severe/fulminant)

ART - tdf+ftc or 3TC. Or entecavir plus full art regime.

What to do if treating HBV/HIV and develop renal toxicity?

TAF if applicable. If not Stop tenofovir. Switch ARVs. Add entecavir.

Fibroscan staging level f0-f1

2-7 (hep b and c)

Fibroscan staging f2 (hep B)

7-9.5 Hep b and c

Fibroscan f3 (hep b)

8-11

Fibroscan f4 hep B

> 12= cirrhosis

Fibroscan f2 hiv/hcv coinfection

7-11

Fibroscan f3 hiv/hep c coinfection

11-14

Fibroscan f4 hiv/hep c

>14

Who should be tested for HDV

Anyone with hbsag positive

Treatment HDV

Tenofovir containing ART

How is HDV viral activity determined?

HDV RNA

How does HDV superinfection affect prognosis?

More likely to have a severe hepatitis with progression of liver disease and development of cirrhosis and HCC

Who should have anti hcv checked every 3-6 months?

Those with repeated high risk exposure even if transaminses normal

Individuals with unexplained abnormal transaminases in high risk for exposure hcv group should have…

HCV PCR

First line treatment for HCV

DAA First gen PIs boceprovir and telaprovir and IFN therapies not recommended due to insufficient efficacy and increased toxicities

How are DAAa chosen?

Stage of liver fibrosis, genotype, pretreatment history and resistance associated substitutions if tested

DAA of choice if a patient needs re-treatment?

Sof/vel/vox for 12/52

DAA for re treatment in patients with decompensated cirrhosis if liver transplant is contraindicated

Sof/vel (epclusa) 24weeks

which ARV decreases ribavarin levels

Abacavir

Tel sprs it side effects

Anal discomfort Anaemia Skin rash SJS

Side effects boceprevir

Anaemia Neutropenia Dyguesia

When should acute hep c be treated?

If no >2 log drop in RNA 4 weeks after diagnosis or if there is a drop for RNA to still be detectable after 12 weeks to then start tx as naive non cirrhotic

What is the primary aim of HCV treatment?

SVR12 - undetectable rna at 12 weeks

hep C tx monitoring in PLWH with >f3

After 2-4 weeks fbc, creatinine, liver enzymes, bilirubin, albumin, INR. If hbsag neg but core pos and alt rise check hep b dna.

Hep C tx monitoring for those with impaired renal function on SOF based tx

Creatinine

Hep c tx monitoring for everyone

HIV VL every 12/52 RNA at end of tx, week 12 after tx, week 24 after tx to assess SVR

Screening for HCC

All cirrhotic HBV or HCV coonfected PLWH even if treated/suppressed - uss 6/12 and AFP Hep B non cirrhotic - page b score to guide HCC risk

What is EVR?

UndeteCtable viral load or 99% reduction by week 12

What is SVR?

SVR 12 is undetectable VL 12 weeks after finishing therapy SVR 24 is ‘cure’ - undetectable VL 24 weeks after therapy

Treatment options for HCC

Liver transplant

Hepatitis Flashcards

(76 cards)