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hepatitis Flashcards

1
Q

ssRNA viral hepatitis

A

Hep A
Hep C
Hep C
Hep D
Hep E

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2
Q

fecal- oral transmission viral Hepatitis

A

Hep A
Hep E

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3
Q

blood borne and or sexual transmission viral Hepatitis

A

Hep B
Hep C
Hep D

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4
Q

dsDNA viral hepatitis

A

Hep B

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5
Q

acute viral hepatitis

A

Hepatitis A
Hep E
hep b

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6
Q

chronic viral hepatitis

A

Hep B,C ,E

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7
Q

oncogenic hepatitis

A

HEP B
Hep C

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8
Q

Child turcotte-pugh score

A

compensated
Class A: 5-6 points (least severe)

decompensated
Class B: 7-9 points (moderately severe disease)
Class C: 10-15 points ( most severe)

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9
Q

compensated cirrhosis

A

asymptomatic with or without gastro-esophageal varices

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10
Q

decompensated

A

Jaundice
ascites
variceal hemmorage
hepatic encephalopathy

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11
Q

HAV transmission

A

ingestion of fecal matter, even microscropic amounts of
- close person to person contact w infected person
-sexual contact
-ingestion of contaminated food or drinks

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12
Q

HAV treatment

A

supportive care only

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13
Q

pre exposure prevention HAV

A

<6 months & healthy
-immune globulin

6-11months & healthy
-HAV vaccine

> 12month - 40 yo
-HAV vaccine

> 40 yo & healthy
-immune globulin + vaccine

> 6mo ,immunocompromised or liver disease
-immune globulin + vaccine

> 6 mon, vaccine CI or declined
-immune globulin

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14
Q

post exposure propylaxis

A

<12 mo & healthy
-immune globulin

> 12 mo- 40 yo + healthy
-HAV vaccine

> 40 yo & healthy
-immune globulin

> 12 mo & immunocompromised or chronic liver disease
-HAV vaccine +immune globulin

> 12 mo& vaccine CI or declined
-immune glubulin

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15
Q

HAV routine prevention

A

Prevention
-regular hand washing w soap
-avoid contaminated water/ ice, fresh produce, uncooked foods

vaccination
- HAV only (Havrix, Vaqta
—- 2 dose series: 1 shot at 0 & 6 mo
—>12 months
-HAV + HBV (twinrix)
—>18yo only

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16
Q

clinical presentation of HAV

A

-fever, fatigue, loss of appetite, N??V, ab pain, dark urine, clay color stool, jaudice

-iceteric sclera skin, mild weight loss.hepatomegaly

  • positive serum IgM anti-HAv, elevation of serum bilirubin and hepatic transaminase
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17
Q

HBV associated complications

A

cirrhosis
hepatic decompensation
hepatiocellualr carcinoma

18
Q

HBV presentation

A

-appears 1-4 months after exposure

-abdominal pain, dark urine, fever, joint pain, loss of appetite, N?V, weakness and fatigue, yellowing of skin, yellowing of whites eye

19
Q

acute HBV treatment

A

supportive care

20
Q

preferred HBV therapy

A

Pegylated interferon a-2a,a-2b
-least preferred
Entecavir
Tenofovir disoproxil fumarate
Tenofovir alafenamide

21
Q

Pegylated interferon a-2a,a-2b MOA & CI

A

inhibits viral replication, immunomodulary

Contraindication
-uncontrolled major depression
-suicidal ideation
-autoimmune hepatitis or disease
-soluid transplant
-decompensated cirrhosis of HCC
-uncontrolled thyroid disorder

22
Q

Pegylated interferon a-2a,a-2b AE and monitoring

A

AE
-flu like illness
-fatigue
-neutropenia
-anemia
-thrombocytopenia
-mood disturbances
-injection site reaction
-autoimmune disordors

monitoring
-CBC
-TSH
-autoimmune,ischemic, neuropsychiatric, infectious complication

23
Q

Entecavir MOA, ADE,

A

guanosine nucleoside analog inhibits HBV DNA replication

AE
-well tolerated
-HBV if abruptly d/c

administration
- empty stomach**
- 2hr before or after meal

resistance
-high genetic resistance

24
Q

Tenofovir disoproxil fumarate (TDF)

A

adenosine nucleotide analoge inhibits HBV DNA replication

dose
>35kg: 300 mg
>2 and >10kg: weight based
dose reduction in renal dysfunction

AE
-Nausea, nephrotoxicity, osteomalacia, falcon sydrom
-HBV exacerbation if abruptly dc

resistance: low

25
Q

Tenofovir alafenamide (TAF)

A

-phosphonamide prodrug of tenofovir
-adenosine nucleotide analog inhibits HBV DNA replication

Dose
-adults >18yo: 25 mg with food
-avoid in crcl < 15mL.min

AE
-HBV exacerbation if abruptly dc
-HA, ab pain, cough, backache, fatigue
-less BMD and nephrotoxicity vs TDF

metabolism: carboxyesterase hydrolysis, p-gp and BCRP (substrate)

26
Q

HBV/HIV

A

Emtricitabine, lamivudine, TDF and TAF

initial fix dose combination
-TDF/ Emtricitabine
-TDF/lamivudine
-TAF/ Emtricitabine

27
Q

Adult duration of treatment for HBV

A

nucleus(t)ide
- no cirrhosis: 12 months
-cirhossis: indefinite

peg-IFN-a: 48 weeks

28
Q

HBV Prevention: Vaccination

A

HAV+ HBV (IM)
-TWINRIX

HBV (IM)
-ENGERIX-B
-RECOMBIVAX HB
HEPLISAV-B

29
Q

HCV testing recommendations

A

-one-time, routine, opt out for >18 yo
-one time <18 yo if you if risky, activities, exposure, or conditions or circumstances
-routine prenatal care w each pregnancy
-Periodically if if risky, activities, exposure, or conditions or circumstances
-Annually: IVDU, HIV+, MSM unprotected sex, and MSM taking PrEP

30
Q

Direct acting antivirals (DAAs) MOA

A

target specific nonstructural (NS) protein for HCV leading to disruption in viral replication and infection

31
Q

Ledipasvir/sofosbuvir

A

Indication (age ≥ 3 y/o)
* GT1,4,5,6w/o cirrhosiso r w/compensated cirrhosis
*GT1 decompensated cirrhosis +RBV
*GT1 or 4 liver transplant recipient w/o cirrhosis or w/compensated cirrhosis + RBV

*DDIs
* P-gp inducers
* Amiodarone (bradycardia)
* Antacids: separate by 4 hrs
** H2RAs: simultaneously w/or 12 hrs apart; avoid comparable doses > famotidine 40 mg PO BID
* *PPIs: simultaneously w/fasting conditions; avoid comparable doses > omeprazole 20 mg po daily

32
Q

Velpatasvir/sofosbuvir
(pangenotypic)

A

Indication (age ≥ 3 y/o)
* GT 1-6 w/o cirrhosis or w/
compensated cirrhosis (RBV-free) or w/decompensated cirrhosis + RBV

DDIs
* P-gp,CYP2B6,2C8,3A4inhibitorsand inducers
* Amiodarone(bradycardia)
* Antacids:separateby4hrs
*H2RAs:simultaneouslyw/or12hrsapart; avoid comparable doses > famotidine 40 mg PO BID
* PPIs: not recommended; if needed, take Epclusa w/food & 4 hrs before omeprazole 20 mg po daily

33
Q

Elbasvir/grazoprevir

A

Indication (≥ 12 y/o & ≥ 30 kg) * GT1or4
*In combination w/ RBV if NS5A mutations and/or IFN, RBV, or PI-tx experienced)
*NS5A resistance test before tx forGT 1a

Contraindications
*Moderate or severe hepatic impairment
(CTPBorC)
*Strong CYP3A inducers, OATP1B1/3
inhibitors
*Contraindications to RBV apply
DDIs
* CYP3A4, P-gp, OATP1B1/3 inducers and inhibitors

34
Q

Glecaprevir/pibrentasavir
(pangenotypic)

A

Indication (≥ 3 y/o)
*GT 1-6 w/o cirrhosis or w/ compensated cirrhosis
*GT1previously tx w/ NS5A inhibitoror NS3/4A protease inhibitor (not both)

Contraindications
* Moderate-severehepaticimpairment
(CTP Class B or C)
*H/Opriorhepaticdecompensation
*Coadministration w/ atazanavir and rifampin

DDIs
*Pgp,BCRP,OATP1B1/1B3,3A4,1A2, UGT1A1 inducers and inhibitors

35
Q

simplified treatment
naive no cirrhosis preferred regimens

A

GT 1-6: Mavyret® (glecaprevir/pibrentasvir)
300 mg/120 mg w/food x 8 wks

-OR-

GT 1-6: Epclusa® (velpatasvir/sofosbuvir)
100 mg/400 mg x 12 wks

36
Q

simplified treatment
Naive no cirrhosis
with SVR

A

Check HCV VL and LFTs ≥ 12 wks following completion to confirm virologic cure (SVR) and transaminase normalization

counsel risk reduction and test for HCV VL annually and w/e elevated AST,ALT, or bilirubin

avoid excess ETOH

37
Q

simplified treatment
naive w/ compensated cirrhosis preferred regimens

A

GT 1-6: Mavyret® (glecaprevir/pibrentasvir)
300 mg/120 mg w/food x 8 wks

-OR-

GT 1-6: Epclusa® (velpatasvir/sofosbuvir)
100 mg/400 mg x 12 wks
*GT3 if baseline NS5A resistance mutation negative

38
Q

simplified treatment
Naive Compensated Cirrhosis w/SVR

A
  • Check HCV RNA and LFTs ≥ 12 wks upon completion to confirm virologic cure (SVR) and transaminase normalization
  • Assessment for other causes of liver dx if elevated transaminase levels after achieving SVR
  • U/S surveillance for HCC (w/ or w/o AFP testing) Q6mo.
  • Upper endoscopic surveillance for esophageal varices associated-portal
    hypertensive bleeding
  • Counsel if ongoing risk for HCV infection (i.e., IVDU or MSM engaging in
    unprotected sex) about risk reduction and test for HCV VL annually and
    whenever elevated ALT, AST, or bilirubin
  • Advise to abstain from ETOH use
39
Q

simplified treatment
Naive Compensated Cirrhosis failure

A
  • Check HCV RNA and LFTs ≥ 12 wks or later following completion of therapy to confirm virologic cure (SVR) and transaminase normalization
  • If initial HCV tx fails to achieve SVR then evaluate for retreatment by a specialist
  • U/S surveillance for HCC (w/ or w/o AFP testing) Q6mo
  • Assess HCV disease progression Q6-12 mo. w/ hepatic function panel,
    CBC, and INR
  • Advise to abstain from ETOH
40
Q

HCV/HIV co-infected Patients

A
  • Suffer more liver-related M&M, nonhepatic organ dysfunction, and overall mortality vs HCV-monoinfected pts
  • Despite potent ARVs, HIV independently associated w/advanced liver fibrosis and cirrhosis
  • Prioritize tx for providers, pts and payers
  • Monitor liver dx progression if HCV tx delayed
  • Efficacy and ADEs similar to HCV monoinfection
41
Q

HCV Prevention

A
  • No vaccine available
  • Avoid sharing dental or shaving equipment
  • Cover bleeding wounds
  • Avoid use of illicit drugs and recommend substance abuse tx
  • For those who continue with IVDU
  • Avoid reusing or sharing syringes, needles, water, cotton
  • Use new sterile syringes and filters, and disinfected cookers
  • Clean injection site w/new alcohol swab
  • Discard syringes and needles after single use in safe, puncture-proof container
  • Avoid blood donation if HCV-infected
  • Use barrier protection to prevent sexual transmission
  • Mix 1 part household bleach: 9 parts water to clean contaminated
    household surfaces with visible blood. Wear gloves.

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