Liver Flashcards
(18 cards)
HCV treatment after non-response to peginterferon/RBV, relapse to sofosbuvir/ledipasvir, F3 disease
Sofosbuvir/Velpatasvir/Voxilaprevir for 12 weeks in NS5A treatment experienced GT 1-6 patients. Baseline RAs and cirrhosis do not affect treatment failure (POLAR-IS-1 trial)
Approved for genotype 1 and 4 with normal renal function
Sofosbuvir/ledispavir (Harvoni)
Second line therapy for genotype 3 with cirrhosis
Sofosbuvir/daclatasvir for 24 weeks
Approved for treatment naive genotype 2 and 3, compensated cirrhosis
Sofosbuvir/velpatasvir (Epclusa) for 12 weeks (ASTRAL-3 trial)
HCV antiviral therapy in the setting of renal failure for GT 1a, 1b, 4
Elbasvir and grazoprevir are hepatically metabolized (C-Surfer trial, GT1a, 1b, 4 only, advanced renal disease). Sofosbuvir-based rx not approved for CKD 4-5 or on HD.
Approved for treatment experienced genotype 1 patients with well compensated cirrhosis, duration?
Sofosbuvir/velpatasvir (Epclusa) for 12 weeks (ASTRAL-1 trial)
Only treatment approved for shorter duration in treatment experienced patients, approved for GT2 F2
Glecaprevir/pibrentasvir (8 weeks)
UGT1A1 genotype
Genetic test for Gilbert’s syndrome, important for patients who receive iranotecan-based chemotherapy
PPI agreeable DAA
Grazoprevir/elbasvir, which does not have a PPI interaction would be an ideal option for a patient with compensated cirrhosis.
HCV antiviral therapy in the setting of renal failure for all genotypes
Glecaprevir/pibrentasvir for patients with advanced CKD (stage 4 or 5). 19% patients had compensated cirrhosis and 40% were treatment experienced. The duration of therapy of treatment is the same as that recommended for patients without CKD for 8 weeks (EXPEDITION-4 Trial). OK to give with amiodarone. Do not give with statin given increased risk of rhabdomyolysis.
DAA for decompensated cirrhosis
Sofosbuvir/velpatasvir or sofosbuvir/ledipasvir and ribavirin for 12 weeks are approved therapies for decompensated cirrhosis (ASTRAL-4, SOLAR-1, SOLAR-2). Avoid protease inhibitors in decompensated cirrhotics due to risk of decompensation.
DAA protease inhibitors
NS3/4A protease inhibitors (mainly grazoprevir, glecaprevir and voxilaprevir). Do not give to decompensated cirrhosis.
CMV treatment
Intravenous ganciclovir, at 5 mg/kg twice daily, or oral valganciclovir, 900 mg orally twice daily, are the treatment of choice for CMV hepatitis and/or GI CMV.
HCV glomerulonephritis
Membranoproliferative glomerulonephritis (MPGN), IgA nephropathy, membranous glomerulonephritis (more in children)
Short-term management of essential mixed cryoglobulinemia in HCV
Rituximab may control the production of antibodies that play a role in immune complex formation in the short-term.
Extrahepatic manifestation of HCV
(1) Essential mixed cryoglobulinemia - production of antibodies directed at the infecting virus –> large complexes –> small vessels –> skin (purpura), kidneys
(2) B-cell non-Hodgkin lymphoma (marginal zone lymphoma, diffuse large B-cell lymphoma)
(3) Porphyria cutanea tarda
(4) Lichen planus
(5) Mooren’s corneal ulcer
(6) Insulin resistance
Extrahepatic manifestations of HBV
(1) Polyarteritis nodosa –> antibodies complex with HBsAg –> deposit along vascular epithelium of medium-sized vessels –> aneurysmal dilation in heart, liver, brain, mesentery, kidney
(2) Papular acrodermatitis (common in young children) from immune complexes with HBsAg –> deposit in dermis
(3) Aplastic anemia
Extrahepatic manifestations of HEV
Main- neurological injury
(1) Neuralgic amyotrophy
(2) Guillain-Barre syndrome
(3) Encephalitis/ myelitis
Less common:
(4) Glomerulonephritis
(5) Cryoglobulinemia
(6) Severe thrombocytopenia
(7) Pancreatitis
