Viral HEP-Table 1 Flashcards Preview

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Flashcards in Viral HEP-Table 1 Deck (94):
1

Which hep infections can be chronic?

B,C, D

2

How long can Hep A live in an environment? How can you disinfect it?

Up to 1 mo
—Requires disinfection with 1:100 dilution of bleach in tap water
—Minimum of one minute at 85 degrees Celsius

3

What is the infectious cycle of Hep A?

Ingest HAV
Absorption in stomach or small intestine
Entry into circulation
Uptake into liver
Replication
Released into blood and secreted into bile by liver
Excreted in stool

4

Take away points about Hep A?

Acute, self limiting, confers lifelong immunity

5

What is the clinical presentation of HepA?

Non-specific –HA, anorexia, N/V etc

6

What pt population is generally asymptomatic if infected with HepA?

Children under 6 yr old

7

What are the rare complications associated with HepA?

—Relapsing hepatitis
—Cholestatic hepatitis
—Fulminant hepatitis
More likely in patients with chronic liver disease
High fatality rate
—Fatalities
More likely > 50 years of age
More likely if pre-existing liver disease

8

How is Hep A tx?

Supportive- liver transplant if pt has liver failure

9

How can Hep A be prevented?

HAV vaccine part of childhood vaccination schedule at 1 year
Good hand hygiene

10

When is the HAV immunoglobulin most effective? What pts wouldn’t need this?

Most effective if given during incubation period (within 2 weeks of infection)
Patients with at least 1 dose of HAV vaccine at least 1 month prior do not need

11

When is the HAV immunoglobulin recommended?

Close personal contacts of HAV infected person
Staff and attendees of day care center when HAV occurrence is documented
Common source outbreak
Schools, hospitals, work settings with close contact of infected person

12

How is HepB transmitted?

Sexual
—Homosexual
—Heterosexual
Parenteral
—Injection Drug Use
Perinatal
—Most common in areas of high HBV prevalence
Other
—Contact with infected body fluid
—Can survive 7 days in environment

13

What are the potential stages of Hep B?

Incubation, clinical illness, acute case fatality, chronic infection, premature mortality from liver dz

14

What is the average length of the incubation period?

60-90 days but can range from 45-180

15

What is the clinical presentation of Hep B?

Up to half of all adults will have jaundice
Fever
Anorexia
Nausea
Vomiting
Dark urine
Clay colored or pale stools
Abdominal pain
kids can be asymptomatic

16

When is the HBsAg present?

onset of clinical symptoms

17

If the HBsAg is persistent past 6mo, what does this indicate?

Chronic infection

18

If HBsAg is present, Is your pt infectious?

YES

19

When does the antibody to HBsAg indicate?

Immunity to virus and that HBsAg has been cleared

20

What serologic marker will be found in vaccinated pts?

Antibody to HBsAg

21

When is HBeAG present?

Acute phase of infection

22

What is the role of HBeAG ?

Unclear but assumed to be a marker of viral replication/inefectivity

23

When does the antibody to HBeAG (HBeAB or anti-HBe) develop?

Once the infection resolves

24

What is seroconversion and what does it predict/indicate?

Spontaneous conversion from antigen to antibody and predicts long term clearance of HBV and indicates lower levels of HBV

25

When does the hep B core antigen (HBcAg )appear? Where is it expressed?

Appears early and persists for life- it is expressed on hepatocytes and promotes immune mediated cell death

26

Which serologic marker is used to diagnose fulminant acute hep?

Immune globulin M Antibody (IgM anti-HBc)

27

When are IgM anti-HBc at high levels?

During acute infections

28

What does the Total Hepatitis B core Antibody (anti-HBc) indicate?

previous or recent infection

29

Chronically infected HBV patients may experience recurring flares of what?

Serum ALT levels

30

What factors are associated with HBV cirrhosis and dz progression?

Persistence of HBV serum DNA
Infection with genotype C
Co-infection with delta hepatitis
Co-infection with HIV
Age at diagnosis
Severity of liver disease at diagnosis
Male sex
Frequency of severe hepatic flares
Alcohol use
Laboratory/ physical findings of abnormal liver function

31

What is HBV a known risk factor for?

Hepatocellular carcinoma

32

What factors are predicative of hepatocellular carcinoma development?

—Persistently elevated HBV DNA levels (> 10,000 copies/mL)
—Males
—Older age
—Coinfection with HCV or delta hepatitis
—Preexisting cirrhosis
—Continued alcohol ingestion

33

What factors are predictors of survival in hepatocellular carcinoma?

—HBsAg seroclearance
—Younger age
—Maintenance of liver function

34

What is the dose series for the Hep B vaccine?

3 dose series
0, 1-2, 4-6 months

35

What is considered a non-repsonder to HepB vaccine?

If

36

What should you do if your pt is a nonresponder?

revaccinated with > 1 dose of HepB vaccine

37

What can be given as a post exposure prophylaxis?

Hepatits B immunoglobulin (HBIG)

38

What does Hepatits B immunoglobulin (HBIG) provide?

passive and temporary (3-6 month) protection.

39

What combo tx should be given if perinatal transmission is a possibility?

HBIG Hep B series combo is 85-95% effective in preventing infection

40

What is the tx for chronic HBV pts with HBV DNA = 2000 with normal ALT and no histologic disease?

No tx

41

What is the tx for chronic HBV pts with HBV DNA = 2000 with normal ALT and histologic disease is evident?

Consider tx

42

What is the tx for chronic HBV pts with HBV DNA >2000?

TX
(tenofovir, entecavir or Peg-IFN alpha 2a)

43

What was thr first approved therapy for tx of HBV?

Pegylated interferon

44

What is the MOA of pegylated interferon (INF)?

—Acts as host cytokine
Antiviral
Antiproliferative
Immunomodulatory

45

Pts with a response to INF typically have more what?

—more permanent seroconversion
Rates 30-40%

46

What factors are associated withimproved response to INF?

-Increased ALT
-High histological score at biopsy
-Non-Asian Patient

47

What are the ADRs of INF?

-Fatigue
-Fever
-Headahce
-Nausea
-Anorexia
-Rigors
-Myalgai
-Arthralgia
-Musculoskeletal pain
-Alopecia
-Injection Site reactions
-Risk of Infection
-Anxiety
-Insomnia
-Depression
-Suicidal/homicidal ideation

48

When is INF not indicated?

For pts with decompensated cirrhosis

49

Lamivudine has profound antiviral activity, why is it no longer the preferred agent for chronic therapy?

Resistance rates

50

How long does it take Lamivudine to normalize ALT levels?

3-6 months

51

How is the antiviral acvitivity of Lamivudine?

weak

52

How is Lamivudine administered?

Daily for 1 year

53

What is Lamivudine effective against?

wild type and lamivudine resistant HBV

54

When should entecavir not be used?

In HIV co-infected pts
Can use in lamivudine resistance but there is a higher chance of developing resistance

55

What is Telbivudine?

An HBV specific nucleoside analogue that has no other viral activity

56

What are the ADRs of Telbivudine?

Myopathy, peripheral neuropathy

57

When is tenovir used?

Used in HIV co-infection and useful for lamivudine resistant HBV

58

What drugs are used in compensated HBV cirrhosis?

Tenofovir or Entecavir

59

What is the tx from de-compensated HBV cirrhosis?

—Liver transplant
—Lamivudine and Adefovir or Entecavir or Tenofovir

60

What panel should be considered in pts with prior exposure to lamivudine/emtricitabine ?

Baseline HBV resistance panel

61

If pts have HBV and HIV coinfection with a CrCl >50, what is the preferred tx?

—Tenofovir, this is first line in HIV and effective with HBV including lamuvidine resistant

62

If pts have HBV and HIV coinfection with a CrCl

entecavir regimen is preferred since tenofovir can cause proximal tubular injury and worsen kidney disease

63

Where does Hep C replicate?

Within the hepatocytes

64

What can Hep C lead to?

—chronic liver disease
—Hepatocellular carcinoma
—deaths

65

What is the most frequent indication for liver transplant?

Hep C

66

In an acute Hep C infection, when do symptoms typically begin and what are they?

within weeks of exposure, symptoms of jaundice, fatigue, anorexia, weakness, abdominal pain

67

When are the serum labs elevated in acute hep C infections?

HCV RNA within 1-3 weeks exposure
Elevated ALT within 4-12 weeks

68

What are the initial symptoms in chronic Hep C infection?

mild; fatigue, nausea, right upper quadrant discomfort

69

As the dz progressively causes damage in chronic hep c, what are the symptoms?

fluid retention, muscle weakness, jaundice, weight loss

70

What are determinants of the dz progression of hep C?

Excessive alcohol intake
Excessive marijuana smoking
Concomitant disease associated with liver injury
HIV
Advanced histological grade
Persistently elevated aminotransferases
Male sex
Older age
Obesity
Hepatic steatosis
Immune suppression

71

Can Hep C be transmitted perinatal?

Transmission only from women HCV-RNA positive at delivery, this is a pretty low rate and the method of delivery and feeding has no association to transmission

72

What are the goals of HepC therapy?

CURE and prevention of complications

73

What is sofosbuvir?

Nucleotide inhibitor of HCV indicated for genotypes 1-4 as part of combination therapy

74

What is the duration of therapy for sofosbuvir?

12 weeks for tpe 1,2,4 or 24 weeks for type 3… once daily tablet

75

What is simepravir and what type is it effective against?

oral HCV protease inhibitor used as a component of combo antiviral tx
effective against genotype I

76

What are the ADRs of SImepravir?

—Photosensitivity
—Rash, pruritus
—Nausea
—Myalgia
Dyspnea

77

What are the drug interaction with simepravir?

—Carbamazepine
—Phenytoin
—Rifamycins
—Clarithromycin
—St. Johns wort
—Milk thistle
—Most antiretrovirals

78

What lab abnormalities will simepravir cause?

—Hyperbilirubinemia
—Anemia

79

What is the MOA of Ledipasvir?

Inhibits HCV NS5A protein needed for viral replication

80

What drug is ledipasvir always given in combo with?

Sofosbuvir- also effective against genotype I

81

What are the ADRs of ledipasvir?

Fatigue, headache

82

What lab abnormalities are seen with ledipasvir therapy?

Hyperbilirubinemia

83

How is ledipasvir dosed?

Once daily

84

What drugs comprise the Veikira Pak?

Paritaprevir/Ombitasvir/Dasabuvir/ Ritonavir

85

What is the MOA of Paritaprevir?

Protease inhibitor

86

What is the MOA of Ombitasvir?

HCV NS5A inhibitor

87

What is the MOA of Dasabuvir?

HCV virus nonnucleoside polymerase inhibitor

88

Why is Paritaprevir given with Ritonavir?

It’s the “boost”, CYP 3A inhib

89

What are the ADRs of the Pak?

Fatigue, diarrhea, nausea, decreased Hg

90

What are the drug interactions with the Pak?

P450

91

When tx HCV with a HIV co-infection, sofosbuvir should NOT be used with what?

tipranavir

92

When tx HCV with a HIV co-infection, ledipasvir-sofosbuvir should NOT be used with what?

elvitegravir, cobicistat, tenofovir, and emtricitabine

93

When tx HCV with a HIV co-infection, simeprevir should NOT be used with what?

protease inhibitors or non-nucleoside reverse transcriptase inhibitors

94

When tx HCV with a HIV co-infection, ribavirin should NOT be used with what?

didanosine