Viral Hepatitis

Question 1

If HCV and decompensated cirrhosis

Answer 1

No protease inhibitors!

Question 2

If HCV and CKD state 4 or 5 (eGFR < 30)

Answer 2

Elbasvir/grazoprevir
Glecaprevir/pibrentasvir
Mavyret

Question 3

SE’s of HCV drugs

Answer 3

<5%
Nausea
Fatigue
Headache

Question 4

HCV drugs and amiodarone

Answer 4

avoid if possible

Question 5

HCV drugs and statins

Answer 5

just stop the statin unless recent MI

Question 6

HCV drugs and acid-reducers

Answer 6

just stop them

Question 7

HCV diagnosis

Answer 7

HCV antibody
AND
HCV RNA detectable

Question 8

What if HCV and HBV?

Answer 8

Test for HBV
Negative - vaccinate
Positive - risk fulminant hepatitis
- HCV drugs can cause acute flares of HBV

Question 9

NS3/NS4 (-pre-) drugs mechanism

Answer 9

protease inhibitors

block proteolytic processing of hcv polyprotein

Question 10

NS5 (-bu-) drugs mechanism

Answer 10

polymerase inhibitors

block formation of replication complex

Question 11

NS5B (-as-) drugs mechanism

Answer 11

polymerase inhibitors

block viral RNA replication

Question 12

HCV drugs for all gentotypes

Answer 12

sofosbuvir/ velptasvir - Epclusa
sofosbuvir/velpatasvir/voxilaprevir - Vosevi
Glecaprevir/pibrentasvir - Mavyret

Question 13

Which viruses are acute vs. chronic?

Answer 13

Acute: A and E
Chronic: B (D) and C

Question 14

Biggest risk factor for HepA

Answer 14

International Travel - ingestion of contaminated food/water

Question 15

HepA diagnosis

Answer 15

IgM (anti-HAV) will be elevated. ***
Acute sickness
Mild elevations in LFTs

Resolved if IgG elevated, but IgM not.

Question 16

HAV treatment

Answer 16

None.

Prevention and vaccination.

Question 17

HAV vaccinations

Answer 17

Havrix - 2 dose
Vaqta - 2 dose
Twinrix (A/B) - 3 dose

Question 18

HAV postexposure management

Answer 18

Single dose of vaccine or immunoglobuline ASAP.
Immunoglobulin for higher risk.
Recommended for contacts as well.

Question 19

HAV and travel

Answer 19

First dose vaccine as soon as travel is considered.

High risk traveling in less than 2 weeks: vaccine + IG.

Question 20

Hepatitis B (HBV) stage classifications

Answer 20

Immune tolerance: DNA present, normal LFTs.
Active Infection: DNA present, high LFTs.
Inactive carrier: DNA absent, normal LFTs.

Question 21

HBV diagnosis and classification

Answer 21

HBsAg - elevated acutely if infected, but recovered.

HBsAg - elevated > 6months if chronic infection.

Question 22

HBV vaccination

Answer 22

At birth as of today.
Adults (major considerations):
- DM
- ESRD
- Chronic liver disease
- HCV

Question 23

Newborn HBV guidelines

Answer 23

Over 2,000g (4lbs) at birth, mother HBsAg negative: give right away.
- If mother is +: also give HBIG.

Under 2,000g, and mother -: give dose @ 1 month.
- If positive: give three additional doses @ 1 month.

Question 24

Vaccination differences b/w A and B

Answer 24

A: 1st dose -> 96% immunity.
B: Need all three

Question 25

Acute treatment of HBV

Answer 25

Supportive care

Question 26

Who should be treated for chronic HBV

Answer 26

1 - Anyone with liver problems. 2 - Inactive, during chemo/immunosuppression. 3 - Active

Question 27

Who should not be treated for chronic HBV?

Answer 27

Immune tolerant. | Inactive carriers.

Question 28

Treatment methods for chronic HBV

Answer 28

Antiviral agents indefinitely.* Pegylated interferon for 48 weeks. Looking for HBeAg "seroconversion"

Question 29

First-line treatment for treatment naive chronic HBV patients

Answer 29

Entacavir (2 or older) - not if HDV co-infection Tenofovir (12 or older)

Question 30

When to use Peg-interferon alfa in HBV

Answer 30

If HDV co-infection - Bad toxicities - NOT in decompensated cirrhosis - 180 mcg SQ weekly for 48 weeks.

Question 31

Resistance to HBV antivirals:

Answer 31

Switch to tenofovir | - unless adefovir-resistance; go to entacavir.

Question 32

What if pregnant and HBV?

Answer 32

If HBV DNA > 200k - give tenofovir - @ 28-32 weeks gestation until 3months postpartum.

Question 33

HEV Key Points

Answer 33

``` More dangerous in pregnant women. Usually just an acute thing. Contaminated water. International travel. No vaccine. Just prevention. ```

Question 34

Progression of HCV

Answer 34

75% will develop chronic infection. 25% of them will develop cirrhosis. A few of them will develop ESLD. This can take 25-30 years.

Question 35

HCV presentation

Answer 35

Majority are asymptomatic! | You don't know until they have liver disease.