502 Final Quizlet Flashcards
List the different types of viral hepatitis.
A, B, C, D, E
What type of virus causes Hep A?
RNA Virus
Is there a vaccine to prevent Hep A?
Yes
Is Hep A usually acute or chronic?
Acute condition that will resolve (never chronic)
How is Hep A transmitted?
Fecal into oral route
What type of virus causes Hep B?
Partially double-stranded small nonenveloped DNA virus
How is Hep B transmitted?
Blood and infected fluids
Is Hep B acute or chronic?
Chronic
Is there a vaccine to prevent Hep B?
Yes
What type of treatments are available for Hep B? What is the efficacy of these treatments?
Immune modulators and antivirals. These usually don’t completely eliminate the virus.
What is the mechanism of action of Lamivudine?
Cytosine analogue that acts as a reverse transcription inhibitor. (Inhibits DNA polymerase)
What is the MOA of Adefovir and Tenofovir? How are these activated from the prodrug form?
Adenosine analogue that acts as a reverse transcription inhibitor (inhibits DNA polymerase). Activated by adenylate kinase, which adds a second phosphate group.
What is the MOA of Telbivudine?
It converted to the active form With the addition of what chemical group? Thymidine nucleoside analog that inhibits DNA polymerase and causes chain termination of DNA synthesis. Addition of three phosphate groups.
What type of virus causes Hep C?
Positive-sense single-stranded RNA virus
How is Hep C transmitted?
Blood
Is there a vaccine to prevent Hep C?
No
Is Hep C primarily chronic or acute?
Can be either, but 80% progress to chronic.
What is the goal of treatment for Hep C and how is it measured?
Goal is to cure. This is measured with sustained virologist response, which is the absence of detectable HCV RNA in the plasma for 12 weeks following therapy.
What is the general MOA of the serine protease inhibitors?
Inhibit the actions of the NS3/4A serine protease, which is required to cleave the HCV RNA genome to form proteins used for viral replication. NS3/4A is a non-covalent heterodimer complex, where NS3 has the serine protease catalytic domain and NS4A has an activation subunit domain.
What is the general MOA of the NS5B polymerase inhibitors?
They inhibit the action of RNA polymerase which is needed for viral replication. Some act as nucleotide analog substrates while some bind to almost Eric sites on the enzyme and render it non-functional.
Which drug acts as a uridine nucleotide analog?
Sofosbuvir
How is Sofosbuvir activated? What is the rate limiting step?
It activated during first pass metabolism by hepatic kinases. The rate limiting step is addition of the first phosphate group. Active form is triphosphorylated.
Which drug acts as a non-nucleoside inhibitor at the allots Eric site on polymerase-palm 1?
Dasabuvir
What is the general MOA of NS5A inhibitors?
Inhibit NS5A proteins, which are required for viral replication.
Which fluids can Hep A be transmitted with?
Feces, serum, saliva. Fecal to oral route.
What symptoms do patients with Hep A have?
Usually asymptomatic. But can present flu like symptoms, jaundice, fatigue
Is Hep A usually an acute or chronic condition?
Always acute. Can last up to 9 days, when virus dissolves patient will be immune.
Anti-HAV (IgM)
Active infection
Anti-HAV (IgG)
Immunity (can be from past infection or vaccine, no way to know for sure.)
Anti-HAV (IgG) + Ant-HAV (IgM)
Immunity (can be from past infection or vaccine, we can’t tell)
What are the agents used for prevention of Hep A?
Hep A vaccine and immune globulin (IG) Vaccine is the active form and provides long-term immunity IG is passive and provides temporary immunity Both can be used for pre and post-exposure
How many doses does the Hep A vaccine consist of? When are they administered?
2 doses. One at month 0 and the second 6-18 months late Both brands are interchangeable
What is the youngest age Hep A vaccine can be given to?
1 years old
If someone didn’t get vaccinated as a child, what are some risk factors for Hep A that would make it beneficial for the person to get vaccinated?
Chronic liver disease, men who have sex with men, illegal IV drug users, having clotting factor disorders, occupational risk, living in areas with high prevalence, travel
If a person is traveling internationally to an area with high Hep A risk, what type of pre-exposure protection should they get?
Hep A vaccine, Antoine before travel
If a person is traveling in 2 weeks and is immunocompromised, older than 40, and have CLD, what should they get?
Immune globulin plus Hep A vaccine
If a person is traveling internationally and cannot get vaccinated, what should they receive?
Immune globulin. It will provide protection for 2 months.
How soon after exposure to Hep A should post-exposure prevention be given? Who should receive the vaccine and who should receive immunoglobulin?
Within 2 weeks. Healthy patients 12 months - 40 years old should get the vaccine. Patients that are either immunocompromised, older than 40 years old, have chronic liver disease, or have chronic comorbidities should get immune globulin.
Which body fluids are Hep B mostly found in?
Blood, serum, wound exudates, semen, vaginal fluids, saliva
What are the main routes of transmission for Hep B?
IV drug needle sharing (percutaneous), sexual contact, perinatal (mom to baby)
The younger you are the ________ risk for chronic disease with Hep B?
Greater
After exposure to Hep B, the majority of patients will go on experience ________________ symptoms
Majority will have sub clinical Hep B with no symptoms
What are the 3 developments that can occur after patients have been diagnosed with chronic Hep?
Cirrhosis, mild-moderate Hep, or the patient becomes an inactive carrier.
Infection with Hep B can ultimately cause what serious disease?
Years down the line it can cause liver cancer.
Which 2 types of agents are used for Hep B protection?
Vaccine and immune globulin
What are the brands of the Hep B vaccine? Dosing schedule?
Recombivax HB and Engerix-B Three total doses, one at month 0, one at month 1, and one between months 6-12. They are interchangeable
A new born baby with positive HBsAg status should receive a vaccine when? >2kg <2kg
Vaccine + immune globulin within 12 hours of birth for both
A new born baby with Negative HBsAg status should receive a vaccine when? >2kg <2kg
> 2kg - Vaccine within 24 hours of birth <2kg - Vaccine at day 30 post-birth or at hospital discharge
A newborn baby with Unkown HBsAg status should receive a vaccine when? >2kg <2kg
> 2kg - Vaccine within 12 hours of birth + immune globulin regardless of mom HBsAg status <2kg - Vaccine within 12 hours of birth + immune globulin if mom found HBsAg positive or still
What is Twinrix?
Combo Hep A and Hep B vaccine
How old must a patient be to receive Twinrix?
18 years old
Combo Hep A and Hep B vaccine
Twinrix could be used for (pre and/or post) exposure?
Only pre-exposure
Combo Hep A and Hep B vaccine
What dosing schedule does Twinrix follow?
Hep B schedule; month 0, month 1, and between months 6-12
Incidence of cirrhosis and HCC __________ with increasing HBV DNA level?
Increased
What is the goal of HBV treatment?
HBV DNA suppression; there is no cure
When would you initiate treatment for HBV?
Liver histology: moderate-sever inflammation or fibrosis HBV DNA level: >/= 20,000 HBeAg status: Positive ALT: >2xULN
When would you restart treatment for HBV?
Liver histology: moderate-severe inflammation or fibrosis HBV DNA level: >/= 2,000 HBeAg status: Negative ALT: >2xULN
How is IFN/Peg-IFN administered?
Hep B treatment. Subcutaneous
What are the two common and predictable adverse effects if IFN/Peg-IFN?
Injection site reactions and flu=like symptoms
What is the standard of care for neutropenia during IFN/Peg-IFN treatment?
Do not decrease or hold dose. Can give growth colony stimulating factor
What is the standard of care for thrombocytopenia during IFN/Peg-IFN treatment?
Do not reduce or hold the dose
How are psych manifestations handled while taking IFN/Peg-IFN handled? When do these become a contraindication to treatment?
Give patient an SSRI and psych consult Severe depression, mania, or suicidal ideations
What is the primary difference between tenofovir disoproxil (Viread) and tenofovir alafenamide (Vemlidy)?
TAF is more targeted to the liver; less risk for decrease in bone mineral density and nephrotoxicity.
The majority require ________ of oral agents adjustments for renal impairment for Viread and Vemlidy?
Majority require dose reductions
If patient have to start treatment early in life for HBV, what is the best oral agent to avoid resistance development?
Tenofovir
If a patient has never had lamivudine, what oral agent may be a good option in avoiding resistance?
Entecavir
Which oral agents for HBV are the only ones recommended for Hep B treatment?
Tenofovir, Entecavir, IFN/Peg-IFN
Which side effects are common in HBV oral agents? Which are unique to only certain oral agents?
Common: Diarrhea, nause, and headache (more for tenofovir but common in all) Entecavir - Fatigue Tenofovir - AB pain and dsypepsia
Which warnings are common in tenofovir and entecavir?
Lactic acidosis and severe hepatomegaly, acute exacerbation of HBV when to is stopped, HIV resistance in untreated/unrecognized patients
How long should patients with positive HBeAg chronic Hep B and no cirrhosis be treated?
Until patient has undetectable HBV DNA, persistently normal ALT levels, and has completed at least 12 months of additional therapy after development of anti HBe
How often should they monitored for relapse after therapy is discontinued? HBV treatment
Every 3 months for at least 1 year post-treatment
How long should patients with positive HBeAg chronic Hep B and cirrhosis be treated?
Indefinitely
How long should patients with negative HBeAg chronic Hep B be treated?
Indefinitely
What are the strategies that can be implemented if patients develops resistance to treatment?
Switch agent to one with lesser resistance (tenofovir, entecavir) or Add a second drug with no cross resistance
Which oral agent for HBV needs to be taken with food?
Tenofovir aladenamide
Which oral agent for HBV needs to be taken on an empty stomach?
Entecavir
Define co-infection
When a patient get infected with HBV and HDV at the same time
Define superinfection
When a patient has already been infected with HBV and gets infected with HDV at a later time
(Superinfection / Co-infection) can lead to liver complications?
Superinfection is more likely to lead to liver complications
Can a patient acquire HDV without HBV?
No - they can only acquire HDV if they have also been infected with HBV
The transmission and manifestation of Hep E is most similar to?
Hep A
Hep G causes?
Minimal liver damage
How many genotypes are in there in Hep C? What is the most common?
6 genotypes and 1a is the most common
What is the most common way Hep C is transmitted? What are some less common ways?
IV drug use Can also be through sex, perinatal, hemodialysis
What is the most common symptom in patients who develop acute Hep C?
No symptoms
Is there a vaccine available to prevent Hep C? What pre- and post-prophylaxis is recommended?
No vaccine No form of pre-post-prophylaxis Just avoid risk factors
What group of patients should be tested for hep C? How often?
Patients with high risk (IV drug uses, pts with HIV, men who have sex with other men) and patients born between 1945 and 1965 due to unsafe medical practices Patients should be tested annually
Positive HCV antibody indicated ________ exposure.
Past exposure
Are detectable levels of HCV RNA enough for diagnosis of Hep C?
Yes
The majority of patients that have acute Hep C will progress to _________?
Chronic Hep C
What can chronic Hep C eventually lead to?
Cirrhosis, HCC, ESLD/transplant
How does fibroscan work? What score indicates F4 stage?
Sends waves through the liver to measure stiffness. More scarring = more stiff. Score of 12.5 kPa means F4.
What is F4?
Cirrhosis
What is the goal of treatment for Hep C? How is this measured? Goal of treatment care?
Measured with sustained virologist response (SVR) which means undetectable viral load for at least 12 weeks after treatment is discontinued.
How to use Ribavirin?
It must be used with another DAA
Which genotypes are effective against Ribavirin?
Genotypes 1-6
NS3/4A Protease Inhibitors examples
Paritaprevir, Simeprevir, Grazoprevir, Glecaprevir
NS5A Replication Complex Inhibitors examples
Elbasvir, Velpatasvir, Ledipasvir, Daclatasvir, Ombitasvir, Pibrentasvir
- End in asvir
NS5B Inhibitors examples
Sofusbuvir, Dasabuvir
Hep C treatment. Single pill burden examples
Ledipasvir/Sofusbuvir, Elbasvir/Grazoprevir, Sofusbuvir/Velpatasvir
Hep C treatment Must be taken with food examples
Simeprevir, Glecaprevir/Pibrentasvir, Sofusbuvir/Velpatasvir/VOX
Hep C treatment Can be used of patients on dialysis examples
EBR/GZR, GCR/PBR
Hep C treatment No dose adjustment in hepatic impairment
SOF, LDV/SOF, Daclatasvir, SOF/VEL
Hep C treatment Requires acidic environment for absorption
LDV/SOF, SOF/VEL
Hep C treatment Required use of an additional agent
SMV, SOF, Daclatasvir
Hep C treatment Avoid use in decompensated cirrhosis
EBR/GZR, SMV, GCR/PBR
What genotype is Simeprevir effective against?
Genotype 1 (recommend against using if have 1a)
What genotype is Sofosbuvir effective against?
Genotypes 1-6 (in certain combos)
What genotypes is Ledipasvir/Sofosbuvir effective against?
Genotypes 1,4,5,6
What genotypes is Daclatasvir effective against?
Genotypes 1-3
What genotypes is Elbasvir/Grazoprevir effective against?
Genotypes 1,4
What genotypes is Sofosbuvir/Vedipasvir effective against?
Genotypes 1-6
What genotypes is Glecaprevir/Pibrentasvir effective against?
Genotypes 1,2,3,4,5,6
For which medication do you have to check NS5A resistance at baseline and LFTs at week 8 and 12?
EBR/GZR Elbasvir/Grazoprevir
In which patients should you avoid use of a protease inhibitor?
Patients with decompensated cirrhosis
What are the common side effect of Sofosbuvir?
Headache and fatigue
At what time points after initiating therapy should HCV RNA levels be checked?
At week 4 of therapy and 12 weeks after end of treatment
What are the only three treatment options available for patients with decompensated cirrhosis? Which one requires the addition of weight-based Ribavirin?
LDV/SOF, SOF/VEL, DCV/SOF SOF/VEL
What can be done for patients who cannot take Ribavirin?
Extended treatment from 12 weeks to 24 weeks (only can be done for genotypes 1 and 4)
What is the leading cause of cirrhosis? How does this cause cirrhosis?
Alcoholism Genetic predisposition + heavy drinking for more than 10 years greatly increases the risk. Fatty infiltrates cause oxidative damage and scarring
What is the second leading cause of cirrhosis?
Viruses (hepatitis)
Are most patients with cirrhosis symptomatic?
No, their symptoms tend to be insidious
______________ is a terminal diagnosis without a _____ transplant
End stage liver disease (ESLD), liver
What are some complications that can occur in decompensated cirrhosis?
Jaundice, ascities, encephalopathy, varicella bleeding, Caput Medusa (swollen blood vessels on belly), spider Agnioma (broken blood vessels on upper body), palmar erythema (dilation of capillaries on hands)
What are the parameters used in the Child-Pugh classification?
Encephalopathy, ascities, bilirubin, albumin, prothrombin time
What is the MELD classification used for?
Determining who qualifies for liver transplant
What are the parameters that are used for the MELD classification?
INR, bilirubin, SCr, serum sodium. Patients with high MELD score get transplant first
What causes portal hypertension? What is the difference between fixed and variable resistance?
Increased resistance to blood flow in the liver Fixed is irreversible and due to destruction of sinusoids Variable is reversible and due to vasoconstrictors in the liver
What does the wedged hepatic venous pressure (WHVP) and free hepatic venous pressure (FHVP) measure? WHVP - FHVP > _________ indicated portal hypertension?
Measures the difference between the pressure in hepatic sinusoids and the pressure of hepatic outflow 5mmHg
What do larger esophageal varicose increase risk for?
Esophageal bleed
What is the first-line therapy for primary prevention of varicose bleeding? How does this work and what is a side-effect from an off target?
Non-selective beta blockers B2 blockers causes splanchnic vasoconstriction and less blood flow to splanchnic region. Causes bronchoconstriction as well
How does band ligation work? What is one negative aspect to this treatment?
Cuts off blood supply to the varicose and leads to tissue necrosis. Usually requires repeat sessions because of repeat bleed
What is the MOA of octreotide? How is it administered and what are some complications to watch out for?
Somastatin analogue that causes splanchnic vasoconstriction. Given with 50 mcg IV loading dose and then 50 mcg/hr IV drip. Continue this for 72 hours. Usually well-tolerated but can cause glycemic issues, bradycardia, headache, and ab cramping.
What is the purpose of antibiotic therapy? What are the two antibiotic options and how long is treatment?
Improves survival (tears in esophagus can cause bacteria to get in blood). Ceftriaxone or levodopa acid for 5-7 days
Are nitrates or a shunt preferred for secondary prevention?
Shunt
Varicella Hemorrhage Treatment Primary prevention Controlling acute bleed Secondary prevention
Primary: 1st line - beta blocker 2nd line - Band ligation Controlling: 1st line - Octreotide + band ligation 2nd line - TIPS Secondary: 1st line - Beta blocker + band ligation 2nd line - TIPS or transplant
What is ascites? How does this develop?
Fluid accumulation in the peritoneal cavity The liver is not making albumin, there is low solute in the blood and it can’t hold fluid in the vessels as well. Fluid shifts from interstitial space to peritoneal cavity. Leads to vicious cycle of sodium/water retention and third spacing because body thinks it does not have enough blood flow
What method is used to diagnose ascites? What other things would we want to look for in the fluid?
Paracentesis Would also want to look for infection
In ascites treatment, is fluid the main priority over salt restriction?
No, the body needs sodium restriction for diuretics to be effective
Salt restriction should be less than _______?
2 grams a day
Is spironolactone more effective than loop diuretics at treating ascites? What class of medication is spironolactone and what are some side effects?
Yes Potassium sparring diuretic that competitively inhibits aldosterone. Hyperkalemia, hyponatremia, and gynecomastia
What needs to be added in addition to furosemide in ascites treatment?
Low dose spironolactone
When would amiloride be indicated in ascites treatment?
As an alternative to spironolactone with furosemide for male patients who dont want the risk of gynecamstia
What are the major adverse effects of diuretics that need to be monitored for?
Electrolyte imbalances (sodium, potassium), renal impairment, hypotension from fluid loss
What parameters can be monitored for efficacy of diuretic treatment?
Urine output, weight loss
Spontaneous Bacterial Peritonitis If PMN >250/mm^3, would you start empiric therapy? Is this dependent on if the culture is positive or not?
Yes you would regardless on if culture is positive or not
Spontaneous Bacterial Peritonitis Would you start empiric therapy for PMN<250/mm^3 with a positive culture?
Only if patient is symptomatic
Spontaneous Bacterial Peritonitis How does secondary bacterial peritonitis occur? What would be some signs of this and how you treat?
Due to a perforation. Would see glucose less than 50 mg/dL and protein >1 g/dL. Is usually excruciatingly painful and causes fever. Treat with broad spectrum abx covering GNR, anaerobes, enterococcus
SBP What is the antibiotic regimen for SBP? What about patients with a PCN allergy?
Cefotaxime or ceftriaxone for 5 day treatment. Can use a fluoroquinolone for 5 days in patients who have a PCN allergy.
Which patients require SBP prophylaxis? Which antibiotic options do you have for this?
Patients who have had SBP before or patients with ascites protein = 1.5 g/dL and have a Child Pugh score >/= 9 or renal insufficiency Either daily cipro or daily bactrim
Name some of the neurotoxins that cause Hepatic Encephalopathy?
Benzos, ammonia, aromatic amino acids, false neurotransmitters
What is the number one precipitating factor for HE?
Infection (SBP)
How does lactulose work to treat HE? What place in therapy is this? How are acute and chronic dosed?
Non-absorbable sugar that gets metabolized by bacteria in the gut, decreasing colonic pH and trapping ammonia Acute: dosed q2h until diarrhea then titration to 2-4 stools daily Chronic: titration to maintain 2-4 stools daily
Which antibiotic is first choice to treat HE? Which other abx are used and are our concerns with them?
Rifaxamin. Can use metronidazole but worry about resistance. Can use neomycin but worry about renal toxicity
Indicate wether the following statements describe Type 1 or Type 2 hepatorenal syndrome? May require kidney transplant Requires liver transplant Sudden onset Gradual onset Treated with sodium restriction, diuretic D/C, and paracentesis
Type 2 Type 1 Type 1 Type 2 Type 2
What drugs dose the Type 1 HRS cocktail consist of?
Octreotide, midodrine, albumin
Patient population especially susceptible to GERD
Pregnant women
Foods and behaviors that worsen GERD
Alcohol, coffee, citrus, smoking, eating before bed
Exclusion of self-care for GERD
Pregnant patients, elderly, infants, chest pain, vomiting
MOA of antacids Onset, duration Side effects
Reacts with acid in stomach to form neutralizing salt. Increases LES pressure Onset is 5 minutes, lasts 20min-3hrs. Cannot be used to heal GERD Side effects - Mg/Al diarrhea Ca/Al - constipation
can H2RAs be given with antacids?
Yes H2RAs need to be really adjusted Most interaction with cimetidine
PPI MOA
Irreversibly inhibit H+/K+ ATPase in stomach parietal cells.
How does PUD develop
Distrusted mucosal defense acid hypersecretion. Can happen with NSAID use or H. Pylori development
Lifetime complications of PUD
GI bleed, perforation, scarring, edema
PUD alarm symptoms
Anemia, Elena, anorexia, weight loss, severe pain
If pt presents age >50 or with alarm symptoms of PUD, what is the first thing that need to be done? If ulcer is present what should be tested?
Needs to get endoscopy Test if h. Pylori is present
Treatment of H. Pylori How long is therapy
PPI + Clarithomycin + amoxicillin (or metronidazole) BID 14 days
Non-bismuth quadruple therapy How long is therapy
PPI + metronidazole + amoxicillin + clarithomycin Treated for 5 days, shorter duration of therapy
Rome IV criteria for IBS
Recurrent abdominal pain at least 1 day/week in the last 3 months associated with 2 of the 3: -related to defecation -change in stool frequency -change in stool form Criteria fulfilled for the last 3 months, with symptom onset at least 6 months prior to diagnosis
Low FODMAP foods that are recommended in IBS
Cantaloupe
Most appropriate treatment for IBS pain
Antidepressants - TCA (ampitriptyline, nortriptyline, imipramine) - SSRIs Other CNS agents - Mirtazapine, colonizing, buspirone, quetiapine
