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PharmD > Acute Viral Hepatitis > Flashcards

Acute Viral Hepatitis Flashcards

1
Q

What is hepatitis?

A

Inflammation of the liver caused by viruses or non-infectious agents

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2
Q

What are the 5 viruses that can cause viral hepatitis?

A

Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E

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3
Q

How do we define an acute episode of hepatitis?

A

Systemic infection present for <6 months (often less than 6 weeks)

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4
Q

How do we define when a hepatitis infection has become chronic?

A

Presence of virus in blood for >6 months

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5
Q

What are the symptoms of chronic infections?

A

Typically asymptomatic (patient unaware) until development of late-stage disease complications
- Ascites
- Encephalopathy

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6
Q

How does hepatitis lead to ascites?

A

Damaged liver is unable to process blood properly. Increased pressure leads to portal hypertension.
Forces fluid to leak out into abdominal cavity.

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7
Q

How does hepatitis lead to encephalopathy?

A

Liver is damaged to the point it can no longer effectively filter toxins like ammonia from the blood.
Toxins accumulate and reach brain (neurological symptoms).

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8
Q

Can hepatitis B be cured?

A

No, hepatitis B cannot be cured.

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9
Q

If hepatitis B cannot be cured, how can we have acute infection?

A

Hepatitis B cannot be can’t be “cured” in the sense that the virus can be completely eradicated, but it can still present as an “acute” infection, meaning the illness has a sudden onset and typically resolves within a short period of time, allowing the body to fight off the virus without long-term damage

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10
Q

What is the preferred painkiller in hepatitis B patients?

A

Tylenol

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11
Q

Which two types of hepatitis virus can occur as a co-infection?
Why does this happen?

A

Hepatitis B and D
Hepatitis D (delta) is a defective virus that requires Hepatitis B to survive.

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12
Q

What is a HDV co-infection?
What is a HDV superinfection?

A

Co-infection: simultaneous infection of HBV and HDV

Super-infection: patient already has chronic HBV, but then HDV infection follows
- exacerbates liver disease, progresses to severe

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13
Q

Which virus types are the hepatic viruses?

A

HAV= RNA
HBV= DNA
HCV= RNA
HDV= RNA
HEV= RNA

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14
Q

How is HAV transmitted?

A

Fecal-oral

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15
Q

How is HBV transmitted?

A

Percutaneous
Sexual
Perinatal

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16
Q

How is HCV transmitted?

A

Percutaneous
Sexual
Perinatal (uncommon)

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17
Q

How is HDV transmitted?

A

Percutaneous
Sexual
Perinatal

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18
Q

How is HEV transmitted?

A

Fecal-oral
Zoonotic
Parenteral
Perinatal

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19
Q

Which of the hepatitis viruses can progress from acute to chronic disease?

A

HAV= No
HBV= Yes (most common in neonates)
HCV= Yes (common)
HDV= common in superinfection and rare in co-infection
HEV= No, unless patient is immunocompromised

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20
Q

Which of the hepatitis viruses most commonly progresses from acute to chronic infection?

A

Hepatitis B
Hepatitis C

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21
Q

Why is it the most common for hepatitis C to progress from acute to chronic?

A

Acute infection is rarely diagnosed and up to 80% become chronically infected

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22
Q

Which hepatitis virus has immunization for prevention?

A

HAV, HBV, HDV (from immunization of B)

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23
Q

Since HCV and HEV does not have immunization, what can we do for prevention?

A

HCV= blood donor screening, risk behaviour modification
HEV= ensure safe drinking water and adequately cooked pork products

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24
Q

Most acute infections of hepatitis are asymptomatic, but 25-30% will experience symptoms.

When there are symptoms, they appear to be similar in all types of viruses. What are they?

A

May include:
- Fever
- Myalgias
- Arthralgias
- Headache
- Constant Fatigue
- Right upper quadrant pain
- Jaundice
- Dark-urine
- Clay coloured stools
- Tender hepatomegaly
- Rise in aminotransferases (ALT>AST)

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25
Q

Can acute infection lead to acute liver failure?
Is it common?
Who is at increased risk?

A

Yes, but rare.
Pregnant patients are at particular risk

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26
Q

When should we put in an immediate referral for acute hepatitis?

A
  • Prolonged INR
  • Jaundice
  • Encephalopathy
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27
Q

What are some drugs that can cause drug-induced hepatitis?

A

Acetaminophen
Herbal products:
- Buckthorn
- Chaparral
- Comfrey
- Germander
- Nutmeg
- Valerian

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28
Q

How do we identify what type of hepatitis virus is present?

A

Serologic markers (blood)

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29
Q

What do the following HAV markers indicate?
+ Total anti- HAV
+ Anti-HAV IgG
+ Anti-HAV IgM

A

+ Total anti- HAV
Total IgG and IgM
Acute, resolved infection or immunity

+ Anti-HAV IgM
Acute HAV infection

+ Anti-HAV IgG
Immunity from either vaccination or previous exposure (detectable for life and means lifelong protection)

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30
Q

What do the following HBV markers indicate?
+ HBsAG
+ Anti-HBs
+ HBsAg and Anti-HBs
+ Anti-HBc
- Anti-HBc
+ Anti-HBc IgM
+ HBeAg
+ Anti-HBe
+ HBV-DNA

A

+ HBsAG
Infection (either acute or chronic)

+ Anti-HBs
Immunity

+ HBsAg and Anti-HBs
Infection persists despite immunity (chronic infection)

+ Anti-HBc
Immunity developed from prior infection

  • Anti-HBc
    Immunity developed from vaccination

+ Anti-HBc IgM
Indicates acute infection or severe flare up of chronic infection

+ HBeAg
High degree of HBV infectivity and replication

+ Anti-HBe
Low degree of infectivity

+ HBV-DNA
Marker of viral replication/infectivity and used to monitor treatment

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31
Q

What do the following HCV markers indicate?
+ Anti-HCV
- Anti-HCV
+ HCVRNA
- HCVRNA

A

+ Anti-HCV
Indicates infection (acute or chronic)
Will remain positive for life despite clearance of infection

+ HCVRNA
Ongoing viremia

  • HCVRNA
    No active infection
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32
Q

When do we check HDV markers?

A

Only if HBsAg is positive

33
Q

What do the following HCV markers indicate?
+ Anti-HEV
+ Anti-HEV IgM
+ Anti-HEV IgG

A

+ Anti-HEV
Antibodies for HEV

+ Anti-HEV IgM
Indicates acute infection
Can last up to 16 weeks

+ Anti-HEV IgG
Appears following infection and can last for years

34
Q

What is the treatment of choice for acute viral hepatitis?

A

Often self-limiting, so antiviral therapy is mostly not indicated

Supportive therapy allows for majority of patients to recover completely

Exception: Hep C, treatment leads to favourable outcomes so should be considered on a case-to-case basis.

35
Q

If we do decide to treat Hepatitis C infection, what drug do we use?

A

Direct-acting antiviral (DAA) agents
This is the same treatment for chronic hepatitis C

36
Q

What are some non-pharms to recommend for hepatitis patients?

A

Avoid alcohol until full recovery

37
Q

What vitamin supplementation is good for hepatitis?

A

No role for vitamin supplementation

38
Q

What diet is good for hepatitis patients?

A

No dietary restrictions are needed

39
Q

Does physical activity help with hepatitis patients?

A

No

40
Q

Does hepatitis lead to increased or decreased INR?
Why?

A

Increased INR
Liver is in charge of producing majority of blood clotting factors.
Damage leads to less clotting (increased INR)

41
Q

What do we do if patient has prolonged INR (>1.5) in acute hepatitis?

A

Vitamin K 10mg PO or IV

42
Q

Can the Vitamin K be administered in different route?

A

IM and SC is available but increases risk of hematoma and bleeding

43
Q

Do we need to treat acute symptomatic hepatitis B?

A

No. Immune competent adults are able to clear the infection.

44
Q

Is there an exception to if we treat acute hepatitis B?

A
  • Acute liver failure
  • Severe course
    (bilirubin >1.5mg/dL, INR>1.5)
  • Encephalopathy
  • Ascites
45
Q

In these exception cases of acute Hepatitis B, what do we use to treat patient?

A

Oral antivirals
- Tenofovir disoproxil
- Tenofovir Alafenamide
- Entecavir

46
Q

What drug is contraindicated in acute hepatitis B?

A

Peginterferon-alpha therapy

47
Q

If acute hepatitis B patient fails to clear infection after 6 months, how should they be managed?

A

Treat like chronic HBV

48
Q

Is pre-or postexposure prophylaxis of HCV infection recommended?

A

No
Risk of transmitting through exposure is low and DAA can easily and effectively treat acute episodes. Therefore, don’t recommend prophylaxis

49
Q

Regardless of cause, if patient has acute liver failure, what should we consider?

A

Liver transplantation

50
Q

Most patient with hepatitis E will not require therapy. For those with more complicated symptoms (neurologic), what therapy should they consider?

A

Ribavirin

51
Q

Is ribavirin safe in pregnancy and breastfeeding?

A

No, contraindicated

52
Q

What is the best way to prevent viral hepatitis?

A

Vaccination

53
Q

Hepatitis A vaccine is drug of choice for pre-exposure prophylaxis. How long of protection does it confer?

A

Up to 10 years

54
Q

When are antibodies detectable following vaccine?

A

1 month in most patients

55
Q

What is the dosing schedule for hepatitis A vaccine?

A

1st dose at 0 month
2nd dose 6-12 months later

56
Q

What products do Hep A vaccines come in?

A

Single vaccine= Havrix
Combo vaccine with Hep B= Twinrix
Combo with typhoid= Vivaxim

57
Q

Hepatitis B vaccine induces anti-HB production. Response generally decreases with age. how do we boost protection?

A
  1. Revaccinating with single booster (complete 3-dose series)
  2. Using higher concentration vaccines
58
Q

How long does anti-Hbs levels last? Does protection diminish after those levels diminish?

A

10-15 years
Long-lasting protection remains due to immune memory

59
Q

If patient is immunocompetent and vaccine was successful, is there a need for routine booster doses?

A

No

60
Q

What is the dosing schedule for Engerix B (hep B vaccine)?

A

3 doses given at 0, 1, and 6 months

61
Q

When is hepatitis B immune globulin preferred over the vaccine?

A

When someone has been exposed to Hep B but hasn’t been vaccinated (need immediate protection, as vaccine takes time)

No response to vaccine

62
Q

What is the impact of hepatitis A in pregnancy?

A

No birth defects reported but may have increased risk of miscarriage or premature labour.

63
Q

How do you manage hepatitis A infection during pregnancy?

A

No treatment. Mainly supportive.

64
Q

How do you manage hepatitis A in breastfeeding?

A

Breastfeeding can be continued

65
Q

What is the impact of hepatitis B on pregnancy?

A

No teratogenic effects, but there is an increased rate of miscarriage or premature labour.

Also risk of vertical transmission.

66
Q

What increases the risk of vertical transmission. How do we manage this?

A

High viral load in mom
Antiviral therapy

67
Q

If pregnant patient has high viral load, how do we manage this?

A

Treatment in third trimester if HBV DNA>200 000 units/mL

Tenofovir
Lamivudine
Telbivudine (rare in Canada)

Started at 28 weeks gestation and continued for 1 month postpartum

68
Q

Of the antivirals, which is preferred?

A

Tenofovir
- better efficacy
- higher genetic barrier to viral resistance

69
Q

Which antiviral is contraindicated in pregnancy?

A

Entecavir (teratogenicity)

70
Q

Does mode of delivery affect likelihood of HBV transmission?

A

No

71
Q

How do we further lower the risk of parent to child transmission on the newborn’s side?

A

Immunization at birth with hepatitis B immune globulin (HBIg) and hepatitis B vaccine

72
Q

How do we manage hepatitis B in breastfeeding?

A

Safe to breastfeed if infant has received HBIg and HB vaccine within 12 hours of birth

73
Q

When is breastfeeding contraindicated in hepatitis B patients?

A

If mother is experiencing cracking and bleeding of nipples.
Can restart if nipples heal.

74
Q

If patient is on antiviral therapy, is breastfeeding ok?

A

Yes, breastfeeding is not contraindicated

75
Q

How do we manage hepatitis C infection in pregnancy?

A

Mainly supportive
Treatment of patient is delayed until postpartum

No effective way to reduce vertical transmission. Mode of delivery does not modify risk

76
Q

How do we manage hepatitis C in breastfeeding?

A

Safe to breastfeed as long as no cracks or bleeding

77
Q

In summary, what are 4 initial biomarkers that should be tested with acute viral hepatitis?

A

ALT>AST
INR
Bilirubin
Albumin

78
Q
A

PharmD (14 decks)

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