Chapter 19: Hepatitis and Liver Disease

Question 1

What does hepatitis mean?

Answer 1

Inflammation of the liver

Question 2

What are the causes of hepatitis?

Answer 2

Viruses/infections (Hepatitis A through E are the most common)
Alcohol and drugs

Question 3

What is hepatitis A virus?

Answer 3

This is an acute, self-limiting disease. It is contracted through the oral-fecal route due to improper hygiene or contaminated food/water. The symptoms are usually mild and non-specific.

Question 4

What are hepatitis B and C viruses?

Answer 4

These are viruses that can cause acute illness. Progression of these viruses can lead to chronic infection, liver disease, cirrhosis, or even death. They are spread by blood or bodily fluids (sperm, having sex, sharing needles)

Question 5

Know the diagram that compares the 3 different Hepatitis viruses. It is on page 305. Be able to draw it.

Question 6

How many different genotypes of HCV exist?

Answer 6

6

Question 7

What is the treatment regimen for HCV?

Answer 7

2 to 3 direct acting antivirals with different mechanisms for 8-12 weeks.

Question 8

Just like HIV, DAA’s act on different phases of the HCV lifecycle. Give the phases of the HCV lifecycle that the DAA’s act upon.

Answer 8

1. NS3/4A Protease Inhibitors
2. NS5A Replication Complex Inhibitors
3. NS5B Polymerase Inhibitors

Question 9

There are two examples of DAA’s. Give the Generic and Brand Names

Answer 9

1. Glecaprevir/Pibrentasvir (Mavyret)

2. Sofosbuvir/Velpatasvir (Epclusa)

Question 10

DAA’s can interact with many drugs. What are the 3 main ones we should really keep an eye out for?

Answer 10

1. All DAA’s are contraindicated with strong CYP3A4 inducers
   Oxcarbazepine (Trileptal)
   Carbamazepine (Tegretol)
   Phenobarbital
   Phenytoin
   Rifampin
   Rifabutin
   St. John’s Wort
2. DAA’s can increase the myopathy of statins
3. DAA’s can decrease BG when used along with insulin or other diabetic medications. Keep a close eye on this one.

Question 11

What drug should Sofosbuvir NEVER interact with?

Answer 11

Amiodarone. This can cause severe bradycardia.

Question 12

What following 3 drugs can decrease the concentrations of ledipasvir and velpatasvir?

Answer 12

1. Antacids
2. H2RA’s
3. Proton Pump Inhibitors

Question 13

What drugs should Mavyret never be used with?

Answer 13

Remember the generic name of Mavyret: (Glecaprevir/Pibrentasvir)

Efavirenz, HIV Protease Inhibitors (Darunavir, Atazanavir, Ritonavir), Ethinyl-Estradiol Containing products, and cyclosporine.

Question 14

What is Ribaviren

Answer 14

It is an antiviral that inhibits the synthesis of DNA and RNA. It should be used with other DAA’s or interferons but never as monotherapy. Watch out for hemolytic anemia and do not use in pregnant women (teratogenicity)

Question 15

What are interferons?

Answer 15

Interferons are naturally produced cytokines that have antiviral and immunomodulatory effects. They are approved for treating HBV and HCV.

Question 16

What is added to interferons to prolong their half-life?

Answer 16

Polyethylene Glycol

Question 17

What side effects can interferons cause?

Answer 17

Fatigue, depression, GI effects

Question 18

What are NRTI’s

Answer 18

Nucleoside Reverse Transcriptase Inhibitors are used to treat HBV. They inhibit HBV polymerase which ultimately inhibits HBV replication and then ceases DNA synthesis.

Question 19

What is cirrhosis?

Answer 19

This is advanced fibrosis (scarring) of the liver. When the healthy tissue gets replaced with scar tissue, there is decreased blood flow in the liver and this develops consequences such as portal hypertension, ascites, gastroesophageal varices, and hepatic encephalopathy.

Question 20

What are the two most common causes of cirrhosis in the U.S?

Answer 20

Hepatitis C

Alcohol abuse

Question 21

What should be done before we treat someone for HBV? Why do we do this?

Answer 21

We test the patient to see if they have HIV. HBV drugs have activity towards HIV and HIV can develop resistance towards these drugs. We want to make sure we choose the absolute best regimen that will treat both.

Question 22

What is hepatic encephalopathy?

Answer 22

Hepatic Encephalopathy is when the liver doesn’t function properly and cannot detoxify substances. As a result of this, we accumulate nitrogenous substances in the blood (ammonia). This ends up causing symptoms including confusion, changed thinking, decreased concentration, drowsiness, and mood changes.

Question 23

How do we treat hepatic encephalopathy?

Answer 23

1. First, try implementing a proper diet (Meat has a lot of nitrogen, eat less of it.)
2. Pharmacologic treatment: Lactulose, it turns ammonia into ammonium which is then unable to diffuse into the blood barries. Rifaximin also decreases ammonia production.

Question 24

Side effects of lactulose

Answer 24

Abdominal discomfort, flatulence, diarrhea

Question 25

Side effects of Rifaximin

Answer 25

Peripheral edema, dizziness, fatigue, nausea

Question 26

What is ascites?

Answer 26

This is fluid accumulation in the peritoneal space that can lead to spontaneous bacterial infection or hepatorenal syndrome.

Question 27

Who should be considered for a liver transplant?

Answer 27

Patient with both cirrhosis and ascites

Question 28

How is ascited treated?

Answer 28

If ascites is caused by fluid accumulation, the diet should consist of less than 2 grams of sodium per day. Pharmacologic therapy consists of diuretics (Spironolactone and Furosemide): Spironolactone is effective as monotherapy, Furosemide is not. If furosemide were to be used, it would have to be WITH spironolactone.

Question 29

What should be the mg ratio when using Spironolactone and Furosemide together?

Answer 29

Spironolactone 100 mg/Furosemide 40 mg. This is done to maintain potassium balance.

Question 30

What is secondary bacterial peritonitis?

Answer 30

This is when the fluid that has accumulated in the peritoneal cavity has been infected.

Question 31

How is secondary bacterial peritonitis treated?

Answer 31

Ceftriaxone for 5-7 days is the preferred treatment for streptococci and enteric gram negative bacteria. After the patient has survived this disease once, it is recommended that secondary prophylaxis consists of ciprofloxacin or sulfamethoxazole/trimethoprim.

Question 32

What is hepatorenal syndrome?

Answer 32

Hepatorenal syndrome is renal failure caused by cirrhosis. This is due to renal vasoconstriction that is activated by renin angiotensin aldosterone system and sympathetic nervous system. Octreotide and midodrine are approved treatments for it but prevention is the true, superior one.