Chapter 26: Hepatitis & Liver Disease

Question 1

Which of the following are used in the treatment of hepatitis A virus? (Select all that apply)

A. Valacyclovir
B. Ganciclovir
C. Aztreonam
D. Doxycycline
E. No antivirals are required, provide supportive care only

Answer 1

E - HAV is not treated with antiviral therapy, only supportive care

Question 2

Hepatitis B virus (HBV) is a vaccine preventable disease that causes acute illness. Which of the following statements about HBV is correct? (Select all that apply)

A. Transmission requires contact with blood, semen, or other body fluids by having sex with an infected person
B. Treatment duration is well defined
C. HBV can lead to liver cirrhosis, liver cancer, and liver failure
D. Ribavirin is often chosen as a first line agent
E. Viread® and Baraclude® are both considered good treatment options for HBV

Answer 2

A, C, E are true

Transmission of HBV does require this type of contact with an infected person. In addition to cirrhosis of the liver, liver cancer, and liver failure, HBV can lead to chronic infection and death. Tenofovir (Viread®) and entecavir (Baraclude®) are both NRTIs used in the treatment of HBV. These agents are also utilized for HIV patients, however the doses for HIV patients are higher

Treatment duration for HBV is not well defined (it is for HCV). Ribavirin is not even used in the treatment of HBV, only HCV and only in combination with other agents, never as monotherapy.

Question 3

T/F:

Hepatitis A virus (HAV) is a vaccine preventable disease and is primarily transmitted via blood or bodily fluids

Answer 3

False:
HAV is a vaccine preventable disease (Havrix, Vaqta), however the virus is primarily transmitted via fecal-oral route from poor hand washing or contaminated food/water

Question 4

What (2) classes of medications are used to treat HBV?

Answer 4

Hepatitis B virus is treated with interferons and NRTIs

Interferon alfa-2b (Intron®) and pegylated interferon alfa-2a (Pegasys®) are used to treat both HBV and HCV. However, due to their numerous toxicities, use is limited. Toxicities include CNS effects (fatigue, anxiety, depression), GI (N/V, anorexia), increased LFT, myelosuppression, alopecia, flu-like syndrome

NRTIs include tenofovir (Viread®) and others. Viread® is a first line agent, but can cause renal toxicity including renal failure, Fanconi’s syndrome, osteomalacia, and decreased bone mineral density.

Question 5

Which of the following statements about HCV is correct? (Select all that apply)

A. This is a vaccine preventable virus
B. It is most commonly transmitted via IV drug use in the US
C. Treatment regimen depends on which HCV genotype patient is infected with
D. Ribavirin is the go to mono therapy antiviral for HCV treatment
E. Ribavirin has a boxed warning for both teratogenicity and hemolytic anemia

Answer 5

B,C, E
There are no vaccines available to prevent HCV. HCV is transmitted via blood, particularly common in the US via IVDU. There are six different HCV genotypes and treatment options and duration will depend on which genotype being treated. Ribavirin is NEVER used as monotherapy. Ribavirin is pregnancy category X and can cause hemolytic anemia from oral therapy occurring within 4 weeks of start of therapy.

Question 6

Which of the following statements is correct regarding interferon alfa? (Select all that apply)

A. Peg-Intron® is a SC injection given weekly
B. The dose must be reduced in the setting of thrombocytopenia and neutropenia
C. Causes CNS effects and blood disorders
D. Indicated for treatment of HBV only
E. Pretreat patient with beta methadone cream to prevent rash

Answer 6

A,B,C
Peg-Intron® is dosed 1.5mg/kg SC WEEKLY, while Intron® A is dosed 3 million units SC 3x/week. Interferon alfa dose must be reduced if the ANC is less than 500/mm3 or platelets are less than 25,000/mm3, AND for renal dysfunction. Can cause or exacerbate neuropsychiatric events and cause hemolytic anemia.

Incorrect: D,E
Interferon Alfa is indicated for HBV and HCV. Rash is not a SE of interferon Alfa. It can cause flu-like syndrome, patients can be pre-treated with APAP and antihistamine, not betamethasone

Question 7

What is the brand and drug class of lamivudine used for hepatitis B?

Answer 7

Lamivudine (Epivir HBV®) is a NRTIs used for the treatment of HBV and, at higher doses, HIV.

Question 8

What is the brand and drug class of Tenofovir?

Answer 8

Tenofovir (Viread®) is a NRTI used in the treatment of HBV and HIV. It is a first line agent for the treatment of HBV due to its higher efficacy and lower resistance rates.

Question 9

What is the brand and drug class of entecavir?

Answer 9

Entecavir (Baraclude®) is an NRTI and is a 1st line agent for the treatment of HBV.

Question 10

What are (2) boxed warnings associated with the entire drug class of NRTIs used in the treatment of HBV?

Answer 10

1. Lactic acidosis and severe hepatomegaly with steatosis
2. Exacerbations of HBV may occur upon discontinuation

NRTIs used in the treatment of HBV include:
Lamivudine (Epivir HBV®)
Adefovir (Hepsera®)
Tenofovir (Viread®)
Entecavir (Baraclude®)
Telbivudine (Tyzeka®)

All of these NRTIs must be renally dose adjusted with CrCl less than 50 ml/min

Question 11

What is the brand and drug class of Simeprevir?

Answer 11

Simeprevir (Olysio®) is a direct acting antiviral agent (DAA) indicated for treatment of chronic HCV infection. Specifically, simeprevir is a protease inhibitor inhibiting HCV NS3/4A protease which is required for HCV viral replication

Question 12

What is the brand and drug class of sofosbuvir?

Answer 12

Sofosbuvir (Sovaldi®) is a direct acting antiviral agent (DAA) polymerase inhibitor indicated for treatment of HCV only. It is a nucleotide inhibitor of HCV NS5B polymerase and often combined with other DAA in many recommended HCV regimens.

Question 13

What is the brand and drug class of the combination product sofosbuvir + ledipasvir?

Answer 13

Sofosbuvir + ledipasvir (Harvoni®) are both direct acting antiviral agents (DAA) with slightly different MOA used in the treatment of HCV. Sofosbuvir is a polymerase inhibitor inhibiting NS5B polymerase while ledipasvir is an NS5A replication complex inhibitor. It is one tablet taken once daily and is considered a complete HCV regimen.

Combining these 2 medications allows therapy to target HCV by different mechanisms.

Question 14

What is the brand and drug class of daclatasvir?

Answer 14

Daclatasvir (Daklinza®) is a direct acting antiviral agent (DAA) used in combination with Sofosbuvir. Similar to ledipasvir, daclatasvir is an NS5A replication complex inhibitor used in the treatment of HCV.

Question 15

What is the brand and drug class of the combination product elbasvir + grazoprevir?

Answer 15

Elbasvir + grazoprevir (Zapatier®)

Elbasvir, similar to daclatasvir and ledipasvir, is an NS5A replication complex inhibitor while grazoprevir is a protease inhibitor, specifically HCV NS3/4A protease, similar to Simeprevir and paritaprevir. This combination product is specifically used for HCV genotypes 1a, 1b, and 4

Question 16

What is the brand name of the combination product paritaprevir + ritonavir + ombitasvir?

Answer 16

Paritaprevir + ritonavir + ombitasvir (Technivie®) is a combination product of DAA agents for treatment of HCV

Question 17

What is the brand name of the combination product paritaprevir + ritonavir + ombitasvir + dasabuvir?

Answer 17

Paritaprevir + ritonavir + ombitasvir + dasabuvir (Viekira Pak®). This is a combination product of DAA agents for the treatment of HCV. This is different than a similar combination product paritaprevir + ritonavir + ombitasvir (Technivie®) which does not include dasabuvir. Viekira Pak® dosing regimen is a little confusing: Paritaprevir + ritonavir + ombitasvir is combined into one tablet and dasabuvir is a separate tablet. Take 2 tablets of paritaprevir + ritonavir + ombitasvir once daily in the AM and 1 dasabuvir tablet twice daily with meals. So, the patient will take 3 tablets in the AM and 1 tablet in the PM.

Question 18

Which HCV direct acting antiviral agent requires an acidic environment for absorption?

Answer 18

Sofosbuvir + ledipasvir (Harvoni®)

H2-blockers and PPIs can decrease concentration of ledipasvir component. PI suggests the following:

• Separate Harvoni® from antacids by 4 hrs
• Take Harvoni® at the same time as H2-blockers or 12 hrs apart
• Take Harvoni® at the same time as PPIs

Question 19

A pharmacist will counsel a patient who is beginning Peg-Intron® self-injections. Counseling points should include all of the following except:

A. This medication is given by SC injection, usually once weekly
B. Blood tests will be required to monitor SE. If detected, the dose may need to be reduced
C. if the pt is being treated with combo therapy, they will also take Ribavirin capsules or liquid by mouth everyday. Ribavirin should be taken on an empty stomach.
D. The most common SE include flu-like Sx, fatigue, appetite problems, skin reactions, and hair thinning
E. The flu-like Sx can last 24hr and generally appear 1-2 hrs after administration; pre-to with APAP and antihistamine is helpful

Answer 19

C. Ribavirin is always taken with food to improve tolerability

Question 20

Which of the following medications is Viekira Pak® contraindicated with: (Select all that apply)

A. Metoprolol
B. Seasonique
C. Tri-Sprintec
D. Midazolam
E. Viagra®

Answer 20

B, C, D, and E are all contraindicated with Viekira Pak®

Viekira Pak® is contraindicated with several medications including ethinyl estradiol-containing medications, like Seasonique and Tri-Sprintec. Viekira Pak® can cause increased LFTs, especially when combined with ethinyl estradiol meds. It is also CI with concomitant use of other medications highly dependent on CYP3A4 for elimination like midazolam (Versed®) and sildenafil (Viagra®)

Question 21

Which of the following drugs is matched with a hepatitis virus it does NOT treat?

A. Baraclude - HBV
B. Ribavirin - HCV
C. Viekira Pak - HCV
D. Interferons - HBV and HCV
E. Daklinza - HBV

Answer 21

E. Daclatasvir (Daklinza®) is a direct acting antiviral agent (DAA) used in the treatment of HCV only. It is an NS5A replication complex inhibitor and is typically taken in combination with sofosbuvir (Sovaldi®). It is CI with strong CYP3A4 inducers

Question 22

A patient is starting Pegasys®. Which of the following SE should the patient be counseled about: (Select all that apply)

A. Low or high thyroid hormone
B. Increase in visual acuity, increase in hearing ability
C. Skin lesions, hair loss, and a rash on the skin
D. Problems with vision, nerve damage around the eyes, and blood clots in the eyes
E. SOB and trouble breathing which could be signs of lung damage

Answer 22

A, C, D, E are all correct

Due to the risk of ocular hemorrhage, if the patient notices that lines look “squiggly” or if it seems like there is a blotch or obstruction in their field of vision they must get emergency treatment. If the eye is hemorrhaging it must be stopped very quickly or the vision in that eye can be lost, permanently. Sometimes, the hemorrhage will stop itself, and other times, it will not but can be stopped by the ophthalmologist.

Question 23

One of the major SE and boxed warning for ribavirin is hemolytic anemia. What exactly is hemolytic anemia?

Answer 23

Hemolytic anemia is when RBC are destroyed before their normal lifespan is over. A normal healthy RBC lifespan is 120 days. Hemolytic anemia can be diagnosed by a few tests including bilirubin (which is a test that measures the level or RBCs your liver has broken down), hemoglobin, and LFTs

Question 24

Which of the following drugs is interferon alpha-2b?

A. Pegasys
B. Peg-Intron
C. Intron A
D. Avonex
E. Betaseron

Answer 24

C. Intron A is interferon alpha-2b indicated for HBV, HCV, and various malignancies

Pegasys® is peg-interferon alfa-2a indicated for HBV and HCV
Peg-Intron® is peg-interferon alfa-2b indicated for HCV (and melanoma)
Avonex® is interferon beta-1a IM injection indicated for MS
Betaseron® is interferon beta-1b SC injection indicated for MS

Question 25

Why should NSAIDs (including ASA) be avoided in cirrhosis patients seeking OTC pain medication?

Answer 25

NSAIDs (including ASA) can precipitate a GI bleed, blunt the diuretic response, and exacerbate renal dysfunction in these patients. APAP is the preferred OTC pain medication at reduced doses. There are no recommendations listed in Lexicomp®, just to use with caution and use a limited, low-dose therapy.

Question 26

Which of the following is appropriate management for ascites? (Select all that apply)

A. Spironolactone monotherapy
B. Furosemide monotherapy
C. Spironolactone and furosemide
D. Salt restriction
E. Fluid restriction

Answer 26

A, C, D

Salt restriction, but not fluid restriction, is a non-pharmacological option for ascites management. Fluid restriction plays a role in treating hyponatremia which can occur in patients with liver disease

Question 27

The pharmacist receives a prescription for a female patient for Epivir 100mg PO once daily for HBV. What is wrong with this prescription?

A. Incorrect tablet strength
B. Incorrect dosing frequency
C. Drug is for male patients only
D. Drug is incorrect
E. None of the above.  Fill as is.

Answer 27

D. Drug is incorrect

Epivir HBV 100mg PO once daily is used for HBV, while Epivir is used for HIV in higher doses (150mg PO BID or 300mg PO once daily). These two drugs are NOT interchangeable.