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PharmD > Chronic Viral Hepatitis > Flashcards

Chronic Viral Hepatitis Flashcards

1
Q

What are the two types of hepatitis that most commonly transition from acute to chronic?

A

Hepatitis B
Hepatitis C

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2
Q

What differentiates acute vs chronic hepatitis infection?

A

Presence of virus in the blood 6 months after infection

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3
Q

What biomarkers confirm chronic hepatitis B and hepatitis C infection?

A

Hepatitis B:
HBsAg

Hepatitis C:
Both anti-HCV and HCV RNA

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4
Q

What is the consequence of untreated chronic viral hepatitis?

A

Development of cirrhosis, hepatocellular carcinoma and decompensation with end-stage liver disease

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5
Q

Chronic hepatitis D is uncommon, but if patient is co-infected with B and D, the liver disease is typically _______ severe and has ________ clinical outcomes.

A

More
Worse

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6
Q

Goal of therapy for hepatitis B is to __________.
Goal of therapy for hepatitis C is to __________.

A

Control viral replication
Cure

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7
Q

What is defined as sustained viral suppression of hep B?

A
  • Undetectable serum HBV DNA (<10-15 units/mL)
  • Normalization of ALT
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8
Q

___________ cure of hep B is the most desirable goal of therapy but is rare and not the goal for most treatments

A

Functional

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9
Q

What is defined as functional cure of hep B?

A

HBsAg loss with or without appearance of anti-HBs

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10
Q

What does it mean when patient develop anti-HBs following loss of HBsAg?

A

They become immune to hepatitis B. This is rare though.

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11
Q

The goal of hep C is to cure. How do we define cure?

A

Sustained virologic response (SVR) which is defined as undetectable serum HCV RNA (<10-15 units/mL) 12 weeks after end of treatment

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12
Q

Following Hep C cure, can you be re-infected?

A

Yes

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13
Q

If patient is suspected to have chronic hepatitis B, how do we manage close contacts?

A

Test all household members and sexual contacts:
- HBsAg
- Anti-HBs

If contacts are negative for both, offer then hep B vaccine. Retest for anti-HBs 1 month after last dose to ensure response

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14
Q

If HBV is confirmed, what other viruses should we test for? Why?

A

HCV and HIV
They have the same transmission route.

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15
Q

How often should you monitor liver aminotransferases (ALT, AST) and liver function test (total bilirubin, serum albumin, INR) for chronic hep B?

A

Every 6-12 months

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16
Q

Is liver biopsy recommended for hepatitis B patients?

A

No, not recommended.
Non-invasive testing like FibroScan is available.

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17
Q

When is liver biopsy recommended?

A

Coexisting liver disease
Discrepancies from FibroScan, imaging and laboratory testing.

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18
Q

What parameters would warrant treatment?

A
  • If there is HBeAg
  • HBV DNA levels
  • Persistent elevation of ALT >1 x ULN
  • Any indication of severe liver disease (biopsy, noninvasive fibrosis markers, imaging and lab tests
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19
Q

What are some non-pharm we can recommend for patients with chronic hep B?

A
  • Advise against alcohol
  • Encourage smoking cessation
  • Recommend weight reduction if BMI >30
  • Blood sugar control if diabetic
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20
Q

What is the goal of therapy with hepatitis B? Can Hep B be cured?

A

No cure for hep B.
Control disease by complete suppression of HBV DNA

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21
Q

How do we avoid HBV reactivation once disease is resolved?

A

Oral antiviral therapy prophylactically

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22
Q

What are the three classes of medication for treatment of hepatitis B?

A

Peginterferon alfa-2a
Nucleoside Analogues
Nucleotide Analogues

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23
Q

What is the mechanism of action of peginterferon alfa-2a?

A

Antiviral and immunomodulatory effects promote seroconversion from HBeAg positive to anti-HBe positive

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24
Q

When do we use peginterferon alfa-2a as treatment?

A

Chronic hep B patients who are HBeAG positive.
- Have persistently lower HBV DNA levels and elevated serum aminotransferase values

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25
Q

Who should we avoid peginterferon alfa-2a in?

A

Acute episodes of Hep B (decompensated cirrhosis)
- Increased risk of life threatening infection and worsening hepatic decompensation

Immunosuppressed patients with chronic hep B

HIV+

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26
Q

What drugs are in the nucleoside analogue drug class?

A

Lamivudine
Entecavir

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27
Q

What drugs are in the nucleotide analogue drug class?

A

Tenofovir disoproxil fumarate (TDF)
Tenofovir alafenamide (TAF)
Adefovir

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28
Q

Which nucleos(t)ide analogues are first line?

A

TDF, TAF, and entecavir

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29
Q

What is the mechanism of action of nucleos(t)ide analogues?

A

Inhibit replication of HBV in patients who are HBeAg positive or negative

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30
Q

Resistance to therapy was a concern. Which nucleos(t)ide no longer has a concern with resistance?

A

TDF, TAF, entecavir

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31
Q

Why is lamivudine not a first-line therapy?

A

Low potency in reducing HBV DNA and high resistance rate.

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32
Q

What is lamivudine’s role in chronic hepatitis B?

A

Prophylaxis to prevent disease reactivation in patients who are on immunosuppressive therapy who are HBsAg negative but anti-HBc positive

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33
Q

______ is a prodrug of _______ meaning it is inactive until metabolized into it’s active form.

A

TAF is a prodrug of TDF

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34
Q

What is TDF active against?

A

HBV (including lamivudine-resistant HBV)
HIV

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35
Q

Is TDF approved for monotherapy of chronic hep B?

A

Yes

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36
Q

What is TDF active against?

A

HBV (including lamivudine-resistant HBV)
HIV

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37
Q

Is TAF approved for monotherapy of chronic hep B?

A

Yes

38
Q

What makes TAF different from TDF, besides the fact that it is a prodrug?

A

TAF produces higher levels tenofovir diphosphate than TDF and therefore can be given at lower doses (lower toxicity potential).

39
Q

What is the preferred management for the following patient with chronic hep B?
What would you categorize this patient as?

HBsAg -
Anti- HBc +
Anti- HBe +/-
ALT status normal
HBV DNA -

A

Immune from past exposure

No antiviral therapy indicated.

Assess for need of prophylaxis if patient receiving immunosuppressive therapy.

40
Q

What is the preferred management for the following patient with chronic hep B?

What would you categorize this patient as?

HBsAg -
Anti- HBc -
Anti- HBe +/-
ALT status normal
HBV DNA -

A

Resolved infection

No antiviral therapy. Monitor ALT and HBV DNA q 3-6 months.

Assess for need of antiviral prophylaxis if patient undergoing immunosuppression

41
Q

What is the preferred management for the following patient with chronic hep B?

What would you categorize this patient as?

HBsAg +
Anti- HBc -
Anti- HBe +/-
ALT status normal
HBV DNA often <2000

A

HBeAg- negative chronic infection

No antiviral therapy. Monitor ALT and HBV DNA q3-6 months.

Assess for need of prophylaxis therapy if patient is undergoing immunosuppression.

42
Q

What is the preferred management for the following patient with chronic hep B?

What would you categorize this patient as?

HBsAg +
Anti- HBc -
Anti- HBe -
ALT status normal
HBV DNA often > 10 000 000

A

HBe-Ag positive chronic infection

No antiviral therapy. Monitor ALT and HBV DNA q6 months

Assess liver fibrosis. Treat only if severe disease suspected.

43
Q

What is the preferred management for the following patient with chronic hep B?

What would you categorize this patient as?

HBsAg +
Anti- HBc -
Anti- HBe -
ALT status elevated
HBV DNA 10 000-10 000 000

A

HBeAg positive chronic hepatitis

Consider therapy with peginterferon or nucelos(t)ide analogues (entecavir, TDF, TAF) if:
- ALT is ≥1 × ULN ​and
- viral load is >2000

44
Q

What is the preferred management for the following patient with chronic hep B?

What would you categorize this patient as?

HBsAg +
Anti- HBc -
Anti- HBe +
ALT status elevated fluctuates
HBV DNA 1000 -10 000 000

A

HBeAg- negative chronic hepatitis

Consider long-term therapy with nucleos(t)ide analogues (entecavir, TDF, TAF) if:
- ALT is ≥1 × ULN ​and
- viral load is >2000

45
Q

What is the preferred management for the following patient with chronic hep B?

What would you categorize this patient as?

HBsAg +
Anti- HBc -
Anti- HBe +/-
ALT status elevated
HBV DNA >100

A

Decompensated cirrhosis

Nucleos(t)ide analogue therapy lifelong

46
Q

What is the preferred management for the following patient with chronic hep B?

What would you categorize this patient as?

HBsAg +
Anti- HBc -
Anti- HBe +/-
ALT status elevated
HBV DNA +

A

Post- liver transplant

Nucleos(t)ide analogues plus HBIg

47
Q

About ___to ___% of acute HCV infections in adults become chronic.

A

75-85

48
Q

How is HCV most frequently acquired?

A

Illicit drug use (snorting cocaine, injecting drugs)
Blood transfusions
Tattooing
Needle-stick injuries

49
Q

What are risk factors for progressive fibrosis and cirrhosis in patients with chronic hepatitis C?

A
  • Male gender
  • Being >40 years of age
  • Duration of infection
  • Alcohol consumption >50g daily
  • Co-infection with HIB
  • Immune suppression
  • Diabetes
  • Higher BMI
50
Q

What makes the hepatitis C antibody (anti-HCV) different from antibodies in Hep A and B?

A

It’s a marker for exposure, not immunity.

Therefore an anti-HCV test is used for initial HCV testing

51
Q

How do we confirm with there is an active infection?

A

HCV RNA detection by PCR

52
Q

If patient receives negative anti-HCV test, what is the follow-up procedure?

A

HCV RNA or follow-up anti-HCV testing should be done if HCV exposure occurred within past 6 months or if patient is immunocompromised

53
Q

Which patients should be screened for Hep C regardless of risk factors due to their 5x baseline risk?

A

Patients born between 1945-1975

54
Q

Following Hep C treatment completion, patient must return ____-____ weeks after for HCV RNA test to determine sustained virologic response (SVR) status.

A

12-24

55
Q

What are non-pharms for hepatitis C patients?

A
  • Advise minimal alcohol use
  • Advise weight loss if patient is obese
  • Advise glycemic control if patient is diabetic
  • Avoid herbal products and non prescription liver protective agents
56
Q

What exams or scans are usually done prior to the start of treatment of HCV?

A

RNA viral load
Genotyping
Hepatic fibrosis staging (liver biopsy or FibroScan)

57
Q

What are the drug of choice for treatment of HCV?

A

DAA (direct-acting antiviral)

58
Q

What are the three classes of DAAs?

A
  • NS5B polymerase inhibitors
  • NS5A inhibitors
  • NS3/4A protease inhibitors
59
Q

What drug is under the NS5B polymerase inhibitor class?

A

Sofosbuvir

60
Q

Is sofosbuvir usually used as monotherapy?

A

No, often used in combo with other antiviral agents.

61
Q

What are the combo products of sofosbuvir?

A
  • Sofosbuvir/Ledipasvir= Harvoni
  • Sofosbuvir/Velpatasvir= Epclusa
  • Sofosbuvir/Velpatasivr/Voxilaprevir= Vosevi
62
Q

Is sofosbuvir a prodrug?

A

Yes

63
Q

What are two drug interaction we need to watch out for with sofosbuvir?

A

Rifampin and sofosbuvir
- decreases sofosbuvir concentrations

Sofosbuvir, NS5A inhibitor and amiodarone
- severe bradycardia

64
Q

What drugs are part of the NS5A inhibitor drug classes?

A

Ledispasvir
Pibrentasvir
Velpatasvir

65
Q

Are NS5A drugs usually used as monotherapy?

A

No, typically utilized in combo with other drugs like with the NS5B polymerase inhibitors mentioned prior.

66
Q

What are NS5A inhibitors all susbtrates of?

A

CYP3A4

67
Q

Does that mean they have drug interactions with statins, antituberculosis medications and HIV regimens?

A

Minimal drug interaction

68
Q

What is a drug interaction that we do have to watch out for with NS5A inhibitors? Is there specific NS5A inhibitors that are more at risk of this interaction?

A

Use of PPIs or antacids

Ledipasvir
Velpatasvir

69
Q

What drugs are part of the protease inhibitors or NS3 inhibitors drug class?

A

Glecaprevir
Voxilaprevir

70
Q

Are these protease inhibitors used as monotherapy?

A

No, typically used in combo with polymerase and NS5A inhibitors.

71
Q

What is a common drug interaction with protease inhibitors?

A

Moderate or strong inducers or inhibitors of CYP3A4

72
Q

Where does ribavirin come into play for Hep C chronic infection?

A

Only used in combo with other agents for the treatment of HCV

73
Q

What is an example of immunosuppression in Hep B patients?

A

Use of immunosuppressive drugs like prednisone
- many Hep B carriers experience flare up in later course of tx or withdrawal of immunosuppressive drug

74
Q

Nucleos(t)ide analogue therapy is usually used as monotherapy for HBV patients. When should we not use monotherapy?

A

In HBV patients who are also HIV positive patients.
- Increased risk of developing resistant HIV strains

75
Q

Which of the hepatitis viruses is most likely be transmitted in daycare setting?

A

HAV and HEV, as they’re both fecal-oral

76
Q

What does Epclusa include?

A

Sofosbuvir and Velpatasvir

77
Q

What genotypes does Epclusa cover?

A

1, 2 3, 4, 5, 6

78
Q

What drugs are in Harvoni?

A

Ledipasvir and Sofosbuvir

79
Q

What genotypes does Harvoni cover?

A

1, 3, 4, 5, 6 (not 2)

80
Q

What drugs are in Holkira Pak?

A

Ombitasvir, pariteprevir, ritonavir, dasabuvir

81
Q

What genotypes does Holkira Pak cover?

A

1a, 1b, 4

82
Q

What drugs are in maviret?

A

Glecaprevir and pibrentasvir

83
Q

What genotypes does maviret cover?

A

1, 2, 3, 4, 5, 6

84
Q

What drugs are in Technivie?

A

Ombitasvir, paritaprevir, and ritonavir

85
Q

What genotype does technivie cover?

A

4

86
Q

What drugs are in Vosevi?

A

Sofosbuvir, velpatasvir, voxilaprevir

87
Q

What genotypes does vosevi cover?

A

1, 2, 3, 4, 5, 6

88
Q

What drugs are in zepatier?

A

Elbasvir, grazoprevir

89
Q

What genotypes does zepatier cover?

A

1a if with ribavirin
1b
3 with sofosbuvir
4

90
Q

Which of the hepatitis C drugs need to be taken with food?

A

Vosevi
Technivie
Holkira

PharmD (14 decks)

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