exam 4 lecture 6 Flashcards
What type of viruses are hepatitis
RNA viruses (except HBV, which is DNA virus)
Name the main transmission, perinatal transmission and common risk factors for all hepatitis types
HAV- main transmission- fecal
perinatal transmission- no
Most common risk factor- direct contact with someone with HAV
HBV- main transmission- blood sexual, perinatal- yes,
most common risk factor- Born to infected mother
HCV- main transmission- blood
Perinatal transmission- yes
Most common risk factor- inj drug use
Which hepatitis are chronic
B and C
What is the course of infection of hep A, B and C
A- acute then resolved
B- acute then chronic sometimes
C- acute, then usually chronic
Which hepatitis is not curable
B
Which hep do we have no vaccines towards
C
How is Hep A diagnosed
requires detection of IgM anti HAV or HAV RNA in serum or stool
How many HAV doses are given for newborns? WHat type of vaccine is it (pregnancy)? When should post exposure prophylaxis be recommended
Two doses given at 0 and 6-12 months
Inactivated vaccine- safe in pregnancy
Post exposure prophylaxis should be given ASAP after exposure (within 2 wks)
How is hep B spread?
sex
injected drug
mother to child
contact with blood or open sores
needle
Razors or toothbrush
What are the 3 triple panel test constituents
- hep B surface antigen (HBsAg)
- Antibody to hepatitis B surface antigen (anti HBs)
- Antibody to hep B core antigen (anti- HBc)
- Immunoglobulin M class of antibody to hepatitis B core antigen (IgM anti HBc)
What questions do each of the triplepanel test of hep B tell us
Hep B surface antigen- Is patient infectious
antibody to hep B surface antigen- is patinet immune
Antibody of hep B core antigen- has the patient been exposed to virus
IgM anti HBc- has atient been recently exposed to virus
What does it men if HBsAg is positive but IGM anti HBc is negative? IgM anti HBC positive?
HBsAg positive/IgM anti HBc negative- chronic infection
IgM anti HBc positive- acute infection
What does anti-HBs positive/ anti HBc positive mean? Anti HBc negative?
anti-HBs positive/ anti HBc positive- resolved infection
Anti HBc negative- immune from prior vaccination
Management of acute infection of HBV
no tx
supportive care
goals of therapy of HBV tx
achieve sustained suppression of HBV replication
Remission of liver disease
Prevent cirrhosis, hepatic fx and HCC
Functional cure- HBsAg loss with or without anti- HBe gain- is attainable
virological cure not yet positive
What labs do we look at to see what phase of hepatitis a person is in
Liver panel
HBeAg
HBV DNA PCR
What phase of chronic HBV has Normal ALT but elevated HBV DNA?
Normal ALT but low/undetectable HBV DNA
normal ALT- elevated HBV- e+ Immune tolerant
Normal ALT- low undetectable HBV- e- inactive (carrier)
What phase of chronic HBV would a person be in if they had elevated ALT with elevated HBV DNA
e + Immune active or e- immune reactivation
What phase of chronic HBV is elevated ALT, elevated HBV DNA and low albumin/ low platelet going to be in?
e= cirrhosis or e- cirrhosis
define cirrhosis
low albumin, low platelets
ALT upper limit of normal for men and women
35 for men
25 for women
is hep B nucleoside analog txtemporary or lifelong
lifelong
How do we decide tx eligibility of HBV
DNA >2000 IU/ml (viral load)
ALT>2xULN
or
cirrhosis
When should we treat for e+ immune active/reactive
e+ immune active- treat if ALT > 2x ULN, HBV DNA >20,000
e- immune reactivation treat indefinitely if ALT > 2x ULN, HBV DNA > 2000
when shoud we treat for e cirrhosis
e+ Cirrhosis- tx indefinitely if HBV DNA > 2000
e- cirrhosis- treat indefinitely if HBV DNA >2,000 otherwise nonitor
What is first line for HBV
tenofovir (TDF or TAF)
entecavir
side effects after treating HBV
potential ALT flared on withdrawal
side effects for TAF, TDF and entecavir? Monitoring for each?
TAF- lactic scidosis, monitor lactic acid levels
Entecavir- lactic acidosis ; monitor lactic acid levels if clinical concern test for HIV before tx initiation
TDF- nephropathy, lactic acidosis, osteomalacia. Monitor Crcl baseling, bone density if hx of fracture
all doses have to be adjusted with renal dysfunction in HBV tx with TAF, TDF and entecavir
yes
What to monitor for HBV patients
monitor ALT 3-6 months and e antigen 6-12 months
follow up every 3-6 months after therapy initiated
if we stop HBV therapy, how often should we monitor patients
every 3 months for at least 1 year
Who should receive HCC surveillance every 6 months (even if on tx)
All HBsAG + patients with cirrhosis and high risk non cirrhotics
What are some high risk cirrhotics that need to be monitored every 6 months
Asian or black men over 40, asian women a=over 50 and those with 1st degree relatives with HCC
HCV what percent develop chronic infection? What is chronic infection defined as? What percent of people with chronic HCV develop cirrhosis
> 50% with acute HCV develop chronic infection
Defined as persistently detectable HCV RNA for >6 months
5-25% of poeple with chronic HCV develop cirrhosis over 10-20 yrs
diagnostic test of HCV
HCV RNA
goal of therapy for HCV
Obtain virological cure by achieving a sustained virologic response. HCV RNA undetectable 12 wks after cessation of tx
prevent complications (cirrhosis and death)
fundamental principles of HCV tx (what is used, is recent or active drug use contraindication?, warning when using these agents?)
combination therapy of direct acting antivirals (DAAs), prevents emergence of drug resistance
not contraindicated
all DAAs carry warning of HEP B reactivation
name the DAAs used in HCV
NS3/4A protease inhibitors
NS5B polymerase inhibitors
NS5A replication complex inhibitors
how can we identify the NS3/4A protease inhibitors
-pravir (protease)
grazopravir
What is something to note about grazopravir
ALT needs to be checked at 8 wks
dx if 5 x ULN (upper limit of normal)
LFTs need to be checked too
how to recognize NS5B polymerase inhibitors
-buvir
sofosbuvir
Sofosbuvir side effects, dose adjustments in hepatic impairement?
fatigue and headache
dose adjustment not needed in hepatic impairement (needed in protease inhibitors)
name NS5A replication complex inhibitors
Elbasvir (asvir)
velpatasvir
what is a pre treatment lab needed before elbasvir
genotype 1a patients must screen for presence of resistance associated substitutions (RASs)
What is pre treatment lab needed for velpatasvir
genotype 3 patients must screen for Y93H
