Exam 4: Viral Hepatitis Flashcards
What is hepatitis?
Inflammation of the liver
What are the 3 most common viruses that cause viral hepatitis? (note there are 5 total)
Hepatitis A virus
Hepatitis B virus
Hepatitis C virus
What type of virus is hepatitis?
RNA
*except HBV is DNA
Which forms of hepatitis can cause a chronic infection?
HBV
HCV
What is the main route of transmission for HAV?
Fecal-Oral
What are the main routes of transmission for HBV?
Blood
Sexual
What is the main route of transmission for HCV?
Blood
What is the most common risk factor for getting HAV?
Direct contact with someone with HAV
What is the most common risk factor for getting HBV?
Born to infected mother
What is the most common risk factor for getting HCV?
Injection drug use
The vaccine against which form of hepatitis is recommended at birth?
HBV
Which form of hepatitis does not require chronic treatment?
HAV
Chronic treatment of which hepatitis form is CURATIVE?
HCV
Chronic treatment of which hepatitis form is NOT CURATIVE?
HBV
What is the only form of hepatitis without a vaccine available?
HCV
What are the 2 methods for diagnosing HAV?
Presence of IgM anti-HAV in the serum
Presence oh HAV RNA in the serum/stool
Which antibody is responsible for providing lifelong immunity to HAV?
IgG anti-HAV
How do we assess immunity to HAV?
Total anti-HAV present
(Measure both IgG and IgM)
How do we treat HAV infection?
We don’t!
-Supportive care
When should the HAV vaccine typically be given?
2 dose series:
0 months and 6-12 months
Post-exposure prophylactic vaccine should be given ASAP after exposure
-in people >12 months old
*Give IM immune globulin if < 12 mo old
*Give both immune globulin and vaccine if >40 years old with increased risk
True or False: The HAV vaccine is safe in pregnancy
True
(it is an inactivated vaccine)
What side effect is unique to HAV?
diarrhea
Who should be screened for HBV?
Adults age 18 and older at least once in their lifetime using a triple panel test
Screen for HBsAg during each pregnancy
Test people at ongoing risk periodically
Test anyone who requests to be tested
What 3 markers are tested in an HBV triple panel test?
Hepatitis B Surface Antigen (HBsAg)
Antibody to hepatitis B surface antigen (anti-HBs)
Antibody to hepatitis B core antigen (Total anti-HBc)
Which marker of HBV tells us if the patient is infectious or not?
Hepatitis B Surface Antigen (HBsAg)
Which marker of HBV tells us if the patient is immune or not?
Antibody to hepatitis B surface antigen
Which marker of HBV tells us if the patient has been exposed to the HBV virus?
Antibody to hepatitis B core antigen
If all 3 HBV markers in a triple panel come back negative, and the patient is susceptible but never infected, what do we do?
Offer HepB vaccine
If in an HBV triple panel, HBsAg is negative, anti-HBs is positive, and anti-HBc is positive, what does this mean and what do we do?
Resolved infection
Counsel about HBV reactivation risk
If in an HBV triple panel, HBsAg is negative, anti-HBs is positive, and anti-HBc is negative, what does this mean and what do we do?
Patient has immunity from a prior vaccination
(if documented)
If not vaccinates, complete the vaccine series
If in an HBV triple panel, HBsAg is positive, anti-HBs is negative, anti-HBc is positive, and IGM anti-HBc is positive, what does this mean and what do we do?
Acute infection
Link to hepatitis B care
If in an HBV triple panel, HBsAg is positive, anti-HBs is negative, anti-HBc is positive, and IgM anti-HBc is negative, what does this mean and what do we do?
Chronic infection
Link to hepatitis B care
How do we treat an acute HBV infection?
No treatment
Supportive care
When do we use medication therapy to treat HBV?
Chronic infection
What 3 tests do we do on a patient with chronic HBV to figure out what phase they are in?
Liver panel
HBeAg
HBV DNA PCR
What is the clinical threshold that HBV DNA must be above in order to treat for HBV?
> /= 2000 IU/mL
(>/= 10,000 copies/mL)
ALT is normally elevated in HBV infection, what is the upper limit of normal for men and women?
Men: 35 U/L
Women: 25 U/L
Do we use monotherapy or combination therapy for HBV treatment?
Monotherapy
*combination therapy has not shown higher efficacy
How long does nucleoside analog therapy typically last for HBV?
Indefinite
What requirements must be met with HBV infection to me eligible for treatment?
HBV DNA > 2000 IU/mL
+
ALT > 2xULN or Cirrhosis
If a patient has the e+ Immune-active phase of chronic HBV, what criteria must they meet to be given treatment?
ALT > 2xULN
HBV DNA > 20,000 IU/mL ***
What are the first-line nucleoside analogs used for HBV treatment?
Tenofovir (TDF) 300 mg po daily
Tenofovir alafenamide 25 mg po daily
this tends to be reserved 2nd line
Entecavir
-use 0.5 mg po daily in nucleoside naive patients
-use 1 mg po daily in nucleoside-experienced patients
What are the other agents that can be used for HBV besides the 1st line treatment?
Nucleoside analogs:
-Lamivudine
-Adefovir
-Telbivudine
Cytokine
-not in US
What side effects are we worried about with Tenofovir Disoproxil Fumarate?
*Nephropathy
Fanconi syndrome
Osteomalacia
Lactic acidosis
What side effect are we worried about with all 3 of the first-line nucleoside analogs for HBV? (entecavir, tenofovir disoproxil fumarate, tenofovir alafenamide)
Lactic acidosis
Who has a higher risk for HBV reactivation/flares?
Patients who test positive for both anti-HBc and HBsAg
What is the treatment for HBV in pregnant women?
Beginning at week 28-32 of gestation, treat pregnant women who have HBV DNA > 200,000 IU/mL with tenofovir DF
*note: only use tenofovir DF, no other forms/drugs
What treatment is frequently used for HBV/ HIV coinfection?
Emtricitabine + Tenofovir
When is the HBV vaccine typically administered and how many doses?
3 doses at: 0, 1, and 6 months old
Hepatitis C is divided into what categories?
7 major genotypes (1-7)
then, further classified into 67 subtypes (a, b, c, etc)
What are the most common types of HCV in the us?
1a and 1b
What are the 2nd most common genotypes of HCV?
2 and 3
How is HCV spread?
Repeated percutaneous exposures to infected blood
What is considered a chronic HCV infection?
Persistently detectable HCV RNA for >/= 6 months
How do we diagnose HCV infection?
Presence of HCV RNA
Who should be screened for HCV?
All US adults
Pregnant women during every pregnancy
What is the goal of HCV therapy?
Obtain a virological cure by achieving sustained virological response (SVR)
SVR= HCV RNA is undetectable 12 weeks after cessation of treatment
Who should receive treatment for HCV?
All people with chronic HCV
-except those with short life expectancies (<12 mo)
Should we use combination therapy in HCV treatment?
Yes, it prevents resistance
All Direct Acting Antivirals (DAAs) used in HCV treatment have what black box warning?
Risk of Hepatitis B reactivation
What are the NS3/4A Protease Inhibitors that can be used in HCV treatment?
*Grazoprevir 100 mg po daily or with/without food
Glecaprevir
Voxilaprevir
What is an important clinical pearl about Grazoprevir therapy?
Patients should have ALT checked at 8 weeks, discontinue if >5xULN
What are the NS5B Polymerase Inhibitors used for HCV treatment?
“buvir” = NS5B
Sofosbuvir (no hepatic dose adjustment)
*this is the only one left
What are the NS5A replication complex inhibitors used for HCV treatment?
“asvir”= NS5A
Ledipasvir
Elbasvir
Velpatasvir
Pibrentasvir
What is an important clinical pearl regarding Elbasvir use in HCV?
Prior to use in patients with an HCV genotype 1a, an NS5A genotype must be performed to screen for the presence of resistance-associated substitutions (RASs) at baseline
Presence of any substitutions at codons: 28, 30, 31, or 93 requires extended 16 week course + ribavirin
What is an important clinical pearl for Velpatasvir use in HCV treatment?
Prior to use, in compensated cirrhotic patients with HCV genotype 3, an NS5A genotype must be performed to screen for the presence of the Y93H substitution
-presence requires adding ribavirin or voxilaprevir
What are the FDA Approved combinations for HCV treatment?
Elbasvir + Grasoprevir
Pibrntasvir + Glecaprevir
Velpatasvir + Sofosbuvir + Voxilaprevir 2nd line
Ledipasvir + Sofosbuvir
Velpatasvir + Sofosbuvir
Which combination product is 3 tablets daily taken with food?
Pibrentasvir + Glecaprevir
What are the most common side effects of ribavirin?
*Hemolytic anemia
*Teratogenic
Who is ribavirin contraindicated in?
CrCl <50
How long does HCV therapy last?
12 weeks
Which regimen is a predominantly 8 week course?
Pibrentasvir + Glecaprevir
