Exam 5 - Hepatitis Flashcards
what are the 3 main hepatitis viruses we learned about?
Hep A (HAV) Hep B (HBV) Hep C (HCV)
what does hepatotrophic mean?
systemic infection that primarily affect the liver
the hepatitis viruses are all RNA — except _____ is a DNA virus
Hep B
HAV, HBV, or HCV: which one(s) will produce a chronic infection
B and C
HAV, HBV, or HCV: which one(s) have immunizations to prevent them
A and B has immunizations
HAV, HBV, or HCV:
which one’s source is feces
A
HAV, HBV, or HCV: which one(s) has a high risk via sexual transmission
A and B
not impossible with C tho
HAV, HBV, or HCV: which one(s) has primary prevention that includes handwashing
A (why handwashing signs in bathrooms of restaurants)
HAV, HBV, or HCV: which one(s) has high risk via IV drug use
B and C
HAV, HBV, or HCV:
which one has a high occupational risk
B
HAV, HBV, or HCV: which one(s) is usually acute and then resolves
A
Risk Groups for HAV:
- traveling to where???
- men who _________
- users of _______
- people with _________ disorders
- people working w/ ________________
- traveling to areas with high/med rates of HAV infection
- men who have sex with men
- users of illegal drugs
- people with clotting factor disorders
- people working w/ nonhuman primates susceptible to this infection
People that should get HAV vaccine:
- All children starting at age _____
- Children/adolescents aged 2-18 who ______
- people with ________ disease
- people with ________ disorders
- men who have sex with men
- illegal drug users
-age 1
-who live in area with high incidence of HAV
(or people who travel to places with high/intermed rates of HAV)
-chronic liver disease
- clotting factor disorders
what are the Hep A vaccines that are available?
Havrix
Vaqta
Twinrix (A and B combo)
Hep A vaccines? inactiavted or live vaccine?
inactivated— ok in pregnancy
Routine vaccination is not needed for what people for Hep A?
food service workers sewage workers health care workers children < 12 months old (bc vaccine not approved for them) child care attendees
HAV, HBV, or HCV:
which one is classified as a picornavirus?
A
HAV, HBV, or HCV:
classified as hepadnavirus?
B!!
B is only one that is DNA based (DNA in the name..)
Is this a way that Hep B an be transmitted?
food/water
no
Is this a way that Hep B an be transmitted?
injection drug use
yes
Is this a way that Hep B an be transmitted?
breastfeeding
no (unlike HIV)
Is this a way that Hep B an be transmitted?
mother-child transmission
yes
Is this a way that Hep B an be transmitted?
sharing razors/toothbrushes
yes
HBV Serologic Markers:
what does HBsAg stand for?
hepatitis B surface antigen
HBV Serologic Markers:
what does HBsAg mean clinically?
it is marker of presence of ongoing infection
if + result = pt is INFECTIOUS
if - result = pt is NOT infectious
HBV Serologic Markers:
what does anti-HBs stand for?
antibody to hepatitis B surface antigen
HBV Serologic Markers:
what does anti-HBs mean clinically?
marker of IMMUNITY
if + result = patient is IMMUNE
if - result = pt is not immune
HBV Serologic Markers:
what does HBcAg stand for
hepatitis B core antigen
HBV Serologic Markers:
what does HBcAg mean clinically?
it isnt used clinically….
no free HBcAg circulates in the blood
HBV Serologic Markers:
what does Total anti-HBc stand for
antibody to hepatitis B core antigen
HBV Serologic Markers:
what does total anti-HBc mean clinically?
marker of exposure to the infection/actually virus
if + = pt has been exposed to the virus
HBV Serologic Markers:
what does IgM anti-HBc stand for?
immunoglobulin M class of antibody to hepatitis B core antigen
HBV Serologic Markers:
what does IgM anti-HBc mean clinically?
marker of ACUTE/recent acquired infection
if + result = pt been exposed to virus within past 6 mos
HBV Serologic Markers:
what does HBeAg and anti-HBe stand for
hepatitis B e antigen and
antibody to the hep B e antigen
HBV Serologic Markers:
what does HBeAg and anti-HBe mean clinically?
relates to the virus if it is actively replicating or has it stopped
what HBV Serologic Marker’s result lets you know that the person has been exposed to the virus?
total anti-HBc (anitbody to hepatitis B core antigen)
what HBV Serologic Marker lets you see that the patient has been recently/past 6 mos exposed to the virus
IgM anti-HBc
what HBV Serologic Marker says that the patient is infectious?
HBsAg
hepatitis B surface antigen
what HBV Serologic Marker lets you know that the patient is immune?
anti-HBs
antibody to hepatitis b surface antigen
what HBV Serologic Marker lets you distinguish if the patient is immune due to disease or vaccination
none!!
anti-HBs lets you know if they are immune … no test to distinguish how the patient is immune
Goals of Therapy for HBV:
- Achieve sustained suppression of _______
- remission of ________
- prevent what 3 things?
- HBV replication
- liver disease
- prevent cirrhosis, hepatic failure, and HCC (hepatic carcinoma)
Fundamental Principles of Treatment for HBV:
Initiate treatment when HBV DNA >/= _________ or >/= ___________ because it is associated with increased risk of cirrhosis and HCC
> 2,000 IU/mL
OR
10,000 copies/mL
Fundamental Principles of Treatment for HBV:
What is the ULN (upper limit of normal) for ALT?
Males: 35 U/L
Females: 25 U/L
Fundamental Principles of Treatment for HBV:
Patients with _________ and all patients with _______ need to be treated INDEFINITELY
e- immune reactivation
and
all pts with cirrhosis
Fundamental Principles of Treatment for HBV:
For e+ patients: treatment should be continued for at least __________
(want loss of HBeAg and want gain of anti-HBe or at least HBsAg loss)
12 months
Fundamental Principles of Treatment for HBV:
what is his “2 outta 3 rule aint bad” rule mean??
need 2/3 criteria for treatment: MUST have HBV DNA > 2000 IU/mL and then need just ONE of the following ALT > 2 x ULN or Cirrhosis present
what are the 4 first line agents possible for HBV?
peginterferon alfa 2a
TDF (tenofovir disoproxil fumarate)
TAF (tenofovir alafenamide)
Entecavir
which first line agent of HBV is used given SQ and given 48 weeks
peginterferon alfa 2a
which first line agent of HBV must be taken on an empty stomach
entecavir
what are the contraindications for peginterferon use?
Hx of psychosis Severe depression Neutropenia/thrombocytopenia Symptomatic heart disease decompensated liver disease uncontrolled seizures
which first line agent of HBV has a dose adjustment if lamivudine exposure has happened
Entecavir
How do you dose adjust Entecavir if the patient has had lamivudine before?
pt gets double the dose (normally is 0.5 mg daily if naive — but if lamivduine given before, give 1 mg PO daily)
what is another reason you would double the dose of Entecavir (other than lamivudine)
if decompensated cirrhosis
ADEs from peginterferon
flu like sxs fatigue mood disturbances cytopenia autoimmune disorders anorexia
Monitoring for peginterferon
CBC Q month to Q 3 months
TSH Q3 months
Clinical monitoring for autoimmune, ischemic, neuropsychiatric, and infectious complications
Monitoring for Entecavir
Lactic acid levels (only concerned in decompensated cirrhosis)
also test for HIV before treatment initiation
ADEs of TDF?
Nephropathy
Fanconi syndrome
Osteomalacia
Lactic acidosis
Monitoring for TDF and TAF
CrCl (at least baseline and other times too)
Bone density study
Check phosphate, urine glucose, and protein at least annually if renal impairment risk
test for HIV before treatment initiation
TAF is the same as above but no bone density scan needed…
what is fanconi syndrome?
rare disorder of kidney tubule function that results in excess amounts of glucose, bicarbonate, phosphates (phosphorus salts), uric acid, potassium, and certain amino acids being excreted in the urine.
ADE of Lamivudine and thus what monitoring??
Pancreatitis — check amylase if Sxs present
Lactic acidosis — check lactic acid levels
test for HIV before treatment
what HBV drugs need renal adjustment if renal insufficiency?
nucleoside analogs
TDF, TAF, and Entecavir
For pts on HBV therapy:
check HBV DNA levels (viral load) how often?
check Q 3 months until undetectable then check Q3-6 months
what 3 things do you look at to put a patient in a Clinical phase of chronic HBV?
Look at E antigen, ALTs, and Cirrhosis
what question does HBeAg answer?
answers if virus is ACTIVELY replication
what question does anti-HBe answer?
has the virus recently stopped replicating?
Treating Pregnant women with HBV:
want to minimize perinatal transmission:
thus begin at weeks _______ of gestation
28 - 32
Treating Pregnant women with HBV:
treat pregnant women with HBV DNA > ________ IU/mL with __________
200,000!!!!
give TDF
(other options not studied)
HAV, HBV, or HCV:
which one is a flavivrus
C
HCV:
is differentiated into _____ different genotypes
___ and ___ are the two most common in the US
6;
1a and 1b
Chronic HCV infection is defined as what?
persistently detectable HCV RNA >/= 6 months
Goals of Therapy: HCV?
obtain virological CURE by achieving a SVR (sustained virological response) aka
HCV RNA is undetectable 12 weeks after cessation of treatment
also prevent cirrhosis, HCC, and death
Treatment for HCV is recommended for who?
everybody!!! unless the person is gonna die within the year (due to non liver issues)
all DAAs carry what black box warning?
Hep B reactivation
Hep B reactivation appears to be correlated with ________ before HCV treatment
HBsAg positivity
what are the 3 main DAA classes for HCV
NS3/N4A protease inhibitors
NS5B polymerase inhibitors
NS5A replication/assembly complex inhibitors
what DAA drug class ends with -previr
N3A/N4A PRotease inhibitors
what DAA drug class ends with -asvir
NS5A replication/assembly complex inhibitors
what DAA drug class ends with -buvir
NS5B polymerase inhibitors
which DAA drug class will have nucleoside analogs
NS5B polymerase inhibitors
which DAA drug class is a potent CYP3A4 inhibitor
N3A/N4A Protease inhibitors/-previr
which N3A/N4A Protease inhibitor/-previr needs to have ALT checked at 8 weeks and discontinue if ALTs are too high
grazoprevir
Discontinue grazoprevir when?
if ALTs are 5 x the ULN
which DAA drug class is well tolerated (have very vague side effects.. HA/Nausea etc)
N3A/N4A Protease inhibitors/-previr
which DAA drug class has pangenotypic coverage
NS5B polymerase inhibitors/-buvirs
what drug means you should avoid amiodarone coadministration due to risk of symptomatic bradycardia
sofosbuvir
which NS5A replication/assembly complex inhibitor is affected by pH (and how is it affected)
ledipasvir
(antacids/high pH = DECREASED absorption/solubility)
aka separate from antacids
which NS5A replication/assembly complex inhibitor is metabolized by CYP3A4 (will dose adjust if coadministered if strong inhibitors or inducer)
daclatasvir
which NS5A replication/assembly complex inhibitor do you need to needs to test for RAV (resistance associated variants) presence
elbasvir
what do you do if RAV (resistance associated variants) is present when giving elbasvir
treat for 16 weeks and add ribavirin
Normally HCV treatment is for how long?
12 weeks
Counseling for preventing spread of Hep C
dont share toothbrushes/shaving equipemnt
cover bleeding wounds
do not use illicit drugs/dont share needles at least
do not donate blood, organs, tissues, semen
test for what prior to using velpatasvir and do what with results?
if genotype 3/compensated cirrhotic pt — check for Y93H variant — if present GIVE and ribavirin
