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phrm 865 > Exam 5: Viral Hepatitis > Flashcards

Exam 5: Viral Hepatitis Flashcards

1
Q

what is hepatitis

A

inflammation of the liver

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2
Q

what is viral hepatitis

A

hepatitis caused by one of at least five distinct viruses

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3
Q

How is hepatitis delta virus developed

A

requires HBV co-infection for replication and expression

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4
Q

How is hepatitis E virus location

A

Primarily occurs in India, Asia, Africa, and Central America

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5
Q

What type of virus is HBV

A

DNA

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6
Q

What is the primary virus of hepatitis

A

RNA

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7
Q

Viral hepatitis acute illness characteristics

A

Nausea, anorexia, fever, malaise, and abdominal pain

Jaundice or elevated liver transaminases

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8
Q

Which hepatitis can produce chronic infection

A

HBV and HCV

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9
Q

Viral hepatitis chronic infection characteristics

A

Subclinical to cirrhosis or hepatocellular carcinoma (HCC)

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10
Q

HAV main transmission

A

fecal-oral

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11
Q

HBV main transmission

A

Blood

sexual

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12
Q

HCV main transmission

A

Blood

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13
Q

HAV perinatal transmission

A

Does not happen

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14
Q

HBV perinatal transmission

A

Yes

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15
Q

HCV perinatal transmission

A

Yes

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16
Q

HAV most common risk factor

A

direct contact with someone with HAV

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17
Q

HBV most common risk factor

A

born to infected mother

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18
Q

HCV most common risk factor

A

Injection drug use

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19
Q

HAV chronic infection

A

Does not happen

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20
Q

HBV chronic infection

A

Yes

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21
Q

HCV chronic infection

A

Yes

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22
Q

HAV course of infection

A

acute, then resolved

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23
Q

HBV course of infection

A

Acute, then sometimes chronic
90% of infants
25-50% of children ages 1-5
5% of adaults

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24
Q

HCV course of infection

A

Acute, then usually chronic

>50% develop chronic infection

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25
Q

HAV treatment of chronic infections

A

N/A

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26
Q

HBV treatment of chronic infections

A

Yes, not curative

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27
Q

HCV treatment of chronic infections?

A

Yes, curative

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28
Q

HAV protective immunity

A

Yes

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29
Q

HBV protective immunity

A

Yes

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30
Q

HCV protective immunity

A

No

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31
Q

HAV vaccine available

A

Yes

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32
Q

HBV vaccine available

A

Yes

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33
Q

HCV vaccine available

A

No

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34
Q

HAV incubation period

A

28 days (range 15-50 days)

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35
Q

HAV virology

A

picornavirus that replicates in the liver, excreted in the bile, and is shed in the stool

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36
Q

HAV symptoms

A

Abrupt onset, usually lasts less than 2 months:

fever, fatigue, loss of appetite, jaundice, joint pain

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37
Q

HAV death rate

A

Rarely fatal

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38
Q

HAV diagnostic testing

A

IgM anti-HAV in serum (usually detectable in 15-20 days)
or
HAV RNA in serum or stool

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39
Q

What remains detectable providing lifelong immunity in HAV

A

IgG anti-HAV

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40
Q

what is used to assess immunity in HAV

A

Total anti-HAV (measuring both IgG and IgM)

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41
Q

Role of antiviral agents in HAV

A

No role

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42
Q

HAV management

A

supportive care only

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43
Q

How many doses of HAV vaccine

A

Two: given at 0 and 6-12 months

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44
Q

HBV virology classification

A

hepadnavirus

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45
Q

HBV pathogenesis

A

virus enters the liver through the bloodstream, replicates in the liver

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46
Q

What can HBV NOT be spread by

A 
FOOD
Water
Sharing eating utensils
breastfeeding
kissing
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47
Q

HAV or HBV: diarrhea

A

HAV

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48
Q

HBV acute symptoms

A

same as HAV but with no diarrhea

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49
Q

HBV chronic infection symptoms

A

typically asymptomatic until onset of cirrhosis, end-stage liver disease or HCC

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50
Q

HBsAg marker

A

Hep B Surface antigen

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51
Q

HBsAg significance

A

Is the patient infectious?

Marker of presence of ongoing infection

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52
Q

anti-HBs marker

A

antibody to hepatitis B surface antigen

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53
Q

anti-HBs significance

A

Is the patient immune?

Marker of immunity (indistinguishable whether acquired from disease or vaccination)

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54
Q

Total anti-HBc marker

A

antibody to hepatitis B antigen

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55
Q

Total anti-HBc significance

A

Has the patient been exposed to the virus?

Marker of exposure to the infection: persists for life, does not account for time since infection

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56
Q

IgM anti-HBc marker

A

Immunoglobulin M class of antibody to hepatitis B core antigen

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57
Q

IgM anti-HBc marker significance

A

Has the patient been recently exposed to the virus?

Marker of acute or recently acquired HBV infection (can give false positives)

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58
Q

HBeAg marker

A

Hepatitis B e antigen

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59
Q

HBeAg significance

A

Is the virus actively replicating?

Marker of high infectivity in acute or chronic HBV infection (corresponds to viral replication)

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60
Q

anti-HBe marker

A

antibody to hepatitis B e antigen

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61
Q

anti-HBe significance

A

Has the virus recently stopped replication?

Marker of loss of viral replication and lower levels of virus

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62
Q

HBV acute infection management

A

No treatment available

Supportive care

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63
Q

HBV chronic infection management

A
  1. achieve sustained suppression of HBV replication
  2. remission of liver disease
  3. prevent cirrhosis, hepatic failure, and HCC
  4. functional cure- HBsAg loss with or without anti-HBe gain- is attainable
  5. virological cure- eradication of ccDNA from hepatocyte nuclei- is not yet attainable
64
Q

Lab values to monitor in HBV chronic infection

A

CBC, liver panel, INR, HBeAg, anti-HBe, HBV DNA PCR

65
Q

What phases of chronic HBV can cause elevated ALT

A 
e+ Immune-active
e- Immune active (carrier)
e-Immune reactivation
e+ cirrhosis
e- cirrhosis
66
Q

what phase of chronic HBV displaces low/undetectable HBV DNA

A

e- inactive (carrier)

67
Q

e+ immune tolerant chronic HBV characteristics

A

normal ALT

elevated HBV DNA (++++)

68
Q

e- inactive (carrier) chronic HBV characteristics

A

normal ALT

low/undetectable HBV DNA

69
Q

e+ immune active chronic HBV characteristics

A

elevated ALT

elevated HBV DNA (+++)

70
Q

e+ cirrhosis chronic HBV characteristics

A

elevated ALT
elevated HBV DNA (+++)
low albumin
low platelets

71
Q

e- immune reactivation chronic HBV characteristics

A

elevated ALT

elevated HBV DNA (+++)

72
Q

e- cirrhosis chronic HBV characteristics

A

elevated ALT
elevated HBV DNA (++_
low albumin
low platelets

73
Q

males ALT upper limit of normal

A

35 U/L

74
Q

females ALT upper limit of normal

A

25 U/L

75
Q

does HBV treatment eradicate it

A

No

76
Q

HBV treatment eligibility

A

2/3 aint bad

  1. HBV DNA >2000 IU/mL PLUS
  2. ALT >2x ULN
    or
  3. Cirrhosis
77
Q

HBV Treatment eligibility: e+ immune-tolerant

A

Monitor

78
Q

HBV Treatment eligibility: e- inactive (carrier)

A

monitor

79
Q

HBV Treatment eligibility: e+ immune active

A

TREAT if ALT > 2x ULN and HBV DNA >20,000 IU/mL

otherwise monitor

80
Q

HBV Treatment eligibility: e- immune reactivation

A

TREAT INDEFINITELY if ALT >2ULN, HBV DNA>2,000 IU/mL

otherwise monitor

81
Q

HBV Treatment eligibility: e+ cirrhosis

A

TREAT INDEFINITELY HBV DNA>2,000 IU/mL

otherwise monitor

82
Q

HBV Treatment eligibility: e- cirrhosis

A

TREAT INDEFINITELY HBV DNA>2,000 IU/mL

otherwise monitor

83
Q

first line treatment of HBV

A

nucleoside analogs:
TDF
TAF
entecavir

84
Q

HBV nucleoside MOA

A

inhibit HBV replication through incorporation into viral DNA by the HBV reverse transcriptase to result in DNA chain termination

85
Q

HBV nucleoside DOC

A

tenofovir TDF 300mg PO QD

TAF 25 mg PO QD

86
Q

What can happen if you withdrawal of tenofovir

A

potential ALT flares

87
Q

entecavir dosing in HBV

A

0.5 mg PO QD in nucleoside naive pts

1mg PO qd in nucleoside experienced pts

88
Q

entecavir clinical pearls

A

take on empty stomach

89
Q

first line cytokine for HBV MOA

A

cytokine with antiviral, antiproliferative, and immunomodulatory effects

90
Q

what cytokine is used to treat HBV

A

peginterferon alfa 2a

91
Q

peginterferon alfa 2a dosing

A

180mcg SQ QW for 48 weeks

92
Q

peginterferon alfa 2a contraindications

A

Pts with current psychosis, severe depression, neutropenia, thrombocytopenia, symptomatic heart disease, decompensated liver disease, and uncontrolled seizures

93
Q

peginterferon alfa 2a potential side effects

A

flu-like symptoms, fatigue, mood disturbances, cytopenia, autoimmune disorders, anorexia

94
Q

peginterferon alfa 2a monitoring

A

CBC x 1-3 months
TSH x 3 months
Monitoring of side effects

95
Q

entecavir potential side effects

A

lactic acidosis in decompensated cirrhosis only

96
Q

entecavir monitoring

A

Lactic acid levels

HIV testing before initiation

97
Q

TDF potential side effects

A

nephropathy
fanconi syndrome
osteomalacia
lactic acidosis

98
Q

TDF monitoring

A

CrCl

Bone density

99
Q

TAF potential side effects

A

lactic acidosis

100
Q

TAF monitoring

A

lactic acid

101
Q

Immune tolerant HBV monitoring

A

ALT q3-6 months

eAg q6-12 months

102
Q

e- inactive HBV monitoring

A

ALT q6-12 months

103
Q

NA therapy HBV monitoring

A

HBV DNA levels q3 months until undetectable (within 96 weeks) then q 3-6 months

104
Q

HIV co-infection with HBV treatment

A

emtricitabine/tenofovir (truvada, descovy)

105
Q

HCV virology

A

flavivirus

106
Q

HCV replication site

A

liver

107
Q

HCV average time from exposure to symptom onset

A

4-12 weeks (range 2-24 weeks)

108
Q

HCV transmission

A

spread through large or repeated percutaneous exposures to infected blood

109
Q

HCV acute infection symptoms

A

most are asymptomatic

similar to HBV

110
Q

Can HCV become chronic

A

Yes: >50% with acute HCV develop chronic infection

111
Q

Classification of chronic HCV

A

persistently detectable HCV RNA for > 6 months

112
Q

How to detect HCV

A

anti-HCV after 8-11 weeks of infection

HCV RNA of current infection

113
Q

Goals of HCV therapy

A
  1. obtain virological cure by achieve a sustained virological response- HCV RNA undetectable 12 weeks after cessation of treatment
  2. Prevent complications (cirrhosis, HCC) and death
114
Q

HCV therapeutic agents

A

Direct acting antivirals:
NS3/4A protease inhibitors
NS5B polymerase inhibitors
NS5A replication complex inhibitors

ribavirin
interferons

115
Q

NS3/4A protease inhibitors

A

Grazoprevir
Glecaprevir
Voxilaprevir

116
Q

grazoprevir administration

A

Only coformulated with Zepatier

117
Q

grazoprevir dosing

A

100 mg PO QD with food

118
Q

grazoprevir AE

A

fatigue, headache, nausea, anemia, ALT elevations

119
Q

grazoprevir monitoring

A

ALT monitoring at 8 weeks; D/C if >5x ULN

Contraindicated in Child-Pugh class B or C

120
Q

glecaprevir administration

A

only in coformulated mavyret: 3 tabs daily

121
Q

glecaprevir dosing

A

300mg PO QD WITH FOOD

122
Q

glecaprevir AE

A

headache, fatigue

123
Q

glecaprevir monitoring

A

Contraindicated in Child-Pugh class B or C

124
Q

voxilaprevir administration

A

coformulated Vosevi

125
Q

voxilaprevir dosing

A

100mg PO QD with food

126
Q

voxilaprevir indication

A

approved for patients who have been previously treated with an NS5A replication complex inhibitors

127
Q

voxilaprevir monitoring

A

not recommended in Child-Pugh class B or C

128
Q

NS5b polymerase inhibitor

A

Sofosbuvir

129
Q

sofosbuvir brand name

A

sovaldi

130
Q

sofosbuvir coformulations

A

Epclusa, Harvoni, and Vosevi

131
Q

sofosbuvir dosing

A

400mg PO QD with or without food

132
Q

sofosbuvir AE

A

fatigue, headache

133
Q

sofosbuvir drug interactions

A

Avoid amiodarone coadministration due to risk of symptomatic bradycardia

134
Q

NS5A replication complex inhibitors

A

Ledipasvir
Elbasvir
Velpatasvir
Pibrentasvir

135
Q

ledipasvir administration

A

coforumulated Harvoni

136
Q

ledipasvir adverse effects

A

fatigue, headache

137
Q

ledipasvir drug interaction

A

ledipasvir solubility decreases as pH increases, so spacing apart acid reducing agents in necessary

138
Q

ledipasvir dosing

A

90 mg PO QD with or without food

139
Q

elbasvir administration

A

coformulated Zepatier

140
Q

elbasvir dosing

A

100mg PO QD with or without food

141
Q

velpatasvir administration

A

coformulated epclusa and vosevi

142
Q

velpatasvir dosing

A

100mg PO QD with or without food

143
Q

velpatasvir adverse effects

A

fatigue, headache

144
Q

pibrentasvir administration

A

coformulated with mavyret

145
Q

pibrentasvir dosing

A

120mg PO QD with food

146
Q

Zepatier name

A

elbasvir/grasoprevir

147
Q

Zepatier adult dose

A

1 tab qd with or without food

148
Q

mavyret name

A

pibrentasvir/glevaprevir

149
Q

mavyret adult dosing

A

3 tabs qd with food

150
Q

vosevi name

A

velpatasvir/sofosbuvir/voxilaprevir

151
Q

vosevi adult dose

A

1 tab qd with food

152
Q

harvoni name

A

ledipasvir/sofosbuvir

153
Q

harvoni adult dose

A

1 tab qd with food

154
Q

epclusa name

A

velpatasvir/sofosbuvir

155
Q

epclusa adult dose

A

1 tab qd with or without food

phrm 865 (59 decks)

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