HCV (Exam 2 Cut Off) Flashcards
1
Q
HCV
A
- RNA virus with 6 major genotypes
- Commonality: GT1 > GT3 > GT2 (NM specific)
- 85% infected develop cirrhosis
- Can further develop ESLD, liver cancer, transplant need
- HIV and continued alcohol use can severely affect progression
- Infections tend to be asymptomatic
2
Q
Extrahepatic HCV Manifestations
A
- HCV causing disease outside of the liver
- Diabetes, joint pain, neuropathy, Parkinson’s
3
Q
Testing Recommendation
A
-Anyone >=18 y.o. should be tested for HCV antibody at least once
4
Q
HCV Transmission
A
- Blood contact
- IDU major driver of current HCV infections
- Non-professional tattoos
- Comorbidities associated with higher HCV prevalence
- Children born to HCV positive mother
- Occupational exposure
- HCV+ sexual partners
- MSM
5
Q
HCV Diagnosis
A
- HCV antibody test to identify exposure
- HCV RNA necessary to determine if chronic infection
6
Q
Anti-HCV Caveats
A
- Those who spontaneously clear or undergo HCV therapy will continue to test anti-HCV positive
- HCV Ab positive doesn’t confer immunity against HCV
7
Q
HCV Treatments Goals
A
- Goal: Cure
- Viral eradication defined as sustained virologic response
- Preventing complications like fibrosis, cirrhosis, ESLD, HCC
- Improving QoL
- Reducing symptoms
- Resolve extrahepatic manifestations
8
Q
Interferon Based Therapy
A
- Low SVR rates, long treatment courses (up to a year)
- Major toxicities, lab abnormalities
- Causes fear in older patients since many new an interferon patient and they now fear the SE
9
Q
DAA Based Therapy
A
- Current standard of care, preferably pan-genotypic therapy
- Specific DAAs act on 1 of 3 targets on the HCV virion to inhibit viral replication
- Current therapies are combination of 2 or more drugs
10
Q
Suffix + Drug Targets
A
- Previr = PI
- asvir = NS5A inhibitor
- buvir = NS5B inhibitor
11
Q
DAA Concerns/Limitations
A
- Concerns to resistance especially in regards to interrupted regimens
- HBV reactivation is a warning for all these drugs, can result in liver failure and death (watch for LFT increase and serologies)
- PI can’t be used in patients with decompensated cirrhosis, precipitates liver failure
12
Q
Mavyret
A
- Glecaprevir/Pibrentasvir
- Pan-genotypic
- Approved for 12 y.o.+
- Take with food
- Can be used in all renal insufficiency but not in decompensated cirrhosis
- Avoid ethinyl estradiol products while on medication, raises ALT
13
Q
Epclusa
A
- Sofosbuvir/Velparasvir
- Pan-genotypic
- Approved for 6 y.o.+
- Safe in all levels of renal and hepatic disease
- Test for resistance before treating GT3, add ribavirin if resistance found
- Avoid PPIs
- Take H2 blockers at the same time or 12 hours apart
- Antacids should be take 4 hours after last dose and 8 hours before the next
14
Q
Vosevi
A
- Sofosbuvir/Velpatasvir/Voxilaprevir
- Pan-genotypic
- Used for previously failed DAA therapy, including previously failed NS5A inhibitor
- With or without food
- SE: diarrhea
- Can be used in all renal insufficiency but not in decompensated cirrhosis
15
Q
Harvoni
A
- Ledipasvir/Sofosbuvir
- GT1 and 4
- Approved for 3 y.o.+
- Safe in all levels of renal and hepatic disease
- Ledipasvir requires similar acidic environment to velpatasvir
16
Q
Zepatier
A
- Elbasvir/Grazoprevir
- No longer used due to resistance testing needed before GT1 use
- Used for GT1 and 4
17
Q
Ribavirin
A
- Inhibits viral replication in synergistic effect
- Exact mechanism isn’t understood
- Not effective as monotherapy but can be used to augment existing DAA therapies
- Weight based dosing that is titrated based on expected anemia effect
18
Q
Ribavirin SE
A
- Nausea (split into BID dosing to minimize)
- Hemolytic anemia: monitor until steady state is achieved (worse in renal impaired)
- Teratogen, avoid in pregnancy (recommend 2 forms of birth control during and for 6 mo after), Category X
19
Q
DAAs + Lab Abnormalities
A
- Very few lab abnormalities unless specified
- Few SE, HA is most common
20
Q
DDI for DAAs
A
- Amiodarone: concerns for symptomatic bradycardia
- Serious, symptomatic bradycardia noted in sofosbuvir patients
- Acid suppression: problem for LDV and VEL
- Avoid ethinyl estradiol in GLE/PIB patients
- Avoid herbals due to limited data
- Avoid major CYP inducers like rifampin and AEDs
- Hold statins while on therapy, interactions vary but holding will have minimal lipid panel effects and is the safest option overall
21
Q
Minimizing Further Liver Damage
A
- Vaccinate for HAV, HBV, flu, and pneumonia
- Avoid/decrease alcohol
- Avoid/minimize smoking
- Weight loss in overweight/obese
22
Q
HCV + Cirrhotic Patients
A
- Screen for hepatocellular carcinoma every 6 months with AFP and abdominal US
- Evaluate for varices with endoscopy
- Avoid NSAIDs and aspirin due to increase bleed risk, renal toxicity potential, and impaired response to diuretics