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DipHIV > Hepatitis > Flashcards

Hepatitis Flashcards

1
Q

How often should people with cirrhosis be monitored for HCC?

A

6/12 USS

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2
Q

Differences in hep b natural history with HIV coinfection

A

Lower rates eAg clearance
Increased HBV VL
More rapid onset of fibrosis, cirrhosis, HCC - old studies

Several HBV drugs also have HIV activity - ? Resistance risk

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3
Q

HBV/HIV treatment?

A

TDF/TAF

3TC, adefivir, telbivudine monotherapy not recommended - high risk of resistance

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4
Q

How long may HEp B viral load take to decline?

A

Can take longer >48 weeks
Continue therapy if ongoing decline

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5
Q

Risk with discontinuing HIV tx in HBV coinfection?

A

Liver flare potentially needing transplant

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6
Q

What to do for HBV core pos antigen neg having transplant or immunosuppression?

A

Ensure on tenofovir/entecavir as risk of reactivation

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7
Q

HBV monitoring

A

Serology 6/12, hep B dna 6/12
All HIV+ plus hep b and c - 6/12 USS - even if hcv cured or HBV dna suppressed

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8
Q

Does entecavir have activity against HIV?

A

Yes but weak, may select m184v
Can only be used with fully active ART

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9
Q

How to manage hep b co infection if renal impairment?

A

Switch TDF to TAF
At eGFR <30 switch to entecavir with fully active ART regime
If has HD can go back on tenofovir

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10
Q

Entecavir dosing?

A

Depends on renal function
Dose doubled if previous lamivudine resistance documented or suspected (ie if prev 3TC monotherapy for HBV)

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11
Q

What PrEP should be given to a patient who has HBV monoinfection?

A

If hepatologist says needs hep B treatment then they start this

If not and only starting PrEP-
Have to be on daily dosing
Counsel on stopping - risk of flare

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12
Q

Hep C genotypes

A

1-6
Don’t affect prognosis but do affect drug choice

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13
Q

In Hep C if antibody positive but RNA negative what does this mean?

A

Do not have hep C
Do not need further monitoring

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14
Q

What is sustained virological response in Hep C?

A

Cure.
If negative hep c RNA 12 weeks after the END of treatment.
(SVR12)

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15
Q

Reinfecton vs tx failure in hepatitis C

A

Cannot get late relapse
If negative at SVR 12 and beyond they are cured so if become positive again it’s reinfection

If becomes positive between end of tx and 12 weeks that would be treatment failure

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16
Q

Who gets hepatitis C treatment?

A

Everyone.

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17
Q

Cure rate for hepatitis c?

A

90-95%

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18
Q

Do we still use interferons for hep c treatment?

A

No

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19
Q

What do we do if someone fails HCV tx?

A

Sof/vel if had sof/lip

Sof/vel/vox 12 weeks is mainstay of treatment if failed - contains PI so may have DDI

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20
Q

HCV protease inhibitors

A

End in Pravir

Can’t have with HIV PiS, NNRTIs except doravirine
II fine (except elv as requires booster)

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21
Q

How should acute HCV be treated?

A

Repeat RNA 4 weeks
If <2 log decrease VL crack on with tx
If >2 log decline then repeat as 12, 24, 48 weeks to ensure cleared

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22
Q

Baseline hepatitis tests at HIV diagnosis

A

Hep A IgG
Hep B infection and immunity
Hep c antibody

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23
Q

Definition of chronic hep B

A

sAg persisting after 6 months

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24
Q

What could isolated Hep B core mean?

A

False positive or previous infection but loss of antibodies or level below detection due to immune dysfunction - may improve with immune reconstitution

Vaccinating can discriminate between the two

V rarely can be after sag gone, before sAb build

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25
Q

What tests should those with isolated hep bcore pos have?

A

HBV dna - low would indicate resolving infection
Anti hbc IgM to exclude recent infection

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26
Q

How does abacavir affect response to peg IFN/RBV therapy?

A

Decreased

Ribavarin should be dosed >1000mg or >13.2mg/kg

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27
Q

How does HIV impact on Hep B infection?

A

More likely to progress to chronic HBV
Reduced rate of natural clearance of HBeAg
Higher HBV VL - associated with faster disease progression - progression to cirrhosis and HCC more rapid in hbv/hiv coinfection

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28
Q

How is chronic hep b infection defined?

A

Hbsag persisting longer than 6 months

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29
Q

When should hep b resistance be checked?

A

New diagnosis in someone exposed to ARVs that might have anti hep b activity

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30
Q

Genetic barrier to resistance in previously untreated hep b positive patients

A

Low with 3TC, ftc, telbivudine, low to intermediate with adefovir, high with entecavir and tenofovir

Barrier to entecavir lowered by previous 3TC exposure

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31
Q

Primary non response to NA therapy for HBV

A

<1 log drop in HBV DNA at 12 weeks

32
Q

Virological response to HBV tx when NA therapy used

A

Undetectable HBV DNA at 24 weeks

33
Q

Partial response to NA therapy in HBV

A

Fall of > 1 log but not undetectable at 24 weeks

34
Q

Virological breakthrough HBV

A

Rise of >1 log HBV dna from nadir level on therapy

35
Q

Virological response to PEG IFN tx for TB

A

HBV DNA <2000 after 6 months, at end of therapy and 6 and 12 months after the end of therapy

36
Q

HBV sustained response to peg IFN therapy

A

HBV dna <2000 at least 12/12 after end of therapy

37
Q

How often should hep b dna be measured post treatment in stable patients with HIV?

A

Annually

38
Q

Who is recommended to have treatment for HBV?

A

HBV DNA >2000 regardless of fibrosis score

More than minimal fibrosis on biopsy or fibroscan >9 regardless of hbv dna

39
Q

First line treatment of HBV

A

Tenofovir containing art

Entecavir can be given if TDF/TAF contraindicated but with fully suppressive art as otherwise can select for hiv resistance and only if no prior 3TC exposure

40
Q

Second line tx HBV

A

Adefovir or 48 weeks PEG-IFN

41
Q

Monitoring of HBV therapy

A

6 monthly hep B dna

42
Q

In whom is peg-IFN for HBV indicated?

A

Patients with repeatedly raised ALT, low HBV DNA, minimal fibrosis
E antigen pos or neg

43
Q

Risks of PEG-IFN

A

Decompensation, worsening of current decompensation and development of liver failure

Repeat tests every 3 months to see if seroconverts

44
Q

Definition of severe acute hep B

A

Acute HBV with INR >1.5

45
Q

Definition of fulminant acute hep B

A

Severe acute hep B plus hepatic encephalopathy

46
Q

Treatment for acute hep B (severe/fulminant)

A

ART - tdf+ftc or 3TC.
Or entecavir plus full art regime.

47
Q

What to do if treating HBV/HIV and develop renal toxicity?

A

TAF if applicable. If not Stop tenofovir. Switch ARVs. Add entecavir.

48
Q

Fibroscan staging level f0-f1

A

2-7 (hep b and c)

49
Q

Fibroscan staging f2 (hep B)

A

7-9.5
Hep b and c

50
Q

Fibroscan f3 (hep b)

A

8-11

51
Q

Fibroscan f4 hep B

A

> 12= cirrhosis

52
Q

Fibroscan f2 hiv/hcv coinfection

A

7-11

53
Q

Fibroscan f3 hiv/hep c coinfection

A

11-14

54
Q

Fibroscan f4 hiv/hep c

A

> 14

55
Q

Who should be tested for HDV

A

Anyone with hbsag positive

56
Q

Treatment HDV

A

Tenofovir containing ART

57
Q

How is HDV viral activity determined?

A

HDV RNA

58
Q

How does HDV superinfection affect prognosis?

A

More likely to have a severe hepatitis with progression of liver disease and development of cirrhosis and HCC

59
Q

Who should have anti hcv checked every 3-6 months?

A

Those with repeated high risk exposure even if transaminses normal

60
Q

Individuals with unexplained abnormal transaminases in high risk for exposure hcv group should have…

A

HCV PCR

61
Q

First line treatment for HCV

A

DAA

First gen PIs boceprovir and telaprovir and IFN therapies not recommended due to insufficient efficacy and increased toxicities

62
Q

How are DAAa chosen?

A

Stage of liver fibrosis, genotype, pretreatment history and resistance associated substitutions if tested

63
Q

DAA of choice if a patient needs re-treatment?

A

Sof/vel/vox for 12/52

64
Q

DAA for re treatment in patients with decompensated cirrhosis if liver transplant is contraindicated

A

Sof/vel (epclusa) 24weeks

65
Q

which ARV decreases ribavarin levels

A

Abacavir

66
Q

Tel sprs it side effects

A

Anal discomfort
Anaemia
Skin rash
SJS

67
Q

Side effects boceprevir

A

Anaemia
Neutropenia
Dyguesia

68
Q

When should acute hep c be treated?

A

If no >2 log drop in RNA 4 weeks after diagnosis or if there is a drop for RNA to still be detectable after 12 weeks to then start tx as naive non cirrhotic

69
Q

What is the primary aim of HCV treatment?

A

SVR12 - undetectable rna at 12 weeks

70
Q

hep C tx monitoring in PLWH with >f3

A

After 2-4 weeks fbc, creatinine, liver enzymes, bilirubin, albumin, INR. If hbsag neg but core pos and alt rise check hep b dna.

71
Q

Hep C tx monitoring for those with impaired renal function on SOF based tx

A

Creatinine

72
Q

Hep c tx monitoring for everyone

A

HIV VL every 12/52

RNA at end of tx, week 12 after tx, week 24 after tx to assess SVR

73
Q

Screening for HCC

A

All cirrhotic HBV or HCV coonfected PLWH even if treated/suppressed - uss 6/12 and AFP

Hep B non cirrhotic - page b score to guide HCC risk

74
Q

What is EVR?

A

UndeteCtable viral load or 99% reduction by week 12

75
Q

What is SVR?

A

SVR 12 is undetectable VL 12 weeks after finishing therapy
SVR 24 is ‘cure’ - undetectable VL 24 weeks after therapy

76
Q

Treatment options for HCC

A

Liver transplant

DipHIV (19 decks)

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