Hepatitis Flashcards
How often should people with cirrhosis be monitored for HCC?
6/12 USS
Differences in hep b natural history with HIV coinfection
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
HBV/HIV treatment?
TDF/TAF
3TC, adefivir, telbivudine monotherapy not recommended - high risk of resistance
How long may HEp B viral load take to decline?
Can take longer >48 weeks
Continue therapy if ongoing decline
Risk with discontinuing HIV tx in HBV coinfection?
Liver flare potentially needing transplant
What to do for HBV core pos antigen neg having transplant or immunosuppression?
Ensure on tenofovir/entecavir as risk of reactivation
HBV monitoring
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
Does entecavir have activity against HIV?
Yes but weak, may select m184v
Can only be used with fully active ART
How to manage hep b co infection if renal impairment?
Switch TDF to TAF
At eGFR <30 switch to entecavir with fully active ART regime
If has HD can go back on tenofovir
Entecavir dosing?
Depends on renal function
Dose doubled if previous lamivudine resistance documented or suspected (ie if prev 3TC monotherapy for HBV)
What PrEP should be given to a patient who has HBV monoinfection?
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
Hep C genotypes
1-6
Don’t affect prognosis but do affect drug choice
In Hep C if antibody positive but RNA negative what does this mean?
Do not have hep C
Do not need further monitoring
What is sustained virological response in Hep C?
Cure.
If negative hep c RNA 12 weeks after the END of treatment.
(SVR12)
Reinfecton vs tx failure in hepatitis C
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
Who gets hepatitis C treatment?
Everyone.
Cure rate for hepatitis c?
90-95%
Do we still use interferons for hep c treatment?
No
What do we do if someone fails HCV tx?
Sof/vel if had sof/lip
Sof/vel/vox 12 weeks is mainstay of treatment if failed - contains PI so may have DDI
HCV protease inhibitors
End in Pravir
Can’t have with HIV PiS, NNRTIs except doravirine
II fine (except elv as requires booster)
How should acute HCV be treated?
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
Baseline hepatitis tests at HIV diagnosis
Hep A IgG
Hep B infection and immunity
Hep c antibody
Definition of chronic hep B
sAg persisting after 6 months
What could isolated Hep B core mean?
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
What tests should those with isolated hep bcore pos have?
HBV dna - low would indicate resolving infection
Anti hbc IgM to exclude recent infection
How does abacavir affect response to peg IFN/RBV therapy?
Decreased
Ribavarin should be dosed >1000mg or >13.2mg/kg
How does HIV impact on Hep B infection?
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
How is chronic hep b infection defined?
Hbsag persisting longer than 6 months
When should hep b resistance be checked?
New diagnosis in someone exposed to ARVs that might have anti hep b activity
Genetic barrier to resistance in previously untreated hep b positive patients
Low with 3TC, ftc, telbivudine, low to intermediate with adefovir, high with entecavir and tenofovir
Barrier to entecavir lowered by previous 3TC exposure
Primary non response to NA therapy for HBV
<1 log drop in HBV DNA at 12 weeks
Virological response to HBV tx when NA therapy used
Undetectable HBV DNA at 24 weeks
Partial response to NA therapy in HBV
Fall of > 1 log but not undetectable at 24 weeks
Virological breakthrough HBV
Rise of >1 log HBV dna from nadir level on therapy
Virological response to PEG IFN tx for TB
HBV DNA <2000 after 6 months, at end of therapy and 6 and 12 months after the end of therapy
HBV sustained response to peg IFN therapy
HBV dna <2000 at least 12/12 after end of therapy
How often should hep b dna be measured post treatment in stable patients with HIV?
Annually
Who is recommended to have treatment for HBV?
HBV DNA >2000 regardless of fibrosis score
More than minimal fibrosis on biopsy or fibroscan >9 regardless of hbv dna
First line treatment of HBV
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
Second line tx HBV
Adefovir or 48 weeks PEG-IFN
Monitoring of HBV therapy
6 monthly hep B dna
In whom is peg-IFN for HBV indicated?
Patients with repeatedly raised ALT, low HBV DNA, minimal fibrosis
E antigen pos or neg
Risks of PEG-IFN
Decompensation, worsening of current decompensation and development of liver failure
Repeat tests every 3 months to see if seroconverts
Definition of severe acute hep B
Acute HBV with INR >1.5
Definition of fulminant acute hep B
Severe acute hep B plus hepatic encephalopathy
Treatment for acute hep B (severe/fulminant)
ART - tdf+ftc or 3TC.
Or entecavir plus full art regime.
What to do if treating HBV/HIV and develop renal toxicity?
TAF if applicable. If not Stop tenofovir. Switch ARVs. Add entecavir.
Fibroscan staging level f0-f1
2-7 (hep b and c)
Fibroscan staging f2 (hep B)
7-9.5
Hep b and c
Fibroscan f3 (hep b)
8-11
Fibroscan f4 hep B
> 12= cirrhosis
Fibroscan f2 hiv/hcv coinfection
7-11
Fibroscan f3 hiv/hep c coinfection
11-14
Fibroscan f4 hiv/hep c
> 14
Who should be tested for HDV
Anyone with hbsag positive
Treatment HDV
Tenofovir containing ART
How is HDV viral activity determined?
HDV RNA
How does HDV superinfection affect prognosis?
More likely to have a severe hepatitis with progression of liver disease and development of cirrhosis and HCC
Who should have anti hcv checked every 3-6 months?
Those with repeated high risk exposure even if transaminses normal
Individuals with unexplained abnormal transaminases in high risk for exposure hcv group should have…
HCV PCR
First line treatment for HCV
DAA
First gen PIs boceprovir and telaprovir and IFN therapies not recommended due to insufficient efficacy and increased toxicities
How are DAAa chosen?
Stage of liver fibrosis, genotype, pretreatment history and resistance associated substitutions if tested
DAA of choice if a patient needs re-treatment?
Sof/vel/vox for 12/52
DAA for re treatment in patients with decompensated cirrhosis if liver transplant is contraindicated
Sof/vel (epclusa) 24weeks
which ARV decreases ribavarin levels
Abacavir
Tel sprs it side effects
Anal discomfort
Anaemia
Skin rash
SJS
Side effects boceprevir
Anaemia
Neutropenia
Dyguesia
When should acute hep c be treated?
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
What is the primary aim of HCV treatment?
SVR12 - undetectable rna at 12 weeks
hep C tx monitoring in PLWH with >f3
After 2-4 weeks fbc, creatinine, liver enzymes, bilirubin, albumin, INR. If hbsag neg but core pos and alt rise check hep b dna.
Hep C tx monitoring for those with impaired renal function on SOF based tx
Creatinine
Hep c tx monitoring for everyone
HIV VL every 12/52
RNA at end of tx, week 12 after tx, week 24 after tx to assess SVR
Screening for HCC
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
What is EVR?
UndeteCtable viral load or 99% reduction by week 12
What is SVR?
SVR 12 is undetectable VL 12 weeks after finishing therapy
SVR 24 is ‘cure’ - undetectable VL 24 weeks after therapy
Treatment options for HCC
Liver transplant
