hepatitis Flashcards
ssRNA viral hepatitis
Hep A
Hep C
Hep C
Hep D
Hep E
fecal- oral transmission viral Hepatitis
Hep A
Hep E
blood borne and or sexual transmission viral Hepatitis
Hep B
Hep C
Hep D
dsDNA viral hepatitis
Hep B
acute viral hepatitis
Hepatitis A
Hep E
hep b
chronic viral hepatitis
Hep B,C ,E
oncogenic hepatitis
HEP B
Hep C
Child turcotte-pugh score
compensated
Class A: 5-6 points (least severe)
decompensated
Class B: 7-9 points (moderately severe disease)
Class C: 10-15 points ( most severe)
compensated cirrhosis
asymptomatic with or without gastro-esophageal varices
decompensated
Jaundice
ascites
variceal hemmorage
hepatic encephalopathy
HAV transmission
ingestion of fecal matter, even microscropic amounts of
- close person to person contact w infected person
-sexual contact
-ingestion of contaminated food or drinks
HAV treatment
supportive care only
pre exposure prevention HAV
<6 months & healthy
-immune globulin
6-11months & healthy
-HAV vaccine
> 12month - 40 yo
-HAV vaccine
> 40 yo & healthy
-immune globulin + vaccine
> 6mo ,immunocompromised or liver disease
-immune globulin + vaccine
> 6 mon, vaccine CI or declined
-immune globulin
post exposure propylaxis
<12 mo & healthy
-immune globulin
> 12 mo- 40 yo + healthy
-HAV vaccine
> 40 yo & healthy
-immune globulin
> 12 mo & immunocompromised or chronic liver disease
-HAV vaccine +immune globulin
> 12 mo& vaccine CI or declined
-immune glubulin
HAV routine prevention
Prevention
-regular hand washing w soap
-avoid contaminated water/ ice, fresh produce, uncooked foods
vaccination
- HAV only (Havrix, Vaqta
—- 2 dose series: 1 shot at 0 & 6 mo
—>12 months
-HAV + HBV (twinrix)
—>18yo only
clinical presentation of HAV
-fever, fatigue, loss of appetite, N??V, ab pain, dark urine, clay color stool, jaudice
-iceteric sclera skin, mild weight loss.hepatomegaly
- positive serum IgM anti-HAv, elevation of serum bilirubin and hepatic transaminase
HBV associated complications
cirrhosis
hepatic decompensation
hepatiocellualr carcinoma
HBV presentation
-appears 1-4 months after exposure
-abdominal pain, dark urine, fever, joint pain, loss of appetite, N?V, weakness and fatigue, yellowing of skin, yellowing of whites eye
acute HBV treatment
supportive care
preferred HBV therapy
Pegylated interferon a-2a,a-2b
-least preferred
Entecavir
Tenofovir disoproxil fumarate
Tenofovir alafenamide
Pegylated interferon a-2a,a-2b MOA & CI
inhibits viral replication, immunomodulary
Contraindication
-uncontrolled major depression
-suicidal ideation
-autoimmune hepatitis or disease
-soluid transplant
-decompensated cirrhosis of HCC
-uncontrolled thyroid disorder
Pegylated interferon a-2a,a-2b AE and monitoring
AE
-flu like illness
-fatigue
-neutropenia
-anemia
-thrombocytopenia
-mood disturbances
-injection site reaction
-autoimmune disordors
monitoring
-CBC
-TSH
-autoimmune,ischemic, neuropsychiatric, infectious complication
Entecavir MOA, ADE,
guanosine nucleoside analog inhibits HBV DNA replication
AE
-well tolerated
-HBV if abruptly d/c
administration
- empty stomach**
- 2hr before or after meal
resistance
-high genetic resistance
Tenofovir disoproxil fumarate (TDF)
adenosine nucleotide analoge inhibits HBV DNA replication
dose
>35kg: 300 mg
>2 and >10kg: weight based
dose reduction in renal dysfunction
AE
-Nausea, nephrotoxicity, osteomalacia, falcon sydrom
-HBV exacerbation if abruptly dc
resistance: low
Tenofovir alafenamide (TAF)
-phosphonamide prodrug of tenofovir
-adenosine nucleotide analog inhibits HBV DNA replication
Dose
-adults >18yo: 25 mg with food
-avoid in crcl < 15mL.min
AE
-HBV exacerbation if abruptly dc
-HA, ab pain, cough, backache, fatigue
-less BMD and nephrotoxicity vs TDF
metabolism: carboxyesterase hydrolysis, p-gp and BCRP (substrate)
HBV/HIV
Emtricitabine, lamivudine, TDF and TAF
initial fix dose combination
-TDF/ Emtricitabine
-TDF/lamivudine
-TAF/ Emtricitabine
Adult duration of treatment for HBV
nucleus(t)ide
- no cirrhosis: 12 months
-cirhossis: indefinite
peg-IFN-a: 48 weeks
HBV Prevention: Vaccination
HAV+ HBV (IM)
-TWINRIX
HBV (IM)
-ENGERIX-B
-RECOMBIVAX HB
HEPLISAV-B
HCV testing recommendations
-one-time, routine, opt out for >18 yo
-one time <18 yo if you if risky, activities, exposure, or conditions or circumstances
-routine prenatal care w each pregnancy
-Periodically if if risky, activities, exposure, or conditions or circumstances
-Annually: IVDU, HIV+, MSM unprotected sex, and MSM taking PrEP
Direct acting antivirals (DAAs) MOA
target specific nonstructural (NS) protein for HCV leading to disruption in viral replication and infection
Ledipasvir/sofosbuvir
Indication (age ≥ 3 y/o)
* GT1,4,5,6w/o cirrhosiso r w/compensated cirrhosis
*GT1 decompensated cirrhosis +RBV
*GT1 or 4 liver transplant recipient w/o cirrhosis or w/compensated cirrhosis + RBV
*DDIs
* P-gp inducers
* Amiodarone (bradycardia)
* Antacids: separate by 4 hrs
** H2RAs: simultaneously w/or 12 hrs apart; avoid comparable doses > famotidine 40 mg PO BID
* *PPIs: simultaneously w/fasting conditions; avoid comparable doses > omeprazole 20 mg po daily
Velpatasvir/sofosbuvir
(pangenotypic)
Indication (age ≥ 3 y/o)
* GT 1-6 w/o cirrhosis or w/
compensated cirrhosis (RBV-free) or w/decompensated cirrhosis + RBV
DDIs
* P-gp,CYP2B6,2C8,3A4inhibitorsand inducers
* Amiodarone(bradycardia)
* Antacids:separateby4hrs
*H2RAs:simultaneouslyw/or12hrsapart; avoid comparable doses > famotidine 40 mg PO BID
* PPIs: not recommended; if needed, take Epclusa w/food & 4 hrs before omeprazole 20 mg po daily
Elbasvir/grazoprevir
Indication (≥ 12 y/o & ≥ 30 kg) * GT1or4
*In combination w/ RBV if NS5A mutations and/or IFN, RBV, or PI-tx experienced)
*NS5A resistance test before tx forGT 1a
Contraindications
*Moderate or severe hepatic impairment
(CTPBorC)
*Strong CYP3A inducers, OATP1B1/3
inhibitors
*Contraindications to RBV apply
DDIs
* CYP3A4, P-gp, OATP1B1/3 inducers and inhibitors
Glecaprevir/pibrentasavir
(pangenotypic)
Indication (≥ 3 y/o)
*GT 1-6 w/o cirrhosis or w/ compensated cirrhosis
*GT1previously tx w/ NS5A inhibitoror NS3/4A protease inhibitor (not both)
Contraindications
* Moderate-severehepaticimpairment
(CTP Class B or C)
*H/Opriorhepaticdecompensation
*Coadministration w/ atazanavir and rifampin
DDIs
*Pgp,BCRP,OATP1B1/1B3,3A4,1A2, UGT1A1 inducers and inhibitors
simplified treatment
naive no cirrhosis preferred regimens
GT 1-6: Mavyret® (glecaprevir/pibrentasvir)
300 mg/120 mg w/food x 8 wks
-OR-
GT 1-6: Epclusa® (velpatasvir/sofosbuvir)
100 mg/400 mg x 12 wks
simplified treatment
Naive no cirrhosis
with SVR
Check HCV VL and LFTs ≥ 12 wks following completion to confirm virologic cure (SVR) and transaminase normalization
counsel risk reduction and test for HCV VL annually and w/e elevated AST,ALT, or bilirubin
avoid excess ETOH
simplified treatment
naive w/ compensated cirrhosis preferred regimens
GT 1-6: Mavyret® (glecaprevir/pibrentasvir)
300 mg/120 mg w/food x 8 wks
-OR-
GT 1-6: Epclusa® (velpatasvir/sofosbuvir)
100 mg/400 mg x 12 wks
*GT3 if baseline NS5A resistance mutation negative
simplified treatment
Naive Compensated Cirrhosis w/SVR
- Check HCV RNA and LFTs ≥ 12 wks upon completion to confirm virologic cure (SVR) and transaminase normalization
- Assessment for other causes of liver dx if elevated transaminase levels after achieving SVR
- U/S surveillance for HCC (w/ or w/o AFP testing) Q6mo.
- Upper endoscopic surveillance for esophageal varices associated-portal
hypertensive bleeding - Counsel if ongoing risk for HCV infection (i.e., IVDU or MSM engaging in
unprotected sex) about risk reduction and test for HCV VL annually and
whenever elevated ALT, AST, or bilirubin - Advise to abstain from ETOH use
simplified treatment
Naive Compensated Cirrhosis failure
- Check HCV RNA and LFTs ≥ 12 wks or later following completion of therapy to confirm virologic cure (SVR) and transaminase normalization
- If initial HCV tx fails to achieve SVR then evaluate for retreatment by a specialist
- U/S surveillance for HCC (w/ or w/o AFP testing) Q6mo
- Assess HCV disease progression Q6-12 mo. w/ hepatic function panel,
CBC, and INR - Advise to abstain from ETOH
HCV/HIV co-infected Patients
- Suffer more liver-related M&M, nonhepatic organ dysfunction, and overall mortality vs HCV-monoinfected pts
- Despite potent ARVs, HIV independently associated w/advanced liver fibrosis and cirrhosis
- Prioritize tx for providers, pts and payers
- Monitor liver dx progression if HCV tx delayed
- Efficacy and ADEs similar to HCV monoinfection
HCV Prevention
- No vaccine available
- Avoid sharing dental or shaving equipment
- Cover bleeding wounds
- Avoid use of illicit drugs and recommend substance abuse tx
- For those who continue with IVDU
- Avoid reusing or sharing syringes, needles, water, cotton
- Use new sterile syringes and filters, and disinfected cookers
- Clean injection site w/new alcohol swab
- Discard syringes and needles after single use in safe, puncture-proof container
- Avoid blood donation if HCV-infected
- Use barrier protection to prevent sexual transmission
- Mix 1 part household bleach: 9 parts water to clean contaminated
household surfaces with visible blood. Wear gloves.
