Hepatitis Flashcards
Define the following Hepatitis A serologies: Anti-HAV, Anti-HAV IgM and Anti-HAV IgG
Anti-HAV (total antibody = IgG + IgM): present/past infection or immunity due to vaccination
Anti-HAV IgM: Current, recent or acute infection
Anti-HAV IgG: Immunity to HAV from past infection or vaccination
What patient populations should be recommended the Hepatitis A vaccination?
- All children > 1 year of age
- Persons with travel to areas with intermediate-high rates of infection
- MSM
- Illegal and IVDU
- Homelessness
- Persons with clotting factor disorders
- Persons working with HAV-infected primates
- Persons with chronic liver disease, including HBV and HCV
- Exposed to outbreak
- PEP
How would you dose hepatitis A vaccines?
Havrix (0 and 6-12 mo) and Vaqta (0, 6-18 mo)
*Havrix has neomycin - avoid in allergy
Which patient population should get HepA immune globulin as pre-exposure prophylaxis?
< 6 months or vaccine CI
> 40 years or immunocompromised/chronic liver disease - give HAV vaccine x 1 dose +/- immune globulin
How would you treat for HepA as post-exposure management?
Single dose of HAV vaccine or immune globulin within 2 weeks of exposure
< 12 months - immune globulin
> 12 months - 40 years - HAV vaccine
> 40 years or > 12 months + chronic liver disease or immunocompromised - HAV vaccine x 1 dose +/- immune globulin
When would you treat hepatitis B?
HBeAg +
Per AASLD, HBV DNA > 20,000 AND ALT > 2xULN OR Cirrhosis
Men: 33 units/L and female 25 units/L
What side effects are related to Peg-interferon?
Hepatotoxicity, neutropenia, thrombocytopenia, depression
What are major drug interactions concerns with first-line HepB treatment?
TAF - CI with adefovir, carbamazepine, fosphenytoin, Rifampin/Rifabutin/Rifapentine, St Johns Wort
When do you discontinue Hepatitis B treatment?
Confirmed HBsAg loss +/- HBsAb seroconversion
Non-cirrhotic HBeAg-positive patients with chronic HBV and stable HBeAg seroconversion + undetectable HBV DNA + 12 mo of therapy
Selected cirrhosis HBeAg negative with long term virologic suppression > 3 years
When should HCV be treated?
All patients with chronic HCV infection should be treated (HCV Ab + and HCV DNA +)
Do not treat patients with short term life expectancy regardless of HCV treatment, liver transplantation
Which HCV treatments should receive HS5A RAS resistance testing?
Elbasvir/grazoprevier for any patient with genotype 1 A
Ledipasivir/sofobuvir for treatment experienced genotype 1A
Sofosbuvir/velpatasvir for genotype 3 with treatment naive patients with cirrhosis and treatment experienced patients without cirrhosis
What are the medication endings for HC DAAs?
NS3/4A Protease Inhibitors: -previr (low barrier to resistance)
NS5A inhibitors: -asvir (Intermediate resistance)
NS5B Nucleotide polymerase inhibitor: -buvir (high barrier to resistance)
When should ribavirin be discontinued?
Hgb < 8.5 if no cardiac history
Plt <25K
WBC <1000
ANC < 500
Describe Elbasvir/Grazoprevir contraindications and DDIs?
Zepatier for Class 1 and 4
CI with Child Pugh B or C
Genotype 1a: test for NS5A resistance polymorphisms
CI with Moderate/strong CYP3A4 inhibitors and inducers
Describe the contraindications and DDIs with glecaprevir/pibrentasivir
Mavyret for all genotypes
Contraindicated Child Pugh Class C
DDIs: Atazanavir, rifampin
Describe the contraindications and DDIs with ledipsavir/sofosbuvir
Harvoni for genotype 1 and 4
Contraindicated in pregnancy/male partners of pregnant women when used with RBV
DDIs: CI - amiodarone (symptomatic bradycardia), carbamazepine, oxcarbazepine, phenobarbital, rifabutin/rifampin
Separate antacids/H2 blockers (up to famotidine 40 mg daily) and PPIs (up to 20 mg/daily) - reduces ledipsavir levels
Describe the contraindications and DDIs with sofosbuvir/velpatasvir
Epclusa for all genotype
Contraindicated with amiodarone (symptomatic bradycardia), CYP2B6 and CYP3A4 inducers
Separate antacids/H2 blockers (up to famotidine 40 mg daily) and PPIs (up to 20 mg/daily) - reduces velpatasvir levels
Describe the contraindications and DDIs with sofosbuvir/velpatasvir/voxilaprevir
Vosevi for resistance HCV genotype
Contraindicated for Child Pugh B and C
Contraindicated with amiodarone (symptomatic bradycardia), CYP2B6 and CYP3A4 inducers
Separate antacids/H2 blockers (up to famotidine 40 mg daily) and PPIs (up to 20 mg/daily) - reduces velpatasvir levels
What is the treatment duration of HCV naive treatments?
ELB/GZR: Genotype 1a/1b and genotype 4: 12 weeks
GLE/PIB: All genotypes for 8 weeks
LDV/SOF: Genotype 1a/1b and genotype 4: 12 weeks
SOF/VEL: All genotypes for 12 weeks
SOF/VEL/VOX: for Genotype 3 for 12 weeks
*Only for chronic HCV, no cirrhosis and no previous treatment for HCV
How do you treat previously treated PEG or RBV HCV?
ELB/GZR:
- Genotype 1a (no NS5A RASs) - 12 weeks
- Genotype 1b - 12 weeks
- Genotype 3 with CIRRHOSIS: 12 weeks + RBV
- Genotype 4: 12 weeks
GLE/PIB
- No cirrhosis: 8 weeks EXCEPT 16 weeks in genotype 3 and RBV
- Cirrhosis: 12 weeks EXCEPT 16 weeks in genotype 3
LDV/SOF
- No cirrhosis: genotype 1a/1b and genotype 4-6 - 12 weeks
- Cirrhosis: genotype 1a/1b + RBV and Genotype 4 + RBV, Genotype 5 and 6 - 12 weeks
How do you treat PEG/RBV experienced treatment with SOF/VEL and SOF/VEL/VOX?
SOF/VEL
- 12 weeks except genotype 3/cirrhosis - 12 weeks + RBV
SOF/VEL/VOX: 12 weeks and ADD RBV in no cirrhosis for genotype 3
How do you treat previously treated PEG/RBV and NS3 Protease inhibitors (glecaprevir/grazoprevir/voxilaprevir)?
ELB/GZR - 12 weeks + RBV
GLE/PIB - 12 weeks
LDV/SOF - 12 weeks and in cirrhosis 12 weeks + RBV
SOF/VEL - 12 weeks
How do you treat SOF experienced HCV?
GLE/PIB - 12 weeks
LDV/SOF - in no cirrhosis: 12 weeks + RBV
SOF/VEL - ONLY in genotype 1b : 12 weeks
SOF/VEL/VOX - 12 weeks
How do you treat glecaprevir/pibrentasvir treatment failure?
GLE/PIB: all genotypes for 16 weeks + SOF + RBV
SOF/VEL/VOX: 12 weeks and consider RBV in cirrhosis
How do you treat HCV in decompensated cirrhosis?
LDV/SOF
- RBV eligible: 12 weeks for genotype 1, 4-6
- RBV ineligible or SOF or NS5A failure: 24 weeks for genotypes 1, 4-6
SOF/VEL
- RBV eligible: 12 weeks for all genotypes
- RBV ineligible or SOF failure or NS5A failure: 24 weeks for all genotypes
Which HCV treatments should be avoided due to renal dysfunction with TDF?
Ledipasvir/Sofosbuvir
Sofosbuvir/Velpatasvir
Sofosbuvir/Velpatasvir/Voxilaprevir
What HCV treatments should be avoided with ritonavir?
Glecaprevir/Pibrentasvir
Sofosbuvir/Velpatasvir/Voxilaprevir
What HCV treatments should be avoided with cobicstat?
Elbasvir/Grazoprevir
Glecaprevir/Pibrentasvir
Sofosbuvir/Velpatasvir/Voxilaprevir
What HCV therapies should TDF be avoided with?
Ledipasvir and velpatasvir
What counseling point should be said with entecavir?
Take 2 hours before or after a meal
Which HCV treatment regimens is CI with decompensated cirrhosis?
Zepatier, Mavyret, Vosevi
Which SOF- based regimens should have ribavirin in combination? What scenarios?
Harvoni - all genotypes with compensated cirrhosis
Epclusa - genotype 3 with compensated cirrhosis or Y93H present
