Hepatitis and liver disease Flashcards
EOR exam 5
1
Q
What does hepatitis mean?
A
Hepatitis means inflammation of the liver.
2
Q
How is hepatitis A virus (HAV) usually characterized?
A
Hepatitis A virus (HAV) usually causes an acute, self-limiting illness
3
Q
How is HAV primarily transmitted?
A
Transmission occurs primarily via the fecal-oral route, due to either improper handwashing after exposure to an infected person or ingestion of contaminated food/water.
4
Q
What can hepatitis B virus (HBV) and hepatitis C virus (HCV) cause?
A
Hepatitis B virus (HBV) and hepatitis C virus (HCV) can cause acute illness and can lead to chronic infection, cirrhosis, liver cancer, liver failure and death.
5
Q
How are HBV and HCV transmitted?
A
Transmission occurs from contact with infectious blood and/or other body fluids (e.g., having sex with an infected person, sharing contaminated needles to inject drugs, perinatal transmission from a mother to her newborn).
6
Q
Who should be screened for HBV and HCV?
A
- A one-time screening for HBV and HCV is recommended for anyone ≥ 18 years of age. Periodic, repeat screening is recommended for those with enhanced risk.
- Pregnant women should be screened for HBV and HCV with each pregnancy
7
Q
Who is HBV vaccination recommended for?
A
HBV vaccination is also recommended for all adults.
8
Q
How do Hepatitis A, B, and C differ in terms of causing acute and/or chronic infection?
A
- Hepatitis A: Acute only
- Hepatitis B: Both acute and chronic
- Hepatitis C: Both acute and chronic
9
Q
How do Hepatitis A, B, and C differ in terms of transmission routes?
A
- Hepatitis A: Fecal-oral
- Hepatitis B: Blood and body fluids
- Hepatitis C: Blood
10
Q
How do Hepatitis A, B, and C differ in terms of vaccine availability?
A
- Hepatitis A: Yes*
- Hepatitis B: Yes*
- Hepatitis C: No
11
Q
How do first-line treatments differ for Hepatitis A, B, and C?
A
- Hepatitis A: Supportive care
- Hepatitis B: PEG-IFN or NRTI (tenofovir or entecavir)
- Hepatitis C: DAA combination (for treatment-naïve patients)
12
Q
What are additional treatments used for select patients with Hepatitis C?
A
Hepatitis C: DAA combination + RBV
13
Q
How many HCV genotypes are there?
A
There are six different HCV genotypes (1–6) and various subtypes (e.g., 1a, 1b).
14
Q
Who is treatment recommended for in HCV?
A
Treatment is recommended for all patients with acute or chronic HCV
15
Q
What do preferred HCV regimens consists of?
A
Preferred regimens consist of 2–3 direct-acting antivirals (DAAs) with different mechanisms, usually for 8–12 weeks.
16
Q
When is ribavirin added to DAA therapy?
A
Ribavirin may be added for patients with cirrhosis or after treatment failure.
17
Q
Are interferon alfa-based regimens still recommended for HCV?
A
No, interferon alfa-based regimens are no longer recommended due to the success of DAAs.
18
Q
What are the recommended DAA regimens for treatment-naïve HCV patients without cirrhosis (or with compensated cirrhosis) across all genotypes?
A
- Glecaprevir/pibrentasvir (Mavyret) for 8 weeks
- Sofosbuvir/velpatasvir (Epclusa) for 12 weeks
19
Q
What do preferred HCV regimens typically include?
A
Preferred HCV regimens include 2–3 DAAs with different mechanisms of action (often in one tablet).
20
Q
What are NS3/4A Protease Inhibitors and how can you recognize them by name?
A
They end in -previr (P for PI).
Examples: Glecaprevir, Grazoprevir, Voxilaprevir
21
Q
What are NS5A Replication Complex Inhibitors and how can you recognize them by name?
A
They end in -asvir (A for NS5A).
Examples: Elbasvir, Ledipasvir, Pibrentasvir, Velpatasvir
22
Q
What are NS5B Polymerase Inhibitors and how can you recognize them by name?
A
They end in -buvir (B for NS5B).
Example: Sofosbuvir
23
Q
How can you remember that protease inhibitors should be taken with food?
A
Use the mnemonic: Protease Inhibitors & Grub (PIG) = Take With Food
24
Q
What is the boxed warning for all direct-acting antivirals (DAAs)?
A
Risk of reactivating HBV; test all patients for HBV before starting a DAA.
25
What are general warnings for all DAAs?
Potentially serious drug interactions
26
What are common side effects of DAAs?
well tolerated,
Headache, fatigue, diarrhea, nausea
27
What is the brand for Glecaprevir/ Pibrentasvir ?
1. Mayret
28
What is the dosing requirement for Mavyret?
3 tablets once daily with food
29
what is the brand name for sofosbuvir/Velpatasvir ?
Epclusa
30
what is the brand name for sofosbuvir/ Ledipasvir ?
Harvoni
31
what is the brand name for sofosbuvir/ Velpatasvir/ Voxilaprevir ?
Vosevi
32
What is the brand name for Elbasvir/ Grazoprevir?
Zepatier
33
What is the warning associated with combining amiodarone and sofosbuvir?
Do not use amiodarone with sofosbuvir due to the risk of serious symptomatic bradycardia.
34
Is sofosbuvir monotherapy recommended?
No, sofosbuvir monotherapy is not effective and not recommended.
35
What HCV drugs need to be protected from moisture and dispense in the original container.
1. Sovaldi
2. Epclusa
3. Harvoni
4. Vosevi
36
What HCV drugs should avoid or minimize acid-suppressive therapy during treatment.
1.Epclusa
2.Harvoni
3.Vosevi
37
what is the contraindication when taking Zepatier ?
Use with strong CYP3A4 inducers
38
What is a serious lab abnormality warning for elbasvir/grazoprevir?
↑ ALT (> 5× ULN) at or after 8 weeks of treatment; rare cases of liver failure
39
What drugs should be avoided with all DAAs ?
1. Avoid CYP3A4 inducers
2. carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin, and St. John’s wort.
40
What interactions does Mavyret have?
1. Statins (atorvastatin, lovastatin, simvastatin)*
2. Protease inhibitors (atazanavir, darunavir, lopinavir, ritonavir)
3. Cyclosporine
4. Ethinyl estradiol
41
What is the key interaction with sofosbuvir-based regimens?
1. (Epclusa, Harvoni, Vosevi)
2. Do not use with amiodarone — risk of bradycardia
42
How do antacids, H2RAs, and PPIs affect ledipasvir/velpatasvir?
1. They ↓ drug concentrations.
2. Separate from antacids by 4 hours
3. Take H2RAs simultaneously or 12 hours apart and use famotidine < 40 mg BID or equivalent
4. PPIs are not recommended with Epclusa
43
What is ribavirin’s mechanism and key use in HCV treatment?
Ribavirin is an oral antiviral that inhibits RNA/DNA replication. It is used in combination with DAAs, never as monotherapy
44
What is the boxed warning for ribavirin?
1. Significant teratogenic effects
2. Not effective alone for HCV
3. Can cause hemolytic anemia within 1–2 weeks (can lead to MI in heart disease patients
45
What are contraindications to ribavirin?
1. Pregnancy
2. Women of childbearing age who won’t use contraception
46
What are the contraception and pregnancy precautions with ribavirin?
1. Avoid pregnancy during treatment and for 6–9 months after
2. At least 2 reliable forms of contraception required for both men and women
3. Test monthly during and after treatment
47
What is the mechanism of NRTIs in treating Hepatitis B?
NRTIs inhibit HBV replication by inhibiting HBV polymerase, which results in DNA chain termination.
48
What precaution must be taken before starting NRTI therapy for HBV?
1. All patients should be tested for HIV prior to starting NRTIs.
2. To minimize the risk of HIV antiviral resistance, two NRTIs are recommended if co-infected
49
How should dosing be adjusted in patients with renal impairment using HBV NRTIs?
1. ↓ dose or ↓ frequency if CrCl ≤ 50 mL/min
2. (except for Vemlidy).
50
What is the boxed warning for all HBV NRTIs?
1. Lactic acidosis and severe hepatomegaly with steatosis, which can be fatal
2. Exacerbations of HBV can occur upon discontinuation
3. Can cause HIV resistance in co-infected patients if used alone — always test for HIV before starting
51
what is the brand name of TDF in HBV txt?
Viread, preferred therapy
52
what is the brand name of TAF in HBV txt?
Vemlidy, preferred therapy
53
What are the warnings associated with Tenofovir containing products?
TDF>TAF
1. ↑ risk of renal toxicity (acute renal failure, Fanconi syndrome)
2. ↓ bone mineral density
54
What are common side effects of tenofovir containing products?
1. Nausea
2. Diarrhea, headache
3. Lipid abnormalities increased risk with TAF
55
What are special storage or use notes for Vemlidy?
1. Protect from moisture
2. Dispense in original container
3. Approved only for treating HBV (not in combo products for HIV)
56
what is the brand name for entecavir?
Baraclude, preferred therapy
57
How does food affect Entecavir absorption?
Food reduces AUC by 18–20%; take on an empty stomach (2 hours before or after food)
58
what is the brand of lamivudine
Epivir HBV
59
What boxed warning is specific to Lamivudine?
Do not use Epivir HBV for treatment of HIV — can cause resistance due to lower dosing
60
what is the boxed warning for Adefovir?
Caution in patients with renal impairment or at risk of renal toxicity, especially with nephrotoxic drugs or NSAIDs
61
Should tenofovir formulations be used with adefovir? Why or why not?
No, Because it increases the risk of virologic failure and side effects.
62
What is interferon alfa and how is it used in HBV treatment?
Interferon alfa is a naturally-produced cytokine with antiviral, antiproliferative, and immunomodulatory effects.
The pegylated form (PEG-IFN-alfa) is approved as monotherapy for treating chronic HBV.
63
What advantage does PEGylation offer for interferon alfa?
It prolongs the half-life, allowing once-weekly dosing.
64
Why might interferon alfa be preferred over NRTIs in some patients?
It has a finite treatment duration (48 weeks) and may be an alternative for patients unable to use NRTIs.
65
What is the boxed warning for interferon alfa?
It can cause or worsen neuropsychiatric, autoimmune, ischemic, or infectious disorders
66
What is the key warnings for interferon alfa?
Myelosuppression
67
What are common side effects of interferon alfa?
1.CNS effects: fatigue, depression, anxiety, weakness
2. GI upset, ↑ LFTs (5–10× ULN), mild alopecia
3. Flu-like syndrome (fever, chills, headache, malaise); can pre-treat with acetaminophen and an antihistamine
68
What is cirrhosis?
Cirrhosis is advanced fibrosis (scarring) of the liver that is usually irreversible.
69
What are the most common causes of cirrhosis in the U.S.?
Hepatitis C and alcohol consumption
70
What complications can result from cirrhosis?
Portal hypertension, gastroesophageal varices, ascites, and hepatic encephalopathy.
71
What are common symptoms of liver disease/cirrhosis?
1. Nausea
2. Loss of appetite
3. Vomiting
4. Diarrhea
5. Malaise
6. Pain in the upper right abdomen
7. **Yellowed skin and whites of the eyes (jaundice)
8. Darkened urine
9. Light-colored stool (from decreased bile flow)
72
What enzymes are used as markers of liver damage?
1. Aspartate aminotransferase (AST)
2. Alanine aminotransferase (ALT)
3. Normal range: 10–40 units/L
73
What labs are elevated in acute liver toxicity (e.g., from drugs)?
↑ AST/ALT
74
What labs are elevated in chronic liver disease (e.g., cirrhosis)?
↑ AST/ALT, ALP, Tbili, LDH, PT/INR
↓ albumin
75
What lab pattern is seen in alcoholic liver disease?
1. ↑ AST > ↑ ALT (AST will be about 2× ALT)
2. ↑ GGT (gamma-glutamyl transpeptidase)
76
What lab is elevated in hepatic encephalopathy?
↑ Ammonia
77
What lab is elevated in jaundice?
↑ Total bilirubin (Tbili)
78
What lab abnormalities are associated with liver inflammation or disease?
1. ↑ ALT and ↑ AST
2. ↓ Albumin (normal range 3.5–5.5 g/dL)
3. ↑ Alkaline phosphatase (ALP)
4. ↑ Total bilirubin (Tbili)
5. ↑ Lactate dehydrogenase (LDH)
6. ↑ Prothrombin time (PT) and INR
79
What do albumin and PT/INR indicate about liver function?
They are markers of the liver’s synthetic function (i.e., production ability) and are especially altered in chronic liver disease.
80
What is the Child-Pugh score used for, and how is it interpreted?
1. Predicts patient survival, surgical outcomes, and complications (e.g., variceal bleeding)
2. Class A (mild): 5–6
3. Class B (moderate): 7–9
4. Class C (severe): 10–15
81
How should drug dosing be adjusted in liver disease?
1. Use caution with hepatically cleared drugs
2. Dose adjustment may be needed, especially for Child-Pugh Class B or C
82
What natural products are relevant to liver disease patients, and what are the concerns?
1. Milk thistle: commonly used; limited evidence; may cause mild diarrhea
2. Kava and comfrey: known hepatotoxins
83
What is the primary treatment for drug-induced liver injury (DILI)?
1. Stop the drug causing liver damage
2. When LFTs are >3× the upper limit of normal typically d/c
84
Name key drugs that carry a boxed warning for liver damage.
1. Acetaminophen (high doses, acute/chronic use)
2. Amiodarone
3. Isoniazid
4. Ketoconazole
5. Methotrexate
6. Nefazodone
7. Nevirapine
8. Propylthiouracil
9. Valproic acid
10. Zidovudine
85
What is ALD and what causes it?
Alcohol-associated liver disease (ALD) results from chronic alcohol intake, often over years, leading to fatty liver (steatosis).
86
What can ALD progress to if not managed?
1. Alcoholic hepatitis
2. Fatty liver (steatohepatitis)
3. Chronic hepatitis, with fibrosis or cirrhosis
87
What is the most important part of treatment for alcohol-related liver disease?
Alcohol cessation — stopping alcohol intake is essential for improving outcomes.
88
What medications can help with alcohol withdrawal and cravings?
1. Benzodiazepines
2. Gabapentin
3. Carbamazepine
89
What medications are used to prevent alcohol use relapse?
1. Naltrexone (Vivitrol)
2. Disulfiram (Antabuse)
90
What vitamins and nutrients may be supplemented in alcohol-associated liver disease?
1. Vitamin A
2. Vitamin D
3. Thiamine (vitamin B1)
4. Folate
5. Pyridoxine (vitamin B6)
6. These support liver recovery and help prevent malnutrition.
91
What is Wernicke-Korsakoff syndrome and how is it treated?
A brain disorder caused by vitamin B1 deficiency. Treated with thiamine.
92
What causes portal hypertension in cirrhosis?
Fibrosis in the liver blocks blood flow, increasing pressure in the portal vein.
93
What is a common complication of portal hypertension?
1. Esophageal varices
2. Blood backing up and flowing into smaller blood vessels in the esophagus causing them to balloon out.
3. These enlarged vessels are at risk of breaking open resulting in bleeding
94
How is acute variceal bleeding managed?
1. Use band ligation (putting a band around the vessel)
2. Sclerotherapy to stop bleeding (injecting a solution into the vessel to make it collapse and close)
95
What medications are used to reduce bleeding from varices?
1. Medications that vasoconstrict the splanchnic GI circulation can stop or minimize the bleeding
2. Octreotide (selective for splanchnic vessels)
3. Vasopressin (non-selective)
96
what can be used for primary and secondary ppx of variceal bleeding?
1. Non selective BB
97
what is the brand of octreotide ?
Sandostatin
98
What are side effects of octreotide?
1. Bradycardia
2. Cholelithiasis
3. Biliary sludge
99
what drug class is vasopressin
Antidiuretic hormone analog
100
What are non-selective beta-blockers (NSBBs) used for in portal hypertension?
1. Used for primary and secondary prevention of variceal bleeding.
2. Nadolol
3. Propranolol
101
How do NSBBs reduce portal pressure in patients with portal hypertension?
NSBBs decrease cardiac output (via beta-1 blockade) and cause splanchnic vasoconstriction (via beta-2 blockade and unopposed alpha activity); this reduces portal venous inflow, resulting in decreased portal pressure.
102
How are NSBBs dosed and titrated in portal hypertension?
NSBBs are titrated to the maximally tolerated dose (target HR 55–60 BPM, SBP ≥ 90 mmHg) and continued indefinitely.
103
What is unique about carvedilol compared to other NSBBs in portal hypertension?
Carvedilol has an added mechanism via its alpha-1 blocking effects (i.e., causes vasodilation within the intrahepatic circulation which decreases vascular resistance) that further reduces portal pressure.
104
Do guidelines support carvedilol for variceal bleeding prevention?
The AASLD guidelines support the use of carvedilol for the primary prevention of variceal bleeding.
105
what is the brand name for Nadolol ?
Cogard
106
what is the brand name for propranolol ?
Inderal LA, and Inderal XL
107
What is the boxed warning for NSBBs?
1. Do not withdraw beta-blockers abruptly (particularly in patients with CAD/IHD)
2. Gradually taper dose over 1–2 weeks to avoid acute tachycardia, hypertension, and/or ischemia.
108
What are key warnings for NSBBs?
1. Use caution in patients with diabetes: can worsen hypoglycemia and mask symptoms
2. Use caution with bronchospastic diseases (e.g., asthma, COPD)
3. Use caution with Raynaud’s or peripheral vascular disease (requires slow dose titration)
109
What are the side effects of NSBBs?
1. Bradycardia
2. Hypotension
3. CNS effects (e.g., fatigue, dizziness, depression)
4. Impotence
5. Cold extremities (can exacerbate Raynaud’s)
110
What should be monitored with NSBBs?
1. Heart rate (↓ dose if symptomatic bradycardia)
111
What special note is associated with propranolol?
It has high lipid solubility and crosses the blood-brain barrier — associated with more CNS side effects
112
What is the brand for carvedilol ?
Coreg
113
What causes hepatic encephalopathy (HE)?
HE is caused by acute or chronic hepatic insufficiency and the accumulation of gut-derived nitrogenous substances in the blood (such as ammonia, glutamate).
114
What are common symptoms of HE?
1. Musty odor of the breath and/or urine
2. Changes in thinking
3. Confusion
4. Forgetfulness
5. Flapping hand tremor (asterixis)
115
What is the main treatment goal in hepatic encephalopathy?
Treatment includes identifying and treating precipitating factors and reducing blood ammonia levels through diet (by limiting the amount of animal protein) and drug therapy.
116
What drug therapies are commonly used in hepatic encephalopathy?
Drug therapy consists of nonabsorbable disaccharides (e.g., lactulose) and antibiotics (e.g., rifaximin, neomycin).
117
What is the first-line treatment for both acute and chronic (prevention) of HE?
Lactulose is first line for both acute and chronic (prevention).
118
How does lactulose work in HE?
1. It works by converting ammonia produced by intestinal bacteria to ammonium, which is polar and therefore cannot readily diffuse into the blood.
2. Lactulose also enhances diffusion of ammonia into the colon for excretion.
119
How do antibiotics help reduce ammonia in HE?
1. Antibiotics work by inhibiting the activity of urease-producing bacteria, which decreases ammonia production.
2. Rifaximin can be considered for add-on treatment.
120
What are common side effects of lactulose?
1. Flatulence
2. Diarrhea
3. Dyspepsia
4. Abdominal discomfort
121
What should be monitored during lactulose treatment?
1. Bowel movements
2. Ammonia
122
WHat is the brand name for rifaximin ?
Xifaxan
123
What is the boxed warning for neomycin?
1. Neurotoxicity
a. hearing loss, vertigo, ataxia
124
What are side effects of neomycin?
GI upset
125
What is ascites and what complications can it lead to?
Ascites is fluid accumulation within the peritoneal space that can lead to the development of spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS).
126
In what patients should ascites management always be considered?
All patients with cirrhosis and ascites should be considered for liver transplantation.
127
What dietary recommendations are made for patients with ascites due to portal hypertension?
Patients should restrict dietary sodium intake to < 2 grams/day
128
What medications should be avoided in patients with ascites due to portal hypertension?
Avoid sodium-retaining medications (including NSAIDs) and use diuretics to increase fluid loss.
129
What are the diuretic therapy options for ascites?
Diuretic therapy for ascites can be initiated with either spironolactone monotherapy or a combination of furosemide and spironolactone.
130
Is furosemide effective by itself in treating ascites?
Furosemide by itself is ineffective.
131
What is the recommended dosing ratio when combining furosemide and spironolactone?
If possible, a ratio of 40 mg furosemide to 100 mg spironolactone should be used to maintain potassium balance.
132
What procedure is used in severe ascites to remove fluid?
In severe cases, abdominal paracentesis is needed to directly remove ascitic fluid.
133
What is large-volume paracentesis, and what can it cause?
1. Large-volume paracentesis (removal of > 5 L) is associated with significant fluid shifts and addition of albumin (6–8 grams per liter of fluid removed) is recommended to prevent paracentesis-induced circulatory dysfunction and progression to hepatorenal syndrome
134
What is spontaneous bacterial peritonitis (SBP)?
Spontaneous bacterial peritonitis (SBP) is an acute infection of the ascitic fluid.
135
What is the recommended treatment for SBP?
Targeting streptococci and enteric gram-negative pathogens with ceftriaxone (or an equivalent) for 5–7 days is recommended
136
What secondary prophylaxis is recommended after surviving SBP?
Patients who have survived an episode of SBP should receive secondary prophylaxis with oral ciprofloxacin or sulfamethoxazole/trimethoprim.
137
What is hepatorenal syndrome (HRS)?
Hepatorenal syndrome (HRS) is the development of renal failure in patients with advanced cirrhosis
138
What causes renal failure in HRS?
It occurs as a result of renal vasoconstriction, mediated by activation of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS) through a feedback mechanism known as the hepatorenal reflex.
139
What medications are used to treat HRS?
HRS can be treated with vasoconstrictors such as terlipressin or norepinephrine, in combination with albumin
140
What can be used to treat HRS if vasoconstrictors are not available?
When this is not possible, HRS can be treated with a combination of albumin, octreotide and midodrine.
