Hepatitis & Liver Disease Flashcards
This type of hepatitis virus usually causes an acute, self-limiting illness.
Transmission is primarily via the fecal-oral route through improper hand washing after exposure to an infected person or via contaminated food/water
Hepatitis A virus (HAV)
These hepatitis viruses can cause acute illness and can lead to chronic infection, cirrhosis of the liver, liver cancer, liver failure and death.
Transmission occurs from contact with infectious blood or other bodily fluids, or perinatal transmission (mom to baby)
Hepatitis B and Hepatitis C
This virus is ACUTE, fecal-oral, there is a vaccine for it, first line treatment is supportive care
Hep A
Does hep C have a vaccine?
No
First-line treatment is PEG-INF or NRTI (tenofovir or entecavir)
Hep B
Treatment for naive is direct-acting antivirals
Hep C
Treatment in select patients for which liver virus?
Direct-acting antivirals + ribavirin + PEG-INF
Hepatitis C treatment in select patients
How many HCV genotypes are there?
1-6; and various subtypes
Preferred HCV regimens consist of ____ DAAs with different mechanisms usually for how many weeks?
2-3 DAAs (often in one tablet), x8-12 weeks
What is ritonavir used for in HCV treatment?
It is not active for HCV, but is used to boost/increase levels of HCV protease inhibitors
Glecaprevir Grazoprevir Paritaprevir Voxilaprevir are examples of what type of DAA?
NS3/4A Protease Inhibitor
Think –> -previr=P=Protease Inhibitor
Ledipasvir Ombitasvir Pibrentasvir Velpatasvir are examples of what type of DAA?
NS5A Replication Complex Inhibitor
Think –> -asvir=A-N5SA
Dasabuvir
Sofosbuvir
are examples of what type of DAA?
NS5B Polymerase Inhibitor
Think –> -buvir=B=Ns5B
For treatment-naive patients without cirrhosis but has HCV, recommended regimens are:
Glecaprevir/pibrentasvir
NS3/4A Protease Inhibitor/ NS5A Replication Complex Inhibitor
Sofosbuvir/velpatasvir
NS5B Polymerase Inhibitor/NS5A Replication Complex Inhibitor
All DAAs have a risk of reactivating what virus?
HBV - must test all patients before starting a DAA – BOXED WARNING
This DAA has serious symptomatic bradycardia when taken with amiodarone. Do not take these together.
Sofosbuvir
Are all DAAs generally well-tolerated?
Yes-
HA, fatigue, diarrhea, nausea
Monitoring: LFTs, HCV-RNA
Brand: Sovaldi
Generic: sofosbuvir
Brand: Epclusa
Generic: sofosbuvir/velpatasvir
Brand: Harvoni
Generic: sofosbuvir/ledipasvir
Brand: Vosevi
Generic: sofosbuvir/velpatasvir/ voxilaprevir
Brand: Mavyret
Generic: glecaprevir/pibrentasvir
Which DAAs do you take with food?
Mavyret
Mavyret has a contraindication of
mod-severe hepatic impairment
Sofosbuvir monotherapy…
NOT recommended
Which DAAs should be dispensed in original container/protect from moisture?
Sovaldi, Epclusa, Harvoni, Vosevi
Avoid or minimize acid suppressive therapy with which DAAs?
Epclusa, Harvoni, Vosevi
Pan-Genotypic (approved for all 6 HCV genotypes) for treatment naive
Epclusa and Mavyret
Approved for Salvage therapy/failed previous therapy
Vosevi and Mavyret in select patients
Approved for 8-week course of therapy in select patients
Mavyret
Approved for HCV/HIV co-infection
Epclusa, Harvoni, and Mavyret
Approved for children>12 with certain genotypes
Sovaldi and Harvoni
All DAAs are contraindicated with strong inducers of
CYP3A4: carbamazepine, oxcarbamazepine, phenobarbital, phenytoin, rifampin, rifabutin, and St. John’s Wort
Do NOT use which DAA with efavirenz, HIV protease inhibitors, ethynyl estradiol-containing products, and cyclosporine.
Mavyret
Using PPIs with which DAA is not recommended?
Epclusa
Do not use Stribild with which DAA?
Harvoni
This is an oral antiviral drug that inhibits replication of RNA and DNA viruses. It can be used for HCV in combination with other drugs, but never as monotherapy
Ribavirin (RBV)
Brand: Rebetol
Generic: Ribavirin
What is the boxed warning for Ribavirin?
Significant teratogenic effects; not effective for monotherapy of HCV; hemolytic anemia
Can Ribavirin be used in pregnancy?
NO! avoid in pregnancy, female partners of male patients during therapy and 6 months after completion — 2 reliable forms of effective contraception
Do not use Ribavirin with didanosine why?
fatal hepatic failure, peripheral neuropathy, and pancreatitis
Interferon alfa (INF-alfa) is approved for the treatment of which viruses
HBV, HCV
Which forms of INF alfa have a prolonged half-life?
pegylated forms (PEG-INF).. reduces dosing to once WEEKLY (subQ)
This antiviral has a boxed warning that states it can cause or exacerbate neuropsychiatric, autoimmune, ischemic, or infectious disorders; and if used with ribavirin, teratogenic/anemia risk
IFN-alfa
The side effects of this antiviral is extensive, which is why it has fallen out of favor in HCV. Side effects include:
CNS effects, GI upset, inc LFTs, myelosuppresion, flu-like sx
IFN-alfa
Interferon-alfa is approved as monotherapy and is a preferred treatment for
HBV
These drugs inhibit HBV replication by inhibiting HBV polymerase resulting in DNA chain termination
Nucleoside/tid reverse transcriptase inhibitors (NRTIs)
Prior to starting HBV therapy, all patients should be test for…?
HIV.
Antivirals used for HBV can have activity against HIV and if a patient is co-infected with both, it is important to chose therapy appropriate for both to minimize resistance
All HBV NRTIs, dec dose or frequency when CrCl < ?
<50ml/min
ALL NRTIs have a boxed warning for…
Lactic acidosis and severe hepatomegaly with steatosis which can be FATAL
Brand: Viread
Generic: Tenofovir disoproxil fumarate (TDF)
Brand: Vemlidy
Generic: Tenofovir alafebnamide (TAF)
Brand: Baraclude
Generic: Entecavir
Brand: Epivir HBV
Generic: Lamivudine
Warnings of these NRTIs include renal toxicity, Falcon syndrome, osteomalacia, and dec bone mineral density
TDF> TAF
Dispense only in original container in which NRTIs?
Viread tablets and Vemlidy
Which NRTI do you take on an empty stomach?
Entecavir
This NRTI has a boxed warning: do not use for treatment of HIV
Epivir HBV
What are the most common causes of cirrhosis?
Hep C and alcohol
These labs can indicate cirrhosis
INC ALT AST DEC albumin INC alkaline phosphate INC total bilirubin INC in PT
What are markers of production ability in liver function?
Albumin and PT/INR
What is milk thistle?
an extract derived from a member of the daisy family, sometimes used by those w liver disease
When are hepatotoxic drugs typically d/c?
LFTs >3x upper limit >150u of ALT or AST
inc T bili indicates
Jaundice
Inc ammonia indicates
hepatic encephalopathy
Inc AST> Inc ALT (AST is doubled ALT), Inc GGT indicates
Alcoholic liver disease
Inc AST/ALT, Alk Phos, Tbili, LDH, PT/INR
Dec albumin
indicates
chronic liver disease/cirrhosis
INC AST/ALT indicates
acute liver toxicity including from drugs
Can Tylenol be used by patients with cirrhosis?
Yes, limited periods of time and lower dosages;
HOWEVER, NSAIDs should be avoided bc it can lead to decompensation
What drugs can cause acute liver toxicity?
Tylenol Amiodarone Isoniazid Ketoconazole, PO Methotrexate Nefazodone Nevirapine NRTIs Propylthiouracil Tipranavir Valproic acid
This is the most common type of drug-induced liver disease
Alcohol-associated liver disease. Risk increases with the amount of alcohol consumed and duration. Women>men
Chronic alcohol ingestion over a long period of time causes…
“steatosis” or fatty liver
due to a fat deposition in the hepatocytes
Fatty liver, alcoholic hepatitis and chronic hepatitis are all…
Alcohol-associated liver disease
What do treatment programs mainly use for alcohol withdrawal in inpatient vs outpatient?
inpatient - benzos
outpatient- anticonvulsants
Naltrexone (Vivitrol), acamprosate, and disulfiram (Antabuse) are used to…
prevent relapses
What vitamin is used to prevent and treat Wernicke-Korsakoff syndrome?
Thiamine (Vitamin B1)
Portal hypertension (increased blood pressure in the portal vein) can cause complications including the development and bleeding of:
esophageal varices (enlarged veins in the lower part of the esophagus)
Acute variceal bleeding can be FATAL.
Tx for acute variceal bleeding
Supportive therapy (blood volume, resuscitation/blood products, mechanical ventilation), Band ligation, sclerotherapy
Octreotide is selective for the splanchnic vessels whereas vasopressin is non-selective. These drugs are for…
vasoconstrictor the splanchnic (GI) circulation
Short-term antibiotic prophylaxis should be given to cirrhotic patients with a variceal bleed to reduce bacterial infections & mortality
Ceftriaxone or quinolone x 7 days
This class of drugs should be added after resolution of a variceal bleed for secondary prevention
Non-selective beta- blocker
Brand: Sandostatin
Generic: Octreotide (IV)
Can cause low HR!!!
Brand: Corgard
Generic: Nadolol
Brand: Inderal LA, Inderal XL
Generic: Propranolol
This condition is caused by acute or chronic hepatic insufficiency. Sx can include musty odor of the breath, changes in thinking, confusion, hand tremor/asterixis
Hepatic encephalopathy
-want to limit the amount of animal protein
BCAAs > AAAs
Acute and chronic therapy for HE
1st- Lactulose, works by converting ammonia produced by intestinal bacteria to ammonium
2nd- rifaximin, inhibit the activating of urease-producing bacteria, which dec the ammonia production
Others- Neomycin (BW- neurotoxicity) , Flagyl (peripheral neuropathies long term)
?? - Zinc
Brand: Enulose, Constulose
Generic: lactulose
Brand: Xifaxan
Generic: Rifaximin
Fluid accumulation within the peritoneal space
Ascites
Can lead to SBP or hepatorenal syndrome (HRS)
Patients with ascites due to portal HTN, tx:
restrict dietary sodium <2g/day
avoid sodium retaining meds (NSAIDs)
use diuretics to inc fluid loss
Diuretic therapy for ascites
Spironolactone monotherapy
furosemide 40mg + spironolactone 100mg (to maintain potassium balance)
Who should be considered for liver transplants?
All patients with cirrhosis and ascites
An acute infection of the ascitic fluid
SBP
SBP treatment
targeting streptococci and enteric gram neg
ceftriaxone x5-7 days
+albumin (1.5g/kg of body weight on day 1 and 1g/kg on day 3)
Secondary prophylaxis of SBP
Cipro PO or Bactrim
the development of renal failure in patients with advanced cirrhosis due to vasoconstriction, mediated by activation of the RAAS system and SNS through a feedback mechanism known as hepatorenal reflex.
Hepatorenal syndrome (HRS)
