Hepatitis & Liver Disease Flashcards
Hepatitis means…
inflammation of the liver
Causes of hepatitis include…
hepatitis viruses A, B, C, D, E (most common); alcohol, drugs, autoimmune conditions, drugs, other viruses/infections
There 6 different HCV genotypes (1-6) and various subtypes. Preferred HCV regiments consist of…
2-3 direct-acting antivirals (DAAs) with different mechanisms, usually for 8-12 weeks
NS3/4A protease inhibitors
end in -previr (take with food)
NS5A replication complex inhibitors
end in-Asvir
NS5B polymerase inhibitor
end in -Buvir
Which drug can be added to DAA therapy as an alternative?
ribavirin
For treatment-naive patients with cirrhosis, recommended pan-genotypic regimens are…
- glecaprevir/pibrentasvir (Mavyret)
- sofosbuvir/velpatasvir (Epclusa)
Before starting DAAs, test patients for…
HBV (BBW includes risk of reactivating HBV)
Serious symptomatic bradycardia has happened when combining sofosbuvir with…
amiodarone and another DAA. **Do not use amiodarone with sofosbuvir.
Which DAAs should be dispensed in their original containers?
Sovaldi, Epclusa, Harvoni, Vosevi
Which DAAs are approved for HCV/HIV co-infection?
Epclusa, Harvoni and Mavyret
Which DAAs are approved for children ≥ 12 years old with certain genotypes?
Sovaldi and Harvoni
Which DAAs include ritonavir as a PK booster?
- paritaprevir/ritonavir/ombitasvir (Technivie)
- paritaprevir/ritonavir/ombitasvir/dasabuvir (Viekira Pak)
PPIs cannot be used with…
Epclusa
Antacids should be avoided or separated from…
ledipasvir and velpatasvir-containing regimens (Epclusa, Harvoni, Vosevi)
All DAAs are contraindicated with…
strong CYP3A4 inducers
Ethinyl estradiol-containing products, lovastatin, and simvastatin are specifically contraindicated with…
Technivie and Viekira
Viekira Pak counseling
Take 2 tablets of paritaprevir/ritonavir/ombitasvir once daily in the AM and 1 dasabuvir tablet BID with meals
Ribavirin should not be used as monotherapy and is only approved for..
HCV
Ribavirin BBW
Teratogenic (Category X); hemolytic anemia (mostly occurring within 4 weeks of therapy).
C/I: CrCL <50 mL/min
Ribavirin counseling
Avoid pregnancy in females and female partners of male patients during therapy and 6 months after completion; at least 2 reliable forms of effective contraception are required during tx and in the 6-month post-treatment period
RIBA (ribavirin)
R- Renal (CI when CrCl <50 mL/min)
I- In combination only
B- Birth Defects
A- Anemia: hemolytic (primary toxicity)
Pegylated forms have polyethylene glycol, which is added…
to PEG-interferon-alpha (Pegasys, PegIntron) to prolong the half-life (weekly dosing)
Interferon is no longer recommended in HCV guidelines but may be used when other treatments are C/I or too expensive. BBW include…
Can cause or exacerbate neuropsychiatric, autoimmune, ischemic or infectious disorders
Interferon (C/Is and Side effects: Flu-like syndrome) Pre-treat with acetaminophen and an antihistamine.
C/I: autoimmune hepatitis, decompensated liver disease in cirrhotic patients, infants/neonates (Pegasys)
S/Es: CNS effects, fatigue, depression, anxiety, weakness, GI upset, increased LFTs, myelosuppression, mild alopecia
Interferon-alpha is approved as monotherapy, and is a preferred treatment, for…
HBV
Before starting HBV therapy, all patients should be tested for…
HIV
All HBV NRTIS should be renally dose-adjusted when CrCl is less than…
50 mL/min (except Vemlidy)
BBW for all HBV NRTIs:
Lactic acidosis and severe hepatomegaly with steatosis, which can be fatal. Exacerbations of HBV can occur upon discontinuation, monitor closely.
NRTIs approved for HBV are…
- tenofovir disoproxil (Viread)
- tenofovir alafenamide (Vemlidy)
- entecavir (Baraclude)
- adefovir (Hepsera)
- lamivudine (Epivir HBV); contains lower dose for HBV
Entecavir (Baraclude)- Preferred for HBV
Side effects: peripheral edema, pyrexia, ascites, high LFTs, hematuria, nephrotoxicity, high SCr
Notes: Food reduces AUC; take on an empty stomach (2 hours before or after a meal)
Adefovir (Hepsera)
Boxed Warning: Caution in patients with renal impairment or those at risk of kidney toxicity
S/Es: HA, weakness, abdominal pain, hematuria, rash, nephrotoxicity
lamivudine (Epivir HBV)
BBW: Do not use Epivir HBV for treatment of HIV (contains lower dose of lamivudine)
S/Es: headache, N/V/D, fatigue, insomnia, myalgias, increased LFTs, pancreatitis (rare)
SMX/TMP can increase levels.
Tenofovir alafenamide (TAF) can be used as monotherapy for…
HBV only (not HIV)
Cirrhosis is advanced fibrosis (scarring) of the liver caused by…
most commonly hepatitic C and alcohol consumption
Symptoms of cirrhosis include…
N/V/D, loss of appetite, pain in the upper right quadrant of the abdomen, yellowed skin and yellowed white of the eyes (jaundice), darkened urine
Certain labs can suggest cirrhosis or liver damage such as increased…
AST/ALT, alkaline phosphatase (Alk Phos), total bilirubin (Tbili), lactate dehydrogenase (LDH), and PT/INR (due to lack of clotting factors)
Certain labs can suggest cirrhosis or liver damage such as decreased..
albumin and platelets (albumin and TPO are made by the liver)
Child-Pugh Score is used to access the degree of liver damage and ranges from 0-15
Class A (mild disease) <7 Class B (moderate disease) 7-9 Class C (severe disease) 10-15
Hepatoxic drugs should be discontinued when the LFTs are…
> 3 times the ULN
NSAIDs should be avoided in patients with cirrhosis because these drugs…
can lead to decompensation, include bleeding
MELD score is normally used for end-stage liver disease to determine a patient’s eligibility for…
receiving a liver transplant
Drugs with a BBW for liver damage are…
acetaminophen (high doses), amiodarone, isoniazid, ketoconazole (oral), methotrexate, nefazodone, nevirapine, NRTIs, propylthiouracil, tipranavir, valproic acid, bosentan, felbamate, flutamide, lefunomide and teriflunomide, lomitapide, maraviroc, tolcapone
Acetaminophen can be used by patients with cirrhosis, but…
for limited period of time and at lower dosages
Chronic alcohol ingestion over a long period of time causes…
steatosis or fatty liver
In patients with alcohol-associated liver disease, thiamine (vitamin B1) is given to prevent and treat…
Wernicke-Korsakoff syndrome
Portal hypertension is…
increased BP in the portal vein (can cause complications such as bleeding esophageal varices)
Acute variceal bleeding can be fatal. Medications that vasoconstrict the splanchnic (GI) circulation can stop or minimize the bleeding…
octreotide IV bolus (selective for the splanchnic vessels), whereas vasopressin is not
Non-selective beta-blockers or endoscopic variceal ligation (EVL) are mainly used for…
primary prevention of variceal bleeding
The beta-blocker is titrated to the maximally tolerated dose to target a HR of…
55-60 BPM (continue BB indefinitely). These include nadolol or propranolol
Beta-blockers reduce portal pressure by…
reducing portal venous inflow by 2 mechanisms: 1) decreased cardiac output (via beta-1 blockage)
2) decreased splanchnic blood flow by vasoconstriction
Hepatic encephalopathy (HE) is caused by acute or chronic liver insufficiency. Symptoms include…
musty odor of the breath and/or urine, changes in thinking, confusion, forgetfulness, mood changes, poor concentration, tremor.
HE symptoms are due to the…
build-up of nitrogenous substances in the blood (ex. ammonia, glutamate)
HE treatment includes reducing blood ammonia through…
diet (limit animal protein) and drug therapy (lactulose or rifaximin)
Lactulose is metabolized in the gut to acetic acid and lactic acid, it works by
trapping ammonium in the GI tract
Rifaximin works by…
inhibiting the activity of urease-producing bacteria, which decreased ammonia production. Zinc (220 mg PO BID) may be used as a cofactor.
Ascites is…
fluid accumulation within the peritoneal space that can lead to the development of spontaneous bacterial peritonitis (SBP) and HRS
Patients with ascites due to portal HTN should…
restrict dietary Na intake to <2 grams/day, avoid Na-retaining medications (NSAIDs), and use diuretics to increase fluid loss. Restriction of fluid is recommended only if Na< 120 mEq/L.
Diuretic therapy for ascites can be initiated with either….
spironolactone monotherapy or with a combo. of spironolactone and furosemide (100mg:40mg). Titrate dose to a maximal weight loss of 0.5 kg/day.
Large-volume paracentesis (removal of >5 L) is associated with significant fluid shifts and the addition of…
albumin (6-8 g/L of fluid removed) is recommended to prevent paracentesis-induced circulatory dysfunction progression to hepatorenal syndrome
Spontaneous bacterial peritonitis (SBP) should be treated with…
ceftriaxone for 5-7 days (to cover Strep and Gram-negative pathogens)
Patients who have survived an episode of SBP should receive secondary ppx with…
oral ciprofloxacin or SMX/TMP
Hepatorenal syndrome (HRS) is…
the development of renal failure in patients with advanced cirrhosis (due to renal vasoconstriction)
HRS prevention is critical, can be treated with
albumin, octreotide, midodrine
A natural product that is sometimes used for liver disease is…
milk thistle (limited date to show efficacy)
Diarrhea is a major dose-limiting adverse effect of…
lactulose (also an osmotic laxative)
DW has a history of alcohol abuse and cirrhosis secondary to alcohol. Which of the following could be considered to prevent alcohol relapse?
naltrexone, disulfiram, acamprosate
Sofosbuvir (Sovaldi)
400 mg daily with or without food
Sofosbuvir/velpatasvir
Epclusa
sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
take 1 tablet daily with food
glecapravir/pibrentasvir (Mavyret)
take 3 tablets once daily with food
paritaprevir/ritonavir/ombitasvir (Technivie)
take 2 tablets once daily in the AM with a meal
elbasvir/grazoprevir
Zepatier