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Hepatitis & Liver Disease Flashcards

1
Q

Hepatitis means…

A

inflammation of the liver

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2
Q

Causes of hepatitis include…

A

hepatitis viruses A, B, C, D, E (most common); alcohol, drugs, autoimmune conditions, drugs, other viruses/infections

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3
Q

There 6 different HCV genotypes (1-6) and various subtypes. Preferred HCV regiments consist of…

A

2-3 direct-acting antivirals (DAAs) with different mechanisms, usually for 8-12 weeks

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4
Q

NS3/4A protease inhibitors

A

end in -previr (take with food)

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5
Q

NS5A replication complex inhibitors

A

end in-Asvir

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6
Q

NS5B polymerase inhibitor

A

end in -Buvir

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7
Q

Which drug can be added to DAA therapy as an alternative?

A

ribavirin

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8
Q

For treatment-naive patients with cirrhosis, recommended pan-genotypic regimens are…

A
  • glecaprevir/pibrentasvir (Mavyret)

- sofosbuvir/velpatasvir (Epclusa)

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9
Q

Before starting DAAs, test patients for…

A

HBV (BBW includes risk of reactivating HBV)

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10
Q

Serious symptomatic bradycardia has happened when combining sofosbuvir with…

A

amiodarone and another DAA. **Do not use amiodarone with sofosbuvir.

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11
Q

Which DAAs should be dispensed in their original containers?

A

Sovaldi, Epclusa, Harvoni, Vosevi

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12
Q

Which DAAs are approved for HCV/HIV co-infection?

A

Epclusa, Harvoni and Mavyret

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13
Q

Which DAAs are approved for children ≥ 12 years old with certain genotypes?

A

Sovaldi and Harvoni

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14
Q

Which DAAs include ritonavir as a PK booster?

A
  • paritaprevir/ritonavir/ombitasvir (Technivie)

- paritaprevir/ritonavir/ombitasvir/dasabuvir (Viekira Pak)

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15
Q

PPIs cannot be used with…

A

Epclusa

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16
Q

Antacids should be avoided or separated from…

A

ledipasvir and velpatasvir-containing regimens (Epclusa, Harvoni, Vosevi)

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17
Q

All DAAs are contraindicated with…

A

strong CYP3A4 inducers

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18
Q

Ethinyl estradiol-containing products, lovastatin, and simvastatin are specifically contraindicated with…

A

Technivie and Viekira

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19
Q

Viekira Pak counseling

A

Take 2 tablets of paritaprevir/ritonavir/ombitasvir once daily in the AM and 1 dasabuvir tablet BID with meals

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20
Q

Ribavirin should not be used as monotherapy and is only approved for..

A

HCV

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21
Q

Ribavirin BBW

A

Teratogenic (Category X); hemolytic anemia (mostly occurring within 4 weeks of therapy).
C/I: CrCL <50 mL/min

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22
Q

Ribavirin counseling

A

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

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23
Q

RIBA (ribavirin)

A

R- Renal (CI when CrCl <50 mL/min)
I- In combination only
B- Birth Defects
A- Anemia: hemolytic (primary toxicity)

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24
Q

Pegylated forms have polyethylene glycol, which is added…

A

to PEG-interferon-alpha (Pegasys, PegIntron) to prolong the half-life (weekly dosing)

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25
Q

Interferon is no longer recommended in HCV guidelines but may be used when other treatments are C/I or too expensive. BBW include…

A

Can cause or exacerbate neuropsychiatric, autoimmune, ischemic or infectious disorders

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26
Q

Interferon (C/Is and Side effects: Flu-like syndrome) Pre-treat with acetaminophen and an antihistamine.

A

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

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27
Q

Interferon-alpha is approved as monotherapy, and is a preferred treatment, for…

A

HBV

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28
Q

Before starting HBV therapy, all patients should be tested for…

A

HIV

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29
Q

All HBV NRTIS should be renally dose-adjusted when CrCl is less than…

A

50 mL/min (except Vemlidy)

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30
Q

BBW for all HBV NRTIs:

A

Lactic acidosis and severe hepatomegaly with steatosis, which can be fatal. Exacerbations of HBV can occur upon discontinuation, monitor closely.

31
Q

NRTIs approved for HBV are…

A
  • tenofovir disoproxil (Viread)
  • tenofovir alafenamide (Vemlidy)
  • entecavir (Baraclude)
  • adefovir (Hepsera)
  • lamivudine (Epivir HBV); contains lower dose for HBV
32
Q

Entecavir (Baraclude)- Preferred for HBV

A

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)

33
Q

Adefovir (Hepsera)

A

Boxed Warning: Caution in patients with renal impairment or those at risk of kidney toxicity
S/Es: HA, weakness, abdominal pain, hematuria, rash, nephrotoxicity

34
Q

lamivudine (Epivir HBV)

A

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.

35
Q

Tenofovir alafenamide (TAF) can be used as monotherapy for…

A

HBV only (not HIV)

36
Q

Cirrhosis is advanced fibrosis (scarring) of the liver caused by…

A

most commonly hepatitic C and alcohol consumption

37
Q

Symptoms of cirrhosis include…

A

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

38
Q

Certain labs can suggest cirrhosis or liver damage such as increased…

A

AST/ALT, alkaline phosphatase (Alk Phos), total bilirubin (Tbili), lactate dehydrogenase (LDH), and PT/INR (due to lack of clotting factors)

39
Q

Certain labs can suggest cirrhosis or liver damage such as decreased..

A

albumin and platelets (albumin and TPO are made by the liver)

40
Q

Child-Pugh Score is used to access the degree of liver damage and ranges from 0-15

A 
Class A (mild disease) <7
Class B (moderate disease) 7-9
Class C (severe disease) 10-15
41
Q

Hepatoxic drugs should be discontinued when the LFTs are…

A

> 3 times the ULN

42
Q

NSAIDs should be avoided in patients with cirrhosis because these drugs…

A

can lead to decompensation, include bleeding

43
Q

MELD score is normally used for end-stage liver disease to determine a patient’s eligibility for…

A

receiving a liver transplant

44
Q

Drugs with a BBW for liver damage are…

A

acetaminophen (high doses), amiodarone, isoniazid, ketoconazole (oral), methotrexate, nefazodone, nevirapine, NRTIs, propylthiouracil, tipranavir, valproic acid, bosentan, felbamate, flutamide, lefunomide and teriflunomide, lomitapide, maraviroc, tolcapone

45
Q

Acetaminophen can be used by patients with cirrhosis, but…

A

for limited period of time and at lower dosages

46
Q

Chronic alcohol ingestion over a long period of time causes…

A

steatosis or fatty liver

47
Q

In patients with alcohol-associated liver disease, thiamine (vitamin B1) is given to prevent and treat…

A

Wernicke-Korsakoff syndrome

48
Q

Portal hypertension is…

A

increased BP in the portal vein (can cause complications such as bleeding esophageal varices)

49
Q

Acute variceal bleeding can be fatal. Medications that vasoconstrict the splanchnic (GI) circulation can stop or minimize the bleeding…

A

octreotide IV bolus (selective for the splanchnic vessels), whereas vasopressin is not

50
Q

Non-selective beta-blockers or endoscopic variceal ligation (EVL) are mainly used for…

A

primary prevention of variceal bleeding

51
Q

The beta-blocker is titrated to the maximally tolerated dose to target a HR of…

A

55-60 BPM (continue BB indefinitely). These include nadolol or propranolol

52
Q

Beta-blockers reduce portal pressure by…

A

reducing portal venous inflow by 2 mechanisms: 1) decreased cardiac output (via beta-1 blockage)
2) decreased splanchnic blood flow by vasoconstriction

53
Q

Hepatic encephalopathy (HE) is caused by acute or chronic liver insufficiency. Symptoms include…

A

musty odor of the breath and/or urine, changes in thinking, confusion, forgetfulness, mood changes, poor concentration, tremor.

54
Q

HE symptoms are due to the…

A

build-up of nitrogenous substances in the blood (ex. ammonia, glutamate)

55
Q

HE treatment includes reducing blood ammonia through…

A

diet (limit animal protein) and drug therapy (lactulose or rifaximin)

56
Q

Lactulose is metabolized in the gut to acetic acid and lactic acid, it works by

A

trapping ammonium in the GI tract

57
Q

Rifaximin works by…

A

inhibiting the activity of urease-producing bacteria, which decreased ammonia production. Zinc (220 mg PO BID) may be used as a cofactor.

58
Q

Ascites is…

A

fluid accumulation within the peritoneal space that can lead to the development of spontaneous bacterial peritonitis (SBP) and HRS

59
Q

Patients with ascites due to portal HTN should…

A

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.

60
Q

Diuretic therapy for ascites can be initiated with either….

A

spironolactone monotherapy or with a combo. of spironolactone and furosemide (100mg:40mg). Titrate dose to a maximal weight loss of 0.5 kg/day.

61
Q

Large-volume paracentesis (removal of >5 L) is associated with significant fluid shifts and the addition of…

A

albumin (6-8 g/L of fluid removed) is recommended to prevent paracentesis-induced circulatory dysfunction progression to hepatorenal syndrome

62
Q

Spontaneous bacterial peritonitis (SBP) should be treated with…

A

ceftriaxone for 5-7 days (to cover Strep and Gram-negative pathogens)

63
Q

Patients who have survived an episode of SBP should receive secondary ppx with…

A

oral ciprofloxacin or SMX/TMP

64
Q

Hepatorenal syndrome (HRS) is…

A

the development of renal failure in patients with advanced cirrhosis (due to renal vasoconstriction)

65
Q

HRS prevention is critical, can be treated with

A

albumin, octreotide, midodrine

66
Q

A natural product that is sometimes used for liver disease is…

A

milk thistle (limited date to show efficacy)

67
Q

Diarrhea is a major dose-limiting adverse effect of…

A

lactulose (also an osmotic laxative)

68
Q

DW has a history of alcohol abuse and cirrhosis secondary to alcohol. Which of the following could be considered to prevent alcohol relapse?

A

naltrexone, disulfiram, acamprosate

69
Q

Sofosbuvir (Sovaldi)

A

400 mg daily with or without food

70
Q

Sofosbuvir/velpatasvir

71
Q

sofosbuvir/velpatasvir/voxilaprevir (Vosevi)

A

take 1 tablet daily with food

72
Q

glecapravir/pibrentasvir (Mavyret)

A

take 3 tablets once daily with food

73
Q

paritaprevir/ritonavir/ombitasvir (Technivie)

A

take 2 tablets once daily in the AM with a meal

74
Q

elbasvir/grazoprevir

NAPLEX (25 decks)

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