Hepatitis/Liver Disease

Question 1

NS3/4A Protease Inhibitor

Answer 1

• previr (P for PI), type of DAA
• Glecaprevir (part of Mavyret)
• Grazoprevir
• Paritaprevir
• Voxilaprevir

Question 2

NS5A Replication Complex Inhibitors

Answer 2

• asvir (A for NS5A), type of DAA
• Elbasvir
• Ledipasvir
• Ombitasvir
• Pibrentasvir (part of Mavyret)
• Velpatasvir (part of Epclusa)

Question 3

NS5B Polymerase Inhibitors

Answer 3

• buvir (B for NS5B), type of DAA
• Dasabuvir
• Sofosbuvir (part of Epclusa)

Question 4

All DAAs

Answer 4

• Risk of reactivacting HBV, test ALL patients before starting DAA
• Sofosbuvir-regimens: don’t use with amiodarone (parcerone), serious bradycardia
• Well-tolerated medications overall

Question 5

Epclusa

Answer 5

• Sofosbuvir/velpatasvir - 1 tablet daily with or without food
• Monitor drug interactions, some potentially serious
• Sofosbuvir not recommended monotherapy
• Dispense in original container (protect from moisture)
• Avoid/minimize with acid-suppressive therapy (potentially less absorption/untreated hepatitis)
• Pan-genotypic for HCV treatment-naive patients

Question 6

Mavyret

Answer 6

• Glecaprevir/pibrentasvir - 3 tablets by mouth once daily with food
• Only 8 week course of treatment
• Pan-genotypic for HCV treatment-naive patients

Question 7

Regimens for Special HCV Situations

Answer 7

• Salvage therapy: Mavyret (select patients), Vosevi
• HCV/HIV co-infection: Mavyret, Epclusa, Harvoni
• Approved for children: Sovaldi/Harvoni (>3 years old), Epclusa (>6 yo), Mavyret (>12 yo)

Question 8

Viekira Pak

Answer 8

• 2 tablets of paritaprevir/ritonavir/ambitasvir once daily (morning) and 1 tablet of dasabuvir BID with meals
• CI: CYP3A4 inducers/substrates (increase levels and cause toxicities), ethinyl estradiol products (during and 2 weeks after stopping)
• Warning: Hepatic decompensation/failure in cirrhotic patients, increased LFTs (>5x ULN), significant DDI potential

Question 9

Zepatier

Answer 9

• Elbasvir/grazoprevir
• CI: strong inducers of CYP3A4
• Warnings: Increased LFTs (>5x ULN), significant DDI potential

Question 10

Ribavirin

Answer 10

• Used in combination with other agents, never monotherapy
• Aerosolized: used for respiratory syncytial virus (RSV)
• Warnings: hemolytic anemia, significantly teratogenic (child-bearing age women and male partners)
• CI: Pregnancy
• Avoid during therapy and 6 months after completion in child bearing population, use 2 reliable forms of birth control during this time

Question 11

Interferon alfa

Answer 11

• Injected SQ, 3x/week normally (Intron), once/week PEGylated (PegIntron)
• Alfa works on HCV, HBV (monotherapy), and some cancers
• Warning: Can cause neuropsychiatric, ischemic, or infectious disorders; ribavirin coadministration teratogenic/anemia risk
• SE: CNS effects (fatigue, depression), GI upset, increased LFTS (5-10x ULN) myelosuppressions, flu-like syndrome (fever, chills, malaise)
• Pretreat with APAP or antihistamine

Question 12

ALL HBV NRTIs

Answer 12

• Boxed Warning: Lactic acidosis and severe hepatomegaly with steatosis (can be fatal)
• Exacerbations of HBV can occur is discontinued abruptly

Question 13

Tenofovir-containing products

Answer 13

• TDF (Tenofovir disoproxil fumarate)/Viread or TAF (Tenofovir alafenamide)/Vemlidy
• Preferred therapies for HBV
• Warning: (NOF) Fanconi syndrome, osteomalacia, decreased bone mineral density from renal toxicity
• SE: renal impairment/decreased BMD for TDF, nausea for TAF (TAF has less renal tox. than TDF)
• Dispense both in original containers to protect from moisture

Question 14

Baraclude

Answer 14

• Entecavir
• Preferred HBV therapy
• Take on an empty stomach

Question 15

Hepsera

Answer 15

• Adefovir
• Caution in patient with renal impairment or at risk for renal toxicity (nephrotoxic drugs or NSAIDs)
• Don’t use with tenofovir containing regimens due to increased virological failure/side effect potential

Question 16

Epivir HBV

Answer 16

• Lamivudine
• Warning: Do not use Epivir HBV to treat HIV (and vice versa)
• SE: Headache, N/V/D
• DDI with SMX/TMP; decreased excretion leading to increased lamivudine levels

Question 17

Lab tests for Acute Liver Toxicity

Answer 17

-Increased AST/ALT

Question 18

Lab Tests for Chronic Liver Disease

Answer 18

-Increased AST/ALT, Alk Phos, Tbili, LDH, PT/INR
-Decreased albumin
(Ex: cirrhosis)

Question 19

Lab Tests for Alcoholic Liver Disease

Answer 19

• AST > ALT by 2x at least (both elevated)

- Increased GGT

Question 20

Lab Tests for Hepatic Encephalopathy

Answer 20

-Increased ammonia

Question 21

Lab Tests for Jaundice

Answer 21

-Increase Tbili

Question 22

Drug with Liver Damage Box Warnings

Answer 22

• APAP (high doses)
• Amiodarone
• Isoniazid
• Ketoconazole (oral)
• Methotrexate
• Nefazodone
• NNRTIs (especially nevirapine)/NRTIs
• Propylthiouracil
• Tipranavir
• Valproic Acid

Question 23

Vasoconstrictors for Bleeding Varices

Answer 23

• Octreotide is selective for splanchnic circulation and given as an IV bolus
• SE: Bradycardia, cholelithiasis, biliary sludge

-Vasopressin isn’t selective and is a ADH analog

Question 24

B-Blockers for Portal HTN

Answer 24

• Non-selective B-blockers: nadolol and propranolol
• Nadolol (Corgard) given 40 mg QD
• Propranolol (Inderal) given 20 mg BID
• Warnings: Do not withdrawal abruptly to avoid rebound tachycardia/HTN
• Use with caution in those with asthma/COPD/Raynaud’s disease due to unselective nature
• Montior: HR/BP