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NRS 271B > hepatitis meds > Flashcards

hepatitis meds Flashcards

1
Q

Causes of Hepatitis

A
  • viral hepatitis
  • alcoholic hepatitis
  • toxic&drug induced hepatitis
  • autoimmune
  • nonalcoholic fatty liver disease
  • ischemic hepatitis
  • giant cell hepatitis
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2
Q

Which types of viral hepatitis are acute only?

A

A & E

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3
Q

Which types of viral hepatitis are fecal-oral transmission?

A

A & E

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4
Q

Hepatitis A Virus

A
  • transmission: fecal-oral
    • close-personal contact
    • blood exposure (rare)
  • Incubation:
    • approx 30 days; 4 weeks; 1 month
  • Detection of acute infx:
    • HAV-IgM antibodies in serum
  • Detection of immunity:
    • serum HAV-IgG
  • Detecting HAV RNA:
    • RT-PCR: reverse transcriptase PCR
  • No tx → supportive care (nearly all recover within 6 months)
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5
Q

HAV Prevention

A

promote proper sanitary practice

frequent hand washing

safe food prep

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6
Q

HAV Prevention - Immune Globulin

A
  • Passive immunization:
    • IM polyclonal serum immune globulin
      • we administer antibody into the person
    • body does not amount an immune response, it just gets immunity
  • Pre-exposure:
    • at least 14 days before exposure
    • travelers to intermediate and high HAV-endemic regions
      • <3 months: 0.02mL/Kg
      • ≥ 3 months: 0.06mL/Kg (q4-6mo)
  • Post-Exposure:
    • within 14 days of exposure
    • household or other intimate contacts
      • 0.02mL/kg
    • institutions
    • common source exposure (i.e. food made by infected person)
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7
Q

Who should be vaccinated against HAV?

A

children > 1 yr

persons who are at risk for infx or complications

  • Adults should receive 2 dose series at least 2 weeks prior to expected HAV exposure
  • different vaccine, not immunoglobulin
    • these are antigen-initiated immune responses
  • VAQTA & HAVARIX = hep A only
    • VAQTA: <18: 25 units, ≥ 19: 50 units
    • HAVARIX: ≤ 18: 720 units, ≥ 19: 1550 units
  • TWINRIX = Hep A & B
    • only ≥ 18: 720U/20mcg (HBsAg)
      • 3 dose: 0, 1, 6
      • 4 dose: 0, 7d, 21-30d, 12 months
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8
Q

Hepatitis B Virus

A

dsDNA

surface antigen, core antigen, E antigen

  • Transmission: vertical transmission is most common in high prevalence areas
    • close contact (children) in intermediate prevalence areas
    • unprotected Sex & IV drug use in adults in low prevalence areas
  • incubation: ~60-90 days, 2-3 months
  • Acute infx:
    • HBsAg
  • Viral replication:
    • HBeAg
      • demonstrates active & rapid viral replication
  • Active infx, viral replication:
    • HBV DNA
      • guides management of chronic infx
  • Immunity to infx:
    • Anti-HBs
  • inactive infx:
    • Anti-HBe
  • Resolution of infx:
    • Anti-HBc
      • immunized pts do not produce Anti-HBc
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9
Q

HBV immune tolerant phase

A

HBeAG (+)

Viral load > 20K IU/mL

ALT/AST relatively normal

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10
Q

HBV Immune Active Phase

A

HBeAg (+)

→ virus is replicating

elevated viral load & ALT/AST

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11
Q

HBV Inactive chronic hepatitis B Phase

A
  • Viral load = low or undetectable <2K
  • ALT/AST normal
  • HBeAG (-)
    • virus not replicating
  • Anti-HBe present
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12
Q

HBV Immune Reactivation Phase

A
  • HBeAg (-)
    • virus not replicating
  • increased VL & AST/ALT
  • among those who seroconvert from HBeAG (+) to Anti-HBe → 10-30% will continue to have high ALT/AST & viral loads
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13
Q

Normal ALT levels for men & women

A
  • men: < 30U/L
  • women: <19 U/L
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14
Q

When to tx: HBeAg Positive: ALT≤ ULN, ALT > ULN but <2x ULN, ALT ≥ ULN

A
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15
Q

When to Tx: HBeAg negative, ALT ≤ ULN, ALT > ULN but < 2x ULN, ALT ≥ 2x ULN

A
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16
Q

Tenofovir, TDF

A

used for HBV

prodrug

  • Preferred in pregnancy
  • do not D/C abruptly
  • caution in HIV/HBV co-infected patients
    • ritonavir (HIV antiretroviral therapy) will boost levels of tenofovir
  • Renal dose adjustments when CrCl ≤ 50mL/min
  • does not last as long as tenofovir alafenamide
  • SEs:
    • Fanconi syndrome:
      • kidney tubule disorder, excrete glucose, bicarb, phosphate, K+, amino acids
        • should add a CMP + phosphorus
    • Osteomalacia and decreased bone density
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17
Q

Tenofovir alafenamide, TAF

A
  • prodrug of tenofovir
  • Not for CrCl < 15mL/min
  • more stable in plasma → less renal/bone toxicity
  • SEs:
    • lactic acidosis
      *
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18
Q

Entecavir

A

adults & peds ≥ 2 yo for HBV

do not D/C med abruptly, can cause Hep B flare

  • Renal dose adjustments when CrCl ≤ 50mL/min
  • highest potency
  • SEs:
    • lactic acidosis and hepatic steatosis
    • rash, N/V/D , HA, fatigue, abd pain,
    • increased LFTs, increased bilirubin
19
Q

Peginterferon alfa-2a

A
  • can be used for all genotypes (A-J) of HBV
  • MOA: antiviral, antiproliferative, immunomodulator
  • indications:
    • adults with HBeAg (+) or (-)
    • compensated liver disease
    • evidence of viral replication and liver inflammation
    • Renal dose adjustments when CrCl ≤ 30mL/min
  • can increase dose of methadone (opioid) and theophylline
  • Contraindications:
    • ANC < 500, platelet < 90K
    • infants and neonates
    • autoimmune hepatitis, decompensated liver
  • adverse effects:
    • suicidal ideation!!
    • flu-like sxs (1-2 hours post admin = Most common
    • worsen anxiety
    • rash, hair loss, dry skin
20
Q

How do we identify if HBV is replicating?

A

if HBeAg is positive

21
Q

HBV prevention: screening & passive IZ

A
  • screening for high risk populations
  • Passive immunization (pt is given antibody):
    • polyclonal serum immune globulin (HBIG)
    • Post-exposure (most effective within 48 hours)
      • may also be given to neonates who are at increased risk of contracting hep B (HBsAg and HBeAg positive)
22
Q

HBV vaccination

A
  • adults and adolescents:
    • three dose series (0, 1, 6 mo)
  • post-exposure prophylaxis:
    • first dose given asap (within 12 hours of exposure)
      • next two doses follow usual schedule
  • infants:
    • birth, 1-2 months of age, 3rd dose: no earlier than 6 mo
23
Q

HCV

A

+ ssRNA

  • acute and chronic
    • 75-85% will develop chronic HCV
  • 1a, 1b and 2-6 genotypes
  • bloodborne
  • takes 4 weeks after infx before development of antibodies
24
Q

Who to screen for HCV?

A
  • once for everyone ≥ 18yo
  • everyone < 18 with risky behaviors, exposures etc
  • annual HCV testing for IV drug users and for HIV infected men who have unprotected sex with men
  • Risk behaviors:
    • IV drug use
    • intranasal illicit drug use
    • men who have sex with men
  • Risk exposures:
    • hemodialysis, healthcare after needlestick
      *
25
Q

HCV genotype 1a tx

26
Q

How to screen for HCV

A
  • HCV antibody:
    • not useful in acute phase, takes at least 4 weeks after infx before development of antibodies
  • HCV RNA
    • qualitative and quantitative
      • alose used to monitor the response to antiviral therapy
  • Should screen for HCV genotype: 1a, 1b, 2-6
27
Q

NS3-4A protease inhibitors

A

used for HCV

  • simeprevir
  • paritaprevir
  • grazoprevir
  • asunaprevir
28
Q

NS5A drugs

A

used for HCV

“asvir”

  • ledipasvir
  • ombitasvir
  • daclatasvir
  • elbasvir
29
Q

Sofosbuvir/ Velpatasvir (Epclusa)

A

used to tx HCV

  • indications:
    • All HCV genotypes (1-6)
      • without cirrhosis
      • compensated cirrhosis
      • decompensated cirrhosis: epclusa + ribavirin
  • SEs:
    • HA, N/D, fatigue, insomnia (coming from sofosbuvir→ fati, insom)
30
Q

Glecaprevir/Pibrentasvir (Mavyret)

A

used to tx HCV→ top of the list to tx HCV

  • MOA:
    • glecaprevir: protease inhibitor
    • pibrentasvir: NS5A inhibitor
  • contraindications:
    • child-pugh B or C
    • together with atazanavir or rifampin
  • SEs:
    • HA, fatigue, nausea, diarrhea
31
Q

HCV genotype 1b, 2-6 tx

32
Q

NS5B Polymerase Inhibitor Drugs

A

used to tx HCV

“buvir”

  • Dasabuvir
  • Beclabuvir
33
Q

Most common genotype of HCV

34
Q

Ledipasvir-Sofosbuvir (Harvoni)

A

very popular drug used to tx HCV→ top of the list for tx of HCV

  • Ledipasvir: NS5A
  • Sofosbuvir: NS5B
  • swallow tablet whole, do not crush or chew
  • SE:
    • fatigue, HA, insomnia, N/V
35
Q

Ribavirin

A

used to tx HCV

for all genotypes 1-6 and HCV/HIV co-infection

≥ 5 years old

  • contraindications:
    • pregnancy
    • autoimmune hepatitis, hemoglobinopathies
  • Adverse effects:
    • hemolytic anemia
    • worsen cardiac disease, fatigue, headache, nausea, anorexia, insomnia, myalgia
36
Q

Child-Pugh Score (CPS)

A
  • measures how severe the chronic liver disease is → including cirrhosis
  • used to determine drug dosing in hepatic impairment
37
Q

Is HCV immune globulin recommended for pre-exposure or post exposure prophylaxis?

38
Q

Bugs associated with spontaneous bacterial peritonitis

A
  • E.coli, Klebsiella, Strep pneumoniae
39
Q

Tx of Spontaneous Bacterial Peritonitis

A
  • Empiric: Cefotaxime > ceftriaxone
    • ofloxacin
  • Prophylaxis:
    • ceftriaxone
    • norfloxacin
    • Bactrim
40
Q

Variceal Bleed Prophylaxis

A

Beta blockers: non-specific

  • propranolol
  • nadolol
41
Q

Tx of Hepatic Encephalopathy

A
  • Lactulose (constulose, enulose, generlac)
    • MOA: limit GI bacteria that cause ammonia
      • lactulose metabolized to lactic acid in GI → convert NH3 to NH4+
      • ***Titrate to 2-3 soft bowel movements***
    • SEs:
      • flatulence, diarrhea, abd pain, dehydration, hypernatremia, hypokalemia
  • Rifaximin:
    • not absorbed systemically
    • Ses:
      • flatulence, dizziness, nausea, ascites
42
Q

When to tx HBV

43
Q

Elbasvir & Grazoprevir (Zepatier)

A
  • used for HCV genotype 1 & 4
  • adverse effects:
    • fatigue, headache, nausea
    • DO NOT USE IF RAS (resistance associated substitution)
44
Q

How long is the tx for HCV?

A

8-12 weeks

NRS 271B (10 decks)

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