Liver and Renal Disease Flashcards
Which of the following is correct regarding the need to test for HIV before starting HBV therapy?
a. Antivirals used for HBV can have activity against HIV
b. HBV tx requires higher doses of antivirals than HIV tx
c. HIV resistance can occur if HIV if unrecognized
d. A tx regimen for HIV will require the addition of a direct-acting antiviral to treat HBV
e. HIV and HBV share similar routes of transmission
a, c, e
Which of the following antiviral meds would be expected to have a drug-drug interaction with pantoprazole?
a. Paritaprevir/ritonavir/ombitasvir (Technivie)
b. Epclusa
c. Sofosbuvir (Sovaldi)
d. Sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
e. Mavyret
b, d
The concentrations of ledipasvir and velpatasvir can be decreased by antacids, H2RAs, and PPIs. If a product contains either of these drugs, then co-administration with antacids, H2RAs, and PPIs should be avoided or separated.
YB is admitted to the hospital for an acute variceal bleed. She’s unable to provide information about her medical hx.
Labs:
WBC (4-11) = 13.6
Hgb (12-16 female) = 7.8
Hct (36-46 female) = 23.2%
Plt (150-450) = 143
Na (135-145) = 129
SCr (0.6-1.3) = 1.5
Albumin (3.5-5) = 2.8
INR = 2.8
Glucose (100-125) = 122
Ammonia (19-60) = 110
Alk Phos (33-131) = 225
Which of YB’s lab abnormalities indicate chronic liver disease and reduced synthetic function of the liver?
a. Leukocytosis and anemia
b. Hyponatremia and leukocytosis
c. Thrombocytopenia and increased creatinine
d. Hypoalbuminemia and increased INR
e. Thrombocytopenia and hyperglycemia
d
-Albumin and clotting factors are produced by the liver, thus low albumin and increased PT/INR are indicators of the reduced synthetic ability of the liver. This is often seen in chronic liver disease that has progressed to cirrhosis.
-Chronic liver disease labs:
> Increased AST/ALT, Alk Phos, Tbili, LDH, PT/INR
> Decreased albumin
YB is admitted to the hospital for an acute variceal bleed. She’s unable to provide information about her medical hx.
Labs:
WBC (4-11) = 13.6
Hgb (12-16 female) = 7.8
Hct (36-46 female) = 23.2%
Plt (150-450) = 143
Na (135-145) = 129
SCr (0.6-1.3) = 1.5
Albumin (3.5-5) = 2.8
INR = 2.8
Glucose (100-125) = 122
Ammonia (19-60) = 110
Alk Phos (33-131) = 225
Several days later, YB’s variceal bleed has been controlled. Her renal function is much improved, and her other labs are stable. She’s noted to have ascites. In addition to sodium restriction, which of the following is an appropriate recommendation for treating her ascites?
a. Furosemide 40 mg daily
b. Spironolactone 100 mg + HCTZ 12.5 mg daily
c. Furosemide 100 mg daily
d. Spironolactone 40 mg + furosemide 100 mg daily
e. Furosemide 40 mg + spironolactone 100 mg daily
e
Spironolactone + furosemide in a 100:40 ratio is recommended when diuretics are needed to manage ascites. The doses can be titrated, but this ratio should be maintained. Monotherapy with a loop diuretic isn’t effective and isn’t recommended.
YB is admitted to the hospital for an acute variceal bleed. She’s unable to provide information about her medical hx.
Labs:
WBC (4-11) = 13.6
Hgb (12-16 female) = 7.8
Hct (36-46 female) = 23.2%
Plt (150-450) = 143
Na (135-145) = 129
SCr (0.6-1.3) = 1.5
Albumin (3.5-5) = 2.8
INR = 2.8
Glucose (100-125) = 122
Ammonia (19-60) = 110
Alk Phos (33-131) = 225
The pharmacist received a new order for “Lactulose 30 mL PO Q6H. Titrate to 2-4 soft bowel movements per day.” Which of the following best describes the expected effect on YB’s labs?
a. Albumin should increase
b. Hemoglobin should increase
c. Platelets should increase
d. Ammonia should decrease
e. Alkaline phosphatase should decrease
d
Elevated serum ammonia (and other waste) is thought to be the cause of hepatic encephalopathy symptoms. Lactulose is expected to lower serum ammonia level and improve symptoms. Despite the proven effect, ammonia and symptoms aren’t perfectly linked (e.g., a pt with a lower ammonia level could have worse symptoms than another pt with higher serum levels).
YB is admitted to the hospital for an acute variceal bleed. She’s unable to provide information about her medical hx.
Labs:
WBC (4-11) = 13.6
Hgb (12-16 female) = 7.8
Hct (36-46 female) = 23.2%
Plt (150-450) = 143
Na (135-145) = 129
SCr (0.6-1.3) = 1.5
Albumin (3.5-5) = 2.8
INR = 2.8
Glucose (100-125) = 122
Ammonia (19-60) = 110
Alk Phos (33-131) = 225
Several days later, YB’s acute variceal bleed has been controlled. Her renal function is much improved, and her other labs are stable. Her BP is 145/83, and HR is 83. Which of the following recommendations would reduce her risk of having another variceal bleed?
a. Start lisinopril and titrate to a SBP < 100 mmHg
b. Start HCTZ and double after 1 week if HR > 60 BPM
c. Start propranolol and titrate to a HR 55-60 BPM
d. Start nadolol and titrate to a SBP < 100 mmHg
e. Start atenolol and titrate to a HR 70-80 BPM
c
-A non-selective BB is preferred for treating portal HTN to reduce pressure in the splanchnic vasculature.
-Non-selective BBs (propranolol and nadolol) are useful for both primary and secondary prophylaxis of variceal bleeding and would be continued indefinitely.
-Titrate to a HR 55-60 BPM (or highest tolerated dose).
Which of the following natural products is used for liver disease?
a. Coenzyme Q10
b. Milk thistle
c. Feverfew
d. Magnesium
e. Soy
b
A pt complains of abdominal pain, nausea, itching, dark urine, and yellow eyes/skin. Which of the following tests can help evaluate the underlying cause?
a. BUN
b. Thiopurine methyltransferase
c. Total bilirubin
d. Amylase
e. Lipase
c
Pts with liver disease can present jaundiced d/t elevated total bilirubin.
In a pt unable to tolerate lactulose for the prevention of hepatic encephalopathy, which of the following would be the best recommendation?
a. Start rifaximin
b. Start neomycin
c. Start metronidazole
d. Start nadolol
e. Start octreotide
a
Lactulose is the preferred first-line therapy for the prevention of hepatic encephalopathy, followed by rifaximin. This decision is mainly driven by cost. The side effects associated with chronic neomycin or metronidazole treatment limit their use.
SH is beginning therapy with Pegasys (pegylated interferon-alfa-2a). The pharmacist will counsel him on possible side effects from Pegasys therapy. He should receive counseling on which of the following side effects?
a. Depression
b. Hair growth
c. Flu-like syndrome
d. Fatigue
e. Liver damage
a, c, d, e
Interferons have numerous side effects (e.g., CNS effects, GI upset, increased LFTs), making treatment difficult for the pt.
Which of the following meds can cause Fanconi syndrome, renal insufficiency, and osteomalacia?
a. Adefovir
b. Entecavir
c. Epivir HBV
d. Sofosbuvir
e. Viread
e
-Fanconi syndrome is a condition that causes new or worsening renal impairment. Some pts are born with Fanconi syndrome, and others acquire it through the use of certain drugs, such as tenofovir.
-Remember “NOF” for warnings with teNOFovir (N = nephrotoxicity, O = osteomalacia, F = Fanconi syndrome).
What is the benefit of using a pegylated formulation of interferon over a non-pegylated formulation?
a. Can be administered orally
b. Administered less often than non-pegylated interferon
c. Decreases the risk of AEs
d. More effective than non-pegylated interferon
e. Pretreatment with acetaminophen isn’t needed for pegylated interferon
b
The pegylated forms have polyethylene glycol added to the interferon via pegylation. This enhances the drug’s half-life (requiring less frequent dosing).
Which of the following meds have a BBW for liver damage?
a. Tylenol
b. Isoniazid
c. Depakote
d. Aleve
e. Nefazodone
a, b, c, e
Drugs with BBW for liver damage:
-Acetaminophen (high doses, acute or chronic)
-Amiodarone
-Isoniazid
-Ketoconazole (PO)
-Methotrexate
-Nefazodone
-Nevirapine
-NRTIs
-Propylthiouracil
-Valproic acid
Which of the following is a form of tenofovir?
a. Corgard
b. Inderal XL
c. Xifaxan
d. Epclusa
e. Viread
e
What is the preferred management of viral hepatitis A?
a. Supportive care and vaccination for prevention
b. Supportive care only; there’s no vaccine for hepatitis A
c. Pegylated interferon and vaccination for prevention
d. Direct-acting antiviral combo and vaccination for prevention
e. Direct-acting antiviral combo; there’s no vaccine for hepatitis A
a
KL, a 52 y/o male, presents to the ED with his brother. They were together at the mall when KL reported feeling lightheaded and then lost consciousness.
PMH: Hep C, HTN, HF, afib, diabetes
Meds: Epclusa, Toprol XL, Eliquis, Pacerone, Diovan, Lantus, Nexium
Vitals: 5’11”, 187 lbs, BP 137/79, HR 53, RR 16, Temp 99.1F
Abnormal Labs:
Glucose = 81
Which of KL’s meds interacts with his HCV regimen and can cause this presentation?
a. Eliquis
b. Nexium
c. Diovan
d. Lantus
e. Pacerone
e
KL is experiencing symptomatic bradycardia. Serious symptomatic bradycardia (sometimes requiring pacemaker insertion) has been associated with taking amiodarone (Pacerone) with a sofosbuvir-containing regimen. PPIs (e.g., Nexium) interact with Epclusa, leading to a reduced velpatasvir concentration, which can cause potential tx failure (not symptomatic bradycardia).
A pharmacist receives an Epivir Rx for a 32 y/o female whose PMH includes iron deficiency anemia, hypothyroidism, and hep B. The pharmacist should contact the prescriber to discuss which of the following?
a. The need for baseline pulmonary function testing before starting Epivir.
b. The appropriate Epivir formulation for the pt.
c. The contraindication to using Epivir in pts with hypothyroidism.
d. The need for premedication with an antihistamine before each Epivir dose.
e. The requirement to use Epivir in combo with another drug.
b
The Rx requires clarification with the prescriber as lamivudine has 2 brand names (I.e., Epivir and Epivir HBV) that have different doses. These brands aren’t interchangeable. Epivir is the form that’s approved for the tx of HIV. This pt needs to be prescribed Epivir HBV to treat her hep B.
Which of the following is used to assess the severity of liver disease?
a. Ranson’s Criteria
b. APACHE II Score
c. ASCVD Risk Score
d. Child-Pugh Classification
e. Well’s Criteria
d
KP has an uncle who passed away from complications of untreated hep C. She wants to be vaccinated against hep C and wants her children to receive the vaccines also. Her children are currently 2 y/o and 7 y/o. What advice should the pharmacist provide about hep C vaccination?
a. Her children likely received HCV vaccinations as part of the routine childhood vaccination series.
b. They can all receive the HCV vaccine now.
c. She can be vaccinated for HCV now. Her children can’t be vaccinated until they’re >/= 18 years of age.
d. There’s 1 combined vaccine for HAV, HBV, and HCV.
e. There’s no vaccine for HCV.
e
There are vaccines available for HAV and HBV.
Which of the following is an appropriate regimen for treating HCV?
a. Sofosbuvir + dasabuvir
b. Paritaprevir + voxilaprevir
c. Glecaprevir + pibrentasvir
d. Ribavirin
e. Ombitasvir + ritonavir
c
-Treatment of HCV requires at least 2 direct-acting antivirals (DAA) with different mechanisms.
-They include:
> NS3/4A protease inhibitors (-previr)
> NS5a replication complex inhibitors (-asvir)
> NS5B polymerase inhibitors (-buvir)
-Glecaprevir/Pibrentasvir (Mavyret) is a DAA approved for the tx of all 6 HCV genotypes
