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NAPLEX Review > Liver Disease > Flashcards

Liver Disease Flashcards

1
Q

Hepatitis A, B, and C

transmission

A

A - fecal/oral

B,C - blood/bodily fluids

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2
Q

Hepatitis A, B, and C

acute or chronic?

A

A - acute

B,C - both

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3
Q

Hepatitis A, B, and C

Vaccine available?

A

A, B - yes

C - no

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4
Q

Hepatitis A, B, and C

first line treatment

A

A - supportive care
B - PEG-INF or NRTI (tenofovir or entecavir)
C - treatment naive give direct acting antiviral combination

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5
Q

What does DAA stand for?

A

direct acting antiviral

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6
Q

What does PEG-INF stand for

A

pegylated interferon

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7
Q

What does RBV stand for

A

ribavirin

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8
Q

What is the preferred hepatitis C regimen?

A

2-3 direct acting antivirals (DAAs) with DIFFERENT mechanisms for 8-12 weeks

DAA mechanisms: NS3/4A protease inhibitor, NS5A replication complex inhibitor, NS5A polymerase inhibitor

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9
Q

What is the preferred hepatitis A regimen?

A

supportive care

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10
Q

What is the preferred hepatitis B regimen?

A

PEG-INF

Can also use NRTI (tenofovir or entecavir)

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11
Q

Does ritonavir treat hepatitis C virus?

A

No but it increases the level of HCV protease inhibitors that are used with it

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12
Q

What medications are NS3/4A protease inhibitors?

A

Glecaprevir
Grazoprevir
Paritaprevir
Voxilaprevir

-previr — p as in PI

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13
Q

What medications are NS5A replication complex inhibitors?

A

Ledipasvir
Ombitasvir
Pibrentasvir
Velpatasvir

-asvir — a as in NS5A

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14
Q

What medications are NS5B polymerase inhibitors

A

Dasabuvir
Sofosbuvir

-buvir — b as in NS5B

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15
Q

What hepatitis medications need to be taken with food?

A

Protease Inhibitors and Grub (PIG)

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16
Q

Recommended treatment regimens for treatment naive patients with Hepatitis C without cirrhosis

A

Glecaprevir/pibrentasvir

Sofosbuvir/velpatasvir

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17
Q

Black box warning for all DAAs

A

Risk of reactivating HBV - test all patients before initiating DAA

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18
Q

What medication should NOT be taken with sfosbuvir?

A

amiodarone - can cause serious symptomatic bradycardia

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19
Q

Glecaprevir/pibrentasvir (Mavyret) contraindication

A

moderate-severe hepatic impairment (Child Pugh B or C or hx of hepatic decompensation

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20
Q

True or false

DAA have potentially serious drug interactions

A

True

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21
Q

When to use sofosbuvir monotherapy

A

NEVER - not effective

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22
Q

What medications are approved for all 6 genotypes of HCV in treatment naive patients?

A

Sofosbuvir/velpatasvir (Epclusa)

Glecaprevir/pibrentasvir (Mavyret)

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23
Q

What medications are approved for salvage therapy in HCV treatment?

A

Sofosbuvir/velpatasvir/voxilaprevir (Vosevi)

Glecaprevir/pibrentasvir (Mavyret)

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24
Q

What medication is approved for 8 week course of therapy in HCV treatment?

A

Glecaprevir/pibrentasvir (Mavyret)

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25
What medications are approved for HCV/HIV co-infection?
Glecaprevir/pibrentasvir (Mavyret) Sofosbuvir/velpatasvir (Epclusa) Sofosbuvir/ledipasvir (Harvoni)
26
What medications are approved for HCV in children 12 and older with certain genotypes?
Sofosbuvir/ledipasvir (Harvoni) | Sofosbuvir (Sovaldi)
27
Paritaprevir/ritonavir/ombitasvir (Technivie) Paritaprevir/ritonavir/ombitasvir + dasabuvir (Viekira Pak) Warnings
Hepatic decompensation/failure in patients with cirrhosis, risk of increased LFTs, drug interactions
28
Elbasvir/grazoprevir
CI: CYP3A4 inducers Warnings: increased LFTs (>5x ULN), drug interactions
29
All DAAs are contraindicated with what medications?
CYP3A4 inducers | carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin, and St John's wort
30
DAA and statin interaction
increase statin concentration and myopathy risk
31
Ledipasvir and velpatasvir interaction with Antacids, H2RAs, and PPIs
decrease concentration of ledipasvir and velpatasvir
32
Paritaprevir/ritonavir/ombitasvir (Technivie) Paritaprevir/ritonavir/ombitasvir + dasabuvir (Viekira Pak) Contrindications
Strong CYP3A4 inducers, ethinyl estradiol-containing products, lovastatin, simvastatin
33
Dasabuvir affects what CYP enzyme?
2D8 substrate
34
Ribavirin BBW
Teratogenic - do not use in pregnancy Not effective as monotherapy Hemolytic anemia
35
Ribavirin contraindications
Pregnancy
36
Ribavirin clinical pearls
Avoid pregnancy during therapy and 6 months after completion (2 forms of contraception)
37
Ribavirin place in therapy
Can be used for HCV in combination with other DAAs and/or interferon alfa but NEVER as monotherapy
38
What does pegylation do in terms of pharmacokinetics of a medication?
Increases the half-life
39
PEG-INF place in HCV therapy?
INF + RBV (ribavirin) | INF + RBV + DAA(s)
40
Are interferon products recommended for treatment of HCV?
Not any more but they will still be used if nothing else is working
41
Interferon indications
alfa - HBV, HCV and some cancers | beta - multiple sclerosis
42
Interferon boxed warnings and side effects
BBW: neuropsychiatric, autoimmune, ischemic or infectious disorders; if used with ribavirin there is a teratogenic/anemia risk SE: CNS effects (fatigue, depression), GI upset, increased LFTs, myelosuppression, flu like syndrome (can pre-treat with APAP and an antihistamine)
43
Nucleoside/tide reverse transcriptase inhibitor MOA
inhibit HBV polymerase resulting in DNA chain termination
44
BBW for all HBV NRTIs
lactic acidosis and severe hepatomegaly with steatosis, exacerbations of HBV can happen upon discontinuation
45
Tenofovir warnings, SE
Warnings: renal toxicity, fanconi syndrome, osteomalacia, and decreased bone mineral density Tenofovir disoproxil fumarate (TDF) SE: renal impairment, decreased bone mineral density Tenofovir alafenamide (TAF) SE: nausea
46
Entecavir clinical pearl
Take without food - food decreases AUC by 20%
47
Adefovir BBW
nephrotoxicity
48
Lamivudine BBW
do not use for treatment of HIV (can cause HIV resistance)
49
Tenofovir and adefovir interaction
increased risk of virologic failure and potential increase for side effects
50
Lamivudine and SMX/TMP interaction
can increase lamivudine levels due to decreased excretion
51
Most common causes of liver cirrhosis
hepatitis C and alcohol
52
How is liver cirrhosis officially diagnosed?
biopsy! (labs are only suggestive)
53
Labs suggestive of chronic liver cirrhosis
Increased: ALT, AST, Alk phos, total bilirubin, LDH, PT/INR Decreased: albumin
54
Labs suggestive of acute liver cirrhosis
Increased ALT, AST
55
Labs suggestive of alcoholic liver disease
Increased AST > increased ALT (AST will be ~double ALT), increased GGT
56
Labs suggestive of hepatic encephalopathy
Increased ammonia
57
Child Pugh vs MELD
Child Pugh - lower score = less disease | MELD - (0-40) higher number = greater risk of death within 3 months
58
When should you d/c hepatotoxic drugs?
When LFTs are >3 time ULN
59
Why should NSAIDs be avoided in patients with cirrhosis?
Can lead to decompensation and bleeding
60
Key drugs that can cause liver damage
``` APAP Amiodarone Isoniazid Ketoconazole Methotrexate Nefazodone Nevirapine NRTIs Propylthiouracil Tipranavir Valproic acid ```
61
What medications are used to prevent alcohol use disorder relapses?
Naltrexone Acamprosate Disulfiram
62
Why do we supplement thiamine in patients with alcohol use disorder?
To prevent and treat Wernicke-Korsakoff syndrome (can cause encephalopathy and/or brain damage)
63
What can portal HTN cause?
esophageal varices
64
Esophageal varices treatment
Band ligation Sclerotherapy (injecting the vessel to make it collapse and close) Octreotide
65
What medications should be given as secondary prevention for variceal bleeding?
Non-selective beta blockers (nadolol, propranolol)
66
Octreotide SE
Bradycardia, cholelithiasis, biliary sludge
67
Medications for primary prevention of variceal bleeding
non-selective beta blockers (indefinite) and endoscopic variceal ligation
68
When is octreotide given for variceal bleeds?
When they are actually bleeding | Given IV
69
Non-selective beta blocker BBW and caution
BBW: Do not stop abruptly | Caution in patients with asthma, COPD, PVD, Raynaud's disease
70
Hepatic encephalopathy treatment
Limit protein intake to 1-1.5 g/kg daily (contains nitrogen) Lactulose (first line for acute and chronic therapy) Rifaximin
71
Lactulose MOA in hepatic encephalopathy
Converts ammonia produced by intestinal bacteria to ammonium
72
Lactulose SE and monitoring
SE: flatulence, diarrhea, dyspepsia, abdominal discomfort Monitoring: bowel movements (goal 2-3/d), ammonia
73
Rifaximin MOA in hepatic encephalopathy
inhibit activity of bacteria which decreases ammonia production
74
What medication combo is used in ascites and in what dosing ratio?
Spironolactone + furosemide 100mg/40mg ratio Helps to maintain potassium level
75
What should happen when >5 L of ascites fluid is removed from a patient?
Supplement albumin | 6-8 grams per liter of fluid removed
76
Spontaneous bacterial peritonitis treatment
ceftriaxone for 5-7 days targets streptococci and enteric gram-negative pathogens *may add albumin (1.5 mg/kg on day 1 and 1mg/kg on day 3)

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