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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
Q

What medications are approved for HCV/HIV co-infection?

A

Glecaprevir/pibrentasvir (Mavyret)
Sofosbuvir/velpatasvir (Epclusa)
Sofosbuvir/ledipasvir (Harvoni)

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26
Q

What medications are approved for HCV in children 12 and older with certain genotypes?

A

Sofosbuvir/ledipasvir (Harvoni)

Sofosbuvir (Sovaldi)

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27
Q

Paritaprevir/ritonavir/ombitasvir (Technivie)
Paritaprevir/ritonavir/ombitasvir + dasabuvir (Viekira Pak)

Warnings

A

Hepatic decompensation/failure in patients with cirrhosis, risk of increased LFTs, drug interactions

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28
Q

Elbasvir/grazoprevir

A

CI: CYP3A4 inducers
Warnings: increased LFTs (>5x ULN), drug interactions

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29
Q

All DAAs are contraindicated with what medications?

A

CYP3A4 inducers

carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin, and St John’s wort

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30
Q

DAA and statin interaction

A

increase statin concentration and myopathy risk

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31
Q

Ledipasvir and velpatasvir interaction with Antacids, H2RAs, and PPIs

A

decrease concentration of ledipasvir and velpatasvir

32
Q

Paritaprevir/ritonavir/ombitasvir (Technivie)
Paritaprevir/ritonavir/ombitasvir + dasabuvir (Viekira Pak)
Contrindications

A

Strong CYP3A4 inducers, ethinyl estradiol-containing products, lovastatin, simvastatin

33
Q

Dasabuvir affects what CYP enzyme?

A

2D8 substrate

34
Q

Ribavirin BBW

A

Teratogenic - do not use in pregnancy
Not effective as monotherapy
Hemolytic anemia

35
Q

Ribavirin contraindications

A

Pregnancy

36
Q

Ribavirin clinical pearls

A

Avoid pregnancy during therapy and 6 months after completion (2 forms of contraception)

37
Q

Ribavirin place in therapy

A

Can be used for HCV in combination with other DAAs and/or interferon alfa but NEVER as monotherapy

38
Q

What does pegylation do in terms of pharmacokinetics of a medication?

A

Increases the half-life

39
Q

PEG-INF place in HCV therapy?

A

INF + RBV (ribavirin)

INF + RBV + DAA(s)

40
Q

Are interferon products recommended for treatment of HCV?

A

Not any more but they will still be used if nothing else is working

41
Q

Interferon indications

A

alfa - HBV, HCV and some cancers

beta - multiple sclerosis

42
Q

Interferon boxed warnings and side effects

A

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
Q

Nucleoside/tide reverse transcriptase inhibitor MOA

A

inhibit HBV polymerase resulting in DNA chain termination

44
Q

BBW for all HBV NRTIs

A

lactic acidosis and severe hepatomegaly with steatosis, exacerbations of HBV can happen upon discontinuation

45
Q

Tenofovir warnings, SE

A

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
Q

Entecavir clinical pearl

A

Take without food - food decreases AUC by 20%

47
Q

Adefovir BBW

A

nephrotoxicity

48
Q

Lamivudine BBW

A

do not use for treatment of HIV (can cause HIV resistance)

49
Q

Tenofovir and adefovir interaction

A

increased risk of virologic failure and potential increase for side effects

50
Q

Lamivudine and SMX/TMP interaction

A

can increase lamivudine levels due to decreased excretion

51
Q

Most common causes of liver cirrhosis

A

hepatitis C and alcohol

52
Q

How is liver cirrhosis officially diagnosed?

A

biopsy! (labs are only suggestive)

53
Q

Labs suggestive of chronic liver cirrhosis

A

Increased: ALT, AST, Alk phos, total bilirubin, LDH, PT/INR
Decreased: albumin

54
Q

Labs suggestive of acute liver cirrhosis

A

Increased ALT, AST

55
Q

Labs suggestive of alcoholic liver disease

A

Increased AST > increased ALT (AST will be ~double ALT), increased GGT

56
Q

Labs suggestive of hepatic encephalopathy

A

Increased ammonia

57
Q

Child Pugh vs MELD

A

Child Pugh - lower score = less disease

MELD - (0-40) higher number = greater risk of death within 3 months

58
Q

When should you d/c hepatotoxic drugs?

A

When LFTs are >3 time ULN

59
Q

Why should NSAIDs be avoided in patients with cirrhosis?

A

Can lead to decompensation and bleeding

60
Q

Key drugs that can cause liver damage

A 
APAP
Amiodarone
Isoniazid
Ketoconazole
Methotrexate
Nefazodone
Nevirapine
NRTIs
Propylthiouracil
Tipranavir
Valproic acid
61
Q

What medications are used to prevent alcohol use disorder relapses?

A

Naltrexone
Acamprosate
Disulfiram

62
Q

Why do we supplement thiamine in patients with alcohol use disorder?

A

To prevent and treat Wernicke-Korsakoff syndrome (can cause encephalopathy and/or brain damage)

63
Q

What can portal HTN cause?

A

esophageal varices

64
Q

Esophageal varices treatment

A

Band ligation
Sclerotherapy (injecting the vessel to make it collapse and close)
Octreotide

65
Q

What medications should be given as secondary prevention for variceal bleeding?

A

Non-selective beta blockers (nadolol, propranolol)

66
Q

Octreotide SE

A

Bradycardia, cholelithiasis, biliary sludge

67
Q

Medications for primary prevention of variceal bleeding

A

non-selective beta blockers (indefinite) and endoscopic variceal ligation

68
Q

When is octreotide given for variceal bleeds?

A

When they are actually bleeding

Given IV

69
Q

Non-selective beta blocker BBW and caution

A

BBW: Do not stop abruptly

Caution in patients with asthma, COPD, PVD, Raynaud’s disease

70
Q

Hepatic encephalopathy treatment

A

Limit protein intake to 1-1.5 g/kg daily (contains nitrogen)
Lactulose (first line for acute and chronic therapy)
Rifaximin

71
Q

Lactulose MOA in hepatic encephalopathy

A

Converts ammonia produced by intestinal bacteria to ammonium

72
Q

Lactulose SE and monitoring

A

SE: flatulence, diarrhea, dyspepsia, abdominal discomfort
Monitoring: bowel movements (goal 2-3/d), ammonia

73
Q

Rifaximin MOA in hepatic encephalopathy

A

inhibit activity of bacteria which decreases ammonia production

74
Q

What medication combo is used in ascites and in what dosing ratio?

A

Spironolactone + furosemide
100mg/40mg ratio
Helps to maintain potassium level

75
Q

What should happen when >5 L of ascites fluid is removed from a patient?

A

Supplement albumin

6-8 grams per liter of fluid removed

76
Q

Spontaneous bacterial peritonitis treatment

A

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)

NAPLEX Review (79 decks)

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