Pharm - hepatitis and jaundice Flashcards
What list of meds can cause drug induced liver injury
acetaminophen
anesthetics
NSAIDs
antimicrobials
antifungals
HIV antiretroviral therapy
oral hypoglycemics
lipid lowering agents
What is R value
ALT/ULN ALT
DIVIDED BY
ALP/ULN ALP
What is hepatocellular R
R >= 5
more severe prognosis
What is mixed R
R = 2-5
More prone to chronic disease
What is cholestatic R
R <= 2
more prone to chronic disease
What predicts prognosis with acetaminophen OD
Rumack-Matthew nomogram
Kings College criteria
What is the initial management for acetaminophen OD
gastric emptying via lavage
activated charcoal within 4 hours ingestion
What is the specific antidote for acetaminophen OD
Mucomyst (N-acetyl-cysteine)
What antimicrobials can cause drug induced hepatitis
beta lactams
beta lactamase inhibitors
What oral hypoglycemic is assoc with cholestatic injury pattern
Glimepiride
What lipid lowering agents may cause drug induced hepatitis
statins
ezetimibe
What differentiates acute viral hepatitis from chronic viral hepatitis?
greater or less than 6 months
A is only acute
Describe hep A
acute, self-limited
person to person via fecal oral route or ingestion of contaminated food or water
assoc with poor sanitation
Hep A clinical presentation
incubation period 28 days
symptoms may or may not be present
What labs indicated hep A
elevated aminotransferases
detection of IgM antibody to HAV
How to manage hep A
no treatment
supportive
avoid hepatotoxic substances
How to prevent hep A
hand washing
Havrix and Vaqta vaccines
combo vax Twinrix (HAV and HBV)
Immunoglobulin dose
When to give Havrix
0, then 6-12 months
When to give VAQTA
0, then 6-18 months
Who is recommended to get Hep A vax
all children older than 1
Increased infection risk
-MSM
-injection & non-injection drugs
-occupational risks
Postexposure prophylaxis for HAV
if vaxxed, nothing
no vax - vaccine or immunoglobulin as soon as possible within 2 weeks
When is immunoglobulin preferred for HAV postexposure prophylaxis rather than vax?
<12 months
Immunocompromised
Chronic liver disease
What is the same between Hep B and Hep C
transmitted by blood
targets liver
acute or chronic
What is different between Hep B and Hep C
DNA vs RNA virus
vaccine with 3 injections vs no vax
treat with NRTIs vs NSSA inhibitor, protease inhibitor, polymerase inhibitor
What does HBsAg (surface antigen) tell you?
live active virus/active Hep infection
What does HBeAG identify?
active replication of HBV
What does Anti-HBc (core antigen) indicate?
active virus present or was present but cleared by the immune system
What does IgM anti-HBs tell you?
acute phase of infection
What does IgG anti-HBs tell you?
immunity from clearing infection or from immunization
What will be positive if patient is immune to hep B due to infection and NOT the immunization?
anti-HBc
What is the only positive lab if patient is immune to HBV due to immunization?
Anti-HBs
What classification is used for hepatitis B?
child turcotte pugh classification
What is the common co-infection with HBV?
HIV or HCV
What class and specific med is hep B treatment
Nucleoside analog class
NRTI - nucleoside reverse transcriptase inhibitors
What are some treatment considerations for hep B treatment?
- After clearance treat another 6 months
- Renal dose (dose reductions)
- If treatment is stopped prematurely or abruptly severe acute worsening of liver function may occur
What is interferon based therapy for Hep B
Peg-IFN-2a (pegasys) subQ
What are adverse effects of Pegasys
fatigue
autoimmune disorders
What patients are ineligible for Pegasys therapy
Baseline neutrophil count <1500
Platelet count <90,000
Hgb < 10
What are nucleos(t)ide analogs for hep B treatment?
Adefovir
Entecavir
Lamivudine
Tenofovir (also for HIV)
When should Adefovir not be used and why
HIV concomitant infection because if HIV untreated can cause resistance
What is recommended for hep B prevention testing
HBsAG testing
immunization offered to all individuals testing seronegative
Who is recommended to get Hep B vax
multiple sexual partners
MSM
IVDU
HIV + patients
End stage renal disease
Workers at high risk of occupational exposure
What are the single antigen formations of HBV vax
Recombivax HB
Engerix-B
What is a combination HBV vax
Twinrix (HBsAg and HAV)
What vaccines for HBV for children?
comvax
pediarix
When is serologic testing for immunity recommended?
advised in situations of known status indicating clinical management
-health care workers
-HIV infections
-immunosuppressed patients
What determines the efficacy of postexposure prophylaxis?
how quickly the vaccine is administered
-within 7 days for needle stick
-within 14 days for sexual exposure
What should be done for perinatal exposure
if born to a HBsAg + mother give HBV vaccine and HBIG within 12-24 hours after birth
What should be given if exposed to source with HBsAg positive
completed vaccine series - give booster dose
What should be given to unvaccinated individuals when exposed?
HBIG and begin vaccine series within 24 hours postexposure
What are the risk exposures for Hep C that indicate screening/testing
hemodialysis - long term
Needle stick (health care workers)
Newborn of HCV + mother
M/M unprotected sex
What is the goal of Anti-HCV therapy
Virologic cure
continuous absence of detectable HCV RNA at least 12 weeks after completion of therapy
What are the clinical benefits of hep C treatment
reduced complication development
improved quality of life
reduce all-cause mortality
What factor improves outcomes of Hep C treatment
early initiation
What is common co infection with hep C
HIV or HBV
What are the protease inhibitors used to treat Hep C
Grazoprevir
Paritaprevir
Ritonavir
Voxilaprevir
Glecaprevir
MOA with protease inhibitors
inhibit cleavage of HCV-encoded polyprotein
What are NS5B RNA polymerase inhibitors used to treat Hep C and MOA
Dasabuvir
Sofosbuvir
Inhibits NS5B RNA-dependent RNA polymerase activity
What are the NS5A inhibitors used to treat Hep C and MOA
Daclatasvir
Elbasvir
Ledipasvir
Ombitasvir
Veltpatasvir
Pibrentasvir
Binds to the N-terminus on domain 1 of the HCV
What to note about sofosbuvir+Velpatasvir (Epsula)
covers all genotypes (1-6)
What to note about Glecaprevir + Pibrentasvir (Mavyret)
Covers all genotypes (1-6)
Protease + NS5A inhibitor
What to note about Anti-HCV therapy concerns
Treating HCV can lead to reactivation of HBV
Important to obtain adequate history and screening!
What is an Anti-HCV therapy
PEG-IFN-2 (Pegasys) + ribavirin
Is there a vaccine for Hep C prevention
No
