Renal & Liver Disease: Hepatitis & Liver Disease Flashcards
What is Hepatitis?
Inflammation of the liver
Can be caused by Hepatitis virus, alc, other drugs, and other viruses
Hep A info
usually, acute, self limiting illness
due to improper hand hygiene, transmission via fecal-oral route from eating dirty food or contact w/ person
generally mild symptoms
Hep B & Hep C info
can cause acute illness but can lead to chronic infection & cirrhosis of liver, liver cancer, liver failure and death
transmission through blood and body fluids
Who is Hep B vaccination recommended for?
all adults
Preg women should be screened for HBV/HCV w/ each pregnancy
Which Hep virus doesnt have a vaccine?
Hep C
Drug treatments for Hep C
direct acting antivirals (DAAs) for about 8-12 weeks
Ribavirin can be added
PIG (DAAs acronym)
Protease Inhibitors & Grub = Take with food
** Exception Zepatier and fosamprenavir**
For treatment-naive patients without cirrhosis, recommended regimens for HCV are….
Glecaprevir/pibrentasvir (Mavyret)
Sofosbuvir/velpatasvir (Epclusa)
Info for all DAAs
Boxed warning: can reactivate HBV, test everyone
Warning: sofosbuvir regimens, dont use w/ amiodarone d/t serious bradycardia
SE: Well-tolerated
Monitoring: LFTs, HCV-RNA
Which DAAs approved for all 6 HCV genotypes for treatment naive patients
Epclusa
Mavyret (approved for 8 wk course)
Glecaprevir/pibrentasvir (Mavyret) info
Dose: TID w/ food
CI: hepatic impairment (Child Pugh B/C), using strong CYP3A4 inducers, ethinyl estradiol products
List of DAAs
glecaprevir/pibrentasvir (Mavyret)
Sofosbuvir/velpatasvir (Epclusa)
Sofosbuvir/ledipasvir (Harvoni)
Sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
Sofosbuvir (Sovaldi) - mono therapy not recommended
Elbasvir/ grazoprevir (Zepatier)
Which DAA need to be dispensed in original container?
Sovaldi
Epclusa
Harvoni
Vosevi
Which DAA should be avoided with acid suppressive therapy?
Epclusa
Harvoni
Vosevi
Special info about Elbasvir/grazoprevir (Zepatier)
CI: Child Pugh B/C, use w/ strong CYP3A4 inducer
Warnings: increase LFTs, sig drug interaction
** Screen for NS5A polymorphism or HCV 1a genotype **
Mavyret drug interactions
Avoid strong inducers of CYP3A4, ethinyl estradiol products, lovastatin, simvastatin
Epclusa, Harvoni, Vosevi drug interactions
Antacids, H2RAs, PPIs
Separate antacids by 4 hours
Take H2RAs same time or 12hrs separated
PPIs not recommended
Ribavirin info
Can be used in HCV combo therapy but not as mono therapy
Boxed Warning: Sig Teratogenic effects
CI: pregnancy, & those who may become pregant
SE: Hemolytic anemia
** Avoid pregnancy during & 6 months after therapy, have to use 2 types of birthcontrol during and 6 months after **
Drugs that can be used as mono therapy for HBV?
NRTIs (Nucleosides/tide reverse transcriptase inhibitors)
Patients should be tested for HIV prior to starting, if both HBV & HIV then therapy should be appropriate for both
All HBV NRTIs info
Dose: Dc dose or frequency if Crcl < 50 except Vemlidy
Box warning: lactic acidosis & severe hepatomegaly, exacerbation of HBV once D/c’d, can cause HIV resistance
Preferred NRTI therapy for HBV
TDF (Viread)
TAF (Vemlidy) - dont use Crcl < 25
Entecavir (Baraclude) - txm naive 0.5, Lamivudien resistant 1mg (take empty stomach)
TDF & TAF info
Warnings: Renal toxicity, Fanconi syndrome, dec bones density
SE TDF: Renal impairment, dec bone density
SE TAF: Better tolerated, less renal/bone toxicity than TDF
Keep both in original containers
Entecavir (Baraclude) info
SE: peripheral edema, incr LFT/SCr
** Food reduces AUC 15-20%, take empty stomach or 2 hrs before meal **
Lamivudine (Epivir HBV) info
Dose: Daily for HBV, 150 BID or 300 QD if also HIV
Boxed warning: dont use for HIV**
SE: HA/N/V/D
Adefovir (Hepsera)
Boxed warning: Caution pts w/ renal impairment, at risk of renal injury or using NSAIDs/nephrotoxic drugs
Tenofovir formulations should not be used with….
adefovir
What is approved as mono therapy for chronic HBV?
PEG-INF-alfa
use limited due to toxicities and lab abnormalities
PEG-INF-alfa info
Dosing: SC weekly
Boxed warning: neuropsychiatric, autoimmune, ischemic/infectious disorders, teratogenic/anemia risk if used w/ ribavirin
CI: autoimmune hep, decomp liver disease, infants/neonates
SE: CNS effects, GI upset, Inc LFTs, myelosuppresion, flu-like symptoms (pretreat w/ Tylenol)
What is cirrhosis?
advanced fibrosis, scarring, of the liver
usually irreversible and due to Hep C or alcohol
Clinical presentation of liver cirrhosis?
Yellow skin and yellowed whites of the eyes, dark urine
How is cirrhosis diagnosed?
Liver biopsy is definitive
Inc ALT/AST, dec albumin, inc Tbili, inc PT, inc INR can be signs
Liver disease classifications
hepatocellular = inc AST/ALT
cholestatic = inc Alk Phos and Tbili
Mixed = inc AST/ALT/Alk Phos and Tbili
How to asses severity of liver disease?
Child- Pugh classification
MELD for end-stage liver disease
When are hepatotoxic drugs discontinued due to risk of drug-induced liver injury?
LFTs > 3 ULN
Which pain med should be avoided in patients with cirrhosis?
NSAIDs
Drugs with boxed warning for liver damage
Tylenol ( > 4mg/day)
Amiodarone
Isoniazid
Ketoconazole
Methotrexate
Nefazodone
Nevirapine
NRTIs
Propylthiouracil
Valproic Acid
Treatment for Alcohol-associated liver disease?
Stop drinking
Benzo for all withdrawal
Naltrexone/Disulfram/acomprosate prevent relapse
Rehab and support groups
Thiamine = used to prevent Wernicke-Korsakoff Syndrome, caused by lack of Vitamin B1
Portal hypertension can lead to….
esophageal varices, acute vatical bleeding can be fatal
Txm for bleeding Esophageal varices
1st line: Band ligation or sclerotherapy
Vasoconstrictive meds:
Octreotide: selective for splanchnic vessels
Vasopressin: non-selective
pts should get 7 days abx (ceftriaxone or quinolone)
Octreotide (Sandostatin) info
Dose: Bolus IV 25-100mcg, then continuous 25-50mcg for 2-4 days
SE: Bradycardia, cholelithiasis, biliary sludge
Vasopressin (Vasostrict) info
Antidiuretic hormone analog
Beta blockers that are used for primary and secondary prevention of variceal bleeding
Nadolol
propranolol
titrated to max dose w/ HR 55-60 BPM
Carvedilol also used for primary prevention
Nadolol (Cogard) & Propranolol (Inderal) variceal prevention info
Boxed warning: Dont stop abruptly, taper dose if dec
Warnings: pts w/ diabetes, can mask hypoglycemia**, caution Asthma/COPD patients, caution Raynaud’s
SE: Bradycardia, fatigue, hypotension, dizziness, depression, impotence
Monitor: if HR dec below 55, BP
** Propranolol has high lipid solubility, crosses BBB and has more CNS effects**
Carvedilol (Coreg) info
Same as other BB
CI: severe hepatic impairment
** Take w/ food to dec absorption and risk of orthostatic hypotension **
Hepatic Encephalopathy symptoms
Musty odor of breath/urine
changes in thinking, confusion, forgetfulness
hand tremor
sluggish movements
TXM of Hepatic encephalopathy
Reduce blood ammonia levels through diet, 1.2-1.5g/kg protein (animal < veg/dairy)
Drug txm for Hepatic encephalopathy
1st line: Lactulose
2nd line: ABX - Rifaximin
Lactulose Hepatic encephalopathy info
SE: Farting, Diarrhea, abd discomfort, dyspepsia
Monitor: Mental status, bowel movements, ammonia lvls
ABX for Hepatic encephalopathy info
Rifaximin
Dose: txm (off label) approved prevention
Neomycin:
Boxed warning: Neuotoxicity
SE: GI upset
All patients with cirrhosis and ascites should be considered for….
liver transplant
Diuretic therapy for ascites
Spironolactone mono therapy
Combo furosemide/spironolactone (40mg furosemide/ 100mg spironolactone ratio)
Spontaneous Bacterial Peritonitis
acute infection of ascitic fluid
Txm: ceftriaxone 5-7 days, can add albumin, if survive then give secondary prevention of cipro/bactrim
