S45(1) HBV Flashcards by ASCP UNTHSC

High endemic areas of Hepatitis B (HBV) whiich are locations such as sub-saharan Africa, East Asia, the Amazon, it is primarily spread how?

Primarily spread by mother-to-infant perinatal transmission and child-to-child transmission

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Low endemic areas of Hepatitis B (HBV) which are locations such as US and Western Europe, it is primarily spread how?

Perinatal transmission
Injection drug users
Multi-transfused patients
Health-care providers
Sexual partners of HBV

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True or False

HBV is Highly virulent, 50-100x more infectious than HIV.

True

It is a DNA virus – partially double stranded

Viral replications by reverse transcriptase

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Hepatitis B Surface Antigen

HBsAg

Protein found on the surface of HBV (Can be acute OR chronic)

if present for > 6 months it denotes chronic infection

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Hepatitis B Envelope Antigen

HBeAg

Present in active infection

Current replication

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Immunoglobulin Antibody to Hepatitis B Core Antigen

IgM anti-HBc

Indicates acute infection (within 6 months)

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Hepatitis B Virus DNA

HBV DNA

Measured as viral load (IU/mL)

Amount of DNA per mL of plasma

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Hepatitis B Envelope Antibody

HBeAb

Formed in response to HBsAg

Predictor of long-term suppression

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Total hepatitis B Core Antibody

Anti-HBc

Indicates previous or ongoing infection

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Hepatitis B Surface Antibody

Anti-HBs

Produced after recovery of HBV infection or successful completion of the vaccination series

Indicates immunity

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HBsAg - Negative (No surface antigen present)
Anti-HBc - Negative (doesn’t have it or never had it)
Anti-HBs - Negative (never recovered)

Patient is susceptible, recommend HEP B Vaccine

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HBsAg - Negative (No active infection)
Anti-HBc - Positive (had it in the past)
Anti-HBs - Positive (recovered)

Immune due to natural infection

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HBsAg - Negative (No active infection)
Anti-HBc - Negative (doesn’t have it or never had it)
Anti-HBs - Positive (recovered)

Immune due to HBV vaccination

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HBsAg - Positive (Active infection)
Anti-HBc - Positive (previous or ongoing infection)
IgM anti-HBc - Positive ( within six months)
Anti-HBs - Negative (Not recovered)

Acutely infected

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HBsAg - Positive (Active infection)
Anti-HBc - Positive (previous or ongoing infection)
IgM anti-HBc - Negative (greater than six months)
Anti-HBs - Negative (Not recovered)

Chronically infected

No cure
Occurs in most children with perinatal infection
Occurs in <5% of adult-onset infections

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HBsAg - Negative
Anti-HBc - Positive
Anti-HBs - Negative

Resolved infection (most common)
False-positive (susceptible)
“Low level” chronic infection
Resolving acute infection

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Engerix® indicated for All ages

0, 1, 6 months

Recombivax® indicated for ≥ 1 years of age

How many doses?

What interval?

0, 1, 6 months

Heplisav-B® indicated for ≥ 18 years of age

How many doses?

What interval?

0, 1 months

Inititating HBV Treatment:

Anyone with active HBV
Anyone with cirrhosis
Anyone with detectable HBV DNA (depends on criteria)

Anyone with active HBV defined as:

HBV DNA > 2,000 IU/mL

ALT ≥ 2x ULN and/or evidence of advanced fibrosis

Anyone not fulfilling criteria consider with detectable HBV DNA:

Patient’s age
Family history of HCC
Prior history of HBV treatment
Extrahepatic manifestations of HBV

Patient Counseling and Non-Pharmacologic Therapy, Counsel patients on preventing disease transmission

Sexual and household contacts should be vaccinated against HBV

Barrier protection is recommended for sexual partners who have not completed the HBV vaccine series

HBV First Line Treatment options:

Pegylated Interferon

Entecavir (Baraclude®)

Tenofovir Disoproxil Fumarate (Viread®)

Tenofovir Alafenamide ( Vemlidy®)

Pegylated Interferon

First-line treatment option Adult Dose: 180 mcg subcutaneously weekly x 48 weeks Monitoring - CBC and TSH - Clinical monitoring for autoimmune, ischemic, neuropsychiatric, and infectious complications

Entecavir (Baraclude®)

First-line treatment option MOA: guanosine nucleoside analog that inhibits HBV replication by 3 different steps Monitoring - Lactic acid if clinical concern - Has minimal activity for HIV but screen prior to use

Tenofovir Disoproxil Fumarate (Viread®) Adverse Effects: ***nephropathy***, osteomalacia, lactic acidosis, Fanconi syndrome

First-line treatment option MOA: nucleotide analog that inhibits HBV replication by HBV polymerase Monitoring - ***Creatinine clearance***, serum phosphate, urine glucose/protein - Bone mineral density and lactic acid if clinical concern - Activity against HIV, screen prior to use

Tenofovir Alafenamide ( Vemlidy®) Adult Dose: 25 mg tablet daily WITH food****

First line treatment option MOA: nucleotide analog that inhibits HBV replication by HBV polymerase Monitoring - Lactic acid levels if clinical concern - Serum creatinine, serum phosphorus, creatinine clearance, urine glucose, and urine protein - Activity against HIV, screen prior to use

Special Populations: Cirrhosis All cirrhotic patients should be treated

Decompensated patients should be evaluated for a liver transplant ****Entecavir and tenofovir disoproxil fumarate (TDF) are preferred for decompensated patients**** Treatment is continued indefinitely

Special Populations: HDV Co-infection

Pegylated interferon is the drug of choice May add NAs if HBV is not controlled

Special Populations: HIV Co-infection

Therapy should include tenofovir alafenamide or tenofovir disoproxil fumarate Regimen must include 2 agents with activity against HBV and HIV (tenofovir + emtricitabine or lamivudine)

Special Populations: Pediatrics Most do not meet the criteria for treatment

- Lamivudine and entecavir are approved for children ≥ 2 years - Pegylated interferon is approved for children ≥ 1 year - Tenofovir disoproxil fumarate (TDF) is approved for children ≥ 12 years

Special Populations: Pregnancy Major cause of transmission

- If HBV DNA is > 200,000 IU/mL, then Tenofovir disoproxil fumarate (TDF) is recommended in the 3rd trimester - ****Infants should be vaccinated and receive hepatitis B immunoglobulin (HBIG) within 12 hours of birth****

All of the following options are preferred for the treatment of chronic hepatitis B, EXCEPT and why? A.) Lamivudine, high rate of resistance B.) Entecavir, frequent dosing C.) Pegylated interferon, poorly tolerated D.) Tenofovir disoproxil fumarate, nephrotoxicity

A.) Lamivudine, high rate of resistance

JT is a 37-year-old male who tested positive for HBV and upon discussing treatment options he states that he does not want to be on treatment forever he just wants a set timeframe and be done with treatment. What would you recommend?

Desire for finite treatment Use Pegylated interferon

QW is a 27-year-old male who tested positive for HBV and upon discussing treatment options he states he does not tolerate many medications and has Co-Morbidities. What would you recommend?

Concerns for tolerability and presence of co-morbidities AVOID pegylated interferon

FG is a 41-year-old male who tested positive for HBV and upon discussing treatment options you identify that the patient has been on lamivudine and has a history of resistance. What would you recommend?

History of lamivudine resistance AVOID entecavir

RN is a 21-year-old female who tested positive for HBV and upon discussing treatment options you identify that the patient is planning on becoming pregnant. What would you recommend?

Family planning ***Pegylated interferon pre-pregnancy Can us Tenofovir disoproxil fumarate

Initial therapy of chronic HBV usually includes:

tenofovir or entecavir as they are well tolerated however pegylated interferon is an option for patients that do not want life long therapy

The hepatologist wants to start this patient on treatment given chronic infection, elevated AST/ALT and fibrosis. What do you recommend? A. Pegylated interferon 180 mcg subcutaneously once weekly. B. Lamivudine 100 mg orally for the first dose; then 50 mg orally daily. C. Tenofovir disoproxil fumarate 300 mg orally once daily. D. Entecavir 1 mg mg orally every day.

C. Tenofovir disoproxil fumarate 300 mg orally once daily.