S45(1) HBV

Question 1

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

Answer 1

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

Question 2

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

Answer 2

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

Question 3

True or False

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

Answer 3

True

It is a DNA virus – partially double stranded

Viral replications by reverse transcriptase

Question 4

Hepatitis B Surface Antigen

HBsAg

Answer 4

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

if present for > 6 months it denotes chronic infection

Question 5

Hepatitis B Envelope Antigen

HBeAg

Answer 5

Present in active infection

Current replication

Question 6

Immunoglobulin Antibody to Hepatitis B Core Antigen

IgM anti-HBc

Answer 6

Indicates acute infection (within 6 months)

Question 7

Hepatitis B Virus DNA

HBV DNA

Answer 7

Measured as viral load (IU/mL)

Amount of DNA per mL of plasma

Question 8

Hepatitis B Envelope Antibody

HBeAb

Answer 8

Formed in response to HBsAg

Predictor of long-term suppression

Question 9

Total hepatitis B Core Antibody

Anti-HBc

Answer 9

Indicates previous or ongoing infection

Question 10

Hepatitis B Surface Antibody

Anti-HBs

Answer 10

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

Indicates immunity

Question 11

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

Answer 11

Patient is susceptible, recommend HEP B Vaccine

Question 12

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

Answer 12

Immune due to natural infection

Question 13

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

Answer 13

Immune due to HBV vaccination

Question 14

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

Answer 14

Acutely infected

Question 15

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

Answer 15

Chronically infected

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

Question 16

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

Answer 16

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

Question 17

Engerix® indicated for All ages

Answer 17

3

0, 1, 6 months

Question 18

Recombivax® indicated for ≥ 1 years of age

How many doses?

What interval?

Answer 18

3

0, 1, 6 months

Question 19

Heplisav-B® indicated for ≥ 18 years of age

How many doses?

What interval?

Answer 19

2

0, 1 months

Question 20

Inititating HBV Treatment:

Answer 20

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

Question 21

Anyone with active HBV defined as:

Answer 21

HBV DNA > 2,000 IU/mL

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

Question 22

Anyone not fulfilling criteria consider with detectable HBV DNA:

Answer 22

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

Question 23

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

Answer 23

Sexual and household contacts should be vaccinated against HBV

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

Question 24

HBV First Line Treatment options:

Answer 24

Pegylated Interferon

Entecavir (Baraclude®)

Tenofovir Disoproxil Fumarate (Viread®)

Tenofovir Alafenamide ( Vemlidy®)

Question 25

Pegylated Interferon

Answer 25

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

Question 26

Entecavir (Baraclude®)

Answer 26

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

Question 27

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

Answer 27

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

Question 28

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

Answer 28

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

Question 29

Special Populations: Cirrhosis All cirrhotic patients should be treated

Answer 29

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

Question 30

Special Populations: HDV Co-infection

Answer 30

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

Question 31

Special Populations: HIV Co-infection

Answer 31

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

Question 32

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

Answer 32

- 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

Question 33

Special Populations: Pregnancy Major cause of transmission

Answer 33

- 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****

Question 34

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

Answer 34

A.) Lamivudine, high rate of resistance

Question 35

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?

Answer 35

Desire for finite treatment Use Pegylated interferon

Question 36

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?

Answer 36

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

Question 37

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?

Answer 37

History of lamivudine resistance AVOID entecavir

Question 38

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?

Answer 38

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

Question 39

Initial therapy of chronic HBV usually includes:

Answer 39

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

Question 40

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.

Answer 40

C. Tenofovir disoproxil fumarate 300 mg orally once daily.