S45(1) HBV Flashcards
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
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
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
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
Hepatitis B Envelope Antigen
HBeAg
Present in active infection
Current replication
Immunoglobulin Antibody to Hepatitis B Core Antigen
IgM anti-HBc
Indicates acute infection (within 6 months)
Hepatitis B Virus DNA
HBV DNA
Measured as viral load (IU/mL)
Amount of DNA per mL of plasma
Hepatitis B Envelope Antibody
HBeAb
Formed in response to HBsAg
Predictor of long-term suppression
Total hepatitis B Core Antibody
Anti-HBc
Indicates previous or ongoing infection
Hepatitis B Surface Antibody
Anti-HBs
Produced after recovery of HBV infection or successful completion of the vaccination series
Indicates immunity
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
HBsAg - Negative (No active infection)
Anti-HBc - Positive (had it in the past)
Anti-HBs - Positive (recovered)
Immune due to natural infection
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
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
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
HBsAg - Negative
Anti-HBc - Positive
Anti-HBs - Negative
Resolved infection (most common)
False-positive (susceptible)
“Low level” chronic infection
Resolving acute infection
Engerix® indicated for All ages
3
0, 1, 6 months
Recombivax® indicated for ≥ 1 years of age
How many doses?
What interval?
3
0, 1, 6 months
Heplisav-B® indicated for ≥ 18 years of age
How many doses?
What interval?
2
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.
