S45(1) HBV Flashcards

1
Q

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

A

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

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2
Q

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

A
  • Perinatal transmission
  • Injection drug users
  • Multi-transfused patients
  • Health-care providers
  • Sexual partners of HBV
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3
Q

True or False

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

A

True

It is a DNA virus – partially double stranded

Viral replications by reverse transcriptase

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4
Q

Hepatitis B Surface Antigen

HBsAg

A

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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5
Q

Hepatitis B Envelope Antigen

HBeAg

A

Present in active infection

Current replication

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6
Q

Immunoglobulin Antibody to Hepatitis B Core Antigen

IgM anti-HBc

A

Indicates acute infection (within 6 months)

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7
Q

Hepatitis B Virus DNA

HBV DNA

A

Measured as viral load (IU/mL)

Amount of DNA per mL of plasma

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8
Q

Hepatitis B Envelope Antibody

HBeAb

A

Formed in response to HBsAg

Predictor of long-term suppression

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9
Q

Total hepatitis B Core Antibody

Anti-HBc

A

Indicates previous or ongoing infection

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10
Q

Hepatitis B Surface Antibody

Anti-HBs

A

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

Indicates immunity

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11
Q

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

A

Patient is susceptible, recommend HEP B Vaccine

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12
Q

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

A

Immune due to natural infection

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13
Q

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

A

Immune due to HBV vaccination

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14
Q

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

A

Acutely infected

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15
Q

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

A

Chronically infected

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

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16
Q

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

A

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

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17
Q

Engerix® indicated for All ages

A

3

0, 1, 6 months

18
Q

Recombivax® indicated for ≥ 1 years of age

How many doses?

What interval?

A

3

0, 1, 6 months

19
Q

Heplisav-B® indicated for ≥ 18 years of age

How many doses?

What interval?

A

2

0, 1 months

20
Q

Inititating HBV Treatment:

A

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

21
Q

Anyone with active HBV defined as:

A

HBV DNA > 2,000 IU/mL

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

22
Q

Anyone not fulfilling criteria consider with detectable HBV DNA:

A

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

23
Q

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

A

Sexual and household contacts should be vaccinated against HBV

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

24
Q

HBV First Line Treatment options:

A

Pegylated Interferon

Entecavir (Baraclude®)

Tenofovir Disoproxil Fumarate (Viread®)

Tenofovir Alafenamide ( Vemlidy®)

25
Q

Pegylated Interferon

A

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
26
Q

Entecavir (Baraclude®)

A

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
27
Q

Tenofovir Disoproxil Fumarate (Viread®)

Adverse Effects: nephropathy, osteomalacia, lactic acidosis, Fanconi syndrome

A

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
28
Q

Tenofovir Alafenamide ( Vemlidy®)

Adult Dose: 25 mg tablet daily WITH food**

A

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
29
Q

Special Populations: Cirrhosis

All cirrhotic patients should be treated

A

Decompensated patients should be evaluated for a liver transplant

Entecavir and tenofovir disoproxil fumarate (TDF) are preferred for decompensated patients

Treatment is continued indefinitely

30
Q

Special Populations: HDV Co-infection

A

Pegylated interferon is the drug of choice

May add NAs if HBV is not controlled

31
Q

Special Populations: HIV Co-infection

A

Therapy should include tenofovir alafenamide or tenofovir disoproxil fumarate

Regimen must include 2 agents with activity against HBV and HIV (tenofovir + emtricitabine or lamivudine)

32
Q

Special Populations: Pediatrics

Most do not meet the criteria for treatment

A
  • 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
33
Q

Special Populations: Pregnancy

Major cause of transmission

A
  • 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
34
Q

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

A.) Lamivudine, high rate of resistance

35
Q

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?

A

Desire for finite treatment

Use Pegylated interferon

36
Q

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?

A

Concerns for tolerability and presence of co-morbidities

AVOID pegylated interferon

37
Q

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?

A

History of lamivudine resistance

AVOID entecavir

38
Q

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?

A

Family planning

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

39
Q

Initial therapy of chronic HBV usually includes:

A

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

40
Q

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.

A

C. Tenofovir disoproxil fumarate 300 mg orally once daily.