Treatment of Hepatitis

Question 1

What is the definition of hepatitis?

Answer 1

inflammation of the liver.

*can be self-limiting or progress to cirrhosis (fibrosis)

Question 2

How do you treat Hepatitis A?

Answer 2

• no specific treatment (self-limiting disease )
• hospitalization not necessary unless acute liver failure
• therapy is aimed at maintaining nutritional balance (replacement of fluids and electrolytes lost from vomiting and diarrhea).

Question 3

How do we prevent Hepatitis A?

Answer 3

• improved sanitation= safe drinking water, proper disposal of sewage, hand washing.
• Hep A vaccine= injectable inactivated virus (2 dose). 100% gain immunity within 1 month of vaccine that lasts 5-8 years.

Question 4

Who should get the Hep A vaccine?

Answer 4

high incidence areas, men who have sex with men, IVDA, occupational risk, chronic liver disease, household members of adopted children from other countries.

Question 5

What should you do post-exposure with Hep A?

Answer 5

• immunoglobulin injection and hep A vaccine within 2 weeks after exposure.

Question 6

Does the Hep B vaccine have core antigen?

Answer 6

NO just surface antigen, meaning you will only develop antibody against the HBsAg.

Question 7

What is the treatment for acute Hepatitis B?

Answer 7

• No specific treatment.
• supportive care and maintaining nutritional balance.
• can use antivirals in severe acute HBV leading to liver failure.

Question 8

What is the treatment for chronic Hepatitis B?

Answer 8

• ANTIVIRALS (Tenofovir or entecavir)= nucleotide reverse transcriptase inhibitors, which incorporate into viral DNA, resulting in DNA chain termination.
• Tenofovir can cause renal failure, so use entecavir in a pt with renal problems.
• if cirrhosis then LIVER TRANSPLANT

Question 9

Is interferon used anymore?

Answer 9

NO

Question 10

Can you get hepatocellular carcinoma without cirrhosis from hepatitis B?

Answer 10

YES (one of the few diseases that can do that).

*hemochromatosis is another.

Question 11

** What are the 4 characteristic phases for Hepatitis B? (TEST QUESTION)

Answer 11

1. Immune TOLERANT= HBeAg positive NORMAL ALT, high HBV DNA (>2000 IU/mL).
2. HBeAg positive immune ACTIVE= ELEVATED ALT, high HBV DNA.
3. INACTIVE= HBeAg negative, HBeAB positive, NORMAL ALT, low HBV DNA (less than 2000 IU/mL).
4. HBeAg negative immune ACTIVE= elevated ALT, active inflammation, high HBV DNA.

Question 12

** Who should be treated from the 4 phases? (TEST QUESTION)

Answer 12

only those whom are immune ACTIVE/inflammation (aka have elevated ALT)!!!
*it doesn’t matter what the envelope (HBeAg) status is.

Question 13

Whom should you consider treating in special circumstances?

Answer 13

• HBsAg persistence > 6 months.
• compensated cirrhotics= stable bilirubin, no ascites, or esophageal varices. Treat because you don’t want the fibrosis to worsen.

Question 14

When can you defer treatment in chronic hepatitis B?

Answer 14

if they are immune INACTIVE (no inflammation) or immune tolerant.

Question 15

Is the rate of transmission of HBV from mother to baby during birth high?

Answer 15

YES 84%

Question 16

When should treatment of the pregnant mother be started for HBV?

Answer 16

THIRD trimester if HBeAg positive or HBV DNA greater than 200,000 IU/mL

Question 17

What should we do for all newborns of HBV + mothers?

Answer 17

given both the first dose of vaccine and immunoglobulin for prophylaxis
*significantly reduces chance of transmission to 3%

Question 18

Who should receive the HBV vaccine?

Answer 18

• ALL infants soon after birth (3 dose schedule).

Question 19

Other than infants, who else should be vaccinated for HBV?

Answer 19

• children less than 18, frequent blood transfusions, dialysis patients, organ transplant recipients, prisoners, IVDA, household and sexual contacts of those with HBV, health care workers, multiple sexual partners

Question 20

Is screening now recommended for pts born between 1945 and 1964?

Answer 20

YES bc CDC didn’t start screening blood prior to 1989.

*Test for HCV AB positive, confirmed by HCV RNA PCR

Question 21

How do we now treat Hepatitis C infection?

Answer 21

Harvoni (ledipasvir/sofobuvir)= all oral, once a day treatment for genotype 1. These are direct acting antivirals that effect RNA polymerase, terminating viral replication.

• treat for 8-12 weeks. NO SIDE EFFECTS :)
• sustained viral response >90%

Question 22

What drug came out this year for HCV treatment?

Answer 22

• Epclusa (sofosbuvir/velpatasir)= pan-genotypic for all genotypes with an SVR at 12 weeks of 98%!!!
• we don’t even have to genotype anymore with this.

Question 23

What is the most common cause of liver transplants in the U.S.?

Answer 23

HCV cirrhosis

*can have recurrent infection if not eradicated prior to transplant.

Question 24

Is there a vaccine for HCV?

Answer 24

NO, so prevention is dependent on avoiding high risk behaviors.

Question 25

How do we treat Hepatitis D?

Answer 25

- no approved antiviral therapy for active infection. - treatment is just supportive. - treat the HBV with antivirals.

Question 26

How do we prevent HDV infection?

Answer 26

- being immune to HBV

Question 27

How do we treat HEV?

Answer 27

- no treatment; usually self-limited; care is supportive.

Question 28

What are the 3 main non-viral causes of hepatitis?

Answer 28

1. Non-alcoholic Steatohepatitis (NASH) 2. Acute Alcoholic hepatitis 3. Drug-Induced Liver Disease (DILI)

Question 29

What is Non-alcoholic Steatohepatitis (NASH)?

Answer 29

- caused by fat deposition in the liver with INFLAMMATION; resembles alcoholic livers. - This is distinguished from non-alcoholic fatty liver disease (NAFLD) which does NOT have inflammation. - can progress to cirrhosis.

Question 30

What are the risk factors for NASH?

Answer 30

- obesity, T2DM, high cholesterol, and metabolic syndrome

Question 31

How is NASH diagnosed?

Answer 31

- elevated AST/ALT or CT (showing fat in liver).

Question 32

How do we treat NASH?

Answer 32

- lifestyle modifications and long term vitamin E supplement.

Question 33

What is acute alcoholic hepatitis?

Answer 33

inflammation of the liver from long term alcohol use. | - liver is the major site of ethanol metabolism and the resultant product is acetaldehyde= injury.

Question 34

**** How do we diagnose acute alcoholic hepatitis?

Answer 34

classic AST/ALT ratio elevation > 3:1

Question 35

How do we treat acute alcoholic hepatitis?

Answer 35

- alcohol cessation, nutritional support and if DF >32 medicate (prednisolone or pentoxyfylline) - liver transplant if bad enough (and must be sober for at least 6 months and been to AA or they won't make the list).

Question 36

What causes DILI?

Answer 36

- over the counter drugs, prescription meds, and herbal supplements bc the liver is the primary site for drug metabolism. * most common cause of acute liver failure in the U.S.

Question 37

What is the unique AST/ALT marker for DILI?

Answer 37

AST/ALT > 1000

Question 38

Will you often see moderate liver enzyme elevations with the use of statins?

Answer 38

YES, just monitor and they should go back to normal.

Question 39

How do you treat DILI?

Answer 39

- immediately stop the offending drug | - N-acetylcysteine as an antioxidant for acetaminophen toxicity.

Question 40

What is the most common cause of liver transplant now?

Answer 40

HCV cirrhosis, but NASH will soon be the most common cause (unless lifestyles change).