Viral hepatitis Flashcards
HBsAg
hepatitis B surface antigen
is the patient infectious?
Anti-HBs
antibody to hepatitis surface antigen
is the patient immune?
Total anti-HBc
antibody to hepatitis core antigen
has the patient been exposed to the virus?
IgM anti-HBc
immunoglobulin M class of antibody to hepatitis B core antigen
has the patient been recently exposed to the virus
HBsAg - negative
anti-HBs - negative
anti-HBc - negative
susceptible, never infected - offer hepB vaccine per ACIP recommendations
HBsAg - negative
anti-HBs - positive
anti-HBc - positive
resolved infection
counsel about HBV infection reactivation risk
HBsAg - negative
anti-HBs - positive
anti-HBc - negative
Immune from receipt of prior vaccination
HBsAg - positive
anti-HBs - negative
anti-HBc - positive
IgM anti-HBc - positive
acute infection - link to hepatitis B care
HBsAg - positive
anti-HBs - negative
anti-HBc - positive
IgM anti-HBc - negative
chronic infection - link to hepatitis B care
Phases of chronic HBV
E+ immune tolerant
Normal ALT
Elevated HBV DNA
MONITOR
Phases of chronic HBV
E+ immune active
Elevated ALT
Elevated HBV DNA
E+ =TREAT IF ALT >2X ULN, HBV DNA > 20,000 OTHERWISE MONITOR
Phases of chronic HBV
E+ cirrhosis
AND
E- cirrhosis
Low Albumin, low platelets
Elevated ALT
Elevated HBV DNA
TREAT INDEFINITELY IF HBV DNA > 2,000
OTHERWISE MONITOR
Phases of chronic HBV
E- inactive
Normal ALT
Low/undetectable HBV DNA
MONITOR
Phases of chronic HBV
E- immune reactive
Elevated ALT
Elevated HBV DNA
E- = TREAT IF ALT >2X ULN, HBV DNA >2,000 OTHERWISE MONITOR
FIRST LINE TREATMENT nucleoside analogs
Tenofovir 300mg PO daily
Tenofovir alafenamide 25mg PO daily - usually reserved as second line, could be beneficial in those with renal insufficiency
Entecavir 0.5mg or 1mg Po daily
First line cytokine
Peginterferon alfa 2a - not commonly used in the US
Monitoring for HBV
immune tolerant patients: ALT q3-6M
E- inactive: monitor ALT 6-12m
patients on therapy: HBV DNA levels q3M on NA therapy until undetectable; then q3-6M thereafter
if stopped therapy: q3M for at least 1 year
all HBsAg+ patients at high risk non-cirrhotics should receive HCC surveillance q6m even if on treatment
HCV treatment for patient without cirrhosis and 1a genotype
Mavyret - Pibrentasvir/ Glecaprevir (NS5A + NS3/4A)
- 3 pills a day!
Epclusa - Velpatasvir/sofosbuvir (NS5A + NS5B)
- must do genetic testing for Y93H, if present add ribivirin
Harvoni - Ledipasvir/ sofosbuvir (NS5A + NS5B)
Alternative:
Zepatier - Elbasvir/ grasoprevir (NS5A + NS3/4A)
- must do genetic testing for genotype if present add ribavirin- - must get ALT testing at 8 weeks and if >5xULN ALT must D/C
HCV
Direct acting antiviral drugs
NS3/4A protease inhibitors - all end in previr
NS5B polymerase inhibitors - all end in Buvir
NS5A replication complex inhibiotrs - all end in asvir
normal ALT levels in men and women
Men - 35
women -25
Special treatment monitoring for grazoprevir - HCV
Patient should have ALT checked at 8 weeks, discontinue if >5XULN
Specific pretreatment testing for Elbasvir
Before starting elbasvir must perform an NS5a genotype screening for presence of resistance associated substitutions at baseline
Specific pretreatment testing for Velpatasvir
Prior to use in compensated cirrhotic patients with genotype 3, an NS5A genotype must be performed to screen for presence of the y93H substitution - if present must add ribacirin or voxilaprevir
Common side effects among Hep C and Hep B treatment
Fatigue, headache, nausea
