Viral Hepatitis (Final Exam) Flashcards
this is inflammation of the liver caused by inflammation, medication, or immunologic abnormalities
hepatitis
this type of hepatitis has sudden onset (< 6 months). jaundice is present or there is increased serum aminotransferase levels
acute hepatitis
this type of hepatitis (> 6 months) includes ongoing hepatocellular necrosis. complications may include cirrhosis and complications of ESLD
chronic hepatitis
what are the most common viral causes of chronic hepatitis
HBV anf HCV
this occurs when an individual experiences 1 or more complications of liver disease such as bleeding varies, ascites, encephalopathy, jaundice.
decompensated cirrhosis
is HAV a DNA or RNA virus
RNA
how is HAV transmitted
fecal-oral (water/food contaminated, direct contact with an infected person)
is the onset of HAV sudden or insidious
sudden
can HAV become chronic
no
what are the preventative interventions for HAV
pre/post exposure immunization (Hep-A vaccine if no antibodies)
Immune globulin (IG) - esp for those at high risk
- hand washing and contact precautions
- boil food that may be contaminated
what are the tx options for HAV
none
- fluid and electrolyte support as needed
- transplantation in rare cases of liver failure
is HBV a DNA or RNA virus
DNA
how is HBV transmitted
- percutaneous
- sexual
- perinatal
is the onset of HBV sudden or insidious
insidious
can HBV become chronic
yes (5-10% in adults, 90% in infants/children)
what are the preventative interventions for HBV
- pre/pst exposure immunization
- Immune Globulin (IG)
what are the treatment options for HBV
IFN
nucleoside analogs
is HCV a DNA or RNA virus
RNA
how is HCV transmitted
- percutaneous
- sexual
is the onset of HCV sudden or insidious
insidious
can HCV become chronic
yes (70-80%)
what are the preventative interventions for HCV
none - risk factor modification
(avoid sharing personal care items which could be contaminated with blood e.g. toothbrush, razor, etc., avoid injection/inhalation drugs, use of condoms)
what are the treatment options for HCV
- IFN
- Ribavirin
- DAA’s
is HDV a DNA or RNA virus
RNA
how is HDV transmitted
- percutaneous
- sexual
- perinatal
(same as HBV)
is the onset of HDV acute or insidious
insidious
can HDV become chronic
yes
what are the preventative interventions for HDV
HBV immunization prevents HDV infection
what is the treatment options for HDV
IFN
(same as HBV)
what antigen and antibodies are present in hepatitis serology for HAV
antigen - Hep A virus (HAV)
corresponding antibody - Hep A Antibody (anti-HAV)
what antigen and antibodies are present in hepatitis serology for HBV
antigen - Hep B surface antigen (HBsAg), Hep B core antigen (HBcAg) & Hep B envelope antigen (HBeAg)
corresponding antibody: Hep B surface antibody (anti-HBs), Heb B core antibody (anti-HBc) & Hep B envelope antibody (anti-HBe)
what antigen and antibodies are present in hepatitis serology for HCV
antigen - Hep C virus (HCV)
corresponding antibody - Hep C antibody (anti-HCV)
this serology antibody for HBV shows that the person probably had the infection before or has immunity from the vaccine
anti-HBs (surface antibody)
this serology antibody for HBV shows the person had the infection previously and probably cleared it
anti-HBc (core antibody)
this serology antibody for HBV is a marker for infectivity e.g. chronic Hep B
anti-HBe (envelope)
what are the goals of therapy for ALL viral hepatitis
- prevent transmission
- prevent disease progression (e.g. fibrosis, cirrhosis, ESLD)
what ae the goals of therapy for HBV
- prevent transmission
- prevent disease progression (e.g. fibrosis, cirrhosis, ESLD)
+ - seroconversion or loss of HBsAg
- seroconversion or loss of HBeAg
- achieve undetectable HBV DNA
what are the goals of therapy for HCV
- prevent transmission
- prevent disease progression (e.g. fibrosis, cirrhosis, ESLD)
+ - achieve undetectable HCV RNA
- obtain sustained virology response (AKA cure)
what is used for acute hepatitis management
- no specific tx
- supportive care: healthy diet, rest, maintain fluid balance, avoid hepatotoxic drugs (natural health products), abstain from alcohol
true or false: outbreaks of HAV can occur in daycares, household contacts, food service workers
true
what is the incubation period of HAV
~ 28 days thus take a goof history and ask about travel is someone showing up with symptoms because could be about a month before they start showing symptoms of HAV
what are the first symptoms that are seen in someone with HAV that only last 1-2 weeks
nonspecific prodromal symptoms: fatigue, weakness, anorexia, N/V, abdominal pain, elevated ALT
what kind of symptoms may develop in someone with HAV after the non-specific prodromal symptoms
jaundice & mild hepatomegaly
true or false: adults are more likely to be asymptomatic than children
false: other way around - children are more likely to be asymptomatic
how quickly does HAV usually take to resolve on its own
~ 2 months
who is the HAV vaccine recommended for
- travel to countries where HAV is endemic
- children living in communities with high rates of HAV outbreaks
- high risk sex groups
- people who use recreational/ilicit drugs as hygiene may be an issue
-HCPs - people with Hep B or C infection
who is the HBV vaccine recommended for
- universal neonatal vaccination program
- healthcare workers
- travellers to endemic areas
- all adults and children who have immigrated to canada
- chronic liver disease
- haemophiliacs and other receiving repeated infusions of blood or blood products
- chronic renal disease on dialysis
- congenital immunodeficiency, transplant, HIV
what are some options to prevent perinatal transmission of HBV
- administer combination of HB immunoglobulin and hep B vaccine to infant within 12 hours of birth and revaccinate at 1 and 6 months
- mother may take nucleoside therapy during 3rd trimester to reduce viremia (Tenofovir disoproxil fumarate (TDF))
if a person is exposed to HBV and their current status is HBsAg positive, and they are unvaccinated, what should be done?
HB Immunoglobulin x 1 dose and intitiate HBV vaccine series
if a person is exposed to HBV and their current status is HBsAg positive and they have been previously vaccinated (known responder), what should be done
non treatment
if a person is exposed to HBV and their current status is HBsAg positive and they have been previously vaccinated (known-non responder), what should be done
HB Immunoglobulin x 1 dose & initiate vaccine series (may not have responded to first vaccine)
if a person is exposed to HBV and their current status is HBsAg positive and they have been previously vaccinated but the antibody response is unknown, what should be done
test exposed person for anti-HBs. if inadequate, treat as a known non responder
if a person is exposed to HBV and their current HBsAg status is negative and they are unvaccinated, what should be done
initiate HBV vaccine series
if a person is exposed to HBV and their current HBsAg status is negative and they have been previously vaccinated (known responder, known non-responder or antibody response unknown) what should be done
no treatment necessary
if a persons HBsAg status is unknown or unavailable for testing and they are unvaccinated what should be done
initiate HBV vaccine series
if a persons HBsAg status is unknown or unavailable for testing and they have been previously vaccinated (known responder), what should be done
no treatment
if a persons HBsAg status is unknown or unavailable for testing and they have been previously vaccinated (known non-responder) what should be done
if known high-risk source, treat as if HBsAg positive (HBIG x 1 dose and initiate vaccine series)
if a persons HBsAg status is unknown or unavailable for testing and they have been previously vaccinated but their antibody response is unknown, what should be done
test exposed person for anti-HBs. if inadequate, vaccine booster and recheck titre in 1-2 mo
true or false: having HBV can increase your risk for developing liver cancer
true
what serology level persists if someone has chronic HBV
HBsAg
interpret the following serology:
HBsAg - negative
anti-HBc - negative
anti-HBs - negative
susceptible (no infection b/c no surface antigen or no vaccine because no surface antibody)
interpret the following serology:
HBsAg - negative
anti-HBc - positive
anti-HBs - positive
immune due to natural infection
* if both core and surface antibodies are present than had the infection before
interpret the following seorlogy:
HBsAg - negative
anti-HBc - negative
anti-HBs - postive
immune due to hep B vaccination
* if only surface antibody present - had vaccine
interpret the following serology:
HBsAg - positive
anti-HBc - positive
IgM anti-HBc - positive
anti-HBs - negative
acutely infected
* HBsAg being positive shows an infection and IgM shows acute (if it was IgG it would show chronic infection, no surface antibodies therefore did not clear the infection
interpret the following serology:
HBsAg - positive
anti-HBc - positive
IgM anti-HBc - negative
anti-HBs - negative
chronically infected
* no IgM therefore not acute, no surface antibodies therefore have not cleared the infection
what are the HBV-specific outcomes for a chronic HBV infection
typically by the end or during therapy:
- loss of HBeA and conversion to anti-HBe
- virological clearance (undetectable HBV DNA)
- normalization of ALT
- normalize patient specific symptoms
what are some non-pharmacological advice for chronic hepatitis management (HBV and HCV)
- advise weight loss (reduce progression to fibrosis, cirrhosis)
- advise blood sugar control in diabetes
- encourage smoking cessation
- avoid hepatotoxins (alcohol, acetaminophen use less than 1-2g/day, herbal products)
- caution with NSAID use
- to reduce risk of transmission, don’t share personal items (razors, toothbrush, drug use equipment), cover scrapes and cuts, clean blood with bleach and water
what is the recommended therapy for HBeAg positive chronic hepatitis where the patient has increased ALT and high viral load of HBV DNA present
consider therapy with peginterferon or nucleoside analoogs (entecavir, TDF, TAF) if ALT is >1 ULN and viral load is > 2000. the goal is to suppress HBV DNA replication
what is the recommended therapy for HBeAg-negative chronic hepatitis where the patients ALT is fluctuating and has a high viral load of HBV DNA present
consider long term therapy with nucleoside analogs (entecavir, TDF, TAF) if ALT is > 1 ULN and viral load is > 2000
what is the recommended therapy for someone with decompensated cirrhosis
nucleoside (entacavir, TDF, TAF) lifelong
this is a first line treatment option for HBV. it should be avoided in those with high DNA levels and low ALT due to low efficacy. usually used for 24-48 weeks
interferon (IFN)
this is a first line treatment option of HBV. e.g. include entecavir, TDF, TAF. consider d/c 12 mo after seroconversion
oral nucleoside/tide inhibitors
this first line treatment for HBV can be used when HBV DNA levels are lower; advantage is shorter duration of therapy but adverse effects are more severe (not well tolerated)
IFN
what is the preferred therapy for treatment-naive patients in HBV
tenofovir or entecavir
what is the preferred treatment for someone who has HBV and HIV
tnofovir and lamuvidine
when should peginterferon alfa-2a not be used
- uncontrolled MDD (especially with past suicide attempts)
- autoimmune hepatitis or other autoimmune disease
- severe CVD
- decompensated cirrhosis or liver cancer -> risk of infections and further decompensation
- uncontrolled seizure disorder
when are lamuvidine, adefovir and telbivudine indicaited for HBV
not recommended for first-line anti-HBV therapy because of high resistance rates
which of TDF or TAF should caution be taken with renal insufficiency
TDF
what are some s/e of pegylated IFN
early - flu-like symptoms (fever, chills, myalgia fatigue) -> administer at bedtime to sleep through symptoms, pre treat with acetaminophen (only one dose)
late - BM suppression, depression, anxiety, thyroid disorders -> monitor CBC after weeks 1 and 2 then months; TSH q 3 months; treat anxiety and depression
what are some s/e of Tenofovir
nephrotoxicity (less with TAF formulation) -> monitor Screening and phosphate q 3-6 months
what should be monitored for HBV treatment
HBV DNA until undetectable and ALT (both q 3 months)
serology (measure q 6 months while on treatment and then annually after treatment d/c)
- HBsAg and anti-HBs
- HBeAg and anti-HBe
what are some risk factors for HCV
- recreational/illicit drug use
- blood transfusion, organ transplant (pre-1992)
- hemodialysis
- sexual activity (MSM, multiple partners, co-infection with other STI)
list some instances where an individual should be screened for HCV
- history of injection drug use (even once)
- blood transfusion, blood product or organ recipient prior to 1992 in Canada
- history/current incarceration
- born or resided in region where HCV prevalence is > 3%
- born to mother who is HCV infected
- history of sexual contact or sharing of personal care items with someone who is HCV infected
- HIV infection, especially in MSM
- chronic hemodialysis treatment
- elevated ALT
what does a HCV screening test measure in the body
anti-HCV; if reactive, confirm with HCV RNA
true or false: for patients with prior HCV infection, they may get reinfected with different GT virus, therefore if retesting is done, it must be done with HCV RNA since anti-HCV will remain positive lifelong
true
interpret the following HCV screening test:
anti-HCV: nonreactive
HCV RNA: not detected
no current HCV infection or no prior HCV exposure
interpret the following HCV screening test:
anti-HCV: reactive
HCV RNA: not detected (may need to repeat HCV RNA to confirm negative result)
- possible false positive anti-HCV
- prior HCV exposure
- no current HCV infection
- acute HCV with low level viremia
- possible spontaneous viral clearance
- possible successful tx
interpret the following HCV screening test:
anti-HCV: reactive
HCV RNA: detected
acute or chronic HCV infection
interpret the following HCV screening test
anti-HCV: non reative
HCV RNA: detected
- early acute HCV infection
- chronic HCV infection in an immunocompromised patent
true or false: someone can live with HCV for 20-30 years without symptoms even though liver damage is still occurring
true
what are some symptoms of HCV
fature, Right upper quadrant pain, N/V, poor appetite
advanced sxs: palmar erythema, splenomegaly, testicular atrophy, spider nevi
extrahepatic: renal failure, insulin resistance
what are the tx options for HCV
Direct Acting Antivirals (DAAs) (usually combine two drugs that are from different classes)
- well tolerated
- treat for 8-12 weeks
- effective against all genotypes thus don’t need to do genotyping before tx
+/- Ribavirin
- normally added for treatment-experienced pts and those with decompensated cirrhosis
what class of DAAs are these drugs?
- Paritaprevir/ritonavir
- Grazoprevir
- Asunaprevir
- Voxilaprevir
- Glecaprevir
NS3/4A Protease Inhibitors (-PREVIR)
what class of DAAs are these drugs?
- Ledipasvir
-Ombitasvir
- Elbasavir
- Velpatasvir
- Dalclasavir
- Pibrentasvir
NS5A inhibitors (-asvir)
what class of DAAs are these drugs?
-sofosbuvir
-dasabuvir
NS5B RNA polymerase inhibitors (-buvir)
chronic HCV treatment is recommended for ALL patients who will accept treatment and have no contraindications. what are some considerations when choosing treatment
- viral genotype (although some tx that cover all genotypes)
- baseline NS5A resistance associated variants
- treatment naive vs experienced
- liver damage (degree of fibrosis, cirrhosis, compensated, decompensated)
- length of treatment
- cost and drug coverage
- comorbidities, drug interactions
- adherence
- pregnancy
what is the main first line treatment regimen for someone which chronic HCV
always at least two DAAs (may include ribavirin if treatment experienced or decompensated cirrhosis)
know the first line simplified DAA regimens
- EPCLUSA (sofosbuvir (rNAi) + Velpatasavi (NS5Ai) ~12 weeks
- MAVIRET (Glecaprevir (protease i) + Pibrentasvir (NS5Ai) ~ 8 weeks
what are some drug interactions with Epclusa
-PPI, H2RA & antacids
- amiodarone
what are some drug interactions with Maviret
- statins
- ethinyl estradiol
- PPI
true or false: all DAA’s can cause a risk of hepatitis B virus reactivation
true - test all patients for HBV infection before HCV treatment initiation
true or false: protease inhibitor DAAs can be used in those with signs of hepatic decompensation
false - should NOT be used
