Hepatitis

Question 1

Hep B Serologic Markers :

What is it and what does it tell you about the DNA virus ?

1. HbsAg
2. Anti -HBs
3. HBeAg
   4.Anti - HBe
4. HBcAg
5. Anti-HBc

Answer 1

1. Hep B surface antigen –> present in acute and chronic infection ; carriers
2. Antibody to HBsAg –> Past infection and immunity to HBV
3. Hepatitis Be antigen –> Indicates active viral replication
4. Anti body to HBeAg –>Seroconversion
5. Hep B core antigen –> present in nucleus
6. ANtibody to HBcAg –> Indicates prior exposure

Question 2

For the following results, interpret them and state management and if you’d vaccinate

1. HBsAg +, Anti-HBc +, Anti HBs neg
2. HBsAg -, Anti-HBc +, Anti HBs pos
3. HBsAg -, Anti-HBc +, Anti HBs neg
4. HBsAg -, Anti-HBc -, Anti HBs pos
5. HBsAg -, Anti-HBc -, Anti HBs neg

Answer 2

1. Chronic Hep B . additional testing and management needed . no vaccination
2. Past HBV infection that’s resolved. NO further management unless immunocomp or undergoing chemo or immunosupp therapy . No vax
3. Past HBV infection , resolved or false positive. HBV DNA testing if immunocomp pt. YES vaccinate if not from area of intermediate or high endemicity
4. Immune! No further testing. Don’t vax
5. Uninfected and not immune. No further testing. Yes vaccinate.

Question 3

Hep B Clinical Features

1. What are the extrahepatic manifestations? (3)
2. Acute __ failure or fulminant ___
   - onset of ___ within 8 weeks of sx’s
   -poor prognosis
   -Supportive care and ___

Answer 3

1. Arthralgias, rash , glomerulonephritis
2. liver, hepatic failure
   - hepatic encephalopathy
   - liver transplant

Question 4

Approved Therapies for HBV (3) for exam . Dosing + Main AE”s

1. Entecavir (Baraclude)
2. Tenofovir Disoproxil (Viread)
3. Tenofovir Alafenamide (Vemlidy)

Answer 4

1. 0.5 or 1 mg PO daily . Lactic acidosis
2. 300 mg PO daily . Nephropathy, fanconic syndrome, osteomalacia, lactic acidosis
3. 25 mg PO daily. Lactic acidosis.

Question 5

Entecavir (Baraclude)
-More potent than __ and ___ in vitro
-Slower rate of ___
-Dosing?
-In lamivudine resistance, the drug should be ___ when switching to entecavir
-When should you use a higher dose of entecavir?
-What are the common AE’s ? (4)
-What are the serious but rare AE’s?

Answer 5

1. lamivudine, adefovir
2. resistance
3. 0.5 mg daily
4. discontinued
5. lamivudine resistant/refractory patients –> 1mg po daily
6. HA, fatigue, nausea, dizziness
7. Lactic acidosis

Question 6

Tenofovir Disoproxil (Viread)

1. It’s the ___ of ADEFOVIR, but its more __ and less ___
2. Has low ___
3. Dosing?
4. Common ae’s? (4)
5. Rare AE’s? (4)

Answer 6

1. nucleotide analogue . potent, nephrotoxic
2. resistance rates
3. 300 mg PO once daily
4. HA, nasopharyngitis, nausea, fatigue
5. rena insufficiency, fanconi syndrome, osteomalacia, decr bone density

Question 7

Tenofovir Alafenamide (Vemlidy)

1. It’s the prodrug of?
2. This drug is more stable in ___ than viread . Vemlidy is able to establish ___ in target cells at ____ than viread
3. Vemlidy has a lesser effect on ?

Answer 7

1. tenofovir DF (viread)
2. plasma/tissues. higher levels of TFV-disphos , lower doses
3. proximal renal tubule

Question 8

Tenofovir Alafenamide (Vemlidy)

1. Dosing?
2. AE’s common (4)
3. Serious but rare AE’s ? (1)
4. This drug is also a component of which drug used for HIV?

Answer 8

1. 25 mg PO once daily WITH FOOD
2. HA, nasophryngitis, nausea, fatigue
3. Lactic acidosis but has lower incidence of renal and bone effects!
4. Biktarvy

Question 9

1. What are some pros about Entecavir?

2.Pros of Viread? Cons?

3. Pros of Vemlidy? Cons?

Answer 9

1. It’s oral, well tolerated, high potency and low resistance
2. Oral, well tolerated, high pot, low resist. Renal and bone considerations
3. PO, well tolerated, high pot, low resistance. NOT in pt’s with Clcr < 15 mL/min or in dialysis

Question 10

HBV reactivation in pt’s receiving immunosuppression

1. Which pt’s would u consider this in?
2. Serology?
3. monitor? (3)
4. Prophylatic antiviral therapy with?
5. Duration ?

Answer 10

1. pt’s receiving exog immunosupp such as cancer, transplant, autoimmune
2. HBsAg + or -, AND antiHBc +
3. HBV DNA, HBsAg seroconversion (if previously neg), ALT/AST
4. entecavir or tenofovir
5. 6-12 months after discontinuation of anticancer therapy or immunosupp

Question 11

Hep B prevention of transmission

1. What should people who are HBsAg positive do?

Answer 11

1. Have household or sex partners vaxxed, use barrier protection during sex if partner is not vaxxed, not share toothrbush or razors, not share injection equip, not share glucose testing stuff, cover open cuts and scratches, clean blood spills with bleach! Not donate blood, organs or sperm !

Question 12

HEP C : CLinical features

1. Majority of pt’s have ?
2. Chronic infection develops in ?
3. Extraheptic manifestations? (4)
4. Cirrhosis develops in ?
5. Hepatocellular carcinoma (HCC risk)?

Answer 12

1. no/mild sx’s
2. 80%
3. glomerulonephritis, mixed cryoglobulinemia , corneal ulcers, RA
4. 20%
5. 1-4% per year

Question 13

HEP C GOALS of therapy

1. How to cure?
2. What is SVR ? When do we want to see a negative HCV RNA?
3. Improve ___
4. Prevent progression to ___ , ___
5. Prevent devel of ___ and ___

Answer 13

1. eradicate the virus
2. sustained viral response. 12 weeks after the end of therapy
3. clinical sx’s
4. cirrhosis, HCC
5. end stage liver disease , complications

Question 14

Guidance on HC tx?

• TX reccc for ? except those with? who cannot be remediated by?

Answer 14

1. all patients w/chornic HCV infection , except those w/short life expectancies who cant be remediated by treating HCV by transplantation or by other directed therapy

Question 15

Focus on these oral regimens : State component classes and approved for which genotypes

1. Sofosbuvir/Velpatasvir (EPCLUSA)
2. Glecaprevir / Pibrentasvir (MAVYRET)

Answer 15

1. Nucleotide polymerase inhib + NS5A inhib

-Genotypes 1-6

2. Protease inhib + NS5A inhib

Genotypes 1-6

Question 16

Sofosbuvir/Velpatasvir (EPCLUZA)

1. Class?
2. Year approved?
3. fda indicated for which genotypes?
4. AE’s ? (2)
5. Drug interactions?

Answer 16

1. NS5B polymerase inhib /NS5A replication complex inhib
2. 2016 June
3. Genotypes 1-6
4. Fatigue and HA
5. Avoid strong inducers of PGP; avoid PPPI’s and other drugs that increase gastric pH

Question 17

Glecaprevir/Pibrentasvir (Mavyret)

1. Class?
2. year approved?
3. Genotypes?
4. AE’s
5. Drug interactions
6. CI?

Answer 17

1. Protease inhibitor / NS5A inhib
2. August of 2017
3. 1-6
4. Fatigue and headache
5. rifampin, carbamazepine, SJW, HMGCOA reductase inibitors (statins)
6. Child’s class C, rifampin, atazanavir

Question 18

HCV Tx algorithm for tx naive adults w/o cirrhosis

1. Who is eligible?
2. Who is not eligible?
3. For pre-tx , what labs should u run?

Answer 18

1. Adults/w chronic hep C (any genotype) who do NOT have cirrhosis and have NOT previously received hep c tx
2. Pt’s who have any of the following
   - prior hep c tx
   - cirrhosis
   -HIV or HBsAg positive
   -current preg
   -known or suspected hepatocellular carcinoma
   -prior liver transplant
3. Quantitative HCV RNA (HCV viral load)
   -HIV antigen/antibody test
   -HepB surface antigen

Question 19

HCV Recommended tx regimen for tx naive

Name the two regimens and dosing

Answer 19

1. Glecaprevir 300 mg/ pibrentasvir 120 mg . Taken with food for a duration of 8 weeks
2. Sofosbuvir 400 mg/velpatasvir 100 mg . for a duration of 12 weeks

Question 20

On tx monitoring

1. What if a pt is taking diabetes meds?
2. what if a pt is taking warfarin?

Answer 20

1. they may experience potential symptomatic hypoglycemia . Monitor for hypoglycemia
2. changes in anticoag status! Monitor pt INR for subtherapeutic anticoagulation

Question 21

Prior to starting tx, which score do u have to calculate and what value would u not initiate tx in?

Answer 21

U need to calculate FIB-4 score. if the FIB-4 score is >3.25, they have cirrhosis and u cannot start therapy

Question 22

DDI: Mavyret

1. Digoxin , effect ? Monitor?
2. Carbamazepine, Rifampin
3. SJW?
4. Statins

What about rosuvastatin , fluvastatin, and pitavastatin?

5. Cyclosporine?

Answer 22

1. INCR digoxin concs, monitor digoxin concs
2. Decr conc of glecaprevir, pibrentasvir . Concomitant use not recc
3. Decr mavyret concs, concomitant use not recc
4. incr conc of ator, lova, simv, prav. Concomitant use with ator, lova, sim not recommended !

• Decr prava dose by 50%
  -Rosuv dose should be less than or equal to 10 mg
  -use lowest dose possible of fluvatstain or pitava

5. It increases the concentration of mavyret. NOT reccc with cyclosporine doses over 100 mg per day

Question 23

DDI : Epclusa

1. Digoxin?
2. Amiodarone?
3. Carbam, rifampin, phenytoin, phenobarb?
4. SJW?
5. ACid reducers? what changes to dosing do u have to do?
6. Statins?
7. Topotecans
8. Efavirenz

Answer 23

1. Digoxin concentrations incr, need to monitor digoxin concs
2. Amiodarone is CI bc it causes serious bradycardia
3. Decr Epclusa concentrations. concomittant use is NOT recc
4. DECR epclusa concs. Concomitant use NOT recc
5. DECREASES VELPATASVIR.

• Admin H2RAs 12 hrs apart from EPCLUSA (NTE famotidine 40 mg twice daily or equivalent)
  -omeprazole and other PPI’s are not recc ; if necessary take EPCLUSA 4 hrs before omeprazole 20 mg

6. Incr atorvastatin and rosuvastatin concentrations. Dose of rosuv should be equal to or less than 10. MONITOR FOR SAMS
7. Incr topotecan conc. dont use together
8. decr velpatasvir –> dont use together

Question 24

HBV reactivation in pt’s receiving HCV DAA’s

1. Possibly due to?
2. October 2016 FDA issued boxed warning for all ?
3. Need to ?

Answer 24

1. loss of host immune response to HBV
2. HCV DAA therapies
3. check HepB serology PRIOR to starting HCV DAA therapy
   - HBsAg, anti HBc and anti-HBs

Question 25

HepC Prevention 1. There's no __ no effective __ NON PHARM THERAPY 1. __ and __ vax 2. Discontinue ? 3. Balanced __ and __ 4. Avoid __, and __ 5. Practice ___ 6. NO sharing of ___ 7. Cover ___ 8. Use ___

Answer 25

1. vaccine, immunoglobulin 1. hep a and hep b 2. alcohol and tobacco 3. balanced diet , exercise 4. illict drugs, herbal drugs 5. safe sex practices like condoms 6. razors/toothbrushes 7. open wounds 8. needle exhcchange programs