Therapeutics > Viral Hepatitis > Flashcards

Viral Hepatitis Flashcards

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1
Q

what are the signs and symptoms of acute/chronic hepatitis?

A

nausea/vomiting
anorexia
jaundice
fatigue/malaise

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2
Q

what abnormal lab values will you see in acute/chronic hepatitis?

A 
increased AST/ALT
increased ALk Phos
Increased total bilirubin
Increased INR
decreased albumin
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3
Q

what defines chronic hepatitis?

A

an infection that lasts greater than 6 months

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4
Q

who should be screened for hepatitis B infection?

A
  • people from high-intermediate areas: asia, africa, middle east, European mediterranean, south and central america, eastern europe, caribbean
  • household or sexual contacts of hbv+ persons
  • injection drug users
  • high risk or multiple sexual partners
  • inmates of correctional facilities
  • hepatitis C or HIV infected persons
  • hemodialysis patients
  • pregnant women
  • infants born to HBsAg-Positive mothers
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5
Q

how can hepatitis B be transmitted?

A
  • fluids: blood semen
  • mother to baby
  • transfusion: blood, blood products
  • contaminated needles
  • organ and tissue transplantation
  • close contact to contact
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6
Q

what can you give someone if they aren’t vaccinated against hepatitis B and they are post-exposure?

A
  1. Hepatitis B immune globulin (HBIG)

2. vaccinate against hepatitis B

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7
Q

who should receive the hepatitis B immune globulin?

A
  • infants of HBsAg-positive mothers within 12 hours of birth
  • needlestick within 24 hours if possible, up to 7 days
  • sexual exposure within 14 days
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8
Q

what is the vaccination schedule for hepatitis A vaccine (Havrix, VAQTA)?

A

Month 0 and month 6

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9
Q

what is the vaccination schedule for hepatitis B vaccine (Engerix B, recombivax HB)

A

Month 0, month 1, month 6

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10
Q

what is the vaccinate schedule for hepatitis A/B vaccine (twinrix)

A

Month 0, Month 1, Month 6

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11
Q

what does the HBsAg positive mean?

A

it means you have an active infection. If longer than 6 weeks positive, then you are chronically infected

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12
Q

what does HBeAG positive mean?

A

that there is viral replication going on.

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13
Q

what does HBV DNA positive mean?

A

active infection

viral replication

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14
Q

what does anti-HBs positive mean?

A

it means you have antibodies to hepatitis B surface antigen, leading to immunity to infection.

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15
Q

what does anti-HBe positive mean?

A

it means you have resolution of infection because you have antibodies to hepatitis B “e” antigen.

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16
Q

what does anti-HBc positive mean?

A

prior infection or active infection.

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17
Q

what are your goals for treating hepatitis B with antivirals?

A
  1. prevent cirrhosis, hepatic failure and Hepatocellular carcinoma (HCC)
  2. normalization of liver function test ALT
  3. viral suppression : undetectable HBV DNA, HBeAg seroconversion to anti-HBe, loss of HBsAg
  4. improve liver histology
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18
Q

who should you treat with antiviral therapy for Hepatitis B?

A
  1. people with elevated HBV DNA levels
    a. if HBeAg (+): greater than 20,000IU/ml or greater than 10^5 copies/ml
    b. if HBeAG (-): greater than 2,000IU/ml or greater than 10^4 copies/ml
    ————–AND———
  2. persistently elevated ALT levels >2x ULN.
    a. normal ALT men: 30IU/mL
    b. normal ALT women: 19IU/mL
    OR
  3. moderate/advance liver disease on biopsy: stage 2, 3, or 4 fibrosis
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19
Q

what is the first line antiviral agent for hepatitis B?

A
  1. entecavir (ETV, Baraclude)**
  2. tenofovir
  3. peginterferon
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20
Q

what is the second line oral antiviral agents for hepatitis B?

A

telbivudine (TBV, Tyzeka)

adefovir (ADV, Hepsera)

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21
Q

what is the interferon based injectible preparation that can be used for chronic HBV infection?

A

Pegasys

peginterferon alfa-2a

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22
Q

what is the dosing regimen for pegasys?

A

peginterferon alfa-2a

180 mcg SQ q week x 48 weeks

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23
Q

who should get the best response from pegasys?

A

those with high Alt >100 and relatively low HBV DNA <10^7 copies/mL

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24
Q

what are the adverse effects of pegasys?

A

poorly tolerated
flu-like symptoms: fever, chills, tachycardia, HA
CNS: fatigue, dizziness, depression
Hematologic: neutropenia, leukopenia, anemia
muscular: myalgia, weakness, skeletal pain

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25
what is pegasys contraindicated?
liver failure
26
what is the advantage of pegasys?
no emergence of resistance
27
what are the advantages of tenofovir (TDF, Viread)?
- activity against wild-type and LAM-resistant HBV | - Pregnancy category B
28
what is the dosing of tenofovir?
300mg po qd ClCr 30-49 ml/min: 300mg po q 48h ClCr 10-29 ml/min: 300mg po q 72-96hrs
29
what are the side effects of tenofovir?
``` CNS: pain, depression Dermatologic: rash Metabolic: inc triglycerides GI: diarrhea, nausea Renal: nephrotoxicity Rare: lactic acidosis and hepatic steatosis with nucleoside analogues (maily w/ hiv meds) ```
30
what are the advantages of entecavir in Hepatits B infection?
- active against wild-type and LAM-resistant HBV - Reduces HBV DNA levels by 5-6.9 logs - also has activity against HIV
31
what are the disadvantages of entecavir in hepatitis B infection?
by year 5, 1.2% of treatment naive patients develop resistance 43% in LAM-resistant patietns
32
what do you do if you get resistance to entecavir? which options do you have?
1. switch to tenofovir 2. add tenofovir 3. switch to emtricitabine/tenofovir
33
what is the dose of entecavir?
1. Tretmt naive: 0.5mg po qd 2. LAM-resistant: 1mg po qd ClCr: 30-49 mL/min: 50% of usual dose daily or administer normal dose q48h ClCr: 10-29: 30% of usual dose daily or administer the normal dose q72h
34
what are the adverse effects of entecavir?
CV: peripheral edma, headache, fatigue CNS: pyrexia GI: diarrhea/nausea Rare: lactic acidosis and hepatic steatosis with nucleoside analogues (mainly HIV meds)
35
what agents exist to treat HBV infection ?
``` entecavir tenofovir adefovir lamivudine telbivudine pegasys ```
36
how much does lamivudine decrease HBV DNA levels?
greater than 5 logs
37
what are the percentages of resistance to lamivudine ?
year 1: 24% | year 5: 70%
38
what do you do if you have lamivudine resistance?
1. continue lamivudine and add tenofovir | 2. swtich to emtricitabine/tenofovir
39
what is the dose of lamivudine?
1. 100mg po daily 2. For HIV coinfection: 150mg po BID ClCr 30-49 ml/min: 100mg first dose, then 50mg po daily ClCr 15-29 ml/min: 100mg first dose, then 25mg po daily ClCr 5-14 ml/min: 35mg first dose, then 15mg po daily ClCr <5ml/min: 35mg first dose, then 10mg po daily
40
what are the adverse effects of lamivudine?
CNS: HA, fatigue, insomnia GI: diarrhea/nausea, pancreatitis, abdominal pain Hematologic: neutropenia Muscular: myalgia, neuropathy, musculoskeletal pain Rare: lactic acidosis and hepatic steatosis with nucleoside analogues (mainly w/ HIV meds)
41
what are the advantages of adefovir (Hepsera)
- activity agains wild-type and LAM-resistant HBV | - Reduces HBV DNA levels by 3.6-4.5 logs
42
what are the disadvantages of adefovir?
-not as potent at tenofovir, lamivudine, entecavir, telbivudine
43
what are the resistance levels of adefovir?
28% by year 5
44
what do you do if you get resistance to adefovir?
1. switch to entecavir 2. add entecavir (if no LAM-resistance) 3. switch to emtricitabine/tenfovir
45
what is the dose of adefovir?
10mg po qd ClCr 20-49ml/min: 10mg po q48h ClCr 10-19ml/min: 10mg po q72h
46
what are the adverse effects of adefovir?
``` CNS: headache GI: abdominal pain hematologic: neutropenia Muscular: weakness Renal: nephrotoxicity rare: lactic acidosis and hepatic steatosis with nucleoside analogues (mainly w/ hiv meds) ```
47
what are the advantages of Telbivudine (TBV, Tyzeka)?
- lowers HBV DNA levels by 6 logs - less resistance compared to lamivudine - pregnancy category B
48
what are the levels of resistance for telbivudine?
HBeAG (+): yr 1-4.4%, yr 2-21.6% | HBeAG (-): yr 1-2.7%, yr 2-8.6%
49
what is the dose of telbivudine?
600mg po qd ClCr 30-49ml/min: 600mg po q48 ClCr <30 ml/min: 600mg po q72h
50
what are the adverse effects of telbivudine?
similar to lamivudine
51
what are the advantages of emtricitabine (FTC, emtriva)?
-also has activity against HIV
52
what is the dose of emtricitabine?
for HIV 200mg po qd | dose adjustment for ClCr <50ml/min
53
what are the adverse effects of emtricitabine?
similar to lamivudine
54
when is tenofovir indicated?
as first line treatment | in the case of lamivudine, entecavir, or adefovir resistance
55
when is entecavir indicated?
first line option | adefovir resistance
56
how long should treatment be for hepatitis B infection?
at least 12 months
57
when should you consider discontinuing antiviral therapy?
when you get HBsAG seroconversion on 2 separate occasions, at 6-12 months apart.
58
what patient counseling can you give for hepatitis B infection?
1. Avoid Alcohol 2. Avoid hepatotoxins inc: acetamiophen >2g/day 3. consult HCP before beginning new meds like herbal remedies 4. do not share needles, toothbrushes, razors 5. cover open cuts/sores 6. adopt safe sex practices 7. check immunity of household members and sexual partners, vaccinate if needed
59
how is hepatitis C virus transmitted?
``` through the skin -injection drug use -blood transfusion or organ transplant before 1992 -use of clotting factors before 1987 -occupational exposure (needlestick) Permucosal -mother to child -sexual ```
60
who should have risk factor screening for HCV ?
all patients
61
who should receive the HCV antibody test?
patient with risk factors | patients who request testing
62
who should receive the HCV-RNA qualitative or quatitative test?
patients who tested positive for HCV antibody
63
who should receive the HCV-RNA (quantitative) test?
patients whom treatment is to be initiated or who are on treatment to assess response to therapy
64
what are your treatment goals for Hep C antiviral tx?
- improve survival - eradicate virus a. Achieve sustained virologic response(SVR): Undetectable HCV RNA, 6 months post-treatment - improve liver histology - reduce risk of heptocellular carcinoma - reduce need for liver transplantation
65
what are the adverse effects of boceprivir-PEG-ribavirin?
- anemia - neutropenia - altered taste
66
what are the adverse effects of telaprevir-PEG-ribavirin?
- rash, pruritis - anemia - GI upset - altered taste - inc uric acid levels - increased total bilirubin - anorectal symptoms
67
what are the adverse effects of PEG-ribavirin?
- flu-like symptoms - bone marrow suppression - mental helath - GI upset - Rash - Thyroid, DM retinopathy
68
what is the patient counseling for patients with HCV infection?
same as Hep B V plus | Avoide high doses of fat soluble vitamins
69
who should receive HCV antiviral treatment?
- detectable levels of HCV RNA - >18 yo - sigficant fibrosis liver biopsy stage 2 or greater fibrosis - compensated liver disease - acceptable hematological and biochemical indices - willing to adhere - no contraindications
70
what are contraindications for PEG-Ribavirin treatment?
-uncontrolled mental illness -solid organ transplant (renal, heart, lung) -Autoimmune hepatitis or other autoimmune conditions - Untreated thyroid disease or diabetes mellitus - Pregnant or unwilling to comply with contraception - Severe concurrent medical disease - end stage AIDS, cancer
71
what dosing should you use for peginteferon-rivabirin?
1. Peginterferon alfa-2a 180mcg sq q week CrCl < 30ml/min or hemodialysis: 135mcg sq q week OR Peginterferon alfa-2b 1.5mcg/kg sq q week CrCL =75kg) or alternative dosing (see slides) Dose adjust for CrCl <50ml/min TREAT for 48 weeks OR GENOTYPE 2 or 3: rivabirin 800mg/day (2 divided doses) )
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