Viral Hepatitis

Can Hepatitis be Asymptomatic?

True

Generalized symptom of Hepatitis

• Fever

• Nausea/Vomiting/Abdominal pain

• Loss of appetite

• Fatigue

• Joint pain

Liver specific symptoms of Hepatitis

• Jaundice

• Dark Urine

• Light-colored stool

Fecal-oral route, food/water contamination

Modes of Transmission of Hepatitis A

Blood or bodily fluids, shared needles, sexual contact, pregnancy/delivery

Modes of Transmission of Hepatitis B and C

Vaccination, handwashing, and food/water decontamination

Prevention strategies of Hepatitis A

Vaccination, needle exchange, safe sex, and testing

Prevention strategies of Hepatitis B

Needle exchange, safe sex, testing

Prevention strategies of Hepatitis C

Which positive on a serological test indicates Hepatitis?

IgM anti-HAV

How many months separation is Hep A vaccination recommended?

6 months apart

How many doses is the Hep A vaccine?

2 doses

What is the name of the Hepatitis A vaccines?

Vaqta and Havrix

What is the name of the Hepatitis A and B vaccine?

Twinrix

A patient with positive Anti-HBc and Anti-HBs is…

Immune due to previous infection

A patient with no positive results on a serology test is…

Susceptible

A patient with positive Anti-HBs is…

Immune from vaccination

A patient with positive HBsAg, Anti-HBc, IgM Anti-HBc, and HBV DNA is…

Acutely infected

A patient with positive HBsAg, Anti-HBc, and may or may not be positive for HBV DNA is…

Chronically infected

A patient positive for HBsAg alone is…

Unclear; resolved infection, false labs, or “low-level” infection

Hepatitis B dosing schedule from birth is…

1st at birth, 2nd at 1-2 months, and 3rd at 6-15 months

Hep B treatments: Nucleoside analogs

• Entevcavir (Baraclude)

• Tenofovir disoproxil fumarate (Viread)

• Tenofovir alafenamide (Vemlidy)

Entevcavir Unique pearl

Take on empty stomach

Tenofovir disoproxil fumarate Unique pearl

• Nephrotoxic

• Osteomalacia

• Fanconi syndrome

• Preferred agent in pregnancy

Tenofovir alafenamide (Viread) Unique pearl

• Less renal and bone toxicity

• P-gp substrate

• Take with food

Peginterferon Hep B treatment duration

48 weeks

When is Peginterferon contraindicated?

Decompensated cirrhosis

Peginterferon adverse affects

• Flu-like symptoms

• Bone marrow suppression

• Neuropsychiatric symptoms

• Autoimmune diseases

• GI upset

• Dermatologic effects

• Ophthalmologic effects

What is the duration of nucleoside analogs?

Lifelong for most patients

If a patient is negative (nonreactive) for HCV antibody what is the recommended next step?

Stop and consider follow up if exposed within past 6 months

If a patient is positive (reactive) for HCV antibody what is the recommended next step?

Test for HCV RNA

If a patient is negative (not detected) for HCV RNA what is the recommended next step?

Additional testing is appropriate as no HCV infection is current

If a patient is positive (detected) for HCV RNA what is the recommended next step?

Current HCV infection is present, link to care (Genotype before tx)

NS3/4A Protease inhibitors

• Grazoprevir

• Voxilaprevir

• Glecaprevir

NS5A Inhibitors

• Ledipasvir

• Elbasvir

• Velpatasvir

• Pibrentasvir

NS5B Polymerase Inhibitors

Sofosbuvir

What Direct acting antiviral (DAAs) products are currently available?

• Glecaprevir-Pibrentasvir (Mavyret)

• Sofosbuvir-velpatasvir (Eplclusa)

DAA counseling of adverse effects

• Headaches

• Fatigue

• Nausea/diarrhea

• Hypoglycemia

Mavyret with or without foor?

With food

Eplclusa with or without food?

Either with or without food

DAA counseling warning points

• Potential for Hep B re-activation

• Avoid sofosbuvir (component of Eplclusa) in patients taking amiodarone

• Compliance is essential

What is the simplified treatment Hep C algorithm patient criteria?

• Treatment naive

• Any Genotype

• No cirrhosis

• Not pregnant

What is the simplified treatment Hep C algorithm Mavyret duration?

8 weeks duration

What is the simplified treatment Hep C algorithm Epclusa duration?

12 weeks duration

What is the simplified with compensated cirrhosis treatment Hep C algorithm patient criteria?

• Treatment naive

• Not pregnant

• Compensated Cirrhosis

Which Genotype in Hep C simplified with compensated cirrhosis requires resistance testing prior to Epclusa?

Genotype 3

Hep C treatment with decompensated cirrhosis Ribacirin eligible difference from ineligible duration.

• Eligible patients may take either Mavyret or Epclusa and Ribavirin for 12 weeks

• Ineligible patients may take either Mavyret or Epclusa for 24 weeks

Which Genotype in Hep C treatment with decompensated cirrhosis requires resistance testing prior to Epclusa?

Genotype 2 and 3

Ribavirin BBW

• Teratogenic (Contraception required)

• Not effective as monotherapy

• Hemolytic anemia

Ribavirin AEs

• Flu-like symptoms

• Headache

• Fatigue

• GI upset

• Musculoskeletal pain

DAA DDIs CYP3A4 drugs

• Phenytoin

• Phenobarbital

• Carbamazepine

• Rifampin

• Saint John’s Wort

DAA DDIs Statins risk

• Increased risk of myopathy

• Consider hold or decreasing doses

DAA DDIs Diabetic medications monitoring

Monitor for hypoglycemic symptoms and consider dose reduction if s/s occur

DAA DDIs Acid reducers (Sofobubir or Epclusa only) counseling

• Antacid (Separate by 4 hours)

• H2 blockers okay with use

• PPTs (Separate by 4 hours; limit omeprazole dosing to 20mg daily)

Hep C monitoring recommendations

• Variable depending on treatment regimen

• AST/ALT

• Viral load

• CBC

Sofosbuvir (Epclusa) is contraindicated in patients taking…

Amiodarone!!!

Tenofovir alafenamide (Viread) with or without food

Without food

Mavyret simplified regimen duration of treatment

8 weeks

Epclusa simplified regimen duration of treatment

12 weeks