Hepatitis B and C

DNA

hepatitis B is a _______ virus that replicates in the liver

severe fibrosis

fibrosis stage 4 indicates

moderate

which fibrosis is stage 2-3

HBsAg

which Hep B serologic marker indicates person is inectious

Anti-HBs

which hep B serologic marker confers immunity --> whether through past infection or vaccination

anti-HBc

which hep B serologic marker indicates that they've had heb B by being previously onfected or currently infected

c

what does the following serology indicate:

HBsAG: negative

anti-HBc: negative

anti-HBs: positive

a. susceptible

b. immune due to natural infection

c. immune due to hepatitis B vaccination

b

what does the following serology indicate:

HBsAG: negative

anti-HBc: positive

anti-HBs: positive

a. susceptible

b. immune due to natural infection

c. immune due to hepatitis B vaccination

HBsAG

which Hep B serology marker would indicate current infection if found to be positive

positive

in acute HBV, in the first 6 months, IgM anti-HBc is _______ (positive/negative)

true

true or false: it may take decades to move out of the immune tolerant phase

immune active

which phase of hep B is this:

- immune response to replicating HBV more robust --> liver inflammation

HBeAg positive and negative

what are the two subgroups of immune active phase of hep B

seroconversion to negative

what is goal of HBeAg positive hepatitis B immune active phase

immune inactive phase

which phase of hep b is this: occurs after HBeAg positive case seroconverts to negative

true

true or false: pt is still at risk for hepatocellular carcinoma if in immune inactive phase

no treatment

what treatment is indicated in immune tolerant phase of heb B

delay treatment for 3-6 month if non-cirrhotic

if hep B pt is immune active AND HBeAg positive, what should be done INITIALLY

3-6 months

how much time of monitoring (waiting for seroconversion) must pass in HBeAG positive immune active pt that has NOT seroconverted and ALT remains elevated >2x ULN to start treatment

yes (no chance of seroconversion)

do you treat right away in immune active HBeAg Negative if ALT >2x ULN?

true

true or false: in immune active HBeAg negative and ALT is normal or elevated mildly, treat only if moderate or significant fibrosis is present

2000

in compensated cirrhosis (child's pugh A), treat all patients if HBV DNA >______ IU/mL

true

true or false: in decompensated cirrhosis (child's pugh B-C) treat all patients regardless of ALT or HBV DNA

HBV serologies

What baseline screening is required before starting immunosuppressive therapy in patients at risk for HBV

if HBsAg positive (start antiviral therapy before immunosuppression to prevent HBV flare)

When should HBV antiviral prophylaxis be initiated in patients undergoing immunosuppressive therapy?

6-12 months

How long should HBV antiviral prophylaxis be continued after completing immunosuppressive therapy?

give HBV vaccine

What is the recommended management for patients who are not infected and not immune to HBV before immunosuppressive therapy

entecavir, tenofovir, pegylated interferon alpha (less common)

what are first line options to treating Hep B (in the case where they do qualify for treatment)

lamivudine, adefoir, telbivudine

what are the second line monotherapy medications used for Hep B (not second line because first line fails, second line because they are less potent/less effective)

false

true or false: 1st line treatment options for hep B are curable but second line options are not

lactic acidosis

what is the BBW of all nucleoside and nucleotide analogues

nucleoside and nucleotide analogues

inhibit HBV replication at various points

entecavir and tenofovir

what are the preferred nucleoside and nucleotide analogue analogues

12

SCr needs to monitored every ______ weeks for those taking adefovir or tenofovir

12-24

when on nucleoside and nucleotide analogue treatment, need to monitor HBV DNA testing every _______ weeks

12 months and at least 6 months after HbeAg turning negative

what is the MINIMUM treatment duration of those in immune active HBeAg positive

indefinitely

how long do you treat those in immune active HBeAg negative

entacavir and tenofovir disaproxil (TDF)

renal dose adjustments are required for _________ and ________ in hep b treatment

TAF

which tenofovir formulation does NOT require renal dose adjustments

fanconi synrome

increases SCr, urin proteinn, glucose, and phosphates is indicative of _____________, a toxicity often caused by TDF

HIV

you must rule out _______ prior to treatment with tenofovir

interferon alpha

which medication enhances the innate immune response and exerts antiviral actions within infected cells

finite duration (48 weeks)

what is a benefit to treating with interferon alpha

NA (nucleotide analogue)

if patient fails interferon therapy, treat with _____

a

if patient did not achieve primary reponse to NA or developed break through infection and HBV DNA <2000, what should you do

a. continue treatment

b. switch to different NA

b

if patient did not achieve primary reponse to NA or developed break through infection and HBV DNA >2000, what should you do

a. continue treatment

b. switch to different NA

tenofovir

what is preferred hep b treatment in pregnant people

HBV vaccine, hep B immune globulin

within 12 hours of birth, infants should receive... (in relation to hep b)

infection

HCV antibody + HCV RNA quantification of viral load =

aminotransferases

HCV commonly found in cases of unexplained, mildly elevated ___________ or routine screening as recommended by CDC

genotype, stage of liver fibrosis

once chronic HCV infection confirmed, obtain _______ and _________ (or at least whether or not patient is cirrhotic)

12 weeks

goal of HCV treatment is achieve sustained virologic response at _________ (time)

protease inhibitors

drugs ending in "previr" are _____________

NS5A inhibitors

HCV treatment drugs ending in "asvir" are __________

polymerase inhibitors

HCV treatment drugs ending in "buvir" are ____________-

true

true or false: HCV treatment includes utilizing 2 of the 3 classes of meds (protease inhibitors, NS5A inhibitors, polymerase inhibitors)

decompensated cirrhosis and if received prior treatment

what two things do you absolutely need to know before starting HCV treatment

A

which child's pugh classification (a, b, c) is considered compensated cirrhosis

lowers

presence of cirrhosis _______ (lowers/increases) cure rate for some HCV treatment

B and C

which child's pugh classification (a, b, c) is considered decompensated cirrhosis

protease inhibitors ("previrs"

which HCV drug class needs to be AVOIDED in decompensated cirrhosis patients

24 weeks, ribavirin

decompensated cirrhosis worsens DAA cure rates overall so therapies are either longer, __________ (give duration), or addition of __________ is required

c

which of the following hepatitis C DAAS can not be used to treat Hep C in a patient with decompensated cirrhosis?

a. velpatasvir/sofosbuvir

b. ledipasvir/sofosbuvir

c. glecaprevir/pibrentasvir

false (insurance sucks)

true or false: current guidelines recommended not waiting until HCV turns chronic and Insurance also agrees and will cover treatment for acute

8-12 weeks

what is the average length of therapy for HCV treatment for most patients

pangenotypic

if a regiment is effective against genotype 1-6 it is called pangenotypic

protease inhibitors

serious liver injury is rare in treatment of HCV but possible with which drug class?

CYP3A4 inducers

all available HCV DAAs interact with _________

CYP3A4 inducers

rifampin, phenytoin, carbamazepine, and St. Johns Wort are ___________

amiodarone

all sofosbuvir based regimens interact with ___________

false

true or false: pt should keep taking their herbal supplements while receiving HCV treatment

acid suppression

velpatasvir/sofosbuvir (epclusa) interacts with all ________

RAS

velpatasvir/sofosbuvir (EPCLUSA) requires ______ testing in genotype 3 cirrhotic patients

with food

do you take glecaprevir/pibrentasvir (Mabyret) with or without food?

without

do you take velpatasvir/sofosbuvir (EPCLUSA) with or without food?

ethinyl estradiol, statins

glecaprevir/pibrentasvir interacts with __________ containing hormonal contraceptives and ____________

only indicated for those who have failed previous HCV DAA therapy

what is unique about when we use velpatasvir/sofosbuvir/voxilaprevir (Vosevi) compared to other drug combos

acid suppression

velpatasvir/sofosbuvir/voxilaprevir (Vosevi) interacts with all __________

ribavirin

which drug is not a DAA but may be used to supplement therapy in difficult to treat infections

teratogenic

ribavirin is ________ (BBW)

2

pregnancy must be ruled out prior to starting ribavirin and is recommended to be on _______ forms of birth control for duration of treatment + 6 months after

hepatitis A and B

chronic hepatitis is considered a liver disease and thus _________ vaccinations are indicated

IgM

when checking Hepatits A virus antibodies, what meaasures recent acute infection

IgG

when checking Hepatits A virus antibodies, what measures sign of immunity due to vaccine or past infection

true

true or false: if hepatitis A IgM antibody is detected, lab should alert this in report as this would be suspicious for current or recent acute infection

b

Which of the following patient characteristics is essential to know before navigating the clinical guidelines to select evidence-based Hep C treatment?

A. Hepatitis A vaccination status

B. Previous treatment (or lack thereof)

C. Hemoglobin (for assessment of anemia)

D. Fibrosis score for non-cirrhotic patient

b

S.A. is a 59 year old male with confirmed chronic HCV infection (genotype 1a). He has stage 2 fibrosis (non-cirrhotic), hypertension, and GERD with ulcerative esophagitis requiring high dose PPI. His medication list is as follows: Aspirin 81 mg by mouth once daily, Lisinopril 20 mg by mouth once daily, Esomeprazole 40 mg by mouth once daily. Which of the following is the recommended medication routine to start:

a. velpatasvir/sofosbuvir

b. glecaprevir/pibrentasvir

c. velpatasvir/sofosbuvir/voxilaprevir

true

true or false: exact viral load number for HCV RNA quant does NOT represent severity of disease

12 weeks

HCV RNA quant should be rechecked __________ after treatment

SVR4

there is growing evidence for using _______ as a correlative for SVR12 which is helpful more transient populations in HCV treatment

life

HCV antibody will remain detectable for ________-

false (HCV antibody screens blood donors and that remains for life)

true or false: cured HCV patients can donate blood

1 month

consider checking LFTS ________ into treatment if cirrhotic and on a protease inhibitor

monthly

how often do you take a pregnancy test if on ribavirin

hypoglycemia

if receiving treatment for HCV and DM2, monitor for __________

immunization

if no current or previous hep B infection, proceed with HCV DAA and initiate HBV _________ if series not already completed

HBV, 12 weeks

if active Hep B infection with HCV, initiate _________ therapy prior to starting HCV DAAS, and continue for at least _________ (duration) after last HCV DAA Dose

true

true or false: there is risk of HBV reaction in any patient with current or previous HBV infection that is being treated with HCV DAAs

daily adherence

________ is requied for HCV DAA to achieve SVR12 and avoid resistance

true

true or false: completion of entire HCV DAA regiment is needed even if 4 week HCV RNA is undetectable