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30 Cards in this Set
- Front
- Back
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What are the goals of therapy for viral hepatitis?
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Eliminate or significantly suppress HBV replication
Prevent progression to cirrhosis/liver failure Histologic improvement/ALT normalization Seroconversion to HBeAg with anti-HBe |
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What are the 3 first line agents and their doses?
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Entecavir - 0.5 mg tablet PO daily
Tenofovir - 300 mg tablet PO daily Pegylated Interferon alpha 2a - 180 mcg SC once weekly |
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Why are these agents preferred?
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Superior efficacy, tolerability and favorable resistance in HBeAg (+) and (-) patients
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What is the major concern with Tenofovir?
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Renal Toxicity
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How are candidates to treatment stratified?
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HBeAg (+) patients
HBV DNA < 20,000 + normal alt HBV DNA > 20,000 + normal alt HBV DNA > 20,000 + elevated alt |
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Continuation of last answer
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HBeAg (-) patients
HBV DNA <2,000, normal alt HBV DNA >2,000, normal alt HBV DNA>2,000, elevated alt |
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Describe treatment decisions in an HBeAg (+) patient.
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HBV DNA < 20,000 - You do not treat and you monitor every 6-12 months
These patients are likely to be in the inactive carrier state. |
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Continuation
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HBV DNA > 20,000 copies, Normal ALT --> Consider doing a biopsy (Treat if significant disease present), Monitor every 3-12 months
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Continuation
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HBV DNA > 20,000, Elevated ALT --> Treat to HBeAg seroconversion using one of preferred agents
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Describe the treatment decisions made in a HBeAg (-) patient.
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HBV < 2,000 copies - Do not treat, Monitor every 6-12 months
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Continuation
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HBV > 2,000 copies, normal ALT --> Consider biopsy (treat if significant disease present), Monitor ALT, HBV DNA
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Continuation
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HBV DNA >2,000 copies, elevated ALT --> Treat long-term with one of preferred agents
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Entecavir, Tenofovir, Peg-Interferon alpha 2a and Telbivudine are all equally efficacious. Why is Telbivudine not a preferred treatment?
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It has higher rates of resistance than the other 3
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What is the major side effect of Pegylated Interferon alpha 2a?
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Flu-like illness (fever,chills, HA, malaise, myalgia)
Psychological side effects (50% of patients experience depression) |
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Describe phase 1 of infection.
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Immune tolerance
HBeAg (+) - Active replication HBsAg (+) with increased HBV DNA and normal ALT due to a lack of immune response at this point |
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Describe phase 2 of infection.
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Immune active
HBeAg (+) - Active replication HBsAg (+), HBV DNA increase and increased ALT due to immune response. This can lead to cirrhosis/liver failure |
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Describe phase 3 of infection.
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Inactive Carrier State
HBeAg (-) - No active replication HBsAg (+) - No seroconversion HBV DNA decreases ALT normalizes |
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Describe phase 4 of infection
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Mutation (rare)
HBeAg (+) HBsAg (+) HBV DNA increases modestly ALT is elevated This can lead to cirrhosis/liver failure |
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In what patients are the heptatitis vaccine indicated?
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Those who are susceptible
Infants, Children < 19 yo, Susceptible sex partners of HBsAg (+) people, Not monogamous, Seeking evaluation/treatment of an STD, MSM, IVDA, HIV, household contacts of HBsAg (+) people, healthcare workers at risk of blood exposure, ESRD, Travelers to HBV areas, Chronic liver disease, Those seeking protection. |
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How do you decide if someone has Hepatitis C?
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Unlike Hepatitis B, there is only one serologic marker and that is needed is HCV (+).
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What drugs are you limited to in treating Hepatitis C?
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Interferon alpha 2a
Weight based ribavirin |
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What makes someone eligible for therapy?
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If you are Anti-HCV (+) and eligible for therapy.
Eligible for therapy = (+) Liver biopsy and No contraindications to therapy |
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Describe how you decide how to treat Hepatitis C and the doses used.
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Then you look at genotype.
If you are genotype 1, you can use Peginterferon alpha 2a 180 mcg/week or Peginterferon alpha 2b 1.5 mcg/week + Ribaviron 1000 mg (below 75 kg), 1200 mg (above 75 kg) x 48 weeks |
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Continuation
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If you are genotype 2/3 you use Peginterferon alpha 2a 180 mcg/week or Peginterferon alpha 2b 1.5 mcg/week + Ribavirin 800 mg x 24 weeks
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How do you want to monitor these therapies?
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Ask Dr. Schafer!
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What are the benefits of virologic monitoring?
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It shows the rate of viral clearance and predicts likelihood of response
Determines the optimal duration of therapy ***Half of people do not respond to therapy |
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What is EVR? SVR? What is important about these?
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Early Viral Response
Sustained Viral Response 100% of patients who do not achieve EVR do not achieve SVR. 65-72% of those who achieve EVR achieve SVR (but not nearly all) |
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What is the major side effect of Ribavirin?
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Hemolytic anemia in first 2-4 weeks
Baseline Hgb < 13 - not recommended |
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What are the major side effects of Pegylated Interferon alpha?
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Flu-like symptoms
GI Intolerance Neuropsychiatric symptoms Neutropenia (monitor WBC's) Thrombocytopenia (monitor Platelets) |
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What are the contraindications to Hepatitis C therapy? (7)
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Liver Disease
Pregnancy/patients with a female partner who is pregnant Autoimmune Hepatitis Hemoglobulinopathies CrCl < 50 ml/min Hemodialysis patients Ischemic cardiovascular or cerebrovascular disease |
