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30 Cards in this Set

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What are the goals of therapy for viral hepatitis?
Eliminate or significantly suppress HBV replication
Prevent progression to cirrhosis/liver failure
Histologic improvement/ALT normalization
Seroconversion to HBeAg with anti-HBe
What are the 3 first line agents and their doses?
Entecavir - 0.5 mg tablet PO daily
Tenofovir - 300 mg tablet PO daily
Pegylated Interferon alpha 2a - 180 mcg SC once weekly
Why are these agents preferred?
Superior efficacy, tolerability and favorable resistance in HBeAg (+) and (-) patients
What is the major concern with Tenofovir?
Renal Toxicity
How are candidates to treatment stratified?
HBeAg (+) patients

HBV DNA < 20,000 + normal alt

HBV DNA > 20,000 + normal alt

HBV DNA > 20,000 + elevated alt
Continuation of last answer
HBeAg (-) patients

HBV DNA <2,000, normal alt
HBV DNA >2,000, normal alt
HBV DNA>2,000, elevated alt
Describe treatment decisions in an HBeAg (+) patient.
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.
Continuation
HBV DNA > 20,000 copies, Normal ALT --> Consider doing a biopsy (Treat if significant disease present), Monitor every 3-12 months
Continuation
HBV DNA > 20,000, Elevated ALT --> Treat to HBeAg seroconversion using one of preferred agents
Describe the treatment decisions made in a HBeAg (-) patient.
HBV < 2,000 copies - Do not treat, Monitor every 6-12 months
Continuation
HBV > 2,000 copies, normal ALT --> Consider biopsy (treat if significant disease present), Monitor ALT, HBV DNA
Continuation
HBV DNA >2,000 copies, elevated ALT --> Treat long-term with one of preferred agents
Entecavir, Tenofovir, Peg-Interferon alpha 2a and Telbivudine are all equally efficacious. Why is Telbivudine not a preferred treatment?
It has higher rates of resistance than the other 3
What is the major side effect of Pegylated Interferon alpha 2a?
Flu-like illness (fever,chills, HA, malaise, myalgia)
Psychological side effects (50% of patients experience depression)
Describe phase 1 of infection.
Immune tolerance
HBeAg (+) - Active replication
HBsAg (+) with increased HBV DNA and normal ALT due to a lack of immune response at this point
Describe phase 2 of infection.
Immune active
HBeAg (+) - Active replication
HBsAg (+), HBV DNA increase and increased ALT due to immune response.
This can lead to cirrhosis/liver failure
Describe phase 3 of infection.
Inactive Carrier State
HBeAg (-) - No active replication
HBsAg (+) - No seroconversion
HBV DNA decreases
ALT normalizes
Describe phase 4 of infection
Mutation (rare)
HBeAg (+)
HBsAg (+)
HBV DNA increases modestly
ALT is elevated
This can lead to cirrhosis/liver failure
In what patients are the heptatitis vaccine indicated?
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.
How do you decide if someone has Hepatitis C?
Unlike Hepatitis B, there is only one serologic marker and that is needed is HCV (+).
What drugs are you limited to in treating Hepatitis C?
Interferon alpha 2a
Weight based ribavirin
What makes someone eligible for therapy?
If you are Anti-HCV (+) and eligible for therapy.
Eligible for therapy = (+) Liver biopsy and No contraindications to therapy
Describe how you decide how to treat Hepatitis C and the doses used.
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
Continuation
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
How do you want to monitor these therapies?
Ask Dr. Schafer!
What are the benefits of virologic monitoring?
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
What is EVR? SVR? What is important about these?
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)
What is the major side effect of Ribavirin?
Hemolytic anemia in first 2-4 weeks
Baseline Hgb < 13 - not recommended
What are the major side effects of Pegylated Interferon alpha?
Flu-like symptoms
GI Intolerance
Neuropsychiatric symptoms
Neutropenia (monitor WBC's)
Thrombocytopenia (monitor Platelets)
What are the contraindications to Hepatitis C therapy? (7)
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