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Hepatitis & Liver Disease

Terms in this set (32)

Hepatitis A
usually transmitted orally through fecal contamination of food or water
symptoms are generally mild, non-specific and sefl-limiting
treated with supportive care and Hep A vaccination for prevention
Comparison of Hepatitis Viruses
Hep A: acute, fecal-oral, vaccine, first line tx is supportive care

Hep B: can be acute or chronic, bloody, body fluid, vaccine, first line treatment is PEG-INF or NRTI (tenofovir or entecavir)

Hep C: can be acute or chronic, bloody, body fluid, no vaccine, first line treatment is DAA combination
drug treatment for HCV
preferred HCV regimen consists of 2-3 direct acting antiretroviral (DAA) for 8-12 weeks
-ritonavir is not active for HCV but it is used to boost levels of HCV protease inhibitors used with it

NS3/4A Protease inhibitor (-previr): glecaprevir, grazoprevir, paritaprevir, voxilaprevir

NS5A (-asvir): ledipasvir, ombitasvir, pibrentasvir, velpatasvir

NS5B (-buvir): dasabuvir and sofosbuvir

Protease inhibitors take with food
All DAA's
BW: risk of reactivating HBV
Warning: serious symptomatic bradycardia has been reported when sofosbuvir containing products have been used along with amiodarone

contraindicated with strong CYP3A4 inducers
Epclusa (sofosbuvir/velpatasvir)
Mavyret (glecaprevir/pibrentasvir)
Harvoni (sofosbuvir/ledipasvir)
Vosevi (sofosbuvir, velpatasvir, and voxilaprevir)
Sovaldi (sofosbuvir)
sofosbuvir is monotherapy is not recommended
Harvoni, Epclusa, Vosevi: avoid or minimize acid suppressive therapy
Pan-genotypic (approved for all 6 HCV genotypes):
-Epclusa and Mavyret
used for salvage therapy:
-vosevi and mavyret
used for 8 weeks in certain populations:
-mavyret
used for HCV/HIV coinfection:
-Harvoni, Epclusa, and Mavyret
used for children 12 and + with certain genotypes
-Sovaldi and Harvoni
Technivie, (ombitasvir, paritaprevir and ritonavir)
Viekira Pak (paritaprevir, ritonavir, ombitasvir, dasabuvir)
contraindicated in CYP3A4 substrates or inducers and ***contraindicated with use of ethinyl estradiol products
warnings of hepatic decompensation/failure in patients with cirrhosis, risk of inc LFTs
Harvoni, Epclusa, Vosevi
do not use with acid suppressive therapy
interferon alfa
SC dosing
BW bc can cause neuropsychiatric, autoimmune, ischemic or infectious disorders
ribavirin
significant teratogenic affects; not effective for monotherapy of HCV; hemolytic anemia

contraindicated in pregnancy
must have two forms of contraception during and 6 months after discontinuation.
drug treatment for Hep B
Interferon alfa is preferred monotherapy
prior to starting HBV therapy, patients should be tested for HIV (doses for HBV therapy are lower than HIV therapy doses and could lead to resistance)
All HBV NRTIs
CrCl < 50 = decrease dose or frequency
BW: lactic acidosis and hepatomegaly with steatosis which can be fatal
exacerbations of HBV can occur due to discontinuation of tx
tenofovir disoproxil fumarate TDF (Viread)
tenofovir alafenamide TAF (Vemlidy)

both are preferred in HBV
warnings: renal toxicity, Fanconi syndrome, osteolmalacia, decreased bone mineral density

TDF: renal impairment, dec bone mineral density
TAF: nausea
-dispense both in original container
-TAF is associated with dec renal and bone toxicity
Vemlidy is only approved for treating HBV
Entecavir (Baraclude)
preferred for HBV
**take on empty stomach
Lamivudine (Epivir HBV): only indicated for HBV

Epivir: is only used for HIV
H/A, N/V/D
do not use epivir HBV in HIV bc it contains lower dosing
clinical signs of liver disease:
assessed using child Pugh score
Increased ALT, AST, alk phosphate, total bilirubin, lactate dehydrogenase, and prothrombin time
Decrease in albumin
acute liver toxicity, including from drugs
inc AST/ALT
chronic liver disease (cirrhosis)
inc ast/alt, alk phos, Tbili, LDH, Pt/INR
dec albumin
alcoholic liver disease
serum AST>ALT; ↑ serum GGT
Hepatic encephalopathy
inc ammonia
jaundice
inc Tbili
natural products
milk thistle
select drugs with BW for liver damage
acetaminophen
amiodarone
isoniazid
ketoconazole
MTX
nefazodone
nevirapine
NRTIs
PTU
Tipranavir
valproic acid
treatment for alcoholic associated liver disease
alcohol cessation
inpatient: BZDs
outpatient: anticonvulsants
Naltrexone, disulfiram, acamprosate are used to prevent relapses
Thiamine (Vitamin B1)
used to prevent and treart wernicke-korsakoff syndrome
portal hypertension and variceal bleeding
increased blood pressure in the portal vein which can cause complications including development and bleeding of esophageal varices

acute variceal bleeding can be fatal
band ligation and sclerotherapy are recommended first line treatments for bleeding varices
vasoconstricting meds for varices
1) octreotide (sandostatin): bradycardia, cholelithiasis, and biliary sludge
2) vasopressin (ADH)
non-selective BB for portal hypertension
Propranolol (inderal)
Nadolol (Corgard)
do not stop BB abruptly
non-selective BB are used in portal hypertension
monitor HR and BP
hepatic encephalopathy (HE)
symptoms include musty odor of breath or urine, changes in thinking, confusion, forgetfulness

HE results from accumulation of gut derived nitrogenous substance in blood (such as ammonia)
treatment for HE
lactulose (first line): flatulence, diarrhea, dyspepsia, abdominal discomfort
monitor bowel movements, ammonia
-converts ammonia to ammonium

second line: rifaximin (Xifaxan)
ascites
fluid accumulation within peritoneal space that can lead to the development of spontaneous bacterial peritonitis

ascites due to portal hypertension restrict sodium
< 2g/day
diuretic therapy for ascites
initiated with either spironolactone monotherapy or with furosemide

100mg spironolactone + furosemide 40 mg
or 50mg-100mg of spironolactone monotherapy
all patients with cirrhosis and ascites should be considered for liver transplant
Spontaneous bacterial peritonitis
treat with ceftriaxone for 5-7 days
infection of peritoneal fluid
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