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RxPrep
Hepatitis/Liver failure (CH19)
| Question | Answer |
|---|---|
| What lab indicates immunity to hepatitis B? | Anti-HBs |
| What lab indicates previous or ongoing hepatitis B infection? | Anti-HBc |
| What tests confirm active hepatitis C infection? | HCV antibody test and, if positive, HCV RNA viral load |
| What does DAA stand for? What is it used for? | Direct-acting antiviral Hepatitis C treatment |
| What is a DAA regimen? | Combination of 2–3 DAAs with different mechanisms against HCV replication |
| Preferred first-line DAA regimens for treatment-naive HCV without cirrhosis? | Glecaprevir/pibrentasvir (mavyret) for 8 weeks or sofosbuvir/velpatasvir (epclusa) for 12 weeks |
| Box warning for al DAAs? | Risk of reactivating HBV, must test all patients for HBV before starting DAAs. |
| Monitoring for DAAs? | LFTs, HCV RNA load. |
| Which medication CANNOT be used with any sofosbuvir containing regimens? Why? | Amiodarone, when used together they cause serious bradycardia. |
| You have a patient on Amiodarone who needs DAA therapy, which options are safe? | Only Mavyret and Zapatier (since neither contains sofosbuvir) |
| Generic of Mavyret? | Glecaprevir/pilbrentasvir |
| Generic of Epclusa? | Sofosbuvir/vlpatassvir |
| What does pangenotypic mean? And which DAA regimens would be pangenotypic? | Pangenotypic means it is effective against all genotypes of Hep C Mavyret and Epclusa are the only 2 that are pangenotypic |
| For a patient on Mavyret (glecaprevir and pibrentasvir), which meds must be avoided? | Statins, protease inhibitos (-navir drugs or cyclosporine), or estradiol |
| Which regimens require caution with GERD meds? | Epclusa, Harvoni, vosevi Seperate from antacids by 4 hours, seperate H2RAs by 12 hours, AVOID PPIs |
| Generic for Zepaptier? | Elbasavir/grazoprevir |
| Counseling point for Mavyret? | Take with food |
| Mavyret shouldnt be used in patients taking which drugs? | Statins, PIs, estradiol, and strong 3A4 inducers |
| Which DAAs have serious interactions with strong 3A4 inducers? | ALL OF THEM |
| What would be the strong 3A4 inducers to look out for with DAA regimens? | Carbamazepine, oxcarbazepine, phenytoin, phenobarb, primidone, rifampin/rifabutin, St. johns wort. |
| In what conditions should Mavyret be avoided? | Moderate-severe hepatic impairment |
| What is the daily ethinyl estradiol limit with Mavyret? | 20 mcg/day |
| Which DAA regimens contain sofosbuvir? | All of them except Mavyret and Zepatier |
| Zepatier DDIs? | Similar to mavyret, avoid PIs, *also avoid efavirenz*, but statins are OK with Zepatier. |
| What is the concern with DAA and statins? | DAAs can increase statin concentration and myopathy risk |
| Why does DAA therapy require extra monitoring in DM patients? | Glucose metabolism can improve with DAA therapy, watch for hypoglycemia. |
| Ribavirin brand name? | Rebetol |
| What is ribavirin used for in liver disease? | HCV in combination with a DAA regimen, but NEVER as monotherapy |
| Ribavirin boxed warnings? | Teratogenic, hemolytic anemia |
| Which populations require avoidance or extra caution with use of Ribavirin? | Pregnancy (avoid), able to become pregnant (contraception and pregnancy testing), cardiac disease (hemolytic anemia can worsen ASCVD) |
| Ribavirin contraindication in pregnancy? | Avoid in pregnant females AND partners of pregnant females |
| How long to ribavirin patients needs to avoid pregnancy AFTER stopping therapy? | Must continue with 2 forms of BC for 6 months after stopping |
| Ribavirin contraindications listed? | Autoimmune hepatitis, hemoglobinopathies, pregnancy-related contraindications |
| Ribavirin common ADRs? | insomnia, anxiety/mood changes, N/V, anorexia, *myalgia, *hypothyroidism, *alopecia |
| Ribavirin monitoring? | CBC with differential, electrolytes, LFTs, HCV RNA viral load, TSH, pregnancy tests. |
| First-line hepatitis B drug classes? | NRTIs and pegylated interferon alfa-2a |
| Which hepatitis B drugs are NRTIs listed as recommended first-line? | Entecavir, tenofovir disoproxil fumarate (TDF), tenofovir alafenamide (TAF) |
| Which older NRTIs are no longer recommended first-line due to resistance for HBV? | Lamivudine, adefovir |
| What do NRTIs prevent in hepatitis B? | HBV replication by inhibiting HBV polymerase |
| Which HBV NRTI can also treat HIV at higher doses? | Tenofovir |
| Why should HBV/HIV coinfected patients receive tenofovir with two other NRTIs? | To minimize HIV resistance risk |
| What is Vemlidy? | Tenofovir alafenamide (TAF) |
| What is Viread? | Tenofovir disoproxil fumarate (TDF) |
| What is Baraclude? | Entecavir |
| What is Pegasys? | Peginterferon alfa-2a |
| Which form of tenofovir is generally preferred? Why? | TAF is better, lower risk of renal toxicity than TDF |
| Tenofovir DF renal warning? | Nephrotoxicity including acute renal failure and Fanconi syndrome |
| Is HBV usually treated with combo or monotherapy? | Monotherapy |
| Does TAF need another drug with it in order to treat HBV? | NO |
| Tenofavir boxed warnings (for both TAF and TDF)? | Lactic acidosis, hepatomegaly with steatosis, acute exacerbation of hepatitis after d/c. |
| Which HBV medication needs to be taken on an empty stomach? | Entecavir (baraclude) |
| Which HBV meds require renal dose adjustments? | Entecavir and TDF, adjust if CrCl < 50 |
| Unique warnings fot TDF and TAF? | Renal toxicity (Fanconi syndrome), lower MBD, lipid changes (more with TAF) |
| Which HBV drugs MUST be dispensed in their original containers? | TAF and TDF (Vemlidy and Viread) |
| Peginterferon alfa-2a use in HBV? | Monotherapy for some patients; finite duration compared with NRTIs |
| Interferon alfa boxed warning? | neuropsychiatric, autoimmune, ischemic or infectious disorders |
| Interferon alfa common ADRs? | Flu-like symptoms, depression/anxiety, GI upset, increased LFTs, injection site reactions, cytopenias |
| Interferon alfa contraindications? | Autoimmune hepatitis, decompensated liver disease in cirrhotic patients, *infants/neonates* |
| Interferon alfa monitoring? | CBCs, LFTs (5-10x ULN), SCr, electrolytes, lipids, TSH, HBV DNA *Uric acid |
| Which HBV medication can cause myelosuppression? | Interferon alfa (pegasys) |
| Which HBV medication requires pretreatment before dosing? Why? | Interferon alfa, cause flu-like syndrome, pretreat with APAP and antihistamine |
| Which key drugs have boxed warnings for liver damage? | amiodarone, bosentan, isoniazid, ketoconazole, leflunomide/teriflunomide, methotrexate, nefazodone, nevirapine, propylthiouracil, valproic acid, zidovudine |
| Which HCV/HBV drug has boxed warning for HBV exacerbation after stopping? | Tenofovir products (Vemlidy and Viread) |
| Which HBV medication is teratogenic? | Ribavirin (Virazole) |
| What is initial pharmacologic therapy for acute variceal bleeding? | Vasoconstrictors such as octreotide or terlipressin |
| Hepatotoxic drugs are typically d/c when LFTs are ____ ULN | >3x |
| Octreotide brand name? | Sandostatin |
| How long are vasoconstrictors usually continued for variceal bleeding? | 2-5 days |
| What antibiotic prophylaxis is commonly used in variceal bleeding? | Ceftriaxone (preferred over FQs due to resistance) |
| Why use ceftriaxone in acute variceal bleeding? | Reduces risk of infection |
| MOA of octreatide? | Somatostatin analog, acts as vasoconstrictor |
| Octreotide major ADRs listed? | Bradycardia, cholelithiasis, biliary sludge, fatigue, headache, hyperglycemia, hypothyroidism |
| Which of the hepatic diseases medications are the biggest concerns for thyroid impact? | **Interferon alfa** (main concern, hyper or hypo) Ribavirin (hypo) Octreotide (hypo) |
| Which liver drug has a risk for distention and commonly causes GI ADRs? | Octreotide |
| Terlipressin brand name? | Terlivaz |
| Terlipressin box warning? | Serious respiratory failure, avoid in hypoxia or ischmeia |
| Terlipressin monitoring? | Na levels, O2 sat, fluid status |
| Octreotide monitoring? | Blood glucose, HR, ECG |
| How is Octreotide given? | IV, 25-100mcg bolus, then 25-50mcg/hr infusion for 2-5 days |
| Which liver-related medication can cause hyponatremia? | Terlipressin (terlivaz) |
| When are beta blockers used in hepatic diseases? | primary/secondary prevention of varicela bleeding and portal hypertension |
| Which beta blockers are preferred for portal HTN? | Nadolol (Corgard), propranolol, Carvedilol |
| First-line treatment for ascites includes what lifestyle measure? | Na restriction, <2g/day |
| Fluid restriction in ascites is reserved for what? | Severe hyponatremia, serum sodium <125 mEq/L |
| What diuretics are used for ascites? | Furosemide and spironolactone |
| What is the spironolactone:furosemide ratio for ascites? | 100 mg spironolactone : 40 mg furosemide |
| Maximum ascites dose combination doses? | Spironolactone 400 mg/day + furosemide 160 mg/day |
| What is given after large-volume paracentesis? | IV albumin 6–8 g per liter of fluid removed |
| What is SBP? | Acute infection that occurs when ascitic fluid samples have PMNs ≥250 cells/mm³ |
| SBP empiric treatment targets which organisms? | Streptococci and enteric gram-negative pathogens |
| First-line SBP treatment listed? | Ceftriaxone or equivalent |
| SBP tx duration? | 5-7 days |
| What is recommended after SBP episode? | Secondary prophylaxis with sulfamethoxazole/trimethoprim or Cipro |
| Counseling points with beta-blockers? | Do not stop abruptly |
| All of the Hep C and Hep B drugs require LFT monitoring except for? | None, all of them require LFT monitoring |
Created by:
cdaughtry