38 Questions
Which professional works primarily with patients with viral hepatitis, HIV, those on HIV PrEP, and those with other complex infections?
Clinical Pharmacy Specialist
What type of residency training did the person who graduated from University of Health Sciences and Pharmacy ('18) complete?
PGY-2 Ambulatory Care Residency
What is the primary focus of the University of Liverpool Drug Interaction Database?
Drug Interactions with Direct-Acting Antivirals
Which individual listed has no disclosures or acknowledgements?
Ana Muscarella, PharmD, BCACP
What is the main focus area within the Infectious Diseases Clinic at VUMC where Dr. Muscarella works?
Viral Hepatitis and HIV Patient Care
What is the recommended action for individuals with risk factors such as being sexually active, having tattoos, or using illicit drugs?
Get screened for HCV
Which test is used to diagnose active HCV infection?
HCV RNA test
What is the primary consideration in choosing the treatment for HCV?
Severity of fibrosis
What are the common long-term complications associated with HCV?
Cirrhosis and liver cancer
Which scores are used to assess liver dysfunction and predict prognosis in patients with HCV?
CTP score and MELD score
What is an important consideration in the evaluation and treatment of HCV?
Fibrosis status assessment
What is a common cause of cirrhosis?
Hepatitis C
What does decompensated cirrhosis refer to?
Liver disease unable to carry out its functions
What is a primary factor in hepatitis C treatment selection?
Patient's genotype
What tests need to be completed before initiating antiviral therapy for hepatitis C?
Calculation of FIB4 and CTP scores
How long does the treatment duration typically last for hepatitis C?
8-12 weeks
What are the targets for hepatitis C drug therapy?
NS3/4 protease, NS5A, and NS5B
What is one of the leading causes of hepatitis C transmission?
Injection drug use
Which organization reported on Medicaid prescribing restrictions in their 2023 National Progress Report?
National Viral Hepatitis Roundtable
What can treating hepatitis C help to reduce?
HCC and ESLD
Which of the following activities or exposures is considered a risk factor for HCV infection?
Injection drug use
Who provides helpful course modules and overviews of all hepatitis C medications?
The University of Washington
What is the recommended testing approach for individuals at risk of HCV infection according to the AASLD/IDSA Hepatitis C Treatment Guidelines?
Periodic testing for individuals with risk factors
What are the secondary factors in HCV treatment selection?
Side effect profile, drug-drug interactions, pharmacodynamics, and metabolism
Which side effects are commonly associated with DAAs (Direct-acting antivirals)?
Fatigue, headache, and GI upset
Which HCV genotypes have recommended regimens including glecaprevir/pibrentasvir (G/P)?
Genotypes 1a, 1b, and 3
Which regimen must be taken with food?
Glecaprevir/pibrentasvir (G/P)
What is the recommended treatment duration for genotype 4 with cirrhosis?
8 weeks for G/P and 12 weeks for SOF/VEL
For which patient types is resistance testing recommended?
For Zepatier™ (elbasvir/grazoprevir) and Epclusa™ (velpatasvir/sofosbuvir)
Which formulation is available for ribavirin?
200 mg tablets or capsules
What is the starting weight-based dosing for ribavirin?
$600$ mg
What is a contraindication for ribavirin?
Pregnancy
Which treatment option is suitable for ribavirin-eligible patients with genotypes 1-6?
Sofosbuvir/velpatasvir + ribavirin for 12 weeks
In which special population is treatment not recommended at this time?
HIV co-infection
What should be evaluated prior to starting treatment?
Potential drug-drug interactions
Which medication class requires caution and management based on drug classes and individual circumstances when used in combination with DAAs?
Pain medications
"Treating decompensated cirrhosis: Protease inhibitors are contraindicated." What should be done for patients with CTP Class B or C and/or MELD >10?
$1000$ mg ribavirin treatment decisions should be made in collaboration with experts at liver transplant centers.
Study Notes
- Ribavirin is not suitable for monotherapy and must be used in combination with other Direct-Acting Antivirals (DAAs).
- The formulation is available as 200 mg tablets or capsules, with weight-based dosing starting at 600 mg and potentially increasing to 1200 mg. Dose reductions may be needed for renal impairment.
- Ribavirin must be taken with food and is contraindicated in pregnancy, with patients required to have negative pregnancy tests prior to therapy and use contraception.
- Frequent monitoring is necessary due to hemolytic anemia risk and gastrointestinal side effects.
- Treatment options include ledipasvir/sofosbuvir + ribavirin for 12 weeks or sofosbuvir/velpatasvir + ribavirin for 12 weeks for ribavirin-eligible patients with genotypes 1-6.
- For ribavirin-ineligible patients with genotypes 1-6, ledipasvir/sofosbuvir can be used for 24 weeks or sofosbuvir/velpatasvir for 24 weeks.
- Treating decompensated cirrhosis: Protease inhibitors are contraindicated. Treatment decisions should be made in collaboration with experts at liver transplant centers for patients with CTP Class B or C and/or MELD >10.
- Special populations include chronic kidney disease (no dose adjustment needed with DAAs), HIV co-infection (treatment not recommended at this time), and children (testing requirements after birth if born to HCV+ mother, medications approved for age >3 if treatment required).
- Hepatitis C and incomplete adherence: Adherence is crucial. Missed doses should be addressed with the patient, and treatment may need to be re-initiated.
- Prior to starting treatment, potential drug-drug interactions should be evaluated by consulting prescribing information and other resources.
- Drug-drug interactions: Certain medications (antacids, H2RAs, PPIs, ART regimens containing protease inhibitors, cobicistat, ritonavir, amiodarone/dronedarone, anticonvulsants, statins, oral anticoagulants, and hormone therapies) require caution and management based on drug classes and individual circumstances.
- Green flag medication classes: Certain medications (pain medications, benzodiazepines, diabetes medications, SSRIs, SNRIs, mirtazapine, MAT, antibiotics used for STIs, uncomplicated URIs, or SSTIs) are generally safe to use in combination with DAAs.
- Ledipasvir/sofosbuvir, sofosbuvir/velpatasvir, and glecaprevir/pibrentasir interact with PPIs, H2RAs, and antacids, with doses equivalent to pantoprazole 40 mg daily.
Test your knowledge on accepted options for staging liver disease. Also, understand the concept of cirrhosis and its formation due to long-term liver injury.
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