Viral Hepatitis Therapeutic Lecture Notes PDF

This Document has been modified with Flexcil app (Android) https://www.fexcil.com Viral hepatitis Dr. Mohammad Alameen Qasim F.I.B.M.S ( Clinical pharmacy ) Al Nahrain University / college of pharmacy Flexcil - The Smart Study Toolkit & PDF, Annotate, Note ...

This Document has been modified with Flexcil app (Android) https://www.fexcil.com Viral hepatitis Dr. Mohammad Alameen Qasim F.I.B.M.S ( Clinical pharmacy ) Al Nahrain University / college of pharmacy Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hepatitis A ( RNA) : - For all hepatitis virus infections , acute hepatitis is defined as infection for less than 6 months. Whereas chronic hepatitis is infection for more than 6 months. - Transmission occurs mainly through the fecal – oral route , person to person contact. - Most patients are self limited disease lasting less than 2 months. - HAV is not associated with the development of chronic hepatitis. - Fulminant hepatitis can occur in some instances. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hepatitis A Diagnosis : - Clinical sign and symptoms : include , nausea , abdominal pain jaundice , fever , anorexia. - Laboratory data : IgM antibody to HAV ( anti-HAV ) : is detectable in the 5- 10 days before the onset of symptoms. IgG antibody during a 2- 6 month period , these antibodies confer lifelong protective immunity against subsequent infection. - Elevated of aminotransferase ( ALT , AST ). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hepatitis A Treatment : A- Preexposure prophylaxis : - Active ( vaccination ) or passive ( immune globulin ) can be used. - Population required HAV vaccine : (1) all children older than 1 years. (2) children living in area where rate of hepatitis are above twice the national average.(3) people working or travelling to countries with high or intermediate endemicity ( take up to 4 weeks for full protection. (4) illicit drug used. (5) patient with chronic liver disease. (6) patient with clotting factor disorder. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com A- Preexposure prophylaxis : - Populations required HAV immune globulin : (1) travel to endemic countries ( < 2 weeks ). (2) children younger than 1 years.(3) > 40 years old. (4) dialysis. ( 5) immunocompromised patients. B- Postexposure prophylaxis : - Should be used when patient previously unvaccinated and within 2 weeks of exposure. - Immune globulin is used in postexposure prophylaxis. - HAV vaccine used only in patients who are 12 months to 40 years old. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com B- Postexposure prophylaxis : - Ofer to the following : (1) close personal contact. (2) staff or attendees of day care centers. (3) if a food handler receive a diagnosis with HAV , other staff should be administered vaccine or immune globulin. Management : - Acute hepatitis A virus infection is mainly supportive and avoid hepatotoxic medications such as acetaminophen. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hepatitis B ( DNA) : - Transmission routes : - 1) Parenteral ( IV drug use , needlestick, transfusion ). - 2) Body fluids ( saliva, semen , vaginal fluid ). - 3) Sexual contact. - 4) Perinatal : mother to child at birth. - Associated with both acute and chronic disease. Diagnosis : - Clinical sign and symptoms : nausea , fever , abdominal pain , jaundice. - Serological test. - Combination of serological markers must be reviewed to distinguish acute from chronic infections. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com HBV serologies : Serological marker Abbreviation Comment Surface antigen - HBsAg - First detectable in acute infection ( infection present or not ). Anti surface antigen - Anti-HBs - Confer protective immunity antibody ( but not known from immunity or vaccine ). Anti core antigen - Anti-HBc - Immunity from virus not antibody ( IgG) from vaccine. Anti-E antibody - Anti-HBe - Indicated the replication is stopped. HBV DNA ( PCR viral - HBV DNA - Active HBV replication. load ). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com HBV serologies : - Hepatitis B core antibody , IgM ( IgM anti-HBc ) : positively indicated acute infection. Clinical definition of HBV : - Chronic HBV infection : - HBsAg positive > 6 months. - Serum HBV DNA 20,000 IU / ml. - Lower value 2000 -20000 IU /ml are often observed in HbeAg negative chronic HBV. - Persistent intermittent elevation of AST and ALT. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Clinical definition of HBV : - Inactive HBV carrier state : - HBsAg positive > 6 months. - HBeAg negative and anti-HBeAg positive. - Serum HBV DNA < 2000 IU/ ml. - Persistently normal AST and ALT. Treatment of chronic infection : - Treatment of acute infection is not recommended. - Patients who are HBeAg positive with HBV DNA > 20,000 IU/ml should be treated. - Patients who are HBeAg negative with HBVDNA 2000 -20,000 IU /ml with elevated ALT and fibrosis should be treated. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Treatment of chronic infection : - Patients who are HBeAg negative with positive anti-HBe. Normal ALT and HBV DNA < 2000 IU/ml should be monitored every 3 months for 1 years and then every 6- 12 months if they remain in the carrier state. Monitoring for efficacy should be based on the following : - Biochemical : reduction of liver function tests to within normal range. - Virology : reduction of HBV DNA to undetectable concentration and loss of HBeAg if HBeAg positive , assessed by reduction in HBV DNA for HBeAg negative patients. - A primary nonresponse is considered a decrease in HBV DNA of less than 2 log , after at least 24 weeks of therapy should receive alternative treatmentFlexcil. - The Smart Study Toolkit & PDF, Annotate, Note Drug therapy : This Document has been modified with Flexcil app (Android) https://www.fexcil.com - Reverse transcriptase inhibitors : - In general lamivudine and relbivudine are not preferred as first line therapies because of high rates of resistance. - All reverse transcriptase inhibitors carry a black box warning for development of lactic acidosis and severe hepatomegaly with steatosis. - Monitor for worsening liver function tests. - Reductions in bone mineral density have been associated with long term use. - Tenofovir and entecavir are preferred antivirals in HBV with decompensated cirrhosis. - Lamivudine , tenofovir , entecavir , telbivudine required renal dose adjustment. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Treatment recommendation for chronic HBV infection : - HBeAg positive : - Entecavir and tenofovir are preferred oral agents for minimum of 1 years. - HBeAg negative : - Entecavir and tenofovir are preferred oral agents for > 1 years. - Development of resistant HBV : - Lamivudine , telbivudine or entecavir resistance : add on or switch to tenofovir. - Multidrug resistance : - Combined tenofovir and entecavir. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Preexposure prophylaxis of HBV : - Vaccination : indicated in the following : - 1) All infants born to HBsAg negative mother ( within 12 hours ). - 2) Hemodialysis patients. - 3) Household contacts. - 4) International travelers. - 5) Injection drug user. Postexposure prophylaxis of HBV : - HBV vaccine or immune globulin must be given within 7 days of exposure. - Patients should be unvaccinated previously. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Patient populations requiring postexposure prophylaxis : - A) Perinatal transmission : - B) sexual contact or household contact with an infected person : should receive HBV immune globulin plus vaccine if the exposed patient is previously unvaccinated. - C) Sexual contact or household contact with a HBV carrier : should receive vaccine if the exposed patient is previously unvaccinated. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hepatitis C ( RNA) : - Transmission is mainly blood borne - High risk : 1) Transmission. 2) Intravenous drug abuse. 3) Hemodialysis. - Diagnosis and monitoring : - 1) Clinical sign and symptoms : nausea , abdominal pain , jaundice. - 2) Laboratory : serum anti HCV antibodies as an initial screening for HCV. If positive , confirmatory testing by HCV RNA test ( viral load ). - Sustained virologic response ( SVR) : is undetectable HCV RNA 12 weeks after completion of treatment ( is consider a virologic cure ) Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hepatitis C ( RNA) : - Diagnosis and monitoring : - 3 ) Liver biopsy : give information about fibrosis stage. - 4) Genotyping : six genotypes. - Treatment : - 1) Acute hepatitis C virus ( HCV ) : - - Preexposure or postexposure prophylaxis is not recommended. - - Monitor hepatic panel at 2- 4 weeks interval. - - HCV RNA every 4- 6 weeks for 6- 12 months to detect spontaneous clearance. But if decision to treat the patients monitor for at least 12 weeks to 16 weeks to detect spontaneous clearance. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Hepatitis C ( RNA) : Consider chronic HCV - Treatment : - 1) Chronic hepatitis C virus : - - > 6 months if HCV RNA monitor every 4- 6 weeks for 6 – 12 months. - - > 3 months if decision to treat the patients. - Therapy goal : is to attain a SVR , consider a clinical cure if obtained. - Important note : Monotherapy not used in treatment of HCV. Just multiple therapy. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Drugs : - 1- Ribavirin : - Most common side effect : - A) Hemolytic anemia ( fatigue , scleral icterus and pallor ). - B) Teratogenicity both women and men ( require negative pregnancy up to 6 months after treatment ). - C) Pulmonary dysfunction ( dyspnea ). - 2- Protease inhibitors : - Nonstructural( NS) protein 5A include the following : - A) Ns3 protease inhibitor )previr ). - B) Ns5A protease inhibitor ( asvir ). - C) Ns5B protease inhibitor ( buvir ). Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Drugs : - Glecaprevir / pibrentasvir ( mavyret ) ( Pan genotype ) Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com - Sofosbuvir / velpatasvir( Epclusa ) ( Pan genotype ) Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com - Ledipasvir / sofosbuvir ( 1a , 1b ,4,5 genotype ) Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com - Elbasvir / grazoprevir ( 1a , 1b ,4 genotype ) - Duration of treatment is 12 weeks for all type except for mavyret without cirrhosis 8 weeks. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note  This Document has been modified with Flexcil app (Android) https://www.fexcil.com Monitoring : - Baseline : - HCV RNA , Liver function tests ( LFTs ) , pregnancy test for women taking ribavirin. - On therapy : - - Medication adherence. - - HCV viral load. - After treatment : - Check HCV RNA at 12 weeks to assess for SVR. Flexcil - The Smart Study Toolkit & PDF, Annotate, Note This Document has been modified with Flexcil app (Android) https://www.fexcil.com Flexcil - The Smart Study Toolkit & PDF, Annotate, Note