Treatment of Chronic Hepatitis

Question 1

Indications for tx of chronic HBV infection

Answer 1

1. HBsAg(+) > 6 months*
2. Serum HBV DNA >105 copies/mL
3. Persistent or intermittent elevation in ALT and AST levels
4. tx patients w/advanced liver disease

Question 2

Tx options for HBV

Answer 2

• Interferon
  
  • Finite duration of therapy (1 year)
  • Absence of resistant mutations
  • More durable response
• Nucleoside/tide analoges
  
  • Fewer side effects
  • Resistant mutations
• Goals:
  
  • serocoversion of HBeAg ==> HBeAb
  • negative HBV DNA

Question 3

Types of HCV drugs & MOA

Answer 3

• NS3 Protease Inhibitors ==> prevent HCV protein production
  
  • Simeprevir
  • Telaprevir
  • Boceprevir
• Non-NUC/NUC NS5B inhibitors ==> prevent RNA replication
  
  • Sofosbuvir
• NS5A inhibitors ==> prevents RNA replication/assembly
  
  • Ledipasvir

Question 4

Tx for genotype 2/genotype 3 HCV

Answer 4

• NS5B Polymerase (NUC) Inhibitor (Sofosbuvir) + Ribavirin

Question 5

Tx of genotype 1 HCV + tx duration

Answer 5

• NS5B Polymerase (NUC) Inhibitor + NS5A Protein Inhibitor
  
  • = Sofosbuvir + Ledipasvir
• Tx-naive w/ or w/out cirrhosis = 12 weeks
• Tx-experienced w/cirrhosis = 24 weeks

Question 6

Goal of HCV tx

Answer 6

• Goal = clear HCV RNA such that remain HCV RNA negative 12 weeks after stopping therapy
• Sustained virological response (SVR) = cure

Question 7

Tx for hereditary hemochromatosis

Answer 7

•Treatment is therapeutic phlebotomy
–500 mL of whole blood = 200-250 mg iron
–Endpoint is serum ferritin 50 ng/mL
–Maintenance phlebotomy to keep ferritin 50-100 ng/mL
•For anemic patients not able to tolerate phlebotomy, chelation therapy with desfuroxamine

Question 8

Tx for autoimmune hepatitis

Answer 8

•Treatment based on immune suppression
–Corticosteroids
–Azathioprine
•Relapse typically occurs if treatment stopped after liver enzymes normalized

Question 9

Tx of Primary Biliary Cirrhosis

Answer 9

•Therapy is ursodeoxycolic acid (UDCA)
–Secondary bile acid, metabolic byproduct of intestinal bacteria
–Improves bile acid transport, “detoxifies” bile and providing cytoprotection

Question 10

Indications for Primary Biliary Cirrhosis

Answer 10

–Improved liver biochemistries
–Improve survival
–Reduce need for liver transplantation

Question 11

Tx of Primary Sclerosing Cholangitis

Answer 11

• No effective medical therapy
• Treatment focused on management of complications of bile duct obstruction
  
  • Stenting strictures
  • Antibiotics for cholangitis

Question 12

Tx for Wilson’s Disease

Answer 12

•Treatment is copper chelation
–D-penicillamine
–Trientine
•Maintenance therapy with zinc

Question 13

Tx of Non-alcoholic steatohepatitis

Answer 13

•Treatment focused on modifying risk factors
–Obesity
–Diabetes mellitus type 2
–Dyslipidemia
•Investigational therapies
–Diabetes medications – even if not diabetic
–Vitamin E - antioxidant