CSP Clinical Management: Infectious Disease 2 — Questions and Answers
Question 1: A treatment-naive patient with chronic HCV genotype 3 and no cirrhosis starts glecaprevir/pibrentasvir. What is the recommended treatment duration?
- 16 weeks
- 12 weeks
- 8 weeks (Correct answer)
- 24 weeks
Correct answer: 8 weeks
Glecaprevir/pibrentasvir is given for 8 weeks to treatment-naive patients of any genotype, with or without compensated cirrhosis.
Question 2: A patient starting sofosbuvir/velpatasvir also takes amiodarone. What is the primary safety concern?
- Serious symptomatic bradycardia (Correct answer)
- Increased risk of HCV virologic failure
- QT prolongation with torsades de pointes
- Severe hepatotoxicity
Correct answer: Serious symptomatic bradycardia
Giving sofosbuvir with amiodarone can cause serious, sometimes fatal, symptomatic bradycardia.
Question 3: Before starting direct-acting antiviral therapy for HCV, which screening is required because of a boxed warning?
- HLA-B*5701 genotype
- Baseline NS5A resistance testing for all genotypes
- CYP2C19 metabolizer status
- HBsAg and anti-HBc to assess hepatitis B reactivation risk (Correct answer)
Correct answer: HBsAg and anti-HBc to assess hepatitis B reactivation risk
HCV DAAs carry a boxed warning for HBV reactivation, so all patients need HBV screening first.
Question 4: A patient on sofosbuvir/velpatasvir needs a proton pump inhibitor. Why is this combination a concern?
- PPIs induce CYP3A4 metabolism of sofosbuvir
- Higher gastric pH lowers velpatasvir solubility and absorption (Correct answer)
- Velpatasvir greatly raises PPI levels
- PPIs increase the risk of HBV reactivation
Correct answer: Higher gastric pH lowers velpatasvir solubility and absorption
Velpatasvir solubility drops as pH rises, so if a PPI is needed, the DAA should be taken with food 4 hours before omeprazole 20 mg.
Question 5: Which HCV regimen is contraindicated in a patient with decompensated (Child-Pugh B or C) cirrhosis?
- Sofosbuvir/velpatasvir
- Glecaprevir/pibrentasvir (Correct answer)
- Ledipasvir/sofosbuvir
- Sofosbuvir/velpatasvir plus ribavirin
Correct answer: Glecaprevir/pibrentasvir
Regimens containing an NS3/4A protease inhibitor, such as glecaprevir, are contraindicated in decompensated cirrhosis because of hepatotoxicity risk.
Question 6: How is HCV cure (sustained virologic response) defined?
- Undetectable HCV RNA at week 4 of therapy
- Normal ALT at the end of therapy
- Negative HCV antibody 6 months after therapy
- Undetectable HCV RNA 12 weeks after the end of therapy (Correct answer)
Correct answer: Undetectable HCV RNA 12 weeks after the end of therapy
SVR12, meaning undetectable HCV RNA 12 weeks after completing treatment, is considered a virologic cure.
Question 7: Which patient could shorten ledipasvir/sofosbuvir therapy to 8 weeks?
- Treatment-naive, genotype 1, non-cirrhotic, HCV RNA below 6 million IU/mL, HIV-negative (Correct answer)
- Treatment-naive, genotype 3, non-cirrhotic
- Treatment-experienced, genotype 1, compensated cirrhosis
- Treatment-naive, genotype 1, HIV-coinfected, HCV RNA 8 million IU/mL
Correct answer: Treatment-naive, genotype 1, non-cirrhotic, HCV RNA below 6 million IU/mL, HIV-negative
The 8-week ledipasvir/sofosbuvir course is reserved for treatment-naive, non-cirrhotic, HIV-negative genotype 1 patients with baseline HCV RNA below 6 million IU/mL.
