From the Guidelines
The patient with a hepatitis C viral load of 1,840,000 IU requires immediate antiviral treatment with a direct-acting antiviral (DAA) regimen to reduce the risk of liver disease progression and improve quality of life. The most recent and highest quality study 1 recommends a pangenotypic regimen such as sofosbuvir/velpatasvir (Epclusa) or glecaprevir/pibrentasvir (Mavyret) for treatment-naïve patients without cirrhosis.
Key Considerations
- Before starting treatment, the patient should have:
- HCV genotyping
- Assessment for cirrhosis (FibroScan or other methods)
- Baseline laboratory tests including complete blood count, liver function tests, renal function, and HBV serology
- During treatment, the patient should:
- Avoid alcohol
- Maintain regular follow-up appointments
- Have HCV RNA testing 12 weeks after completing therapy to confirm sustained virologic response (SVR)
Treatment Regimens
- Sofosbuvir/velpatasvir (Epclusa) 400mg/100mg once daily for 12 weeks
- Glecaprevir/pibrentasvir (Mavyret) 300mg/120mg (three tablets) once daily with food for 8 weeks These modern DAA regimens are highly effective with cure rates exceeding 95% and work by directly inhibiting specific steps of HCV replication, preventing the virus from multiplying and eventually eliminating it from the body 1. In contrast, older regimens such as pegylated interferon and ribavirin have lower cure rates and more side effects, as noted in the 2011 study 1. Therefore, the newer DAA regimens are preferred for treatment of hepatitis C.
From the Research
HEP. C RNA Levels and Treatment Outcomes
- The patient's HEP. C RNA level is 1840000 IU/mL, which is below the 6 million IU/mL threshold for an 8-week regimen of ledipasvir and sofosbuvir for treatment-naïve patients without cirrhosis 2.
- Studies have shown that viral load measurements can be useful in predicting sustained virological response (SVR) and non-sustained virological response (NSVR) to treatment 3, 4.
- A study found that a 2-log decline from baseline in viral load provided negative predictive values (NPVs) >95% at weeks 8 and 12 3.
- Another study found that low levels of quantifiable HCV RNA at the end of treatment do not preclude treatment success, with some patients achieving SVR despite having quantifiable HCV RNA at the end of treatment 4.
Treatment Options and Outcomes
- The combination of ledipasvir and sofosbuvir has been shown to be highly effective for a broad spectrum of patients with HCV genotype 1 infection, with SVR rates of 96-98% 2.
- The combination of glecaprevir and pibrentasvir has also been shown to be highly effective, with SVR rates of 86-100% in patients with HCV genotype 1 infection and prior virologic failure to HCV DAA-containing therapy 5.
- A study found that sofosbuvir/velpatasvir plus ribavirin combination therapy was effective for retreatment of HCV after failure of glecaprevir/pibrentasvir therapy, with all 3 patients achieving SVR at 24 weeks after completing treatment 6.