From the Guidelines
Patients with a history of hepatitis C should be referred to a specialist experienced in the management of hepatitis, such as a gastroenterologist or hepatologist, to establish long-term care. This referral is crucial as hepatitis C is a genetically diverse RNA virus with 6 different genotypes that affect the choice and efficacy of treatment regimens 1. The goal of treatment is to achieve SVR, defined as undetectable HCV RNA 12 to 24 weeks after completing treatment, which is considered curative.
When referring a patient with hepatitis C history, it is essential to consider the following key points:
- The patient should refrain from using alcohol, as even modest amounts can be associated with progression of liver disease 1.
- Patients with advanced liver disease may require dosage adjustments for some medications, while those with normal hepatic function typically do not need dosage adjustments for most prescription and over-the-counter medications 1.
- Patients should receive counseling about transmission prevention, such as avoidance of sharing personal hygiene articles and avoidance of needle sharing in the setting of intravenous drug use 1.
The specialist will likely order additional tests such as viral load quantification, genotype determination, liver function tests, and possibly imaging or a liver biopsy to assess liver damage. Treatment typically involves direct-acting antiviral medications, which have cure rates exceeding 95% with 8-12 week treatment courses. Regular monitoring during and after treatment is necessary to confirm viral clearance and assess liver health. Early referral is crucial because untreated hepatitis C can progress to cirrhosis, liver failure, or hepatocellular carcinoma over time.
From the Research
Referral Options for Patients with Hepatitis C History
When referring a patient with a history of hepatitis C, several factors should be considered, including the severity of liver disease, treatment history, and presence of cirrhosis.
- Patients with advanced liver disease, including those with decompensated cirrhosis, may benefit from treatment with ledipasvir, sofosbuvir, and ribavirin, as shown in a study published in The Lancet. Infectious diseases 2.
- For patients with genotype 3 infection and advanced liver disease, the combination of daclatasvir, sofosbuvir, and ribavirin has been shown to be effective, with high rates of sustained virological response (SVR12) achieved in a phase III study published in Hepatology (Baltimore, Md.) 3.
- Primary care physicians can monitor and provide treatment for most patients with chronic hepatitis C, using one of two pangenotypic regimens: glecaprevir-pibrentasvir or sofosbuvir-velpatasvir, as recommended in FP essentials 4.
- Patients who do not achieve SVR12 should be referred to a subspecialist experienced in the management of treatment failure 4.
- In cases of acute hepatitis C infection with decompensated cirrhosis, treatment with sofosbuvir and ribavirin may be effective, as reported in a case study published in Medicine 5.
Specialist Referral
Patients with complex cases of hepatitis C, such as those with decompensated cirrhosis or treatment failure, may require referral to a specialist, such as a hepatologist.
- A hepatologist's approach to hepatitis C involves the use of liver biopsy, virus load determination, and genotyping in the pretreatment evaluation and monitoring of patients, as discussed in Clinical infectious diseases 6.