What is the recommended treatment for Hepatitis C (Hep C)?

Recommended Treatment for Hepatitis C

The recommended treatment for chronic hepatitis C is a direct-acting antiviral (DAA) regimen, specifically either sofosbuvir/velpatasvir or glecaprevir/pibrentasvir for 8 weeks in most patients without cirrhosis. 1

First-line Treatment Options

Pangenotypic Regimens (Preferred)

• Sofosbuvir/velpatasvir: 400mg/100mg once daily for 8 weeks (without cirrhosis) or 12 weeks (with compensated cirrhosis)
• Glecaprevir/pibrentasvir: 300mg/120mg once daily (three 100mg/40mg tablets) for 8 weeks (without cirrhosis) or 12 weeks (with compensated cirrhosis)

These pangenotypic regimens are effective against all HCV genotypes (1-6), eliminating the need for genotype testing in many cases 1.

Treatment Duration

Treatment duration depends on several factors:

• Without cirrhosis: 8 weeks for most treatment-naïve patients
• With compensated cirrhosis (Child-Pugh A): 8-12 weeks depending on regimen
• With decompensated cirrhosis (Child-Pugh B/C): 12 weeks (sofosbuvir/velpatasvir with ribavirin)
• Treatment-experienced patients: Duration varies from 8-16 weeks based on prior treatment history and HCV genotype 1, 2

Special Populations

Recently Acquired Hepatitis C

• Treat with sofosbuvir/velpatasvir or glecaprevir/pibrentasvir for 8 weeks 1
• SVR should be assessed at 12 and 24 weeks post-treatment due to possibility of late relapses 1

Decompensated Cirrhosis

• Sofosbuvir/velpatasvir with ribavirin is preferred
• Protease inhibitors (glecaprevir, etc.) are contraindicated in Child-Pugh B/C cirrhosis 1

Renal Impairment

• Glecaprevir/pibrentasvir is preferred for severe renal impairment (eGFR <30 ml/min)
• Sofosbuvir is not recommended in patients with eGFR <30 ml/min 1

Pre-treatment Assessment

1. HBV co-infection screening: Test all patients for HBsAg and anti-HBc before starting treatment 2
2. Fibrosis assessment: Determine stage of liver fibrosis (F0-F4)
3. Medication review: Check for potential drug-drug interactions
4. Baseline laboratory tests: Complete blood count, liver function tests, renal function

Monitoring During Treatment

• Minimal monitoring required for most patients due to high safety profile of DAAs 1
• HCV RNA or HCV core antigen at week 12 post-treatment (SVR12) to confirm cure 1
• Monitor for drug-drug interactions throughout treatment 1
• ALT monitoring at weeks 4,8, and 12 of therapy 1
• More frequent monitoring for patients with decompensated cirrhosis or on ribavirin

Treatment Success Rates

Modern DAA regimens achieve sustained virological response (SVR) rates exceeding 95% in most patient populations 3, including historically difficult-to-treat groups:

• Genotype 1 infection (previously hardest to treat)
• Patients with cirrhosis
• Prior treatment failures

Common Pitfalls and Caveats

1. HBV reactivation: Test all patients for HBV before starting treatment; monitor HBV/HCV co-infected patients for hepatitis flares 2

2. Drug interactions: Review all medications (including over-the-counter and recreational drugs) before starting treatment 1

3. Treatment discontinuation: Stop treatment immediately for severe adverse events or ALT flares >10 times upper limit of normal 1

4. Post-treatment monitoring: Patients with advanced fibrosis (F3) or cirrhosis (F4) require continued HCC surveillance every 6 months indefinitely, even after achieving SVR 1

5. Ribavirin dose adjustment: In patients with decompensated cirrhosis receiving ribavirin, reduce dose if hemoglobin drops below 10 g/dl; stop if below 8.5 g/dl 1

The introduction of DAAs has revolutionized hepatitis C treatment, making it a highly curable infection with short treatment durations and minimal side effects compared to older interferon-based regimens 3, 4.