Recommendation After 17-Day Gap in Mavyret Treatment for Hepatitis C
After a 17-day gap in Mavyret (glecaprevir/pibrentasvir) treatment for hepatitis C, patients should restart the treatment and complete the full originally prescribed course, with consultation from a multidisciplinary team including experienced hepatologists and virologists to determine if any treatment modifications are needed. 1
Understanding the Situation
A 17-day interruption in Mavyret therapy represents a significant gap that could potentially impact treatment efficacy. When addressing this situation, we need to consider:
- The risk of developing resistance-associated substitutions (RASs)
- The impact on sustained virologic response (SVR)
- The appropriate course of action to maximize treatment success
Recommended Approach
Step 1: Immediate Consultation
Contact a hepatologist or multidisciplinary team experienced in HCV treatment as soon as possible. The EASL guidelines specifically recommend that "patients who failed after any of the DAA-containing treatment regimens should be retreated in the context of a multidisciplinary team including experienced treaters and virologists" 1.
Step 2: Resistance Testing
Consider HCV resistance testing to determine if resistance-associated substitutions have developed during the treatment gap. This is particularly important since:
- Resistance testing "is useful to guide retreatment by probabilities of response, according to the resistance profile observed" 1
- Pibrentasvir has a higher barrier to resistance than other NS5A inhibitors, but resistance can still develop 1
Step 3: Treatment Approach Based on Patient Status
For patients without cirrhosis:
- Restart Mavyret and complete the originally prescribed course (typically 8 weeks) 1
- Monitor HCV RNA levels at restart, week 4, end of treatment, and 12 weeks post-treatment 1
For patients with compensated cirrhosis:
- Restart Mavyret and complete a full 12-week course 1
- Consider extending treatment duration if there are concerns about resistance
For patients with decompensated cirrhosis:
- Mavyret is contraindicated in decompensated cirrhosis
- Switch to a sofosbuvir/velpatasvir-based regimen with ribavirin for 24 weeks 1
Important Considerations
Monitoring
- Perform HCV RNA testing at restart, week 2 (to assess adherence), week 4, end of treatment, and 12 weeks post-treatment 1
- Monitor for adverse events, particularly in patients receiving ribavirin
Potential Pitfalls to Avoid
Don't assume treatment failure: A gap in therapy doesn't automatically mean treatment has failed. Mavyret has a high barrier to resistance, particularly with pibrentasvir 1.
Don't restart without expert consultation: Treatment decisions after interruption should be made by specialists with experience in HCV management 1.
Don't ignore the possibility of resistance: While uncommon with Mavyret, resistance can develop, particularly with longer interruptions 1.
Don't overlook adherence issues: Address factors that led to the treatment gap to prevent recurrence.
If Treatment Fails After Restart
If SVR is not achieved after restarting and completing Mavyret therapy, the recommended retreatment option is:
- Sofosbuvir/velpatasvir/voxilaprevir for 12 weeks 1, 2
- This regimen has shown 94% efficacy in patients who previously failed Mavyret therapy 2
Conclusion
A 17-day gap in Mavyret therapy is concerning but manageable. The key is prompt consultation with specialists, consideration of resistance testing, and completion of the full treatment course with appropriate monitoring.