What is the recommended treatment for chronic hepatitis C?

Treatment of Chronic Hepatitis C

Direct-acting antiviral (DAA) therapy based on HCV genotype is the recommended treatment for chronic hepatitis C, with specific regimens tailored to genotype, prior treatment experience, and presence of cirrhosis. 1

Treatment Selection by HCV Genotype

Genotype 1a

• Initial treatment (without cirrhosis):

  • Ledipasvir/sofosbuvir for 12 weeks 1
  • Can be shortened to 8 weeks in treatment-naïve patients with HCV RNA <6,000 IU/mL without cirrhosis or HIV co-infection 1
  • Alternative options: Elbasvir/grazoprevir (12 weeks), Ombitasvir/paritaprevir/ritonavir plus dasabuvir with ribavirin (12 weeks), or Sofosbuvir/velpatasvir (12 weeks) 1

• Initial treatment (with compensated cirrhosis):

  • Ledipasvir/sofosbuvir for 12 weeks with ribavirin 1
  • Without ribavirin, extend to 24 weeks if ribavirin is contraindicated 1

Genotype 1b

• Similar regimens to genotype 1a but without ribavirin requirement for some combinations 1

Genotype 2

• Initial treatment:
  • Sofosbuvir and ribavirin for 12 weeks (without cirrhosis) or 16 weeks (with cirrhosis) 1
  • Sofosbuvir/velpatasvir for 12 weeks 1
  • Glecaprevir/pibrentasvir for 8 weeks (without cirrhosis) or 12 weeks (with cirrhosis) 1

Genotype 3

• Initial treatment:
  • Daclatasvir and sofosbuvir for 12 weeks (without cirrhosis) or 24 weeks with ribavirin (with cirrhosis) 1
  • Sofosbuvir/velpatasvir for 12 weeks (without cirrhosis) or with ribavirin (with cirrhosis) 1
  • Glecaprevir/pibrentasvir for 8 weeks (without cirrhosis) or 12 weeks (with cirrhosis) 1

Genotype 4,5, or 6

• Initial treatment:
  • Ledipasvir/sofosbuvir for 12 weeks 1, 2
  • Alternative options: Elbasvir/grazoprevir, Sofosbuvir/velpatasvir, or Glecaprevir/pibrentasvir 1

Special Populations

Treatment-Experienced Patients

• Regimens typically require longer duration (12-24 weeks) and may require ribavirin addition 1
• For genotype 1a with prior treatment failure:
  • Ledipasvir/sofosbuvir with ribavirin for 12 weeks or without ribavirin for 24 weeks 1

Patients with Cirrhosis

• Compensated cirrhosis: May require longer treatment duration or ribavirin addition 1
• Decompensated cirrhosis: Ledipasvir/sofosbuvir with ribavirin for 12 weeks 2, 3

Post-Liver Transplant

• Ledipasvir/sofosbuvir with ribavirin for 12 weeks (genotype 1 or 4) 2, 3

Treatment Monitoring

• Test all patients for HBV co-infection (HBsAg and anti-HBc) before starting treatment 2
• Monitor for HBV reactivation during and after treatment in co-infected patients 2
• Assess for drug interactions, particularly with HIV medications or amiodarone 4

Clinical Considerations

• SVR rates with modern DAA regimens exceed 90-95% for most genotypes and patient populations 5, 6
• Treatment decisions should prioritize the most effective regimen based on genotype and cirrhosis status rather than treatment duration 6
• Patients with decompensated cirrhosis have lower SVR rates (60-88%) compared to those with compensated disease (>95%) 3

Common Pitfalls to Avoid

• Failing to test for HBV before initiating treatment (risk of HBV reactivation) 2
• Shortening treatment duration to 8 weeks in patients with F3 fibrosis or high viral load (>6 million IU/mL) 1
• Overlooking drug interactions, especially with HIV medications or cardiac drugs like amiodarone 4
• Not adjusting ribavirin dosing based on weight and renal function 2

The treatment landscape for hepatitis C has dramatically improved with DAAs, offering high cure rates with shorter treatment durations and fewer side effects compared to older interferon-based regimens.