What monitoring is required after completing treatment for hepatitis C?

Post-Treatment Monitoring for Hepatitis C

After achieving a sustained virologic response (SVR), monitoring requirements differ based on the patient's fibrosis stage, with patients with advanced fibrosis requiring continued surveillance for hepatocellular carcinoma and varices, while those without advanced fibrosis need minimal follow-up.

Monitoring Based on Fibrosis Stage

For Patients Without Advanced Fibrosis (Metavir F0-F2)

• One final assessment at 48 weeks post-treatment is recommended, including:
  • ALT and HCV RNA testing 1
  • If ALT is normal and HCV RNA remains undetectable, the patient can be discharged from hepatitis C-specific care 1
• No additional hepatitis C-specific follow-up is recommended after this point 1

For Patients With Advanced Fibrosis (Metavir F3) or Cirrhosis (F4)

• Continued surveillance is required:
  • Hepatocellular carcinoma (HCC) screening with ultrasound every 6 months indefinitely 1
  • Disease progression assessment every 6-12 months with:
    • Hepatic function panel (liver enzymes, albumin, bilirubin)
    • Complete blood count
    • International normalized ratio (INR) 1
  • Endoscopic surveillance for esophageal varices if cirrhosis is present 1
    • If varices were present at pre-treatment endoscopy, continue surveillance per guidelines 1
    • If no varices are identified 2-3 years post-SVR, cessation of further endoscopic screening can be considered on an individual basis 1

Special Considerations

Assessment for Other Liver Diseases

• Patients with persistently abnormal liver enzymes after achieving SVR should be evaluated for other causes of liver disease 1, 2, such as:
  • Alcoholic liver disease
  • Nonalcoholic fatty liver disease
  • Other hepatotoxins
  • Medication effects

Monitoring for Reinfection

• For patients with ongoing risk factors (e.g., injection drug use, men who have sex with men engaging in high-risk behaviors):
  • Annual HCV RNA assessment is recommended 1
  • Risk reduction counseling should be provided 1

Thyroid Function Monitoring

• If the patient received interferon-based therapy, thyroid-stimulating hormone and thyroxine levels should be assessed 1 and 2 years after treatment 1
• Not necessary for patients treated with direct-acting antivirals only

Practical Implementation

1. At 12 weeks post-treatment:

   • Confirm SVR with HCV RNA testing and hepatic function panel 1

2. At 48 weeks post-treatment:

   • Final HCV RNA and ALT testing for all patients
   • If normal and patient has F0-F2 fibrosis → discharge from hepatitis C care
   • If F3-F4 fibrosis → continue surveillance as outlined above

3. Ongoing monitoring for F3-F4 patients:

   • HCC surveillance with ultrasound every 6 months (consider adding AFP) 1
   • Hepatic function assessment every 6-12 months
   • Variceal screening per endoscopic findings

Common Pitfalls to Avoid

• Do not discharge patients with advanced fibrosis/cirrhosis from surveillance - they remain at risk for HCC despite achieving SVR 1
• Do not assume normal ALT post-SVR means absence of other liver disease - evaluate persistently abnormal liver enzymes for other causes 2
• Do not overlook the risk of HBV reactivation - monitor HBV/HCV co-infected patients for hepatitis flares during and after treatment 2, 3
• Do not neglect monitoring for reinfection in high-risk populations 1