What is the treatment for hepatitis?

Treatment of Hepatitis C

Antiviral therapy should be considered for all patients with hepatitis C who have no contraindications to treatment, with treatment regimens tailored to the specific HCV genotype. 1

Diagnosis and Evaluation

Before initiating treatment, proper diagnosis and evaluation are essential:

• Test anti-HCV in patients suspected of having acute or chronic HCV infection
• Confirm diagnosis with HCV RNA testing in patients with positive anti-HCV
• Perform HCV RNA quantitative assay and genotyping prior to treatment
• Assess liver disease severity through liver biopsy or non-invasive tests for fibrosis

Treatment Approach by Clinical Presentation

Acute Hepatitis C

• Antiviral therapy is recommended for acute hepatitis C 1
• Treatment can be delayed for 8-12 weeks after onset to allow for potential spontaneous recovery (occurs in 15-45% of cases) 1
• Preferred treatment: Peginterferon alpha monotherapy for 24 weeks 1
• SVR rates of 80-90% can be achieved with this approach 1

Chronic Hepatitis C

Treatment decisions should be based on:

1. Genotype determination - critical for selecting appropriate regimen
2. Fibrosis assessment - patients with significant fibrosis (≥F2) and advanced fibrosis (F3-4) should be prioritized for treatment 1
3. Previous treatment history - treatment-naïve vs. treatment-experienced

Current preferred regimens (by genotype):

Genotype 1:

• Sofosbuvir/ledipasvir for 12 weeks (no ribavirin) 1
• Sofosbuvir/velpatasvir for 12 weeks (no ribavirin) 1
• Ombitasvir/paritaprevir/ritonavir and dasabuvir (duration and ribavirin use depends on subtype and cirrhosis status) 1

Genotype 2:

• Sofosbuvir/velpatasvir for 12 weeks (no ribavirin) 1

Genotype 3:

• Sofosbuvir/velpatasvir for 12 weeks (consider adding ribavirin in patients with NS5A RAS Y93H) 1

Genotype 4,5,6:

• Sofosbuvir/ledipasvir or sofosbuvir/velpatasvir for 12 weeks 1

Contraindications to Treatment

Absolute contraindications to peginterferon alpha and ribavirin include 1:

• Uncontrolled psychiatric illness or depression
• Uncontrolled autoimmune disease
• Transplantation of solid organ (except liver)
• Untreated thyroid illness
• Pregnancy or unwillingness to use adequate contraception
• Severe concurrent medical illness (poorly controlled hypertension, heart failure, coronary heart disease, diabetes, COPD)
• Age ≤2 years
• Hypersensitivity to treatment medications

Monitoring During Treatment

Close monitoring is essential to manage adverse effects and assess treatment response:

• Monitor for flu-like symptoms, fatigue, depression, anemia, and other common side effects
• Patients who receive ≥80% of planned doses have significantly higher SVR rates (63% vs. 52%) 1
• For genotype 1, lack of early virologic response (<2 log decrease in HCV RNA) predicts failure to achieve SVR 2

Treatment Goals and Outcomes

The primary goals of hepatitis C treatment are 1:

1. Eradicate HCV
2. Prevent complications and mortality from liver cirrhosis
3. Prevent hepatocellular carcinoma
4. Improve quality of life

Success is measured by achieving sustained virologic response (SVR), defined as undetectable serum HCV RNA 12 or 24 weeks after treatment completion. SVR is associated with:

• Improved histological hepatic fibrosis in >90% of patients
• Decreased complications of cirrhosis
• Decreased occurrence of hepatocellular carcinoma
• Improved survival rates

Special Considerations

• Cirrhosis: Treatment should be individualized, with careful monitoring for decompensation
• HIV co-infection: Similar response rates can be achieved, but treatment should be coordinated with HIV management
• Renal impairment: Dose adjustments may be necessary; avoid nephrotoxic agents

Pitfalls to Avoid

1. Delayed treatment in patients with advanced fibrosis - these patients should be treated promptly to prevent progression to cirrhosis and HCC
2. Inadequate pre-treatment evaluation - genotyping and fibrosis assessment are essential for treatment planning
3. Poor adherence management - support systems should be in place to ensure treatment completion 3
4. Insufficient monitoring - regular monitoring is needed to manage side effects and ensure treatment success

The landscape of hepatitis C treatment has evolved dramatically with the introduction of direct-acting antivirals (DAAs), which have largely replaced interferon-based therapies in many settings due to higher efficacy and better tolerability. However, treatment decisions should always be based on the most current guidelines and individual patient factors.