What is the recommended treatment for hepatitis C virus (HCV) genotype 1?

Treatment of Hepatitis C Genotype 1 Infection

For patients with hepatitis C genotype 1 infection, the recommended first-line treatment is the fixed-dose combination of sofosbuvir (400 mg) and velpatasvir (100 mg) taken once daily for 12 weeks without ribavirin for both treatment-naïve and treatment-experienced patients, regardless of cirrhosis status 1, 2.

Treatment Options for HCV Genotype 1

First-line Regimen:

• Sofosbuvir/velpatasvir (400 mg/100 mg) once daily for 12 weeks
  • Highly effective across all HCV genotypes (1-6)
  • SVR rates of 98-99% in genotype 1 patients 2, 3
  • No need for ribavirin in most patients
  • Effective in both cirrhotic and non-cirrhotic patients

Alternative Regimens for Genotype 1:

1. For Genotype 1a:

   • Ledipasvir (90 mg)/sofosbuvir (400 mg) daily for 12 weeks 2
   • Paritaprevir (150 mg)/ritonavir (100 mg)/ombitasvir (25 mg) plus dasabuvir (250 mg) with weight-based ribavirin for 12 weeks (no cirrhosis) or 24 weeks (with cirrhosis) 2
   • Sofosbuvir (400 mg) plus simeprevir (150 mg) for 12 weeks (no cirrhosis) or with ribavirin for 12 weeks (with cirrhosis) 2

2. For Genotype 1b:

   • Ledipasvir (90 mg)/sofosbuvir (400 mg) daily for 12 weeks 2
   • Paritaprevir (150 mg)/ritonavir (100 mg)/ombitasvir (25 mg) plus dasabuvir (250 mg) for 12 weeks 2
   • Daclatasvir (60 mg) and sofosbuvir (400 mg) for 12 weeks 2

Special Considerations

Cirrhosis Status:

• For compensated cirrhosis (Child-Pugh A): Same regimens as non-cirrhotic patients in most cases
• For decompensated cirrhosis (Child-Pugh B or C): Sofosbuvir/velpatasvir plus weight-based ribavirin for 12 weeks 4

HBV Co-infection:

• Important safety warning: Test all patients for HBV (HBsAg and anti-HBc) before starting treatment 4
• HBV reactivation has been reported during or after HCV treatment with direct-acting antivirals
• Monitor HBV/HCV co-infected patients for hepatitis flare or HBV reactivation 4

Drug Interactions:

• Check for potential drug interactions, particularly with:
  • Proton pump inhibitors (with ledipasvir/sofosbuvir)
  • Amiodarone (with sofosbuvir-containing regimens)
  • Antiretrovirals in HIV co-infected patients 2, 1

Monitoring and Follow-up

• Monitor for adverse effects: headache, fatigue, and nausea are most common 5, 6
• For patients with cirrhosis, closer monitoring is required
• SVR12 testing (HCV RNA) should be performed 12 weeks after completion of therapy

Efficacy Data

• Sofosbuvir/velpatasvir achieves SVR rates of 98-99% in genotype 1 patients 3, 7
• Efficacy is maintained across different populations including those with cirrhosis 7
• Real-world data from Asian populations shows 97% overall SVR rates 8

Common Pitfalls to Avoid

1. Failing to test for HBV co-infection before starting treatment
2. Not checking for potential drug interactions, especially with commonly used medications
3. Using suboptimal regimens for specific patient populations (e.g., those with prior treatment failure)
4. Not considering resistance-associated substitutions in treatment-experienced patients

The treatment landscape for HCV has dramatically improved with these highly effective direct-acting antiviral regimens, making cure possible for the vast majority of patients with genotype 1 infection, regardless of prior treatment history or cirrhosis status.