Treatment for Acute Hepatitis C
Patients with acute hepatitis C should be treated with a combination of sofosbuvir and an NS5A inhibitor (ledipasvir, velpatasvir, or daclatasvir) for 8 weeks without ribavirin to prevent progression to chronic hepatitis C. 1
First-Line Treatment Options
Recommended Regimens (by genotype):
- All genotypes: Sofosbuvir/velpatasvir for 8 weeks
- Genotypes 1,4,5,6: Sofosbuvir/ledipasvir for 8 weeks
- All genotypes: Sofosbuvir/daclatasvir for 8 weeks
Extended Treatment Duration (12 weeks) for:
- Patients with HIV coinfection
- Patients with baseline HCV RNA >1 million IU/ml (6.0 log IU/ml)
Treatment Rationale
The treatment landscape for acute hepatitis C has evolved significantly:
- 2011 Guidelines: Previously recommended pegylated IFN-α monotherapy for 24 weeks, achieving >90% SVR rates 1
- 2015 Guidelines: Shifted to pegylated IFN-α combined with ribavirin for 24 weeks in HIV-coinfected patients 1
- Current Guidelines (2017): Recommend IFN-free direct-acting antiviral (DAA) regimens for 8 weeks 1
This evolution reflects the superior efficacy, safety profile, and tolerability of DAA regimens compared to interferon-based therapies.
Treatment Timing
The optimal timing for initiating treatment remains somewhat debated:
- Some experts suggest starting at the onset of ALT elevation (with or without symptoms) 1
- Others recommend monitoring HCV RNA levels every 4 weeks and treating only those who remain positive at 12 weeks from onset 1
Given the high efficacy and excellent safety profile of current DAA regimens, early treatment is generally preferred to prevent progression to chronic infection.
Monitoring During and After Treatment
- Measure HCV RNA at baseline, during treatment, at end of treatment, and 12 weeks post-treatment
- SVR should be assessed at both 12 and 24 weeks post-treatment due to rare reports of late relapses 1
- Monitor for potential drug-drug interactions, particularly with HIV medications
Special Considerations
HIV Coinfection
- HIV-positive patients with acute HCV should receive the same DAA regimens but may benefit from extended 12-week treatment duration 1, 2
- A 2019 study demonstrated 100% SVR12 rates with various DAA regimens in HIV/HCV coinfected patients 2
Post-Exposure Prophylaxis
- There is currently no indication for antiviral therapy as post-exposure prophylaxis in the absence of documented HCV transmission 1
Treatment Efficacy
Modern DAA regimens have demonstrated excellent efficacy in acute HCV:
- High SVR rates (>90%) have been reported with sofosbuvir-based regimens 1
- A 2019 study showed 100% SVR12 rates with various DAA regimens in HIV/HCV coinfected patients with acute hepatitis C 2
Common Pitfalls to Avoid
Delaying treatment unnecessarily: While spontaneous clearance occurs in some patients (particularly those with symptomatic disease, female gender, young age, and favorable IL28B genotype), none of these factors reliably predicts resolution at the individual level 1
Using outdated interferon-based regimens: Modern DAA regimens offer superior efficacy and tolerability compared to older interferon-based treatments
Inadequate follow-up: Ensure SVR assessment at both 12 and 24 weeks post-treatment due to possibility of late relapses 1
Administering post-exposure prophylaxis: There is no indication for antiviral therapy as post-exposure prophylaxis without documented HCV transmission 1