Recommended Treatment for Hepatitis C
The recommended first-line treatment for hepatitis C is sofosbuvir/velpatasvir for 12 weeks, which is effective across all HCV genotypes (1-6) regardless of cirrhosis status or treatment experience. 1
Treatment Regimens Based on Patient Characteristics
For Non-Cirrhotic Patients:
Treatment-naïve and treatment-experienced patients with genotypes 1a, 1b, 2,4,5, or 6:
Treatment-naïve patients with genotype 3:
Treatment-experienced patients with genotype 3:
For Compensated Cirrhosis (Child-Pugh A):
Treatment-naïve patients with genotypes 1a, 1b, 2,4,5, or 6:
Treatment-experienced patients with genotypes 1a, 1b, 2,4,5, or 6:
Treatment-naïve patients with genotype 3:
Treatment-experienced patients with genotype 3:
For Decompensated Cirrhosis (Child-Pugh B or C):
- All genotypes:
- Sofosbuvir/velpatasvir with weight-based ribavirin for 12 weeks 2
Special Considerations
NS5A Resistance Testing
- For genotype 3 patients with compensated cirrhosis, if NS5A resistance testing is performed:
Ribavirin Dosing
- Weight-based ribavirin dosing: 1,000 mg daily for patients <75 kg and 1,200 mg daily for patients ≥75 kg, divided into two doses 2
- For patients with contraindications to ribavirin: Consider extending treatment duration to 24 weeks 1
HBV Co-infection Warning
- Test all patients for evidence of current or prior HBV infection (HBsAg and anti-HBc) before starting HCV treatment 2
- HBV reactivation has been reported in HCV/HBV co-infected patients during or after DAA therapy, with some cases resulting in fulminant hepatitis, hepatic failure, and death 2
- Monitor co-infected patients for hepatitis flare or HBV reactivation during and after treatment 2
Treatment Efficacy
Real-world evidence from a study of 5,552 patients treated with sofosbuvir/velpatasvir showed an overall SVR rate of 98.9%, including 98.3% in genotype 3 patients and 97.9% in those with compensated cirrhosis 3. This confirms the high effectiveness of this regimen across diverse patient populations.
Common Side Effects
The most common adverse events with sofosbuvir/velpatasvir are headache, fatigue, and nausea 4. The regimen is generally well-tolerated with low rates of serious adverse events 5.
Key Pitfalls to Avoid
- Failing to test for HBV co-infection before starting treatment
- Not considering drug interactions, particularly with proton pump inhibitors and amiodarone
- Inadequate monitoring of patients with cirrhosis
- Not recognizing the need for ribavirin in specific populations, especially those with decompensated cirrhosis or certain resistance patterns
- Losing patients to follow-up (a significant cause of non-SVR in real-world settings) 3
The pangenotypic nature of sofosbuvir/velpatasvir makes it an ideal first-line choice for hepatitis C treatment, simplifying the approach to therapy while maintaining excellent cure rates across all patient populations.