What are the treatment options for hepatitis C (HCV) and hepatitis B (HBV) co-infection?

Treatment Options for HCV and HBV Co-infection

Patients with HCV-HBV co-infection should be treated with the same anti-HCV regimens as HCV monoinfected patients, while carefully monitoring for HBV reactivation and providing prophylactic HBV treatment when indicated. 1

Initial Assessment for Co-infection

• Test all patients with HCV for evidence of current or prior HBV infection before starting treatment:
  • HBs antigen (HBsAg)
  • Anti-HBc antibodies
  • Anti-HBs antibodies 1, 2, 3
• Test for HIV co-infection if status is unknown 1
• Assess replicative status of both viruses and exclude hepatitis D virus infection 1

Treatment Approach for HCV in Co-infected Patients

Recommended HCV Treatment Regimens

1. For all genotypes without cirrhosis or with compensated cirrhosis:

   • Pangenotypic direct-acting antiviral (DAA) regimens are preferred:
     • Sofosbuvir/velpatasvir for 12 weeks
     • Glecaprevir/pibrentasvir for 8-12 weeks (duration based on genotype and treatment history)
     • Sofosbuvir/velpatasvir/voxilaprevir (for specific cases) 1

2. For genotype 1 specifically:

   • Sofosbuvir/ledipasvir for 8-12 weeks (treatment-naïve without cirrhosis may qualify for 8 weeks if HCV RNA <6 million IU/mL) 2, 4, 5
   • Grazoprevir/elbasvir for 12 weeks (especially for genotype 1b) 1

3. For patients with decompensated cirrhosis:

   • Sofosbuvir/velpatasvir + ribavirin for 12 weeks (if eGFR >30 ml/min/1.73 m²)
   • Sofosbuvir/velpatasvir without ribavirin for 24 weeks (if eGFR <30 ml/min/1.73 m²) 1

Concurrent HBV Management

HBV Treatment Strategy

1. For HBsAg-positive patients:

   • Provide nucleoside/nucleotide analogue prophylaxis according to EASL guidelines
   • Continue HBV treatment at least until 12 weeks post-HCV therapy
   • Monitor monthly if HBV treatment is stopped 1

2. For HBsAg-negative but anti-HBc positive patients:

   • Monitor ALT levels monthly
   • Test HBsAg and HBV DNA if ALT levels do not normalize or rise during/after HCV therapy 1

Risk of HBV Reactivation

• HBV reactivation can occur during or after HCV clearance
• In a study of 111 Taiwanese co-infected patients, approximately two-thirds experienced increased HBV DNA levels after HCV treatment
• Only 5 patients had significant ALT elevation (>2× ULN) and only 2 required HBV treatment initiation 1
• Some cases of HBV reactivation have resulted in fulminant hepatitis, hepatic failure, and death 2, 3

Special Considerations

Renal Impairment

• For severe renal impairment (eGFR <30 ml/min/1.73 m²):
  • Glecaprevir/pibrentasvir is preferred
  • For genotype 1b only, grazoprevir/elbasvir is an alternative 1

Cirrhosis Status

• Treatment duration may need extension for patients with cirrhosis
• Patients with decompensated cirrhosis require specialized regimens with careful monitoring 1

Treatment Efficacy

• Modern DAA regimens achieve high SVR rates (>95%) in co-infected patients, similar to HCV monoinfection 1, 4, 6
• In the Taiwanese study, 100% of co-infected patients achieved SVR with sofosbuvir/ledipasvir for 12 weeks 1

Common Pitfalls to Avoid

1. Failing to screen for HBV before HCV treatment - All patients must be tested for HBsAg and anti-HBc before starting HCV therapy 2, 3

2. Not providing HBV prophylaxis - HBsAg-positive patients should receive nucleoside/nucleotide analogue prophylaxis during and after HCV treatment 1

3. Inadequate monitoring - Regular monitoring for HBV reactivation is essential, especially in the post-treatment period 1

4. Overlooking drug interactions - Carefully evaluate potential interactions between HCV DAAs and HBV antivirals 1

By following these evidence-based recommendations, clinicians can effectively manage HCV-HBV co-infection while minimizing the risk of HBV reactivation and optimizing treatment outcomes.