What is the recommended treatment for a patient with a current Hepatitis C (Hep C) infection?

Treatment of Current Hepatitis C Infection

The recommended first-line treatment for patients with current hepatitis C infection is a direct-acting antiviral (DAA) regimen consisting of either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8 weeks, regardless of HCV genotype. 1, 2

Initial Assessment

Before starting treatment:

• Test for evidence of current or prior HBV infection (HBsAg and anti-HBc) 3, 4
• Assess for cirrhosis using non-invasive methods:
  • Calculate FIB-4 score
  • Consider cirrhosis present if FIB-4 >3.25, transient elastography >12.5 kPa, or clinical evidence of cirrhosis 2
• Check for potential drug-drug interactions 2
• Evaluate for other conditions that may accelerate liver fibrosis (HIV, HBV) 2

Treatment Regimens

For patients without cirrhosis or with compensated cirrhosis (Child-Pugh A):

• First-line options:
  • Sofosbuvir/velpatasvir (400mg/100mg) once daily for 12 weeks 3, 1
  • Glecaprevir/pibrentasvir (300mg/120mg) once daily for 8 weeks 1, 2

For patients with decompensated cirrhosis (Child-Pugh B or C):

• Sofosbuvir/velpatasvir plus ribavirin for 12 weeks 3, 1
  • Ribavirin dosing: 1,000 mg daily for patients <75 kg, 1,200 mg daily for patients ≥75 kg (divided twice daily) 3

Special Populations

Patients with renal impairment:

• Glecaprevir/pibrentasvir is preferred for severe renal impairment (eGFR <30 mL/min) 1
• Sofosbuvir-based regimens should be used with caution in moderate renal impairment 1

HIV/HCV co-infection:

• Same regimens as HCV monoinfection, but carefully check for drug interactions with antiretroviral therapy 1

Liver transplant recipients:

• Without cirrhosis or with compensated cirrhosis: sofosbuvir/velpatasvir for 12 weeks 2, 1

Monitoring During Treatment

• No routine laboratory monitoring required for most patients 2
• For patients on diabetes medications: monitor for hypoglycemia 2
• For patients on warfarin: monitor INR for subtherapeutic anticoagulation 2
• Consider in-person or telehealth visit for patient support and symptom assessment 2

Assessment of Cure

• Check quantitative HCV RNA at least 12 weeks after completing therapy to confirm sustained virological response (SVR) 2, 1
• SVR is defined as undetectable HCV RNA 12 weeks post-treatment and is equivalent to viral eradication 5, 6
• Assess hepatic function panel to confirm transaminase normalization 2

Follow-up for Non-responders

• Patients who fail initial treatment should be evaluated for retreatment by a specialist 2
• For those unable to be retreated, assess for disease progression every 6-12 months with hepatic function panel, CBC, and INR 2

Important Considerations

• Advise patients to abstain from alcohol during and after treatment 2
• Vaccination against hepatitis A, hepatitis B, and pneumococcal infection (for cirrhotic patients) is recommended 2
• Patients with cirrhosis require continued HCC surveillance every 6 months even after achieving SVR 1

Treatment Evolution

Modern DAA therapy has transformed HCV treatment with cure rates exceeding 95% in most patient populations, compared to the 40-50% cure rates with older interferon-based regimens 1, 6. These treatments are highly effective, well-tolerated, and have minimal side effects compared to previous therapies 6.