What is the next step for a patient with a positive Hepatitis C Virus (HCV) quantification?

Next Steps for Patients with Positive HCV Quantification

After a positive HCV quantification test, the next step is to assess liver disease severity through non-invasive methods such as transient elastography (FibroScan) or serum biomarker panels, and determine the HCV genotype to guide treatment decisions. 1

Initial Assessment After Positive HCV Quantification

Liver Disease Severity Assessment

• Determine the stage of liver fibrosis using:
  • Non-invasive methods (preferred first-line approach):
    • Transient elastography (FibroScan) - values >12.5 kPa suggest cirrhosis 1
    • Serum biomarker panels (e.g., FIB-4, FibroSure, Enhanced Liver Fibrosis Test) 1
  • Liver biopsy (reserved for cases with uncertainty or suspected mixed etiologies) 1

Virological Assessment

• Determine HCV genotype and subtype (1-6) 1
• For genotype 1, subtyping (1a/1b) is important as it affects treatment response rates 1
• Baseline HCV RNA quantification (if not already done) 1

Additional Evaluations

• Hepatic function panel (ALT, AST, bilirubin, albumin, INR) 1
• Complete blood count 1
• Assessment for other causes of liver disease:
  • Test for HBV (HBsAg) and HIV co-infection 1
  • Evaluate alcohol consumption 1
  • Screen for metabolic conditions (diabetes, obesity) 1
  • Consider autoimmune markers if clinically indicated 1

Treatment Considerations

Patient Eligibility Assessment

• Determine if patient is eligible for simplified treatment approach:
  • No prior HCV treatment
  • No decompensated cirrhosis (Child-Turcotte-Pugh score <7)
  • No HIV or HBsAg positivity
  • No pregnancy
  • No known or suspected hepatocellular carcinoma
  • No prior liver transplantation 1

Medication Review

• Perform medication reconciliation to identify potential drug-drug interactions with direct-acting antivirals (DAAs) 1
• Document all current medications including over-the-counter drugs and supplements 1

Treatment Regimen Selection

For most patients without complicating factors, one of these pan-genotypic regimens is recommended:

• Glecaprevir (300 mg)/pibrentasvir (120 mg) for 8-12 weeks depending on cirrhosis status 1
• Sofosbuvir (400 mg)/velpatasvir (100 mg) for 12 weeks 1, 2

Treatment duration and specific regimen will depend on:

• Presence or absence of cirrhosis
• HCV genotype
• Prior treatment history
• Presence of resistance-associated substitutions (in specific cases) 1

Special Considerations

For Patients with Cirrhosis

• If cirrhosis is present, initiate hepatocellular carcinoma surveillance with ultrasound every 6 months 1, 3
• Consider endoscopic screening for esophageal varices 3
• More careful monitoring during treatment may be required 1

For Patients with Comorbidities

• Patients with renal impairment may require adjusted treatment regimens 1
• Patients with diabetes should be monitored for hypoglycemia during treatment 1
• Patients on warfarin require INR monitoring 1

Common Pitfalls to Avoid

1. Failing to assess for HBV co-infection before starting treatment (risk of HBV reactivation) 4
2. Not checking for potential drug-drug interactions with DAAs
3. Delaying treatment in patients with advanced fibrosis or cirrhosis (F3-F4), which can lead to worse outcomes 5
4. Overlooking extrahepatic manifestations of HCV that may improve with treatment 4
5. Not providing adequate patient education about adherence and prevention of reinfection 1

Direct-acting antiviral therapy has revolutionized HCV treatment with cure rates exceeding 95% in most patient populations, making early assessment and prompt treatment initiation crucial for improving long-term outcomes and preventing complications of chronic HCV infection.