What are the next steps and plan of care for a patient testing positive for Hepatitis C (HCV)?

From the Guidelines

For a patient testing positive for hepatitis C, the next steps involve confirming chronic infection with HCV RNA testing, assessing liver damage through fibrosis evaluation, and determining the viral genotype to guide treatment, as recommended by the most recent guidelines 1. The plan of care should prioritize the patient's morbidity, mortality, and quality of life.

• Confirming chronic infection with HCV RNA testing is essential to determine the presence of the virus and guide treatment decisions, as stated in the 2014 KASL clinical practice guidelines 2.
• Assessing liver damage through fibrosis evaluation (FibroScan or FibroTest) helps determine the extent of liver damage and guides treatment decisions, as recommended in the 2016 KASL clinical practice guidelines 3.
• Determining the viral genotype is crucial to guide treatment decisions, as different genotypes may require different treatment approaches, as stated in the 2014 KASL clinical practice guidelines 4.
• Direct-acting antiviral (DAA) therapy is the standard of care, with regimens like Epclusa (sofosbuvir/velpatasvir) 400mg/100mg once daily for 12 weeks being highly effective for most genotypes, as recommended by the AASLD-IDSA guidelines 5.
• Alternative options include Mavyret (glecaprevir/pibrentasvir) 300mg/120mg daily for 8-12 weeks.
• Treatment monitoring includes HCV RNA testing at 4 weeks to confirm response, at end of treatment, and 12 weeks after completion to verify sustained virologic response (SVR), as stated in the 2014 KASL clinical practice guidelines 2.
• Patients should be screened for hepatitis A and B, with vaccination if not immune, and regular liver function monitoring and abstinence from alcohol are essential, as recommended by the 2015 AASLD-IDSA guidelines 5.
• For patients with cirrhosis, additional monitoring for hepatocellular carcinoma with ultrasound and alpha-fetoprotein testing every 6 months is recommended, as stated in the 2016 KASL clinical practice guidelines 3. The goal of treatment is to achieve a sustained virologic response (SVR), which is associated with improved morbidity, mortality, and quality of life, as recommended by the most recent EASL position paper on clinical follow-up after HCV cure 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps for a Patient Testing Positive for HCV

• If the anti-HCV antibody test result is positive, current infection should be confirmed with a qualitative HCV RNA test 6
• In patients with confirmed HCV infection, quantitative HCV RNA testing and testing for HCV genotype is recommended 6
• An assessment of the degree of liver fibrosis with liver biopsy or noninvasive testing is necessary to determine the urgency of treatment 6

Plan of Care

• Treatment of patients with chronic HCV infection should be considered based on genotype, extent of fibrosis or cirrhosis, prior treatment, comorbidities, and potential adverse effects 6
• The goal of therapy is to reduce all-cause mortality and liver-associated complications 6
• Medication efficacy is now greater than 90%, with a high barrier to resistance and few side effects 7
• Patient and medication factors including genotype, liver disease status, and comorbidities affecting medication choice should be discussed 7

Communication and Follow-up

• Good communication between the physician, the physician's office staff, and the patient is necessary to keep patients engaged and not lost to follow-up after an initial positive HCV antibody test 8
• Point-of-care tests and PCR reflex testing can alleviate the need for HCV antibody positive patients to arrange subsequent office visits to undergo confirmatory HCV RNA testing 8
• Patients should be educated on the possible outcomes of a positive HCV antibody test, the significance of a positive HCV RNA test, and how to prevent further transmission 8

Treatment Options

• Although interferon-based regimens have been the mainstay of treatment for HCV infection, the U.S. Food and Drug Administration recently approved two combination-pill interferon-free treatments (ledipasvir plus sofosbuvir, and ombitasvir/paritaprevir/ritonavir plus dasabuvir) for chronic HCV genotype 1 6
• Interferon alfa has been demonstrated to be effective in the treatment of transfusion-associated hepatitis C 9