What is the recommended treatment for Hepatitis C (HCV)?

Recommended Treatment for Hepatitis C (HCV)

The recommended first-line treatment for hepatitis C is sofosbuvir/velpatasvir (400mg/100mg) once daily for 12 weeks, regardless of HCV genotype (1-6), prior treatment experience, or compensated cirrhosis status, with sustained virologic response rates exceeding 95%. 1

Treatment Regimens by Genotype

First-Line Options

• Sofosbuvir/velpatasvir (400mg/100mg): Once daily for 12 weeks for all genotypes (1-6)
• Ledipasvir/sofosbuvir (90mg/400mg): Once daily for 8-12 weeks for genotypes 1,4,5, and 6

Genotype-Specific Recommendations

Genotype 1

• Sofosbuvir/velpatasvir for 12 weeks
• Ledipasvir/sofosbuvir for 8-12 weeks (8 weeks for treatment-naïve, non-cirrhotic patients with baseline HCV RNA <6 million IU/mL) 2
• Alternative: Paritaprevir/ritonavir/ombitasvir plus dasabuvir 1

Genotype 2

• Sofosbuvir/velpatasvir for 12 weeks
• Alternative: Sofosbuvir plus ribavirin for 12 weeks 1

Genotype 3

• Sofosbuvir/velpatasvir for 12 weeks
• Alternative: Sofosbuvir plus ribavirin for 24 weeks 1, 3

Genotypes 4,5,6

• Sofosbuvir/velpatasvir for 12 weeks
• Ledipasvir/sofosbuvir for 12 weeks 1, 4

Treatment Duration Based on Patient Characteristics

Non-Cirrhotic Patients

• 8-12 weeks of therapy depending on regimen and patient factors 1
• For ledipasvir/sofosbuvir, 8 weeks can be considered for treatment-naïve genotype 1 patients without cirrhosis and baseline HCV RNA <6 million IU/mL 2

Compensated Cirrhosis (Child-Pugh A)

• 12 weeks of standard DAA regimens 1
• Consider extending therapy to 24 weeks in treatment-experienced patients with genotype 1 and cirrhosis

Decompensated Cirrhosis (Child-Pugh B or C)

• Sofosbuvir/velpatasvir + ribavirin for 12 weeks 1
• Avoid protease inhibitors due to risk of toxicity
• Ledipasvir/sofosbuvir with ribavirin for 12-24 weeks is another option 5

Special Populations

Acute Hepatitis C

• Treat with sofosbuvir and an NS5A inhibitor (ledipasvir, velpatasvir, or daclatasvir) for 8 weeks without ribavirin 5
• For patients with HIV coinfection or high baseline HCV RNA (>1 million IU/mL), consider 12 weeks of therapy 5

HIV Coinfection

• Same regimens as HCV mono-infected patients 1
• Pay attention to potential drug interactions with antiretroviral medications

Post-Liver Transplant

• Ledipasvir/sofosbuvir with ribavirin for 12 weeks 1

Renal Impairment

• For mild to moderate renal impairment (CrCl >30-80 mL/min), no dosage adjustment required for sofosbuvir-based regimens 1
• For severe renal impairment or end-stage renal disease, dosage recommendations cannot be made for sofosbuvir 3

Monitoring and Assessment

• Test all patients for HBV infection (HBsAg and anti-HBc) before starting treatment 1, 3
• Assess for SVR12 (HCV RNA <LLOQ) at 12 weeks post-treatment 5, 1
• For patients with cirrhosis, monitor closely for signs of decompensation during treatment 1

Important Precautions

• Avoid coadministration of amiodarone with sofosbuvir-containing regimens due to risk of serious symptomatic bradycardia 1, 6
• Be cautious with proton pump inhibitors, as they may reduce efficacy of some DAA regimens 1, 2
• For patients on ribavirin, use weight-based dosing (1000mg for <75kg, 1200mg for ≥75kg); start at 600mg daily in decompensated cirrhosis and titrate as tolerated 1

Treatment Failure Management

• For patients who failed previous DAA therapy, resistance testing may be considered, especially for NS5A inhibitor failures 1
• Re-treatment should be with a different class of DAA or combination therapy for extended duration 5

The remarkable efficacy of current DAA regimens has transformed HCV from a difficult-to-treat chronic disease to one that can be cured in over 95% of patients with a short course of well-tolerated oral therapy.