Recommended Treatment for Hepatitis C (HCV)
The recommended first-line treatment for Hepatitis C is either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8 weeks (12 weeks in treatment-experienced patients with cirrhosis), regardless of HCV genotype (1-6). 1
Treatment Regimens Based on Patient Characteristics
Treatment-Naïve Patients
- Without cirrhosis or with compensated cirrhosis (Child-Pugh A):
Treatment-Experienced Patients
Treatment depends on previous regimen and genotype:
Prior NS5A inhibitor treatment (genotype 1):
- Glecaprevir/pibrentasvir for 16 weeks 2
Prior NS3/4A protease inhibitor treatment (genotype 1):
- Glecaprevir/pibrentasvir for 12 weeks 2
Prior PEG-IFN/ribavirin/sofosbuvir treatment:
Special Populations
Decompensated Cirrhosis (Child-Pugh B or C)
- Sofosbuvir/velpatasvir + ribavirin for 12 weeks 1, 3
- Avoid protease inhibitors (glecaprevir/pibrentasvir) due to risk of toxicity 1
Acute Hepatitis C
- Sofosbuvir and ledipasvir (genotypes 1,4,5,6), sofosbuvir and velpatasvir (all genotypes), or sofosbuvir and daclatasvir (all genotypes) for 8 weeks without ribavirin 4
- Consider 12 weeks for patients with HIV coinfection or HCV RNA >1 million IU/ml 4
Dosing Considerations
Sofosbuvir/Velpatasvir
- Adults: One tablet (400mg/100mg) once daily with or without food 3
- When used with ribavirin: Weight-based dosing of ribavirin
- <75kg: 1,000mg/day (divided twice daily)
- ≥75kg: 1,200mg/day (divided twice daily) 3
Glecaprevir/Pibrentasvir
- Adults: Three tablets (total: 300mg/120mg) once daily with food 2
- Pediatric dosing available for patients ≥3 years based on weight 2
Monitoring
- Test all patients for HBV coinfection (HBsAg and anti-HBc) before starting treatment 3, 2
- Monitor for HBV reactivation during and after treatment in coinfected patients 3, 2
- Assess SVR12 (sustained virologic response) at 12 weeks post-treatment 1
- No routine HCV RNA monitoring required during treatment 1
Important Considerations and Potential Pitfalls
Drug Interactions
- Avoid coadministration of amiodarone with sofosbuvir/velpatasvir due to risk of serious symptomatic bradycardia 1
- Check for interactions with proton pump inhibitors and antiretrovirals in HIV co-infected patients 1
HBV Reactivation Risk
- HBV reactivation can occur during or after DAA therapy in HCV/HBV coinfected patients 3, 2
- This can result in fulminant hepatitis, hepatic failure, and death if not monitored 3, 2
Treatment Efficacy
- Modern DAA regimens achieve SVR rates >95% across all genotypes 1, 5
- This represents a significant improvement over older interferon-based therapies 6, 7
- Treatment success has transformed HCV from a chronic disease to a curable infection 6
The evolution of HCV treatment to all-oral, interferon-free regimens with direct-acting antivirals has dramatically improved outcomes with shorter treatment durations, fewer side effects, and higher cure rates across all patient populations 6, 5.