Follow-Up Testing After Hepatitis C Antiviral Therapy
After completing Hepatitis C antiviral therapy with regimens such as sofosbuvir/ledipasvir, patients should undergo HCV RNA testing at 12 weeks post-treatment to confirm sustained virologic response (SVR12), with no further HCV RNA testing required if SVR12 is achieved. 1
Post-Treatment Monitoring Schedule
Essential Follow-Up Testing
- 12 weeks post-treatment:
- HCV RNA testing to confirm SVR12
- Hepatic function panel (liver enzymes)
- 48 weeks post-treatment (optional):
- HCV RNA testing (although rarely necessary if SVR12 is achieved)
- ALT levels 1
The 12-week post-treatment time point has become the standard for determining SVR, as it has been shown to be highly concordant with SVR24 (measured at 24 weeks post-treatment), with positive predictive values exceeding 97% 2. This allows for earlier confirmation of cure and reduces unnecessary follow-up testing.
Monitoring Based on Fibrosis Stage
Patients Without Advanced Fibrosis (F0-F2)
- Once SVR12 is confirmed, patients can be discharged from hepatitis C-specific care 1
- No further HCV-specific monitoring is required unless risk factors for reinfection exist
Patients With Advanced Fibrosis or Cirrhosis (F3-F4)
- HCC surveillance: Abdominal ultrasound ± AFP every 6 months indefinitely 1
- Variceal screening:
- Initial endoscopic screening for all cirrhotic patients
- Repeat endoscopy at 2-3 years if no or small varices were found initially
- Consider cessation of endoscopic screening if no varices are identified 2-3 years post-SVR and no risk factors for progressive cirrhosis exist 3
- Fibrosis assessment: Non-invasive assessment (e.g., transient elastography) can be considered to evaluate fibrosis regression 1
Special Considerations
Patients with Risk Factors for Reinfection
- Annual HCV RNA testing for patients with ongoing risk factors (injection drug use, high-risk sexual behaviors) 1
- Risk reduction counseling should be provided
Patients with Abnormal Liver Tests After SVR
- Evaluate for other causes of liver disease, including:
- Alcoholic liver disease
- Nonalcoholic fatty liver disease
- Medication-induced liver injury
- Other causes of liver injury 1
Patients Previously Treated with Interferon-Based Therapy
- Thyroid function tests (TSH, free thyroxine) at 1 and 2 years post-treatment 1
Clinical Significance of SVR
Achieving SVR is associated with significant clinical benefits:
- Histologic regression of necroinflammation and fibrosis 4
- Reduced risk of liver-related complications and hepatocellular carcinoma 4
- Fewer liver-related deaths compared to non-responders 4
- Reduced risk of impaired fasting glucose and diabetes development 4
Common Pitfalls to Avoid
Premature discontinuation of HCC surveillance: Despite achieving SVR, patients with cirrhosis remain at risk for HCC and require continued surveillance indefinitely.
Overlooking non-HCV causes of liver disease: Patients with persistently abnormal liver enzymes after SVR should be evaluated for other causes of liver injury, including alcohol use, fatty liver disease, and medications 3, 1.
Unnecessary extended HCV RNA testing: The risk of late relapse after achieving SVR12 is extremely low (<1%), making additional HCV RNA testing unnecessary for most patients 2.
Failure to counsel on liver injury prevention: Patients should be counseled regarding other sources of liver injury that can independently contribute to liver fibrosis progression, including alcohol consumption, nonalcoholic fatty liver disease, and hepatotoxic medications 3.