What is the initial treatment recommendation for a patient with hepatitis C?

Initial Treatment Recommendations for Hepatitis C

The recommended initial treatment for patients with hepatitis C is a pangenotypic regimen of either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8-12 weeks, depending on cirrhosis status. 1

Treatment Selection Based on Patient Characteristics

For Treatment-Naïve Patients Without Cirrhosis:

• Glecaprevir/pibrentasvir for 8 weeks 1
• Sofosbuvir/velpatasvir for 12 weeks 1, 2

For Treatment-Naïve Patients With Compensated Cirrhosis:

• Glecaprevir/pibrentasvir for 12 weeks 1
• Sofosbuvir/velpatasvir for 12 weeks 1, 2

For Patients With Decompensated Cirrhosis:

• Sofosbuvir/velpatasvir plus ribavirin for 12 weeks 2, 3

Genotype-Specific Considerations

While pangenotypic regimens are preferred for initial treatment, genotype-specific options may be considered:

Genotype 1:

• Ledipasvir/sofosbuvir for 12 weeks (can be shortened to 8 weeks in non-cirrhotic patients with HCV RNA <6 million IU/mL) 1
• Elbasvir/grazoprevir for 12 weeks (for patients without NS5A RASs) 1

Genotype 2:

• Sofosbuvir and ribavirin for 12 weeks (non-cirrhotic) or 16 weeks (cirrhotic) 1
• Sofosbuvir/velpatasvir for 12 weeks 1

Genotype 3:

• Daclatasvir and sofosbuvir for 12 weeks (non-cirrhotic) or 24 weeks with ribavirin (cirrhotic) 1
• Sofosbuvir/velpatasvir for 12 weeks (non-cirrhotic) or with ribavirin (cirrhotic) 1

Genotype 4:

• Ledipasvir/sofosbuvir for 12 weeks 1
• Ombitasvir/paritaprevir/ritonavir with ribavirin for 12 weeks 1

Pre-Treatment Assessment

Before initiating therapy, the following assessments are essential:

• HCV genotype and viral load determination 1
• Assessment for cirrhosis (FIB-4 score, transient elastography, or other non-invasive methods) 1
• Testing for HBV co-infection (HBsAg and anti-HBc) to prevent HBV reactivation 2, 4
• Medication reconciliation to identify potential drug-drug interactions 1
• Calculation of Child-Turcotte-Pugh score for patients with suspected cirrhosis 1
• Baseline laboratory tests including complete blood count, liver function tests, and renal function 1

Monitoring During and After Treatment

During Treatment:

• No routine laboratory monitoring is required for most patients 1
• For patients on diabetes medications: monitor for hypoglycemia 1
• For patients on warfarin: monitor INR for changes in anticoagulation status 1

After Treatment:

• HCV RNA testing at 12 weeks post-treatment to confirm sustained virologic response (SVR) 1
• Hepatic function panel to assess for normalization of liver enzymes 1
• For patients who do not achieve SVR, referral to a specialist for retreatment options 1

Important Considerations and Caveats

• HBV Reactivation Risk: All patients must be tested for HBV before starting HCV treatment, as reactivation can lead to fulminant hepatitis and death 2, 4
• Simplified Treatment Approach: Not suitable for patients with decompensated cirrhosis, prior HCV treatment, end-stage renal disease, HIV or HBV co-infection, pregnancy, HCC, or prior liver transplantation 1
• Drug Interactions: Assessment for potential drug-drug interactions is critical before starting therapy 1
• Treatment Duration: While 8-12 weeks is standard for most regimens, patients with certain characteristics (cirrhosis, specific genotypes) may require longer treatment 1
• Ribavirin Addition: May be necessary for patients with decompensated cirrhosis or certain treatment-experienced patients 2, 3

The high efficacy of current direct-acting antiviral regimens (>95% SVR) has revolutionized HCV treatment, making it possible to cure most patients with a short course of well-tolerated oral therapy 3, 5, 6.