Recommended Workup and Treatment for Hepatitis C
The recommended workup for hepatitis C begins with HCV antibody testing with reflex HCV RNA PCR testing to confirm active infection, followed by evaluation of liver disease severity and viral characteristics to guide treatment with direct-acting antivirals (DAAs), which can achieve cure rates exceeding 95% in most patients. 1, 2
Initial Diagnostic Testing
- HCV antibody testing should be performed as the initial screening test for hepatitis C infection 1, 2
- If anti-HCV antibodies are detected, HCV RNA testing should be performed using a sensitive molecular method (lower limit of detection <15 IU/ml) to confirm active infection 2
- In cases of suspected acute hepatitis C or in immunocompromised patients, HCV RNA testing should be included in the initial evaluation 2
- Anti-HCV positive, HCV RNA negative individuals should be retested for HCV RNA 3 months later to confirm true clearance of infection 2
- Regular laboratory monitoring (every 4-8 weeks for 6-12 months) is recommended in acute HCV infection until ALT normalizes and HCV RNA becomes repeatedly undetectable, suggesting spontaneous resolution 2
Pre-Treatment Assessment
- Evaluate for liver disease severity using non-invasive methods (FibroScan, FibroTest) or liver biopsy to determine presence of advanced fibrosis or cirrhosis 2
- Determine HCV genotype and viral load (HCV RNA quantification) to guide treatment decisions 2
- Screen for other causes of liver disease, including HBV, HIV, alcohol use, and metabolic factors 2
- Assess for potential drug-drug interactions before initiating treatment 2
- Evaluate for comorbidities that may affect treatment decisions 2
Treatment Recommendations
- The goal of HCV therapy is to cure the infection to prevent hepatic cirrhosis, decompensation, hepatocellular carcinoma, and death 2
- Treatment is defined as successful when sustained virologic response (SVR) is achieved, defined as undetectable HCV RNA 12 weeks (SVR12) or 24 weeks (SVR24) after treatment completion 2
- Direct-acting antiviral (DAA) regimens should be used for all patients with chronic HCV infection 1, 2
- Treatment regimens should be selected based on:
Special Populations
- For patients with acute HCV infection, monitoring for spontaneous clearance for at least 12-16 weeks is recommended before initiating treatment 2
- Patients with decompensated cirrhosis require specialized care and may need adjusted treatment regimens 2
- For patients with HCV who actively inject drugs, access to harm reduction programs is mandatory, and treatment should not be withheld based solely on drug use 2
- Post-liver transplant patients with recurrent HCV infection require specific treatment considerations 2
- Patients with HIV/HCV coinfection may require adjusted treatment regimens and monitoring 2
Post-Treatment Follow-up
- Non-cirrhotic patients who achieve SVR should be retested for HCV RNA at 48 weeks post-treatment to confirm cure 2
- Patients with cirrhosis who achieve SVR should remain under surveillance for hepatocellular carcinoma every 6 months by ultrasound 2
- Patients with advanced fibrosis or cirrhosis require continued surveillance for complications even after achieving SVR 2
Common Pitfalls to Avoid
- Do not rely solely on ALT levels to determine disease severity, as patients with normal ALT may still have significant fibrosis 2
- Avoid assuming that HCV antibody testing alone is sufficient for diagnosis; confirmation with HCV RNA testing is essential 1, 2
- Do not overlook the importance of assessing for alcohol use and counseling patients to abstain during treatment 2
- Do not miss screening for HBV before starting HCV treatment, as HBV reactivation can occur during or after HCV therapy 1
- Do not assume a negative HCV antibody test excludes infection in immunocompromised patients or those with recent exposure; consider HCV RNA testing in these cases 1