What is the assessment and treatment plan for a patient diagnosed with hepatitis C?

Assessment and Plan for Hepatitis C

The optimal treatment for hepatitis C is a pangenotypic regimen of either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8-12 weeks (depending on cirrhosis status), which can achieve sustained virologic response rates exceeding 95% across all genotypes. 1, 2

Assessment

• Confirm active HCV infection with HCV RNA or HCV core antigen testing 1
• Test for evidence of current or prior HBV infection (HBsAg and anti-HBc) before initiating therapy to prevent HBV reactivation 3
• Determine HCV genotype and viral load if genotype-specific treatment will be used 2
• Assess for presence and degree of liver fibrosis using non-invasive methods (FIB-4, APRI, transient elastography) 1
• Evaluate for presence of cirrhosis (compensated vs. decompensated) as this affects treatment duration and regimen selection 1
• Review all medications for potential drug-drug interactions with planned HCV treatment 1, 2

Treatment Plan

Simplified Pangenotypic Approach (Preferred)

• For treatment-naïve patients without cirrhosis:

  • Glecaprevir/pibrentasvir for 8 weeks 1, 4, 5
  • Alternative: Sofosbuvir/velpatasvir for 12 weeks 1

• For treatment-naïve patients with compensated cirrhosis:

  • Glecaprevir/pibrentasvir for 12 weeks 1, 5
  • Alternative: Sofosbuvir/velpatasvir for 12 weeks 1

• For treatment-experienced patients without cirrhosis:

  • Glecaprevir/pibrentasvir for 8 weeks 1, 4
  • Alternative: Sofosbuvir/velpatasvir for 12 weeks 1

• For treatment-experienced patients with compensated cirrhosis:

  • Glecaprevir/pibrentasvir for 12 weeks 1, 6
  • Alternative: Sofosbuvir/velpatasvir for 12 weeks 1

Genotype-Specific Approach (If genotyping available)

• For genotype 1:

  • Ledipasvir/sofosbuvir for 8-12 weeks (can be shortened to 8 weeks in non-cirrhotic patients with HCV RNA <6 million IU/mL) 2, 3, 7
  • Alternative: Glecaprevir/pibrentasvir or sofosbuvir/velpatasvir as above 1

• For genotype 3 with compensated cirrhosis:

  • Sofosbuvir/velpatasvir for 12 weeks (note: slightly lower SVR rates compared to other genotypes) 1
  • Alternative: Glecaprevir/pibrentasvir for 12 weeks (treatment-naïve) or 16 weeks (treatment-experienced) 6

• For patients with decompensated cirrhosis:

  • Sofosbuvir/ledipasvir + ribavirin for 12 weeks (genotype 1) 3
  • Avoid regimens containing glecaprevir/pibrentasvir in decompensated cirrhosis 1

Monitoring

• During treatment:

  • For IFN-free regimens: HCV RNA at baseline, week 2 (for adherence), week 4, and end of treatment 1
  • Minimal laboratory monitoring required for most patients on DAA therapy 2

• After treatment:

  • HCV RNA testing at 12 weeks post-treatment to confirm SVR12 1, 2
  • For patients at high risk of reinfection (e.g., PWID), yearly HCV RNA testing 1
  • Patients with advanced fibrosis (F3) or cirrhosis (F4) require ongoing surveillance for hepatocellular carcinoma every 6 months indefinitely 1
  • Non-invasive assessment of fibrosis every 1-2 years for untreated patients or those with treatment failure 1

Special Considerations

• Drug-drug interactions: Carefully check for interactions before starting therapy, particularly with proton pump inhibitors which may reduce efficacy of some regimens 7

• HCV/HIV co-infection: Follow same regimens as HCV mono-infected patients 3, 8

• Reinfection risk: Higher risk in people who inject drugs; requires counseling and consideration of harm reduction strategies 9

• HBV reactivation: Monitor for hepatitis flare or HBV reactivation during and after HCV treatment in co-infected patients 3

• Acute HCV infection: Consider early treatment to prevent progression to chronic hepatitis C; high SVR rates (>90%) have been reported with sofosbuvir-based regimens 1