Recommended Treatment for Hepatitis C (HCV)
The first-line treatment for hepatitis C is a pangenotypic direct-acting antiviral (DAA) regimen consisting of either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8-12 weeks, depending on cirrhosis status and treatment history. 1, 2
Treatment Selection Based on Patient Factors
Recommended First-Line Options:
- Sofosbuvir/velpatasvir (400mg/100mg) once daily for 12 weeks is a recommended first-line option for all HCV genotypes, with SVR rates of 98% in genotype 1 infection 2
- Glecaprevir/pibrentasvir is an alternative first-line option with treatment duration of 8 weeks for non-cirrhotic patients and 12 weeks for those with compensated cirrhosis 2, 3
- For genotype 2 infection, sofosbuvir/velpatasvir for 12 weeks is highly effective 4, 2
- For genotype 3 infection, sofosbuvir/velpatasvir for 12 weeks and sofosbuvir/daclatasvir for 12 weeks are recommended first-line options 4, 2
Treatment Duration Based on Patient Characteristics:
Non-cirrhotic patients:
Compensated cirrhosis (Child-Pugh A):
Decompensated cirrhosis (Child-Pugh B or C):
Special Populations
Treatment-Experienced Patients:
- For patients who failed previous pegylated interferon and ribavirin treatment, the same DAA regimens can be used as for treatment-naïve patients 4
- For patients who failed previous DAA therapy, treatment should be guided by resistance testing when available 4
HIV Co-infection:
- The same HCV treatment regimens can be used as in patients without HIV infection, with dose adjustments needed in case of interactions with antiretroviral drugs 4
- The dose of daclatasvir must be adjusted to 30 mg in HIV-coinfected patients receiving ritonavir- or cobicistat-boosted atazanavir or cobicistat-boosted elvitegravir, and to 90 mg in HIV-coinfected patients receiving efavirenz 2
Pre-Treatment Assessment
- HCV RNA quantitative assay and genotyping/subgenotyping prior to initiating antiviral treatment 1
- Test all patients for evidence of current or prior HBV infection by measuring HBsAg and anti-HBc before initiating HCV treatment with DAAs 3, 5
- Assessment of liver disease severity to guide therapy decisions and predict prognosis 1
- Evaluation for potential drug-drug interactions with all concurrent medications 1
Treatment Efficacy and Monitoring
- Modern DAA regimens achieve SVR rates exceeding 95% in most patient populations 2
- Sustained virological response (SVR), defined as undetectable HCV RNA 12 weeks after treatment completion, represents a cure of the infection in more than 99% of patients 1
- Monitor HCV RNA or HCV core antigen at 12 weeks post-treatment (SVR12) to assess treatment success 1
Important Caveats and Pitfalls
- Risk of HBV reactivation: Test all patients for evidence of current or prior HBV infection before initiating treatment with DAAs. HBV reactivation has been reported in HCV/HBV coinfected patients who were undergoing or had completed treatment with HCV direct-acting antivirals 3, 5
- Drug-drug interactions: Must be carefully evaluated before initiating DAA therapy, particularly with anticonvulsants, HIV medications, and other commonly prescribed drugs 2, 6
- Post-SVR monitoring: Patients with cirrhosis who achieve SVR still require monitoring for hepatocellular carcinoma with ultrasound every 6 months, as they remain at risk for complications, though at significantly reduced rates 1
- Treatment adherence: Despite shortened treatment durations with modern DAAs, adherence remains crucial for achieving SVR 7
The introduction of all-oral DAA regimens has revolutionized HCV treatment, allowing virtually all patients to achieve SVR regardless of HCV genotype or disease stage, replacing older interferon-based therapies that had lower efficacy and more side effects 1, 8, 9.