What is the preferred treatment for hepatitis C in Canada?

Preferred Treatment for Hepatitis C in Canada

The preferred treatment for hepatitis C in Canada is direct-acting antiviral (DAA) therapy with either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8-12 weeks, depending on HCV genotype, treatment history, and presence of cirrhosis. 1

First-Line Treatment Options by Genotype

Genotype 1 (1a and 1b)

• For treatment-naïve and treatment-experienced patients without cirrhosis: sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8 weeks 1, 2
• For treatment-naïve patients with compensated cirrhosis: sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8 weeks 1, 2
• For treatment-experienced patients with compensated cirrhosis: sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 12 weeks 1

Genotype 2

• For all patient subgroups: sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8 weeks (without cirrhosis) or 12 weeks (with compensated cirrhosis) 1
• Historically, sofosbuvir and ribavirin for 12 weeks was the preferred approach, but newer regimens have supplanted this 1

Genotype 3

• For treatment-naïve patients without cirrhosis: sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8 weeks 1
• For treatment-experienced patients without cirrhosis: sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 12 weeks 1
• For treatment-naïve patients with compensated cirrhosis: sofosbuvir/velpatasvir with ribavirin for 12 weeks, sofosbuvir/velpatasvir/voxilaprevir for 12 weeks, or glecaprevir/pibrentasvir for 12 weeks (can be shortened to 8 weeks in some cases) 1
• For treatment-experienced patients with compensated cirrhosis: sofosbuvir/velpatasvir with ribavirin for 12 weeks, sofosbuvir/velpatasvir/voxilaprevir for 12 weeks, or glecaprevir/pibrentasvir for 16 weeks 1

Genotypes 4,5, and 6

• Treatment recommendations are the same as for genotype 1 1

Special Populations

Decompensated Cirrhosis

• Sofosbuvir/velpatasvir with ribavirin for 12 weeks is the preferred regimen 1, 3
• Protease inhibitors (including glecaprevir) are contraindicated in patients with decompensated cirrhosis 1, 4

Chronic Kidney Disease (CKD)

• For patients with severe renal impairment (eGFR <30 ml/min/1.73 m²) or end-stage renal disease on hemodialysis: glecaprevir/pibrentasvir is the treatment of choice 1
• Sofosbuvir-based regimens should be used with caution in patients with severe renal impairment 1

HIV Co-infection

• Patients co-infected with HIV-HCV should receive the same HCV treatment regimens as those without HIV co-infection, with attention to potential drug interactions with antiretroviral therapy 1, 2

Treatment Considerations

Treatment Duration

• Treatment duration varies based on HCV genotype, treatment history, and presence of cirrhosis 1
• Shorter treatment durations (8 weeks) are possible with glecaprevir/pibrentasvir in many patients without cirrhosis 1

Monitoring

• Given the high efficacy and low viral breakthrough rates of current DAA regimens, on-treatment viral load monitoring is no longer required 1
• Assessment of sustained virological response at 12 weeks post-treatment (SVR12) is recommended to confirm cure 2
• Patients with cirrhosis require continued monitoring for hepatocellular carcinoma with ultrasound every 6 months, even after achieving SVR 2

Common Pitfalls and Caveats

• Drug-drug interactions must be carefully evaluated before initiating DAA therapy 2
• Patients with decompensated cirrhosis require special consideration and should not receive protease inhibitor-containing regimens 1, 4
• Testing for hepatitis B virus (HBV) co-infection is essential before starting HCV treatment, as HBV reactivation can occur during or after DAA therapy 3
• Patients with cirrhosis have historically had lower SVR rates compared to non-cirrhotic patients, but newer DAA regimens have largely overcome this limitation 1, 5

Benefits of Treatment

• Achieving SVR reduces the risk of liver-related complications including cirrhosis, hepatocellular carcinoma, and mortality 1, 6
• SVR is associated with resolution of liver disease in patients without cirrhosis and may lead to regression of fibrosis in those with cirrhosis 1, 6

The treatment landscape for hepatitis C has evolved dramatically with the introduction of DAAs, which have replaced interferon-based regimens due to their superior efficacy, tolerability, and shorter treatment durations 1, 7. Current regimens can achieve SVR rates exceeding 95% in most patient populations, including those previously considered difficult to treat 1, 5.