What medications are used to treat hepatitis C?

First-Line Treatment Options for Hepatitis C

The most effective medications for treating hepatitis C are direct-acting antivirals (DAAs), with sofosbuvir/velpatasvir being the preferred pangenotypic regimen for all HCV genotypes, administered for 12 weeks without ribavirin in most patients. 1, 2

Recommended First-Line Treatment Options

• Sofosbuvir/velpatasvir (400mg/100mg) is a fixed-dose combination taken once daily for 12 weeks without ribavirin for treatment-naïve and treatment-experienced patients with all HCV genotypes (1-6), with or without compensated cirrhosis 2
• Glecaprevir/pibrentasvir is recommended for 8 weeks in non-cirrhotic patients and 12 weeks in patients with compensated cirrhosis 1, 3
• Ledipasvir/sofosbuvir is effective for genotypes 1,4,5, and 6, administered for 12 weeks (can be shortened to 8 weeks in treatment-naïve patients without cirrhosis and with baseline HCV RNA <6 million IU/mL) 1, 2
• Elbasvir/grazoprevir is effective for genotypes 1 and 4, administered for 12 weeks (for patients without NS5A resistance-associated substitutions) 1, 2

Treatment Based on HCV Genotype

Genotype 1-6 (Pangenotypic Options)

• Sofosbuvir/velpatasvir achieves SVR rates of 97-100% across all genotypes, making it an ideal first-line pangenotypic option 2, 4
• Glecaprevir/pibrentasvir is another pangenotypic option with high efficacy across all genotypes 1, 3

Genotype-Specific Options

• For genotype 1: Ledipasvir/sofosbuvir, elbasvir/grazoprevir, or ombitasvir/paritaprevir/ritonavir plus dasabuvir (with or without ribavirin depending on subtype) 2
• For genotypes 5-6: Sofosbuvir/ledipasvir for 12 weeks without ribavirin in treatment-naïve patients, or with ribavirin in treatment-experienced patients 2

Special Populations

Patients with Cirrhosis

• For compensated cirrhosis (Child-Pugh A): Standard regimens can be used with appropriate duration adjustments 5, 6

  • Sofosbuvir/velpatasvir for 12 weeks without ribavirin 2, 6
  • Glecaprevir/pibrentasvir for 12 weeks 1, 3

• For decompensated cirrhosis (Child-Pugh B or C):

  • Sofosbuvir/velpatasvir plus ribavirin for 12 weeks 1, 5
  • Voxilaprevir-containing regimens are not recommended in moderate or severe hepatic impairment 7

Treatment-Experienced Patients

• For patients who failed previous DAA therapy containing an NS5A inhibitor: Sofosbuvir/velpatasvir/voxilaprevir for 12 weeks 7, 8
• For genotype 3 treatment-experienced patients with cirrhosis: Sofosbuvir/velpatasvir plus ribavirin for 12 weeks 2, 8

Monitoring During Treatment

• HCV RNA levels should be measured at baseline, week 4, week 12, at the end of treatment, and 12-24 weeks after completion to assess sustained virological response (SVR) 1
• Monitor for drug-drug interactions throughout treatment, especially with commonly used medications 3
• For patients with cirrhosis, regular monitoring for signs of hepatic decompensation is essential 5, 7

Important Considerations and Pitfalls

• Test all patients for hepatitis B virus (HBV) coinfection before starting HCV treatment, as HBV reactivation can occur during or after DAA therapy 7
• Despite achieving SVR, patients with cirrhosis still require ongoing surveillance for hepatocellular carcinoma 5
• Drug-drug interactions are common with DAAs and require careful medication review before initiating therapy 3
• The goal of treatment is to achieve sustained virological response (SVR), defined as undetectable HCV RNA 12 weeks after completion of therapy, which is considered a virological cure 1

Treatment Efficacy

• Modern DAA regimens achieve SVR rates >95% in most patient populations 9, 10
• Sofosbuvir/velpatasvir has demonstrated 95-100% SVR rates across all genotypes in clinical trials 9, 6
• Even in traditionally difficult-to-treat populations (cirrhosis, prior treatment failure), current regimens achieve high cure rates 6, 4