What is the initial treatment approach for a patient who is hepatitis C (HCV) positive?

Initial Treatment Approach for Hepatitis C Positive Patients

For patients newly diagnosed with hepatitis C virus (HCV) infection, the recommended initial treatment approach is to confirm active infection with HCV RNA testing, assess liver fibrosis severity, and initiate direct-acting antiviral (DAA) therapy with either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8-12 weeks depending on cirrhosis status. 1, 2, 3

Initial Assessment

• Confirm active HCV infection with HCV RNA or HCV core antigen testing if only antibody testing was performed 2, 3
• Test for HBV coinfection by measuring hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) before initiating treatment 4, 5
• Screen for HIV coinfection as this affects prognosis and treatment decisions 3
• Assess liver fibrosis severity using non-invasive methods:
  • Calculate FIB-4 score or APRI (AST-platelet ratio index) 1, 2
  • Consider transient elastography (FibroScan) if available 1
  • Liver biopsy is not mandatory but can help determine treatment urgency in uncertain cases 1
• Determine HCV genotype and viral load if genotype-specific treatment will be used 2, 6
• Evaluate for presence of cirrhosis (compensated vs. decompensated) 1, 2
• Review all medications for potential drug-drug interactions with planned HCV treatment 1, 2

Treatment Selection

For Treatment-Naïve Patients Without Cirrhosis:

• Glecaprevir/pibrentasvir for 8 weeks 1, 2, 6
• Alternative: Sofosbuvir/velpatasvir for 12 weeks 1, 2, 6

For Treatment-Naïve Patients With Compensated Cirrhosis:

• Glecaprevir/pibrentasvir for 12 weeks 1, 2, 6
• Alternative: Sofosbuvir/velpatasvir for 12 weeks 1, 2, 6

For Patients With Decompensated Cirrhosis:

• Sofosbuvir/velpatasvir with ribavirin for 12 weeks (avoid glecaprevir/pibrentasvir) 2, 6

Monitoring During Treatment

• No routine laboratory monitoring is required for most patients during treatment 1, 6
• For patients on diabetes medications, monitor for hypoglycemia 1
• For patients on warfarin, monitor INR for subtherapeutic anticoagulation 1
• An in-person or telehealth visit may be scheduled for patient support and assessment of symptoms 1

Post-Treatment Follow-up

• Test for HCV RNA at 12 weeks after completing treatment to confirm sustained virologic response (SVR) 1, 2, 6
• Assess hepatic function panel to confirm normalization of liver enzymes 1, 6
• For patients with advanced fibrosis or cirrhosis, continue surveillance for hepatocellular carcinoma every 6 months indefinitely, even after achieving SVR 2, 3
• For patients at high risk of reinfection, consider yearly HCV RNA testing 2

Special Considerations

• If acute HCV infection is suspected, consider monitoring HCV RNA for 12-16 weeks to detect potential spontaneous clearance before initiating treatment 3
• Active substance use is not a contraindication to HCV treatment 3
• For HCV/HBV coinfected patients, monitor for HBV reactivation during and after HCV treatment 4, 5, 7
• For patients with HCV/HIV coinfection, follow the same treatment regimens with attention to potential drug interactions with antiretroviral therapy 1, 3

Common Pitfalls to Avoid

• Delaying treatment, especially in patients with advanced fibrosis 3
• Failing to test for HBV coinfection, which can lead to HBV reactivation during or after HCV treatment 4, 5
• Overlooking potential drug-drug interactions with DAA therapy 1, 2
• Neglecting post-SVR surveillance for hepatocellular carcinoma in patients with advanced fibrosis or cirrhosis 2, 3