What is the recommended medication for acute hepatitis C?

Treatment of Acute Hepatitis C

For patients with acute hepatitis C, the recommended treatment is a combination of sofosbuvir and an NS5A inhibitor (ledipasvir, velpatasvir, or daclatasvir) for 8 weeks without ribavirin. 1

Initial Management Approach

• Consider delaying treatment for 8-12 weeks after onset of acute hepatitis C to allow for potential spontaneous clearance, which occurs in 20-50% of cases 1
• Spontaneous clearance is more likely in symptomatic patients, females, younger individuals, and those with favorable IL28B (IFNL3) genetic polymorphisms 1
• Monitor HCV RNA levels every 4 weeks during this observation period to assess for spontaneous clearance 1
• If HCV RNA remains positive at 12 weeks after initial presentation, antiviral treatment should be initiated 1

Current First-Line Treatment Recommendations

• For all HCV genotypes (1-6), use one of the following direct-acting antiviral (DAA) regimens for 8 weeks 1:

  • Sofosbuvir/ledipasvir (for genotypes 1,4,5, and 6)
  • Sofosbuvir/velpatasvir (for all genotypes)
  • Sofosbuvir/daclatasvir (for all genotypes)

• For patients with HIV coinfection or high baseline HCV RNA (>1 million IU/ml), consider extending treatment to 12 weeks with the same regimens 1

• Sustained virologic response (SVR) rates exceeding 90% can be achieved with these DAA regimens 1

Special Considerations

• Assess for HBV coinfection before starting treatment, as HBV reactivation can occur during DAA therapy 2
• No ribavirin is needed for most patients with acute hepatitis C when using DAA regimens 1
• Monitor for potential drug-drug interactions when using DAAs 3
• Assess SVR at both 12 and 24 weeks post-treatment, as late relapses have been reported 1

Historical Context

• Previously, pegylated interferon alpha monotherapy for 24 weeks was the standard treatment for acute hepatitis C, with SVR rates of 80-90% 1
• Peginterferon alpha-2b and ribavirin combination therapy did not increase SVR rates compared to peginterferon monotherapy in acute HCV 1
• A randomized controlled study showed no significant difference in SVR rates between 12-week and 24-week peginterferon monotherapy regimens 1

Clinical Pitfalls and Caveats

• Diagnosis of acute hepatitis C can be challenging as many patients are asymptomatic 1
• Anti-HCV antibodies may be negative early in infection; HCV RNA testing is essential for diagnosis when acute hepatitis C is suspected 1
• Differentiation between acute hepatitis C and acute exacerbation of chronic hepatitis C can be difficult; in uncertain cases, treat according to chronic HCV guidelines 1
• There is no indication for antiviral therapy as post-exposure prophylaxis in the absence of documented HCV transmission 1

The evolution of treatment for acute hepatitis C has shifted dramatically from interferon-based therapies to highly effective, well-tolerated DAA regimens. Current evidence strongly supports the use of sofosbuvir-based combinations with NS5A inhibitors for 8 weeks, which provides excellent cure rates with minimal side effects.