Treatment of Symptomatic Acute Hepatitis C
For symptomatic patients with acute hepatitis C, treat with sofosbuvir/ledipasvir, sofosbuvir/velpatasvir, or sofosbuvir/daclatasvir for 8 weeks without ribavirin to prevent chronic infection and achieve sustained virologic response rates exceeding 90%. 1, 2
Initial Assessment and Monitoring
- Test HCV RNA immediately when acute hepatitis C is suspected, as anti-HCV antibodies may be negative early in infection 2
- Screen all patients for hepatitis B by measuring HBsAg and anti-HBc before initiating treatment, as HBV reactivation has been reported during DAA therapy and can result in fulminant hepatitis, hepatic failure, and death 3, 4
- Consider monitoring HCV RNA every 4 weeks if delaying treatment to assess for spontaneous clearance, though this approach is less commonly used now given the high efficacy and safety of DAAs 1, 2
First-Line Treatment Regimens
Standard 8-week regimens for all genotypes: 1, 2
- Sofosbuvir/ledipasvir (genotypes 1,4,5,6)
- Sofosbuvir/velpatasvir (all genotypes)
- Sofosbuvir/daclatasvir (all genotypes)
No ribavirin is required for most patients with acute hepatitis C when using these DAA combinations 1, 2
Special Populations Requiring Modified Duration
Extend treatment to 12 weeks in the following circumstances: 1, 2
- HIV coinfection
- Baseline HCV RNA >1 million IU/mL (6.0 log IU/mL)
- Consider 12 weeks if uncertain about acute versus chronic infection 1
Post-Treatment Monitoring
- Assess sustained virologic response (SVR) at both 12 and 24 weeks post-treatment, as late relapses have been documented in acute hepatitis C 1, 2
- SVR12 is defined as HCV RNA below the lower limit of quantification at 12 weeks after treatment cessation 3
Critical Safety Considerations
HBV reactivation monitoring is mandatory: 3, 4
- Monitor HCV/HBV coinfected patients for hepatitis flare or HBV reactivation during and after HCV treatment
- Initiate HBV antiviral therapy as clinically indicated
- This applies regardless of HBV infection stage (chronic, occult, or resolved) 4
Drug-drug interactions must be evaluated before initiating DAA therapy, particularly in patients on HIV antiretroviral therapy or other concomitant medications 5, 6
Common Pitfalls to Avoid
- Do not use post-exposure prophylaxis with antivirals in the absence of documented HCV transmission 1, 2
- Do not delay treatment indefinitely waiting for spontaneous clearance—while 20-50% may clear spontaneously, none of the predictive parameters (symptomatic disease, female gender, young age, IL28B polymorphisms) accurately predict individual outcomes 1, 2
- Do not use protease inhibitor-containing regimens in patients with decompensated cirrhosis if cirrhosis status is uncertain 1, 5
Historical Context
Previously, pegylated interferon-alpha monotherapy for 24 weeks was standard treatment with SVR rates of 80-90%, but this has been superseded by DAA regimens that achieve >90% SVR with shorter duration and no injection requirement 1, 2