Treatment Recommendation for Hepatitis C with Elevated Liver Enzymes and High Viral Load
This patient should be treated immediately with direct-acting antiviral (DAA) therapy without delay, specifically sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8 weeks, as all patients with chronic HCV infection should be offered treatment regardless of liver enzyme levels or fibrosis stage. 1, 2
Immediate Treatment Initiation
- All patients with confirmed chronic HCV infection (positive HCV antibodies and detectable HCV RNA) should receive treatment without waiting, as modern DAA regimens achieve cure rates exceeding 95-97% across all patient populations 1, 2
- The elevated ALT (207) and AST (127) indicate active hepatic inflammation, but normal transaminases are NOT required to initiate therapy 3
- The high viral load (5,680,000 IU/mL) does not preclude treatment success with modern DAAs 2
Pre-Treatment Assessment Required
Before initiating therapy, you must evaluate:
- HCV genotype determination - this is essential to select the optimal regimen duration 4, 3
- Liver fibrosis staging using non-invasive methods (FibroScan, APRI, FIB-4) or imaging to determine presence of cirrhosis 4, 3
- Hepatitis B testing (HBsAg and anti-HBc) - this is mandatory before starting DAAs due to risk of HBV reactivation 5, 4
- HIV testing - co-infection affects drug-drug interactions but not treatment eligibility 4, 2
- Renal function (eGFR) - severe renal impairment (eGFR <30) contraindicates sofosbuvir-based regimens 2, 5
- Current medications - evaluate for drug-drug interactions with DAAs 2
First-Line Treatment Regimens
For Treatment-Naïve Patients Without Cirrhosis:
- Sofosbuvir/velpatasvir 400mg/100mg: one tablet daily for 12 weeks (pan-genotypic, SVR rate 98%) 1, 2
- Glecaprevir/pibrentasvir 300mg/120mg: three tablets daily for 8 weeks (pan-genotypic) 2, 5
For Treatment-Naïve Patients With Compensated Cirrhosis:
- Sofosbuvir/velpatasvir: 12 weeks 2
- Glecaprevir/pibrentasvir: 8 weeks for genotypes 1,2,4,5,6 2
- For genotype 3 with cirrhosis: extended therapy may be needed (sofosbuvir/velpatasvir with ribavirin for 12 weeks, or glecaprevir/pibrentasvir for 12 weeks) 2
Treatment Priority Considerations
This patient should be prioritized for immediate treatment if any of the following apply:
- Advanced fibrosis (F3) or any degree of cirrhosis (F4) - these patients are at highest risk for hepatic decompensation and hepatocellular carcinoma 1, 3
- Significant fibrosis (≥F2) - treatment prevents progression to cirrhosis 3
- Risk of transmission - people who inject drugs, men who have sex with men with high-risk practices, hemodialysis patients 1
Critical Contraindications and Cautions
Absolute contraindications:
- Decompensated cirrhosis (Child-Pugh B or C) - protease inhibitors are contraindicated; use sofosbuvir/velpatasvir with ribavirin instead 3, 2
- Severe renal impairment (eGFR <30) or dialysis - avoid sofosbuvir; use glecaprevir/pibrentasvir 2, 5
Important warnings:
- HBV reactivation risk - all HCV/HBV co-infected patients require HBV monitoring during and after HCV treatment; some cases have resulted in fulminant hepatitis and death 5
Post-Treatment Monitoring
- Confirm cure with HCV RNA testing at 12 weeks post-treatment (SVR12) - this represents permanent viral eradication in >99% of cases 1, 4
- Patients with established cirrhosis (F4) or advanced fibrosis (F3) require lifelong HCC surveillance with ultrasound every 6 months, even after achieving SVR, as cancer risk is reduced but not eliminated 1, 4, 2
- Patients without cirrhosis who achieve SVR do not require ongoing HCC surveillance 4
Additional Counseling
- Avoid alcohol consumption - even moderate amounts can enhance disease progression 3
- Avoid hepatotoxic medications including excessive acetaminophen 3
- Hepatitis A and B vaccination if not immune 3
- Reinfection risk counseling for those with ongoing risk behaviors (injection drug use, high-risk sexual practices) 3
Clinical Benefits of Treatment
Achieving SVR provides: