What is the recommended treatment for a patient in their 60s with a new diagnosis of hepatitis C?

Treatment of Hepatitis C in a Patient in Their 60s

All patients in their 60s with newly diagnosed chronic hepatitis C should be treated immediately with pangenotypic direct-acting antivirals (DAAs), specifically sofosbuvir/velpatasvir (400mg/100mg) or glecaprevir/pibrentasvir (300mg/120mg) for 8-12 weeks, as modern regimens achieve cure rates exceeding 95-97% and prevent progression to cirrhosis, hepatocellular carcinoma, and death. 1, 2

Pre-Treatment Assessment

Before initiating DAA therapy, the following evaluations are mandatory:

• Test for hepatitis B virus (HBV) infection by measuring hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), as HBV reactivation during HCV treatment can result in fulminant hepatitis, hepatic failure, and death 3, 4
• Assess liver fibrosis stage using noninvasive markers (FibroScan, APRI, FIB-4) or imaging to determine presence or absence of cirrhosis, as this affects treatment duration and monitoring requirements 1
• Test for HIV co-infection, as this impacts drug-drug interaction considerations 1
• Vaccinate against hepatitis A and hepatitis B if the patient is susceptible 1
• Counsel on alcohol abstinence, as alcohol accelerates liver fibrosis and increases risk of hepatocellular carcinoma 1

First-Line Treatment Regimens

For Treatment-Naïve Patients Without Cirrhosis:

• Sofosbuvir/velpatasvir 400mg/100mg once daily for 8 weeks (pangenotypic, covers genotypes 1-6) 1, 2
• Glecaprevir/pibrentasvir 300mg/120mg once daily for 8 weeks (pangenotypic, covers genotypes 1-6) 1, 3

For Treatment-Naïve Patients With Compensated Cirrhosis (Child-Pugh A):

• Sofosbuvir/velpatasvir 400mg/100mg once daily for 12 weeks 1, 2
• Glecaprevir/pibrentasvir 300mg/120mg once daily for 8 weeks 1, 3

For Patients With Decompensated Cirrhosis (Child-Pugh B or C):

• Ledipasvir/sofosbuvir plus weight-based ribavirin for 12 weeks (genotype 1 only) 4
• Glecaprevir/pibrentasvir is contraindicated in decompensated cirrhosis 3

Treatment Administration

• All DAAs should be taken once daily with food to optimize absorption 3, 4
• HCV genotyping is no longer required before treatment initiation if using pangenotypic regimens (sofosbuvir/velpatasvir or glecaprevir/pibrentasvir) in treatment-naïve patients without cirrhosis 1
• Quantitative HCV RNA testing should be performed at baseline to document viremia 1

Monitoring During Treatment

• Minimal on-treatment monitoring is required with modern DAA regimens, as they are extremely well-tolerated with <1% discontinuation rates due to adverse events 1
• Check for drug-drug interactions with all concurrent medications, including over-the-counter preparations, as DAAs can interact with statins, proton pump inhibitors, and other common medications 1
• Monitor HCV/HBV co-infected patients for hepatitis flare or HBV reactivation during and after HCV treatment 3, 4

Post-Treatment Assessment

• Confirm sustained virologic response (SVR) by measuring HCV RNA at 12 weeks post-treatment (SVR12), which represents permanent viral eradication in >99% of cases 1, 2
• SVR24 (24 weeks post-treatment) should also be checked in certain populations, as late relapses have been reported 1

Long-Term Surveillance

For Patients Without Cirrhosis Who Achieve SVR:

• Retest ALT and HCV RNA at 48 weeks post-treatment, then discharge if normal 1
• No ongoing HCC surveillance is required 1

For Patients With Cirrhosis (Including Those Who Achieve SVR):

• Lifelong HCC surveillance with ultrasound every 6 months is mandatory, as cancer risk is reduced but not eliminated after viral eradication 1, 2
• Continue monitoring for portal hypertension and varices according to standard cirrhosis management guidelines 1

Special Considerations for Patients in Their 60s

• Age is not a contraindication to treatment, and older patients benefit equally from DAA therapy 1
• Review all medications carefully for potential drug-drug interactions, as polypharmacy is common in this age group 1
• Avoid hepatotoxic drugs (excessive acetaminophen >2g/day, certain herbal supplements) and nephrotoxic drugs (NSAIDs) if cirrhosis is present 1

Treatment Priority

Patients with advanced fibrosis (F3) or any degree of cirrhosis should be prioritized for immediate treatment, as they are at highest risk for hepatic decompensation and hepatocellular carcinoma 2. However, all patients with chronic HCV should receive treatment without delay, as modern DAAs prevent disease progression and eliminate transmission risk 1, 2.

Common Pitfalls to Avoid

• Do not delay treatment waiting for "normal" liver enzymes—elevated transaminases indicate active inflammation but are not required to be normal before initiating therapy 2
• Do not assume high viral load predicts treatment failure—modern DAAs achieve >95% cure rates regardless of baseline viral load 2
• Do not forget HBV screening—failure to test for HBV before HCV treatment can result in fatal HBV reactivation 3, 4
• Do not discontinue HCC surveillance in cirrhotic patients after achieving SVR—cancer risk persists lifelong 1, 2