Treatment for Acute Hepatitis C
Patients with acute hepatitis C should be treated with sofosbuvir/velpatasvir (or sofosbuvir/ledipasvir or sofosbuvir/daclatasvir) for 8 weeks without ribavirin, after considering a watchful waiting period of 8-12 weeks to allow for potential spontaneous clearance. 1
Initial Management Strategy
Delay treatment for 8-12 weeks after diagnosis to allow for spontaneous viral clearance, which occurs in 20-50% of cases. 1, 2 This approach is supported by randomized controlled trials showing that delayed treatment is non-inferior to immediate treatment when accounting for spontaneous recovery rates. 1
During the Observation Period:
- Monitor HCV RNA levels every 4 weeks to assess for spontaneous clearance 2
- Initiate treatment if HCV RNA remains positive at 12 weeks after initial presentation 2
- Recognize that spontaneous clearance is more likely in symptomatic patients with jaundice, females, younger individuals, and those with favorable IL28B (IFNL3) genetic polymorphisms 1, 2
Diagnostic Considerations:
- Test for HCV RNA directly when acute hepatitis C is suspected, as anti-HCV antibodies may be negative early in infection (appearing 8-12 weeks post-infection) 1, 2
- Most patients with acute hepatitis C are asymptomatic, making diagnosis challenging 1, 2
Current First-Line Treatment Regimens
Standard Therapy (All Genotypes):
Treat for 8 weeks with one of the following direct-acting antiviral (DAA) combinations without ribavirin: 1, 2
- Sofosbuvir/velpatasvir (400 mg/100 mg) - covers all genotypes 1, 2, 3
- Sofosbuvir/ledipasvir - for genotypes 1,4,5, and 6 1, 2
- Sofosbuvir/daclatasvir - for all genotypes 1, 2
These regimens achieve sustained virologic response (SVR) rates exceeding 90% in acute hepatitis C. 1, 2 A recent 2023 study confirmed 100% SVR12 in all adherent patients with acute HCV monoinfection treated with 8 weeks of sofosbuvir/velpatasvir. 4
Extended Duration for High-Risk Patients:
Extend treatment to 12 weeks (using the same DAA combinations) for patients with: 1, 2
- HIV coinfection
- Baseline HCV RNA level >1 million IU/ml (6.0 log IU/ml)
Post-Treatment Monitoring
- Assess SVR at both 12 and 24 weeks post-treatment, as late relapses have been reported in acute hepatitis C 1, 2
- This differs from chronic hepatitis C where SVR12 alone is typically sufficient 1
Important Clinical Pitfalls
What NOT to Do:
- Do not use antiviral therapy as post-exposure prophylaxis in the absence of documented HCV transmission 1, 2
- Do not add ribavirin to DAA regimens for acute hepatitis C in most patients, as it provides no additional benefit and increases adverse effects 1, 2
Historical Context:
Prior to the DAA era, peginterferon alpha monotherapy for 24 weeks was standard treatment, achieving SVR rates of 80-90%. 1, 2 However, this interferon-based approach has been completely replaced by the superior efficacy, shorter duration, and better tolerability of DAA regimens. 1, 2
Strength of Evidence
The EASL 2017 guidelines provide the most comprehensive and recent recommendations for acute hepatitis C treatment, based on three small trials with sofosbuvir/ledipasvir showing SVR rates of 77-100% after 4-6 weeks of treatment. 1 The recommendation for 8 weeks of therapy is extrapolated from chronic hepatitis C data requiring at least 8 weeks to maximize SVR rates, given the limited sample sizes in acute hepatitis C studies. 1 The 2023 HepNet study further validates this 8-week approach with sofosbuvir/velpatasvir. 4