Treatment Duration for Hepatitis
Hepatitis B Treatment Duration
For HBeAg-positive chronic hepatitis B, treat for a minimum of 1 year with nucleos(t)ide analogues (NAs), continuing for an additional 12 months after confirmed HBeAg seroconversion to reduce relapse risk. 1
HBeAg-Positive Patients
- Nucleos(t)ide analogues (lamivudine, adefovir, tenofovir, entecavir): Minimum 1 year, then continue for at least 12 months after HBeAg seroconversion is confirmed on two separate occasions at least 2 months apart 1, 2
- Peginterferon-α: Fixed duration of 48 weeks 1
- Standard interferon-α: 16 weeks 1
- The ideal endpoint is HBsAg loss, but this is rarely achieved with NA therapy alone 1
HBeAg-Negative Patients
- Nucleos(t)ide analogues: Longer than 1 year, with optimal duration not established; continue until HBsAg loss is achieved 1, 2
- Peginterferon-α: 48 weeks minimum 1
- Standard interferon-α: 12 months 1
- Treatment discontinuation may be considered when undetectable HBV DNA has been documented on three separate occasions 6 months apart 1
Special Populations
Compensated cirrhosis (HBeAg-positive):
- Continue NA therapy for at least 12 months after HBeAg seroconversion 1
- Long-term treatment is generally required 1
Decompensated cirrhosis:
- Long-term treatment is mandatory, coordinated with transplant centers 1, 2
- Plan for indefinite therapy including consideration of liver transplantation 1
Pediatric patients:
- Follow same duration guidelines as adults for both interferon and lamivudine 1
HIV coinfection:
Common Pitfall
Stopping NA therapy too early after HBeAg seroconversion leads to reactivation in 40-90% of patients 1. Always maintain treatment for the full 12 months post-seroconversion period.
Hepatitis C Treatment Duration
For chronic hepatitis C, use direct-acting antiviral (DAA) regimens for 8-12 weeks depending on genotype, treatment history, and cirrhosis status; peginterferon-based regimens are now obsolete. 3, 4
Current DAA Regimens (Preferred)
Genotype 1,4,5, or 6:
- Treatment-naïve without cirrhosis: Ledipasvir/sofosbuvir for 12 weeks (can consider 8 weeks if HCV RNA <6 million IU/mL) 3
- Treatment-naïve with compensated cirrhosis: Ledipasvir/sofosbuvir for 12 weeks 3
- Treatment-experienced without cirrhosis: Ledipasvir/sofosbuvir for 12 weeks 3
- Treatment-experienced with compensated cirrhosis: Ledipasvir/sofosbuvir for 24 weeks (or 12 weeks with ribavirin) 3
- Decompensated cirrhosis: Ledipasvir/sofosbuvir + ribavirin for 12 weeks 3
- Liver transplant recipients: Ledipasvir/sofosbuvir + ribavirin for 12 weeks 3
Genotype 2:
- All patients: Sofosbuvir + ribavirin for 12 weeks 4
Genotype 3:
- All patients: Sofosbuvir + ribavirin for 24 weeks 4
Acute hepatitis C:
- Consider observation for 8-12 weeks to allow for spontaneous clearance (occurs in 20-50% of cases) 5
- If HCV RNA remains positive at 12 weeks, treat with sofosbuvir/velpatasvir or sofosbuvir/ledipasvir for 8 weeks 5, 6
Historical Peginterferon-Based Regimens (No Longer Recommended)
These are included only for context when managing patients who previously failed such therapy:
- Genotype 1 or 4: Sofosbuvir + peginterferon-α + ribavirin for 12 weeks 4
- Genotype 1 (interferon-ineligible): Sofosbuvir + ribavirin for 24 weeks 4
- Hepatocellular carcinoma awaiting transplant: Sofosbuvir + ribavirin for up to 48 weeks or until transplantation 4
Pediatric Patients (≥12 years or ≥35 kg)
Critical Monitoring
Pre-treatment testing:
- Test all patients for HBsAg and anti-HBc before initiating HCV treatment to identify HBV coinfection risk 3, 4
Post-treatment:
- Assess sustained virologic response (SVR) at 12 weeks after treatment completion 5
- Monitor HBV/HCV coinfected patients for HBV reactivation during and after HCV treatment 3, 4
Common Pitfall
Do not use amiodarone with sofosbuvir-containing regimens due to risk of serious symptomatic bradycardia 4. If no alternative exists, cardiac monitoring is mandatory.