What is the recommended treatment for a pediatric patient with Hepatitis C (HCV)?

Pediatric Hepatitis C Treatment

All children and adolescents with HCV infection aged ≥3 years should receive direct-acting antiviral (DAA) therapy regardless of disease severity, as they will benefit from antiviral treatment to reduce future morbidity and mortality. 1

Treatment Recommendations by Age and Genotype

Adolescents ≥12 Years or ≥45 kg

• Glecaprevir/pibrentasvir (300 mg/120 mg) for 8 weeks is the first-choice treatment for all HCV genotypes in treatment-naive or interferon-experienced adolescents without cirrhosis or with compensated cirrhosis (Child-Pugh A). 1
• This pangenotypic regimen demonstrates high efficacy and safety comparable to adult outcomes. 1
• Avoid coadministration with carbamazepine, efavirenz-containing regimens, and St. John's wort, as these decrease circulating concentrations of glecaprevir and pibrentasvir. 1

Children Aged 3-11 Years

For genotypes 1,4,5, or 6:

• Ledipasvir/sofosbuvir (weight-based dosing) for 12 weeks is recommended for treatment-naive or interferon-experienced children without cirrhosis or with compensated cirrhosis. 1, 2
• For interferon-experienced patients with compensated cirrhosis, extend treatment to 24 weeks. 1
• Clinical trials demonstrated SVR12 rates comparable to adults. 1

For genotypes 2 or 3:

• Sofosbuvir plus ribavirin (weight-based dosing) is FDA-approved for children aged ≥3 years. 1, 2
• 12 weeks for patients without cirrhosis; 24 weeks for those with compensated cirrhosis. 1
• Registration trials showed 98% SVR12 in children aged 3 to <12 years. 1
• Consider awaiting approval of pangenotypic regimens (sofosbuvir/velpatasvir or glecaprevir/pibrentasvir) unless immediate treatment is compelling, as these were under FDA review at guideline publication. 1

Priority Treatment Scenarios

Early antiviral therapy should be initiated immediately for:

• Extrahepatic manifestations (cryoglobulinemia, rashes, glomerulonephritis) 1, 2
• Advanced fibrosis or compensated cirrhosis 1, 2
• These conditions require early treatment to minimize future morbidity and mortality. 1

Pre-Treatment Testing Requirements

Before initiating DAA therapy, test all pediatric patients for:

• HBsAg, anti-HBc, and anti-HBs to assess for active or prior HBV infection, as HBV reactivation can occur during or after HCV treatment. 1, 3

Monitoring During and After Treatment

For children with diabetes:

• Monitor glucose levels on-treatment and post-treatment for hypoglycemia, as DAA-related HCV clearance can alter dose-response relationships. 1

For children taking warfarin:

• Monitor INR on-treatment and post-treatment due to potential alterations in anticoagulation response. 1

Special Populations

DAA-experienced pediatric patients:

• Rarely encountered in clinical practice. 1
• Treat using adult HCV guidance under supervision of a pediatric HCV specialist. 1

Decompensated cirrhosis or post-liver transplant:

• Require specialty care; refer to online HCV guidance for specific management. 1

Common Pitfalls to Avoid

Loss to follow-up:

• The largest care cascade drop-off occurs after initial clinic evaluation, particularly in children aged ≤5 years. 4
• Enhanced linkage to care efforts are critical in younger children. 4

Medication availability and swallowing ability:

• Time to treatment initiation is significantly impacted by DAA availability at referral (OR = 41.47) and inability to swallow the dosage form at evaluation (OR = 3.94). 4
• Implement swallowing practice programs before treatment initiation. 4

Drug interactions:

• Intestinal P-gp inducers (rifampin, St. John's wort) may alter sofosbuvir concentrations. 3
• Amiodarone coadministration with sofosbuvir-containing regimens can cause serious symptomatic bradycardia and is not recommended. 3

Treatment Rationale

• Hepatic fibrosis progresses over time in children with HCV, with complications potentially developing in early adulthood. 1
• Curative DAA therapy during childhood supports the treatment-as-prevention paradigm, critical for HCV elimination strategies. 1
• This is particularly important given the recent increase in HCV infection among women of childbearing age, with an estimated 29,000 HCV-infected women giving birth annually. 1