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

Pediatric Hepatitis C Treatment in Residency Programs

Core Treatment Principle

All children and adolescents with HCV infection aged ≥3 years should receive direct-acting antiviral (DAA) therapy regardless of disease severity, as treatment reduces future morbidity and mortality while supporting HCV elimination strategies. 1, 2

Treatment Regimens by Age and Genotype

Adolescents ≥12 Years or ≥45 kg (All Genotypes)

• First-line: Glecaprevir 300 mg/pibrentasvir 120 mg once daily for 8 weeks in treatment-naive or interferon-experienced patients without cirrhosis or with compensated cirrhosis (Child-Pugh A) 1, 2
• This regimen achieves high cure rates comparable to adults across all HCV genotypes 1, 2

Children Aged 3-11 Years

For Genotypes 1,4,5, or 6:

• Ledipasvir/sofosbuvir (weight-based dosing) for 12 weeks in treatment-naive or interferon-experienced children without cirrhosis or with compensated cirrhosis 1, 2, 3
• SVR12 rates are comparable to adult outcomes 2

For Genotypes 2 or 3:

• Sofosbuvir plus ribavirin (weight-based dosing) for 12 weeks in patients without cirrhosis 2, 4
• 24 weeks for those with compensated cirrhosis 2, 4
• Registration trials demonstrated 98% SVR12 in children aged 3 to <12 years 2

Priority Treatment Scenarios

Immediate treatment initiation is indicated for:

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

Pre-Treatment Requirements

Mandatory Testing Before DAA Initiation

• HBV screening: Test all patients for HBsAg and anti-HBc to assess for active or prior HBV infection, as HBV reactivation can occur during or after HCV treatment 2, 4
• HIV screening: HIV antigen/antibody testing 1
• Baseline laboratories: CBC, INR, hepatic function panel, eGFR within 3 months of therapy initiation 1
• Quantitative HCV RNA 1
• Genotype testing if sofosbuvir/velpatasvir is planned (for RAS testing in genotype 3 with cirrhosis) 1

On-Treatment and Post-Treatment Monitoring

Glucose Monitoring

• Monitor glucose levels during and after treatment in children with diabetes, as DAA-related HCV clearance can alter dose-response relationships and cause hypoglycemia 2, 3
• Adjust diabetes medications as warranted 2

Anticoagulation Monitoring

• Monitor INR during and after treatment in children taking warfarin due to potential alterations in anticoagulation response 2, 3
• Adjust warfarin dosing as needed 2

Hepatic Monitoring

• Patients experiencing deteriorating hepatic parameters, new-onset jaundice, ascites, encephalopathy, or other liver-related symptoms should promptly see a liver specialist 1

Special Populations and Considerations

Cirrhosis Management

• HCC surveillance: Liver ultrasound (with or without alpha-fetoprotein) every 6 months for pediatric patients with cirrhosis 1
• Varices screening: Baseline endoscopy to detect esophageal varices, then every 3 years in absence of viral clearance 1
• Successful DAA therapy substantially reduces cirrhosis complication risk 1

Medication Management in HCV-Infected Children

Avoid if possible:

• Medications accelerating hepatic fibrosis (e.g., methotrexate) in children with advanced fibrosis or cirrhosis 1
• NSAIDs and aspirin in patients with cirrhosis and esophageal varices due to GI bleeding and nephrotoxicity risks 1, 3

Safe to use:

• Acetaminophen is safe and effective when dosed per packaging recommendations 1, 3
• Antimicrobial, antiepileptic, and cardiovascular agents require no dosage adjustments 1
• Corticosteroids and immunosuppressants are not contraindicated despite potentially enhancing HCV replication; prescribe based on risk-benefit analysis 1

DAA-Experienced Patients

• Treat using adult HCV guidance under supervision of a pediatric HCV specialist, as this scenario is rarely encountered 2

Decompensated Cirrhosis or Post-Transplant

• Refer to specialty care and online HCV guidance for specific management 2

Lifestyle and Prevention Counseling

• Alcohol abstinence is strongly advised to reduce liver disease progression risk 1, 3
• Weight management: Counsel patients and parents about maintaining healthy body weight due to deleterious effects of insulin resistance on HCV-related fibrosis progression 1, 3

Critical Pitfalls to Avoid

Loss to Follow-Up

• The largest cascade of care drop-off occurs following initial clinic evaluation, primarily in children aged ≤5 years 5
• Enhanced linkage to care efforts are essential in this age group 5

Delayed Treatment

• Do not delay treatment waiting for older age, as hepatic fibrosis progresses over time and complications may develop in early adulthood 1, 2
• The rationale for treating pediatric HCV mirrors adults: reducing disease-related morbidity and mortality 1

HBV Reactivation Risk

• Failure to screen for HBV before treatment can result in fulminant hepatitis, hepatic failure, and death from HBV reactivation 4
• Monitor HCV/HBV coinfected patients for reactivation during and after treatment 4