When to initiate treatment for Hepatitis C (HCV) infection?

From the Guidelines

Treatment for hepatitis C should begin as soon as possible after diagnosis for all patients with chronic HCV infection, regardless of liver disease severity. The standard of care involves direct-acting antivirals (DAAs) such as sofosbuvir/velpatasvir (Epclusa), glecaprevir/pibrentasvir (Mavyret), or sofosbuvir/ledipasvir (Harvoni), typically taken for 8-12 weeks depending on the specific regimen, viral genotype, and presence of cirrhosis 1. Before starting treatment, patients should undergo baseline testing including HCV genotype, viral load, liver function tests, assessment for cirrhosis, and screening for hepatitis B co-infection. Treatment should be initiated promptly because early intervention prevents progression to advanced liver disease, reduces transmission risk, and improves quality of life. The modern DAA regimens have cure rates exceeding 95% with minimal side effects compared to older interferon-based therapies 1.

Some key considerations for treatment include:

• The specific HCV genotype, as this can influence the choice of treatment regimen 1
• The presence of cirrhosis, as this can affect the duration and type of treatment 1
• The patient's overall health and presence of any co-morbidities, as this can impact the risk of treatment side effects and the likelihood of successful treatment 1
• Regular monitoring during treatment to check for medication adherence, side effects, and viral response 1

Patients with decompensated cirrhosis or other severe complications may require specialized management and should be referred to a hepatologist. Overall, the goal of treatment is to achieve a sustained virological response (SVR), which is associated with improved liver function, reduced risk of liver disease progression, and improved quality of life 1.

From the FDA Drug Label

Test all patients for evidence of current or prior hepatitis B virus (HBV) infection before initiating treatment with sofosbuvir and velpatasvir Test all patients for evidence of current or prior HBV infection by measuring hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc) before initiating HCV treatment with ledipasvir and sofosbuvir Test all patients for HBV infection by measuring HBsAg and anti-HBc.

The treatment of hepatitis C should be started after testing all patients for evidence of current or prior HBV infection. The decision to start treatment should be based on the results of these tests and the patient's overall clinical condition, including the presence of cirrhosis or decompensated cirrhosis. Treatment regimens and durations may vary depending on the patient population and HCV genotype. It is essential to follow the recommended treatment regimens and durations as outlined in the drug labels for each medication, including sofosbuvir, velpatasvir, and ledipasvir 2, 3, 4.

From the Research

Treatment Initiation for Hepatitis C

The decision on when to start treatment for hepatitis C depends on various factors, including the patient's genotype, presence of cirrhosis, and previous treatment experience.

• Patients with any risk factor for HCV should first be screened for HCV antibodies, and in the case of positive antibodies, reflex testing for RNA polymerase chain reaction (PCR) should be done without waiting for genotype 5.
• For patients with positive PCR, fibrosis assessment should be conducted using laboratory panels, and if advanced fibrosis is suspected, additional non-invasive fibrosis assessment is needed 5.
• Treatment can be initiated in patients with chronic HCV, including those with compensated cirrhosis, and the choice of treatment regimen depends on the genotype and other factors 6, 7, 8, 9.

Patient Factors Influencing Treatment Initiation

Several patient factors can influence the decision to start treatment, including:

• Presence of cirrhosis: Patients with compensated cirrhosis can be treated with ledipasvir/sofosbuvir for 12 or 24 weeks, with or without ribavirin 6.
• Previous treatment experience: Treatment-experienced patients may require a different treatment regimen or duration, such as the addition of ribavirin or extension of treatment to 24 weeks 6.
• Genotype: The choice of treatment regimen depends on the genotype, with pangenotypic drugs such as Glecaprevir/pibrentasvir or Sofosbuvir/velpatasvir available for treatment-naïve patients with genotype 1-6 5, 7.
• Presence of comorbidities: Patients with comorbidities, such as HIV coinfection, may require referral to a liver clinic for treatment 5.

Treatment Regimens and Duration

Various treatment regimens are available for hepatitis C, including:

• Ledipasvir/sofosbuvir for 12 or 24 weeks, with or without ribavirin 6, 9.
• Sofosbuvir/velpatasvir for 12 weeks 7.
• Glecaprevir/pibrentasvir for 8 weeks 5.
• Sofosbuvir/daclatasvir for 12 weeks 8. The choice of treatment regimen and duration depends on the patient's genotype, presence of cirrhosis, and previous treatment experience.