MedCompanion

Chronic Hepatitis C

Hepatitis / Viral

Source: IDMP View on spectrum chart →
Patient + scenario modifiers
Patient
Clinical scenario / source

Annotations only — chart still shows the full chemistry of each drug.

1. Clinical Syndrome

Chronic HCV = detectable HCV RNA ≥6 months. Curable in the modern DAA era (>95% SVR12 with 8–12 weeks PO therapy). USPSTF universal screening recommendation for adults ≥18 once + pregnant women each pregnancy.

Excludes: acute HCV (consider deferral for spontaneous clearance ~20% in 6 months, but treatment now also recommended in acute HCV per AASLD 2024 — shortens infectious window).

2. Pathogens

Consider the patient: Treatment-naïve vs treatment-experienced, cirrhosis (compensated vs decompensated Child-Pugh B/C — adds ribavirin), co-infection (HBV, HIV, HDV), renal function (eGFR <30 was historic restriction, now relaxed for some DAAs), pregnancy (defer typically).

Consider the case: Genotype mostly historical with pangenotypic DAAs. Drug interactions — sofosbuvir + amiodarone contraindicated; PPI absorption issues; HIV ART overlap. Cost / insurance approval can be the rate-limiting step in some practice settings.

Common

    • Hepatitis C Virus

      Sole cause. Pangenotypic DAAs now standard; genotype testing only when treatment failure or insurance requires.

3. Empiric Therapy

TierFirst choiceAlternativesDurationComments
Outpatient
  • 400 / 100 mg fixed-dose combo · PO daily × 12 weeks · PO · 12 weeks (treatment-naïve; compensated cirrhosis included)
  • Glecaprevir / pibrentasvir (Mavyret) 300 / 120 mg (3 tabs of 100/40) · PO daily × 8 weeks with food · PO

    **Alternative pangenotypic** — 8-week regimen for treatment-naïve no-cirrhosis (shorter course is the advantage). Not seeded here but workhorse option.

12 weeks (sofosbuvir-velpatasvir) or 8 weeks (Mavyret naïve no-cirrhosis)**Treatment-naïve + compensated cirrhosis or no cirrhosis** — 12 weeks sofosbuvir-velpatasvir → cure (SVR12) >95%. **Screen HBsAg + anti-HBc before starting** — HBV reactivation possible during DAA therapy if HBV+ + not on HBV-active treatment.
Outpatient — with comorbidities
  • 400 / 100 mg · PO daily × 12 weeks · PO
  • 1000 mg (<75 kg) or 1200 mg (≥75 kg) divided BID · PO · PO · 12 weeks
—12 weeks combo**Decompensated cirrhosis (Child-Pugh B/C)** — add ribavirin. Avoid pregnancy (ribavirin Category X) — strict contraception both partners during + 6 months after. CBC q1–2 weeks for ribavirin hemolytic anemia.

4. Directed Therapy

Universal screening + universal treatment — AASLD 2024 says treat everyone with viremia.

Regimen selection (most cases pangenotypic — genotype testing optional):

  • Treatment-naïve, no cirrhosis: sofosbuvir-velpatasvir × 12 wk OR Mavyret × 8 wk
  • Treatment-naïve, compensated cirrhosis: sofosbuvir-velpatasvir × 12 wk OR Mavyret × 8 wk (per AASLD 2024 — older guidance 12 wk)
  • Decompensated cirrhosis (Child-Pugh B/C): sofosbuvir-velpatasvir + ribavirin × 12 wk (avoid protease inhibitors in decompensated)
  • Treatment-experienced (DAA failure): sofosbuvir + velpatasvir + voxilaprevir (Vosevi) × 12 wk; resistance testing helpful

Critical pre-treatment workup:

  • HCV RNA (confirm viremia + baseline)
  • Genotype (optional if pangenotypic regimen)
  • HBV serology (HBsAg, anti-HBs, anti-HBc) — REACTIVATION risk
  • HIV testing
  • Liver fibrosis: FibroScan or APRI / FIB-4
  • Pregnancy test
  • HAV / HBV vaccination if non-immune
  • Drug interaction review (amiodarone, PPI, HIV ART, anti-rejection)

Cure (SVR12): HCV RNA undetectable 12 weeks after end of treatment → cure. Continue HCC screening in cirrhotic post-cure (q6mo US ± AFP for life — cure removes virus, not cumulative liver damage).

5. Monitoring

On treatment: HCV RNA at baseline, week 4 (rapid response), end-of-treatment, SVR12 (12 weeks post-completion = cure). ALT trend (should normalize).

Off treatment / post-cure: HCC screening in cirrhotics q6mo for life. Reinfection screening q12mo in ongoing risk factors (IV drug use, MSM HIV+).

Toxicity: DAAs generally exceptionally well tolerated. Ribavirin (when added) → CBC q1–2 weeks for hemolytic anemia.

Pearls

HCV is curable in the modern era — 12-week PO DAA → >95% cure. Universal screening + universal treatment (AASLD 2024). Pangenotypic regimens simplify care; genotype testing optional. HBV reactivation risk — screen anti-HBc + HBsAg before tx. Amiodarone contraindicated with sofosbuvir (bradycardia + cardiac arrest). No alcohol + HAV/HBV vaccination + HIV testing in every HCV patient. Decompensated cirrhosis: add ribavirin; avoid protease inhibitor-containing regimens. Cure removes virus but not cumulative liver damage — HCC screening q6mo continues in cirrhotic forever.

References