HCV Treatment guidelines Flashcards
After stating HCV treatment, what is the follow up procedure?
Weeks 2-4:
Contact (usually by telephone) to assess for compliance and complications
Weeks 4-end of treatment:
Contact depending on case complexity and support requirements
Week 12 - End of treatment:
HCV RNA check for SVR
LFT
Fibroscan - if >7kPa at initial assessment
If Fibroscan is >7kPa at initial assessment, will need follow up for fibrosis/ cirrhosis/ HCC in future, even once cleared HCV
HCV patient completed 12 weeks treatment
When can they be discharged from clinic?
Discharge
Following SVR12 assessment, patients should be discharged if the following criteria are met:
- FibroScan score < 7kPa
- Normal LFT, plt and PT
Advice should be given regarding blood borne virus prevention, vaccination recommendations and liver disease risk factor avoidance.
How are patients prioritised for HCV treatment?
- Liver function - patients with liver failure will receive top priority.
- Liver disease stage - more severe will be prioritised
- Medical co-morbidities. Examples include medical complications of hepatitis C, liver cancer, HIV and conditions that require immunosuppression such as liver transplantation.
- Other hepatitis C associated complications
- Infection risk to others
- Patient being within a limited “treatment window”
- Iatrogenic infection
- Time on waiting list
Treatment of genotype 1 & 4
Non-cirrhotic
First line
Grazeprovir NS3A/NS4A
Elbasavir NS5A
12 weeks
Treatment of genotype 1 & 4
Cirrhotic - compensated
First line
Grazeprovir NS3A/NS4A
Elbasavir NS5A
12 weeks
Treatment of genotype 2/ 3/ 5/ 6
Non-cirrhotic
First line
Velpatasvir NS5A
Sofosbuvir NS5B
12 weeks
Treatment of genotype 2/ 3/ 5/ 6
Cirrhotic - compensated
First line
Velpatasvir NS5A
Sofosbuvir NS5B
12 weeks
+/- ribavirin for genotype 3
Treatment of genotype 1 - 6
Cirrhotic - decompensated
First line
Genotype 1 -
- Ledipasavir
- Sofosbuvir
- Ribavirin
Genotype 2-6 -
- Velpatasavir
- Sofosbuvir
- Ribavirin
12 weeks
HCV DAA treatment duration normally 12 weeks
In what circumstances would you extend to 16 weeks?
Consider increasing to 16 weeks, and adding ribavirin -
- genotype 1a
- high viraemia - >800 000 copies
- NS5A RAVs (resistance associated variants)
Patient is re-infected with HCV, following successful treatment of previous infection
What are first line drugs for re-infection?
Given it is a new infection, treat with first line therapy depending on genotype
HCV DAA treatment failure
Without decompensated cirrhosis
What is rescue treatment option?
Voxilaprevir NS3A/ NS4A
Velpatasvir NS5A
Sofosbuvir NS5B
12 weeks
Make sure to re-genotype virus, and check for resistance mutations
HCV DAA treatment failure
With decompensated cirrhosis
What is rescue treatment option?
Sofosbuvir
Velpatasvir
Ribavirin
24 weeks
HCV/ HBV co-infection
How to decide which to treat first?
Viral loads to assess which disease is dominant - this should be treated first
Once the dominant virus has controlled, close observation is required as it may have been suppressing the other virus, which could then require treatment.
HCV/ HIV co-infection
HIV is significant risk factor for HCV disease progression, so would want to treat early. However, many drug interactions.
What is recommended treatment goals in these patient groups:
- CD4 <350
- CD4 350 - 500
- CD4 >500
1) In the presence of co-infection, if CD4 count is < 350 x 106 cells/L then HIV therapy is recommended. If treatment for HCV is being instigated then HIV therapy should be established first.
2) If CD4 count is 350-500 x 106 cells/L and HCV treatment is required, HIV therapy should be instigated first.
3) If CD4 count is > 500 x 106 cells/L then HCV treatment can be instigated before HIV therapy is required.
What are common examples of
NS3A/ NS4A DAA
NS3A/ NS4A DAA
Glecaprevir*
Grazeprovir
Voxilaprevir
*less commonly used
What are common examples of
NS5A DAA
NS5A DAA
Elbasavir
Ledipasvir
Pibrentasvir*
Velpatasvir
*less commonly used
What are common examples of
NS5B DAA
NS5B DAA
Sofosbuvir
