S46(2) Treatment Recommendations

Question 1

Treatment Naïve Without Cirrhosis

HCV Genotype 1a

Answer 1

Elbasvir/grazoprevir x 12 weeks
Glecaprevir/pibrentasvir x 8 weeks
Sofosbuvir/ledipasvir x 8 or 12 weeks
Sofosbuvir/velpatasvir x 12 weeks

Question 2

Treatment Naïve Without Cirrhosis
HCV Genotype 1a
No NS5A resistance detected

Answer 2

Elbasvir/grazoprevir x 12 weeks

Question 3

Treatment Naïve Without Cirrhosis
HCV Genotype 1a
8 weeks can be considered in patients without HIV and baseline HCV RNA of < 6 million

Answer 3

Sofosbuvir/ledipasvir x 8 or 12 weeks

Question 4

Treatment Naïve Without Cirrhosis

HCV Genotype 1b

Answer 4

Elbasvir/grazoprevir x 12 weeks
Glecaprevir/pibrentasvir x 8 weeks
Sofosbuvir/ledipasvir x 8 or 12 weeks
Sofosbuvir/velpatasvir x 12 weeks

Question 5

Treatment Naïve Without Cirrhosis
HCV Genotype 1b
8 weeks can be considered in patients without HIV and baseline HCV RNA of < 6 million

Answer 5

Sofosbuvir/ledipasvir x 8 or 12 weeks

Question 6

Treatment Naïve Without Cirrhosis

HCV Genotype 2 and 3

Answer 6

Glecaprevir/pibrentasvir x 8 weeks

Sofosbuvir/velpatasvir x 12 weeks

Question 7

Treatment Naïve Without Cirrhosis

HCV Genotype 4

Answer 7

Elbasvir/grazoprevir x 12 weeks
Glecaprevir/pibrentasvir x 8 weeks
Sofosbuvir/ledipasvir x 8 or 12 weeks
Sofosbuvir/velpatasvir x 12 weeks

Question 8

Treatment Naïve Without Cirrhosis
HCV Genotype 4
8 weeks can be considered if baseline HCV RNA is < 6 million, does not have GT 4r, and not prior treatment history

Answer 8

Sofosbuvir/ledipasvir x 8 or 12 weeks

Question 9

Treatment Naïve With Compensated Cirrhosis

HCV Genotype 1a

Answer 9

Elbasvir/grazoprevir x 12 weeksa
Glecaprevir/pibrentasvir x 8 weeks
Sofosbuvir/ledipasvir x 12 weeks
Sofosbuvir/velpatasvir x 12 weeks

Question 10

Treatment Naïve With Compensated Cirrhosis
HCV Genotype 1a
no NS5A resistance detected

Answer 10

Elbasvir/grazoprevir x 12 weeks

Question 11

Treatment Naïve With Compensated Cirrhosis
HCV Genotype 1a
not co-infected with HIV

Answer 11

Glecaprevir/pibrentasvir x 8 weeks

Question 12

Treatment Naïve With Compensated Cirrhosis

HCV Genotype 1b

Answer 12

Elbasvir/grazoprevir x 12 weeks
Glecaprevir/pibrentasvir x 8 weeks
Sofosbuvir/ledipasvir x 12 weeks
Sofosbuvir/velpatasvir x 12 weeks

Question 13

Treatment Naïve With Compensated Cirrhosis
HCV Genotype 1b
not co-infected with HIV

Answer 13

Glecaprevir/pibrentasvir x 8 weeks

Question 14

Treatment Naïve With Compensated Cirrhosis

HCV Genotype 2 and 3

Answer 14

Glecaprevir/pibrentasvir x 8 weeks
- not co-infected with HIV

Sofosbuvir/velpatasvir x 12 weeks
- Pretreatment resistance testing recommended

Question 15

Treatment Naïve With Compensated Cirrhosis

HCV Genotype 4

Answer 15

Elbasvir/grazoprevir x 12 weeks
Glecaprevir/pibrentasvir x 8 weeks
Sofosbuvir/ledipasvir x 12 weeks
Sofosbuvir/velpatasvir x 12 weeks

Question 16

Treatment Naïve With Compensated Cirrhosis
HCV Genotype 4
not co-infected with HIV

Answer 16

Glecaprevir/pibrentasvir x 8 weeks

Question 17

HCV Decompensated Cirrhosis

Answer 17

Defined as CTP Class B or C cirrhosis
Should be managed by a liver expert
Avoid NS3/4A protease inhibitors
Ribavirin is usually added or treatment extended to 24 weeks

Question 18

HCV Persons Who Inject Drugs

Answer 18

Not a contraindication for treatment
Multi-disciplinary approach
At risk for re-infection

Question 19

HCV Alcoholism

Answer 19

Cessation is recommended

Use is not a reason to prevent or delay treatment

Question 20

HCV Genotype 3

Answer 20

Most difficult to treatment in the setting of prior treatment and/or cirrhosis

Question 21

HCV DAA Experienced

Answer 21

Usually retreated with sofosbuvir/velpatasvir/voxilaprevir

Question 22

HCV HIV Co-infection

Answer 22

No significant difference with treatment or response

Potential for drug-drug interactions

Question 23

HCV HBV Co-infection

Answer 23

Must screen at baseline due to risks of re-activation

Requires treatment and/or monitoring while on DAA therapy

Question 24

HCV Pregnancy and Children

Answer 24

No FDA approved treatment for pregnancy
Sofosbuvir/ledipasvir approved for ≥ 3 years
Glecaprevir/pibrentasvir approved for ≥ 12 years

Question 25

HCV Monitoring Post treatment

Answer 25

Hypoglycemia for diabetic patients 
INR for patients on warfarin 
HCV viral load 12 weeks post treatment 
HCC surveillance via imaging every 6 months for cirrhotics
Re-infection in those at risk