HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of chronic liver disease, including assessment of liver function tests, evaluation for severity of liver disease and possible treatment, and determination of the need for Hepatitis A and Hepatitis B vaccination.
When might a specialist be consulted in the management of HCV-infected persons?
Any physician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C; this can include some internal medicine and family practice physicians as well as specialists such as infectious disease physicians, gastroenterologists, or hepatologists.
What is the treatment for acute hepatitis C?
Treatment for acute hepatitis C is similar to treatment for chronic hepatitis C. This issue was addressed in the 2009 AASLD Practice Guidance, the response rate to treatment is higher among persons with acute than with chronic HCV infection. However, the optimal treatment regimen and when it should be initiated remains uncertain.
What is the treatment for chronic hepatitis C?
Until recently, the mainstay of treatment for chronic hepatitis C virus (HCV) infection has been pegylated interferon and ribavirin, with possible addition of boceprevir (Victrelis™) and telaprevir (Incivek™) (both protease inhibitors) for HCV genotype 1 infection. After given for 24-48 weeks, this treatment resulted in a sustained virologic response (a marker for cure), defined as undetectable HCV RNA in the patient's blood 24 weeks after the end of treatment in 50%–80% of patients (with higher SVR among persons with HCV genotypes 2 or 3 infections versus infections with HCV genotype 1, the most common genotype found in the United States).
In late 2013, The Food and Drug Administration approved two new direct acting antiviral drugs, Sofosbuvir (Sovaldi™) and Simeprevir (Olysio™) to treat chronic HCV infection. Both medications have proven efficacy when used as a component of a combination antiviral regimen to treat HCV-infected adults with compensated liver disease, cirrhosis, HIV co-infection, and hepatocellular carcinoma awaiting liver transplant. Clinical trials have shown that these new medications achieve SVR in 80%-95% of patients after 12-24 weeks of treatment.
Sofosbuvir (Sovaldi™) is a nucleotide analogue inhibitor of the hepatitis C virus (HCV) NS5B polymerase enzyme, which plays an important role in HCV replication. It is taken orally once a day at a 400-mg dose. The drug is approved for two chronic hepatitis C indications: In combination with pegylated interferon and ribavirin for treatment-naïve adults with HCV genotype 1 and 4 infections, and in combination with ribavirin for adults with HCV genotypes 2 and 3 infection. The second indication is the first approval of an interferon-free regimen for the treatment of chronic HCV infection. For more information, see prescribing information[PDF - 34 pages] .
Simeprevir (Olysio™) is a protease inhibitor that blocks a specific protein needed by the hepatitis C virus to replicate. It is to be used as a component of a combination antiviral treatment regimen of peginterferon-alfa and ribavirin for genotype 1 infections only. It is taken orally once a day at a 150-mg dose. The treatment duration is 24-48 weeks depending on prior treatment history and response to treatment. Because the efficacy of simeprevir is substantially reduced in patients infected with HCV genotype 1a with an NS3 Q80K polymorphism, screening for this mutation is strongly recommended by the manufacturer before treatment initiation. For more information, see prescribing information[PDF - 44 pages] .
For current information on approved treatments for hepatitis C, please visit the Food and Drug Administration (FDA).
How many different genotypes of HCV exist?
At least six distinct HCV genotypes (genotypes 1–6) and more than 50 subtypes have been identified. Genotype 1 is the most common HCV genotype in the United States.
Is it necessary to do viral genotyping when managing a person with chronic hepatitis C?
Yes. Because there are at least six known genotypes and more than 50 subtypes of HCV, genotype information is helpful in defining the epidemiology of hepatitis C and in making recommendations regarding treatment. Knowing the genotype can help predict the likelihood of treatment response and, in many cases, determine the duration of treatment.
- Patients with genotypes 2 and 3 are almost three times more likely than patients with genotype 1 to respond to therapy with alpha interferon or the combination of alpha interferon and ribavirin
- When using combination therapy, the recommended duration of treatment depends on the genotype. For patients with genotypes 2 and 3, a 24-week course of combination treatment is adequate, whereas for patients with genotype 1, a 48-week course is recommended.
Can superinfection with more than one genotype of HCV occur?
Superinfection is possible if risk behaviors (e.g., injection drug use) for HCV infection continue, but it is believed to be very uncommon.