Test Your Knowledge of Hepatitis C Virus: A Simple Treatment Regimen
AUTHOR:
Daniel S. Fierer, MD
Associate Professor of Medicine, Infectious Diseases, Icahn School of Medicine at Mount Sinai
Infectious Diseases Specialist, The Mount Sinai Hospital
New York, New York
CITATION:
Fierer DS. Test your knowledge of hepatitis C virus: a simple treatment regimen. Consultant360. Published online July 20, 2021.
A 28-year-old woman presented to your primary care office for a new-patient visit. She reported that she had never been screened for hepatitis C virus (HCV), although she did not describe any risk exposures for infection.
Since this is the patient’s first time in your office, you conducted general laboratory testing that included a complete blood cell count panel, comprehensive metabolic panel, and lipid panel, as well as conducted screening for HCV using an antibody test with reflex to viral RNA (viral load).
Results of the HCV antibody test were positive, and viral RNA was detected. You decide that you want to treat her in your practice instead of referring her to a specialist, so you review the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines for treatment recommendations. You find that your patient may be eligible for simplified treatment, requiring very little additional screening.
Answer and discussion on next page.
Correct Answer: D. Liver biopsy
HCV medications are now so safe and effective that the AASLD/IDSA guidelines1 recommend that adults with chronic HCV (any genotype) be assessed for eligibility for simplified HCV treatment.2 “Simplified treatment” means that all primary care providers are able to treat their patients’ HCV infections without referring to a specialist by learning the basic eligibility criteria and becoming familiar with just 2 combination medications.
Adults are eligible for simplified treatment if they have not been treated previously, do not have HIV infection, do not have active hepatitis B virus infection, are not pregnant, and do not have cirrhosis. Answer D, liver biopsy, should not be performed to assess for cirrhosis. This assessment should be done noninvasively. The simplest assessment to exclude cirrhosis in this situation is to perform a FIB-4 calculation, which only requires laboratory test results from the complete blood cell count panel and comprehensive metabolic panel.3
The recommended regimens for simplified treatment are 2 fixed-dose, pangenotypic regimens, each of which have cure rates of more than 95% regardless of genotype:4
- Glecaprevir, 300 mg, plus pibrentasvir, 120 mg, 3 tablets once daily, for 8 weeks
- Sofosbuvir, 400 mg, plus velpatasvir, 100 mg, as a single tablet daily, for 12 weeks
Either regimen would be safe and effective in the presented patient.
The other essential learning point of this vignette is to show the use of universal screening for HCV. The Centers for Disease Control and Prevention have recently updated their HCV screening guidelines to recommend that all adults should receive at least one screening in their lifetime.5 The patient in the vignette was screened based on this new recommendation (although the vignette describes that the patient brought up the screening, this was done to demonstrate that she had not been screened previously). People who are considered at ongoing risk for HCV infection, such as men who have sex with men with HIV and those who use injection drugs, should be screened more often, and pregnant women should be screened at each pregnancy.5
References
1. Initial treatment of adults with HCV infection. HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. American Association for the Study of Liver Diseases and Infectious Diseases Society of America. Updated August 27, 2020. Accessed July 8, 2021. https://www.hcvguidelines.org/treatment-naive
2. Simplified HCV treatment for treatment-naïve adults without cirrhosis. HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. American Association for the Study of Liver Diseases and Infectious Diseases Society of America. Updated August 27, 2020. Accessed July 8, 2021. https://www.hcvguidelines.org/treatment-naive/simplified-treatment
3. Fibrosis-4 (FIB-4) Calculator. Hepatitis C Online. Published 2006. Accessed July 20, 2021. https://www.hepatitisc.uw.edu/page/clinical-calculators/fib-4
4. Hepatitis C. World Health Organization. Updated July 27, 2020. Accessed July 8, 2021. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
5. Testing recommendations for hepatitis C virus infection. Centers for Disease Control and Prevention. Updated July 29, 2020. Accessed July 8, 2021. https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm