Today’s direct-acting antiviral (DAA) treatments for hepatitis C are highly effective. The standard course of eight or 12 weeks of daily medication puts your chances of being cured in the high 90% range. While these drugs are associated with some side effects, typically these are mild, especially compared with the burdensome toll of the older and now obsolete interferon-based hep C treatment that thankfully is no longer used to treat the virus.
Hep C treatment guidelines are the simplest for people who are being treated for the first time, do not have additional health problems, do not have severe liver disease and are not pregnant. Most people with such straightforward cases won’t need to see a specialist, such as a hepatologist (liver specialist) or infectious disease physician. Instead, a general practitioner or primary care physician should be able to oversee their treatment.
People with advanced cirrhosis, end-stage kidney disease, liver cancer or a liver transplant and those who are pregnant should consult with a specialist physician about the best strategy for treatment.
Before determining the best course of treatment for hep C, your health care provider will first want to conduct a series of tests and ask you questions about the following:
Genotype testing: A test will determine which of the six major genetic forms of hepatitis C virus (HCV), called genotypes, you have. Some types are easier to treat than others. Older DAAs work only against certain types, but newer drugs work against all types. If you have HCV genotype 3, this may require additional considerations to ensure you receive the most effective treatment regimen.
Liver damage: Your provider may conduct blood tests, imaging scans or a biopsy to assess the extent of any liver damage hep C may have caused. Liver fibrosis, or scarring, has four stages. The most advanced stage is cirrhosis. Compensated cirrhosis is the less severe form of this advanced liver disease and decompensated cirrhosis is the more severe form.
Other infections: You should also be tested for HIV and hepatitis B virus (HBV).
End-stage kidney disease: Hep C treatment requires particular tailoring for people with advanced kidney disease.
Liver cancer: Blood tests, scans or biopsies can diagnose hepatocellular carcinoma, the most common type of liver cancer. Having liver cancer can affect the course of hep C treatment.
Pregnancy: Taking DAAs while pregnant has some risks.
Other meds and supplements: It’s important to discuss with your doctor all other medications you may be taking, including over-the-counter products, herbs, supplements and street drugs. This conversation is meant to determine whether there may be potentially unsafe interactions between those drugs or supplements and hep C therapy.
Numerous DAA regimens for hep C treatment are on the market today, and you will have the most options if you are starting treatment for the first time. The treatment guidelines from the American Association for the Study of Liver Diseases favor some regimens over others. The following guidelines are for treatment first-timers with straightforward cases.
If you do not have cirrhosis, the following are your best treatment options:
- Mavyret (glecaprevir/pibrentasvir) taken once daily for eight weeks
- Epclusa (sofosbuvir/velpatasvir) taken once daily for 12 weeks.
If you have compensated cirrhosis, the following are your best treatment options:
- Mavyret taken once daily for eight weeks
- Epclusa taken once daily for 12 weeks. If you have HCV genotype 3, you should first receive a test to see whether your virus has a mutation associated with resistance to one of the drugs in Epclusa; if so, you should use a different regimen.
If you were previously treated for hep C but not cured, you have a good chance of success in beating the virus if you try again. You should see a specialist—either a hepatologist or infectious disease physician—to select the best retreatment regimen for your specific needs.
If you previously received the older hep C treatment, interferon plus ribavirin, you and your physician have multiple DAA regimens to choose from, depending on your HCV genotype and whether you have cirrhosis.
There are specific recommendations for those who previously received interferon plus an older DAA from the protease inhibitor class. These drugs, Incivek (telaprevir) and Victrelis (boceprevir), are now obsolete.
If you are among the very small percentage of people for whom a first round of newer DAA treatment did not cure your hep C, you still have good options for retreatment.
If your previous regimen included DAA drugs called NS5A inhibitors, your clinician may test to see whether your hep C became resistant to this drug class. If so, your retreatment regimen may require extra considerations. NS5A drugs are a component of combination regimens including Epclusa, Mavyret, Harvoni (ledipasvir/sofosbuvir) and Zepatier (grazoprevir/elbasvir).
As with an initial round of hep C treatment, there are special considerations for those with decompensated cirrhosis, end-stage kidney disease, liver cancer or a liver transplant and those who are pregnant.
Until you receive retreatment with a modern DAA regimen, you should be monitored every six to 12 months to see whether your liver disease has progressed.
Newer DAAs are safe and well tolerated. In clinical trials of the regimens, the most common adverse health events were headache, fatigue and nausea; usually, these were mild. Just 0.1% of Mavyret trial participants and 0.2% of Epclusa trial participants stopped taking the medications because of side effects or other negative health outcomes.
Treatment for hep C can cause HBV to reactivate. If you also have hep B, your physician should closely monitor you while you’re on treatment for hep C.
For people with compensated cirrhosis, in rare cases this condition may progress to the decompensated form during DAA treatment. Your clinician may run tests for this outcome while you’re on hep C therapy. You should see a liver specialist if there is worsening of the key blood tests assessing liver health, including ALT and AST liver enzymes, or if you develop jaundice (yellowing of the skin and eyes), ascites (fluid buildup in the abdomen), encephalopathy (brain problems) or any other liver-related symptoms during treatment.
Are You Cured?
Twelve weeks after finishing DAA treatment, you are considered cured if a test is unable to detect hep C in your blood, which is known as a sustained virologic response.
If you are cured of hep C but are at ongoing risk of acquiring the virus again, which is known as reinfection, you should continue to receive at least annual testing for the virus. Risk factors include sharing injection drug equipment and, for men, having sex without a condom with other men.
If you don’t have cirrhosis, you don’t need to keep seeing a doctor routinely to monitor your liver health after you’re cured of hep C. That said, you should continue to receive routine checkups with your primary care physician for your overall health and well-being. People with cirrhosis should receive monitoring for liver cancer every six months.