The American College of Physicians (ACP) has issued best practice advice for the treatment of people with chronic hepatitis C virus (HCV) infection. These recommendations were published in the Annals of Internal Medicine.
Based on World Health Organization (WHO) guidelines, the advice was crafted by the ACP Scientific Medical Policy Committee. Although the WHO guidelines are primarily targeted at low- and middle-income countries, they are also relevant for the United States, where equity and resource allocation issues are important considerations.
“By following ACP’s best practice advice, physicians can practice high-value care by offering treatment to all patients with chronic HCV infection using a ‘treat all’ strategy without any invasive testing,” ACP president Jacqueline W. Fincher, MD, said in a press release.
The incidence of hep C, or the rate of new infections, is 1.2 for every 100,000 persons in the United States. The prevalence is 2.4 million cases, with a yearly death rate of more than 15,000.
The WHO’s recommendations call for treatment for people over age 12 with chronic hep C infection. Under these guidelines, the WHO supported the use of combination therapy with direct-acting antiviral agents that are both safe and effective. WHO promoted the creation of treatment plans that target all HCV genotypes, streamlining testing before and during treatment. Also, the WHO proposed lowering the cost of treatment but not the quality.
The newest hep C medications work against all viral genotypes. According to the ACP’s best practices, viral genotyping is not required for treatment with pangenotypic drugs unless the treatment involves using Mavyret (glecaprevir/pibrentasvir).
Adults who do not have cirrhosis should be treated with Epclusa (sofosbuvir/velpatasvir) for 12 weeks or with Mavyret for eight weeks, unless they have HCV genotype 3, for which they should take Mavyret for 16 weeks.
Adults with compensated cirrhosis should be given Epclusa or Mayvret for 12 weeks, except in case of a genotype 3 infection, for which Mavyret is recommended for 16 weeks.
The WHO guidelines also recommend sofosbuvir (Sovaldi) plus daclatasvir (Daklinza), but this regimen has fallen out of favor in the United States due to lower response rates.
Invasive testing, such as liver biopsies to assess the extent of fibrosis is unnecessary, and economical noninvasive diagnostics can identify people with cirrhosis. Moreover, laboratory tests are needed only at the beginning and end of treatment, not during the course of therapy. Closer monitoring is suggested for people with decompensated cirrhosis, meaning liver failure due to cirrhosis.
Ultimately, this streamlining of treatment regimens makes it possible for people with straightforward hep C infection to be treated in a primary care setting.
Click here to read the study in the Annals of Internal Medicine.
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