In 2011, when the first generation of hepatitis C direct-acting antivirals was approved, I wrote, “Now all we need is a cure that is easier to tolerate and works 100% of the time.” Theoretically, we are nearly there, except for severe access problems (see Harvoni: Tips for Navigating Insurance Prior Authorizations for Hepatitis C Treatment). However, while the press is highlighting the new hepatitis C medications, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) quietly updated the HCV Guidelines. You might have missed it, but there was a profound shift in hepatitis C treatment...

The shift occurred to how we treat hepatitis C in people with cirrhosis. In the first guidelines, cirrhotics were placed in their own category of unique patient populations. In the updated guidelines, people with compensated cirrhosis are included under the regular treatment recommendations. Those with decompensated cirrhosis are in their own category of unique patient populations. The difference between these two classifications of cirrhosis is that the liver still functions reasonably well with compensated cirrhosis, whereas in decompensated cirrhosis the liver is in end-stage disease.

Why is this update important? For two reasons. First, it means that cirrhosis is highly treatable, which for many decades it wasn’t. Second, it gives clear guidelines and hope for those people with decompensated cirrhosis, something they didn’t have in the past. 

What are the recommended treatments for those with decompensated cirrhosis? To begin with, they should only be treated by highly-experienced medical practitioners, ideally in a liver transplant center. 

Patients with HCV genotype 1 or 4
  • Harvoni (ledipasvir/sofosbuvir) and ribavirin (initial dose of 600 mg, increased as tolerated) for 12 weeks 
  • Patients who are anemic or intolerant to ribavirin: Harvoni (ledipasvir/sofosbuvir) for 24 weeks
  • Patients with prior failure with Sovaldi (sofosbuvir-based) treatment: Harvoni (ledipasvir/sofosbuvir) and ribavirin (initial dose of 600 mg, increased as tolerated) for 24 weeks 
Patients with HCV genotype 2 or 3 
  • Sovaldi (sofosbuvir) and weight-based ribavirin for up to 48 weeks 
The following is NOT recommended:
  • Any interferon-based therapy
  • Monotherapy with peginterferon, ribavirin, or a direct-acting antiviral
  • Any treatment using Incivek (telaprevir), Victrelis (boceprevir), or Olysio (simeprevir) 
  • Viekira Pak (Pariteprevir, ombitasvir, dasabuvir)