AASLD-IDSA Practice Guidelines—Hepatitis C—December 2019 Update

January 7th, 2020

SCREENING:
- New update: One-time, routine HCV screening recommended for all individuals aged 18 or older
o Prior USPSTF recommendation between 1945 and 1965, but new rise in HCV infections between
2009 and 2017 was in patients born after 1965 and ages 20-39
o More cost-effective than birth-cohort screening alone
- Risk-based testing
o One-time testing for patients <18 years old with increased risk of HCV infection (behaviors, exposures,
etc.)
 Not enough evidence for universal screening in pediatric population
o Offer periodic repeat HCV testing to patients with continued risk of HCV exposures
 No specific interval has yet been defined
o Annual HCV testing recommended for patients who use IV drugs and men with HIV who have
unprotected sex with men
o Increased risk behavior, exposures, and conditions:
 IVDU, intranasal drug use
 Men who have sex with men
 Hemodialysis
 Percutaneous/parenteral exposures in unregulated settings
 Medical/public safety workers with exposure to needle-sticks, sharps, mucosal exposures
with HCV-infected blood
 Children born to HCV-infected women
 Incarceration (ever)
 Blood transfusions from donor who was HCV positive
 Blood products or organ transplant < July 1992
 Clotting factor concentrates < 1987
 HIV infection
 Sexually-active persons about to start PrEP for HIV
 Unexplained chronic liver disease with elevated ALT
 Solid organ donors and solid organ transplant recipients
DIAGNOSTIC METHODS:
- First-line = HCV antibody with reflex HCV RNA PCR
o If negative antibody but had HCV exposure within the prior 6 months, can order HCV RNA testing
OR follow-up HCV antibody testing
o If negative and immunocompromised, order HCV RNA PCR testing
- If patient has had prior infection and concern for reinfection, can order just HCV RNA testing
- If HCV antibody is positive but PCR testing is negative, there is no current infection
o But must inform patients that still at risk of re-infection (no protection)
- Recommend quantitative HCV RNA testing prior to initiation of antiviral agents for a baseline viral load
- Consider HCV genotype testing if it may alter treatment recommendations
o Not always required due to pangenotypic DAA regimens
o Recommend genotyping if patient has prior HCV treatment failure

COUNSELING AND CLINICAL CARE FOR PATIENTS WITH ACTIVE HCV:

- Recommend alcohol abstinence and interventions to facilitate cessation as appropriate
o No known safe level of alcohol use in patients with chronic HCV
AASLD-IDSA Practice Guidelines—Hepatitis C—December 2019 Update
January 7th, 2020

o Ongoing EtOH use is not a contraindication to antiviral therapy (data indicates that it does not
affect therapeutic outcomes)
- Should be provided education about how to prevent HCV transmission to others
o No sharing of toothbrushes, dental or shaving equipment, cover blood
o Don’t share IV drug equipment, clean injection site with alcohol swab, dispose needles/syringes
after 1 use
o Barrier precautions for sexual transmission
- Evaluation for advanced fibrosis with non-invasive markers is recommended
o Elastography, FIB-4, APRI, imaging, serum fibrosis marker panels
o Can use liver biopsy if other causes of liver disease are suspected
- Evaluation for other conditions that will accelerate liver fibrosis (i.e. hepatitis B, HIV) is recommended
o If HBsAg positive, will require additional monitoring during HCV treatment due to HBV reactivation
risk
- Vaccinate against hepatitis A, hepatitis B in active HCV infected patients
- Vaccinate against pneumococcal infections if patient is cirrhosis

TREATMENT:
- Antiviral treatment is recommended for all adults with acute or chronic HCV infection, except those with a
short life expectancy that cannot be remediated by HCV therapy, liver transplantations, or other directed
therapy
o Includes patients with ongoing substance or drug use
o Studies are showing that treatment-committed individuals in active substance use population
achieve comparable SVR rates to those without active substance use
- Simplified Chronic HCV Treatment Algorithm for Treatment-Naïve Adults without cirrhosis
o Not recommended if have HIV, HBV infections, prior liver transplant, HCC, ESRD, pregnancy (need
more nuanced care)
o Treatment regimens
 Glecaprevir (300mg)/pibrentasvir (120mg) daily for 8 weeks
 Sofosbuvir (400mg)/velpatasvir (100mg) daily for 12 weeks
o On-treatment monitoring:
 Symptomatic hypoglycemia, may need to adjust diabetes meds
 Monitor INR (subtherapeutic?), may need to change warfarin
o Post-treatment assessment of SVR
 Check HCV RNA 12 weeks or later after completion of therapy to confirm that it is
undetectable (SVR)
 If transaminases are elevated again after achieving SVR, full assessment for other causes of
liver disease
 If SVR achieved, no other liver-related follow-up necessary
 If fail to achieve SVR, refer to specialist (yay!)
- Simplified Chronic HCV Treatment Algorithm for Treatment-Naïve Adults with Compensated
Cirrhosis (CP A)
o Genotype 1-6: glecaprevir (300mg)/pibrentasvir (120mg) for 8 weeks
o Genotypes 1,2,4,5, or 6
 Sofosbuvir (400mg)/velpatasvir (100mg) daily for 12 weeks
 If genotype 3, must get baseline NS5A resistance-associated substitution (RAS) testing—if
no presence of Y93H, can still use this therapy
AASLD-IDSA Practice Guidelines—Hepatitis C—December 2019 Update
January 7th, 2020

o On-treatment monitoring:
 Monitor for liver injury + potential decompensation during therapy
 Similar hypoglycemia, subtherapeutic INR concerns
o Post-treatment assessment of SVR
 Check HCV RNA 12 weeks or later after completion of therapy to confirm that it is
undetectable (SVR)
 Follow-up testing
 Need appropriate HCC screening every 6 months
 Variceal surveillance as recommended
 If fail to achieve SVR, refer to specialist
- Acute HCV Infection
o First 6 months of infection
o 75% of patients with acute infection progress to chronic infection
o Fluctuations in viremia during acute phase can lead to higher HCV RNA levels than during chronic,
in addition to fluctuating ALT levels
o HCV Antibody and HCV RNA testing is recommended for evaluation of suspected acute HCV infection
 HCV RNA becomes reliable at 2-3 weeks after exposure
 HCV Ab seroconverts around 2-3 months
o After initial diagnosis of acute HCV with viremia (quantifiable RNA), HCV treatment should be
initiated without awaiting spontaneous resolution
 Data shows that treatment in acute HCV reduces HCV viremia
 Reduces HCV incidence by reducing transmission to other patients
 Delaying treatment may increase number of patients who are lost to follow-up
o Counseling is recommended for patients with acute HCV infection to avoid other insults (including
hepatotoxic drugs [i.e. Tylenol], alcohol, reduce risk of HCV transmission to others
o Referral to addiction medicine specialist recommended if related to substance use
- Due to the high efficacy and safety, the same regimens that are recommended for chronic HCV are
recommended for acute infection
o Glecaprevir (300mg)/pibrentasvir (120mg) daily for 8 weeks
o Sofosbuvir (400mg)/velpatasvir (100mg) daily for 12 weeks
AASLD-IDSA Practice Guidelines—Hepatitis C—December 2019 Update
January 7th, 2020

Simplified algorithm for treatment of HCV in patients who are treatment-naïve and do not have cirrhosis
AASLD-IDSA Practice Guidelines—Hepatitis C—December 2019 Update
January 7th, 2020

Simplified algorithm for treatment of HCV in patients who are treatment-naïve and have compensated
cirrhosis