Overview of Antiviral Therapy for HCV

The development of antiviral medications for chronic hepatitis C virus (HCV) infection has changed the way the condition is treated. HCV has largely become a curable disease with the use of antiviral treatment. Treatment is customized for each individual, and doctors consider which medications will work best for their patient based on several factors, some of which include the specific genotype (strain) of HCV a person has, if the person has had any previous treatment for HCV, if they have complications like cirrhosis, if they have other conditions like human immunodeficiency virus (HIV), or if they have had a liver transplant.1,2

Treatment recommendations for HCV

The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (ISDA) have created guidelines for treatment recommendations for people with chronic HCV, and the information below is based on these treatment recommendations. However, because of the rapidly evolving treatment landscape with new medications becoming available, these guidelines are frequently revised. Patients are encouraged to talk to their doctor about which treatments are appropriate for them. 2

What treatments are recommended for people who have never had treatment for HCV?

People with chronic HCV who have not previously had any treatment for their infection are called “treatment naïve” patients. The treatment options are based on the specific genotype, as well as whether the person has cirrhosis.

For genotype 1 and 4, the recommended treatment regimens are:

For genotype 2 and 3, the recommended treatment regimens are:

  • Mavyret (glecaprevir/pibrentasvir)
  • Epclusa (sofosbuvir/velpatasvir)2

For genotype 5 and 6, the recommended treatment regimens are:

  • Mavyret (glecaprevir/pibrentasvir)
  • Epclusa (sofosbuvir/velpatasvir)
  • Harvoni (ledipasvir/sofosbuvir)2

In approximately 10-15% of people with genotype 1 who have not had previous treatment, the HCV is resistant to NS5A inhibitors (class of antiviral medications). Testing may be done prior to starting treatment to identify if an individual has the genetic mutations that make HCV resistant to certain medications.2

What treatments are best for people who have had previous treatment for HCV?

Sometimes, a particular treatment doesn’t work for an individual patient and doesn’t cure their HCV. For people with chronic HCV who have received prior treatment, treatment recommendations are based on the genotype of HCV, which treatments they have had before, and whether they have cirrhosis.

For those who have previously had treatment, the recommended treatments include:

  • Zepatier (elbasvir/grazoprevir)
  • Mavyret (glecaprevir/pibrentasvir)
  • Harvoni (ledipasvir/sofosbuvir)
  • Epclusa (sofosbuvir/velpatasvir)
  • Vosevi® (sofosbuvir/velpatasvir/voxilaprevir)2

What treatments are best for people with HIV?

For those who have HCV and HIV, treatment for both conditions must be taken into consideration. It is important for people who have HCV and HIV to communicate their conditions with all their doctors, as they may have different doctors prescribing treatments for each condition. In some cases, the treatment for HIV may need to be modified during the treatment for HCV. The recommended HCV treatments for people with HIV include:

  • Daklinza™ (daclatasvir)
  • Zepatier (elbasvir/grazoprevir)
  • Mavyret (glecaprevir/pibrentasvir)
  • Olysio® (simeprevir)
  • Epclusa (sofosbuvir/velpatasvir)
  • Harvoni (ledipasvir/sofosbuvir)
  • Viekira Pak™ (ombitasvir/paritaprevir/ritonavir & dasabuvir) or Viekira XR™ (dasabuvir/ombitasvir/paritaprevir/ritonavir)
  • Vosevi (sofosbuvir/velpatasvir/voxilaprevir)2

What treatments are best for people who have cirrhosis?

Chronic HCV can cause cirrhosis (scarring of the liver). Cirrhosis can be characterized as compensated (it’s not causing symptoms) or decompensated (symptoms are present, including jaundice, swelling, bleeding in the esophagus or stomach, and changes in mood or behavior). For individuals who have compensated cirrhosis, the treatment recommendations are based on their genotype and whether they have had treatment before. These treatment recommendations are outlined above.2

For individuals who have decompensated cirrhosis, most will benefit from treatment with direct-acting antivirals (DAAs), but the treatment may not be enough to prevent needing a liver transplant. The recommended treatments for people with decompensated cirrhosis are dependent on the genotype of HCV and other conditions they may have, such as anemia (low red blood cell count), kidney disease, or pregnancy. People with these conditions should not take regimens that include ribavirin.2,3

For genotypes 1, 4, 5 and 6 who are eligible to take ribavirin, the recommended treatment regimens are:

  • Harvoni (ledipasvir/sofosbuvir) with ribavirin
  • Epclusa (sofosbuvir/velpatasvir) with ribavirin
  • For genotype 1 and 4 only: Daklinza (daclatasvir) with Sovaldi® (sofosbuvir) and ribavirin2

For genotypes 1, 4, 5 and 6 who cannot take ribavirin, the recommended treatment regimens are:

  • Harvoni (ledipasvir/sofosbuvir)
  • Epclusa (sofosbuvir/velpatasvir)
  • For genotype 1 and 4 only: Daklinza (daclatasvir) plus Sovaldi (sofosbuvir) 2

What treatments are best for people who have had a liver transplant?

Some people with chronic HCV may need a liver transplant. While a liver transplant can resolve some of the complications, in most cases a transplant does not cure HCV, and those who have had a liver transplant may need additional medication. Treatment is based on genotype and whether the person has cirrhosis.2

The recommended treatments for people who have had a liver transplant with genotypes 1, 4, 5, or 6 and who do not have cirrhosis are:

  • Mavyret (glecaprevir/pibrentasvir)
  • Harvoni (ledipasvir/sofosbuvir) plus ribavirin2

The recommended treatment for people who have had a liver transplant with genotypes 1, 4, 5, or 6 and who have compensated cirrhosis is Harvoni (ledipasvir/sofosbuvir) plus ribavirin.2

The recommended treatments for people who have had a liver transplant with genotypes 2 or 3 and who do not have cirrhosis are:

  • Mavyret (glecaprevir/pibrentasvir)
  • Daklinza (daclatasvir) plus Sovaldi (sofosbuvir) with low initial dose of ribavirin2

The recommended treatment for people who have had a liver transplant with genotypes 2 or 3 and who have compensated cirrhosis is Daklinza (daclatasvir) plus Sovaldi (sofosbuvir) with low initial dose of ribavirin.2

The recommended treatments for people who have had a liver transplant with genotypes 2 or 3 and who have decompensated cirrhosis are:

  • Daklinza (daclatasvir) plus Sovaldi (sofosbuvir) with low initial dose of ribavirin
  • Epclusa (sofosbuvir/velpatasvir) with ribavirin2
Written by: Emily Downward | Last reviewed: March 2018.
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