Best practices for HCV care include less invasive testing for many patients, says ACP

The College's new advice on treating hepatitis C virus (HCV) identifies patients who can be safely treated in primary care with laboratory monitoring limited to the beginning and end of treatment and no invasive testing.

Viral genotyping and invasive testing may not be needed in the treatment of hepatitis C virus (HCV) infection, according to new ACP Best Practice Advice aimed at simplifying and improving treatment of patients with the disease.

The College advises that viral genotyping is unnecessary when treating HCV with pangenotypic medications unless planning treatment with glecaprevir-pibrentasvir (GLE-PIB), in which case genotyping is necessary to identify genotype 3, which requires longer treatment. The article was published Oct. 6 by Annals of Internal Medicine.

Invasive testing to establish the degree of fibrosis is also not necessary, and inexpensive laboratory tests can reliably identify patients with cirrhosis, the paper said. Pretreatment testing is required only to distinguish patients with cirrhosis from those without to determine treatment duration, which can be reliably accomplished with inexpensive, noninvasive tests. When clinical circumstances require a more refined assessment of the degree of precirrhotic fibrosis, noninvasive techniques, such as vibration-controlled transient elastography, can be considered instead of liver biopsy.

Further, ACP advises that laboratory monitoring can be limited to the beginning and end of treatment in adults with no or compensated cirrhosis. Patients with decompensated cirrhosis will need closer monitoring. Those with compensated cirrhosis should be treated with sofosbuvir-velpatasvir for 12 weeks or GLE-PIB for 12 weeks (16 weeks in cases with known genotype 3 infection), the advice said.

Many patients with uncomplicated HCV infection do not require subspecialist involvement, the College advised. Patients with decompensated cirrhosis, hepatitis B or HIV co-infection, or chronic kidney disease; pregnant women; and those in whom a prior direct-acting antiviral regimen has been unsuccessful should be managed in consultation with a subspecialist and will likely require more careful laboratory monitoring. “The simplification of treatment and monitoring enables patients with uncomplicated HCV infection to receive treatment in primary care settings,” the paper concluded.

This ACP Best Practice Advice is based on a guideline from the World Health Organization (WHO). While the WHO guideline is primarily targeted toward policymakers in low- and middle-income countries, recommendations are relevant to the United States, where equity and resource allocation issues are also important considerations, the ACP paper said.