For people who were previously not cured with combination DAA therapy, the panel recommends sofosbuvir/velpatasvir/voxilaprevir for 12 weeks, glecaprevir/pibrentasvir plus sofosbuvir for 12 weeks in people with predictors of poor response, or one of these combinations with added ribavirin or extended to 16 or 24 weeks for the most difficult-to-treat people, including those with NS5A resistance mutations who were not cured with two prior treatment attempts.
The panel added a recommendation of sofosbuvir/ledipasvir for adolescents over age 12 with HCV genotypes 1, 2, 5 or 6. Those with genotypes 2 or 3 can be treated cautiously with other regimens approved for adults, given the lack of data for this age group. Children under 12 should hold off on treatment until pangenotypic regimens are approved for them, according to the panel.
People who use drugs should be considered eligible for treatment – and in fact are a priority if they are at risk of transmitting the virus.
"Keep it simple," said panel member Olav Dalgard of Akershus University Hospital in Norway. "You don't need to build up a big support network for people who inject drugs. You can usually treat them like others. We don't want to erect more barriers."
For people with decompensated cirrhosis, the panel recommends sofosbuvir/ledipasvir or sofosbuvir/velpatasvir with ribavirin for 12 weeks, or without ribavirin for 24 weeks for those who cannot tolerate it. Glecaprevir/pibrentasvir and sofosbuvir/velpatasvir/voxilaprevir are not recommended because people with decompensated liver disease should not use HCV protease inhibitors.
Based on the latest data, the panel was able to offer more insight on when to treat people awaiting a liver transplant. Some patients and providers have expressed concern that treatment could improve liver function enough to make people ineligible for a transplant, but not enough to give them a good quality of life.
The panel now recommends that people with a MELD score below 18-20 should be treated for hepatitis C before transplantation, while those with a score of 18-20 or higher should receive a transplant first, without antiviral treatment, and be treated for HCV afterwards. However, the latter group can go ahead with treatment if the transplant waiting time is expected to exceed 6 months. For people with HCV recurrence after transplantation, treatment should be started within 3 months using regimens similar to those used for non-transplant patients.
Now that treatment for hepatitis C is so successful, organs from HCV-positive people can be used for transplantation for either HCV-positive or HCV-negative recipients with informed consent and if post-transplant DAA therapy is guaranteed.
Successful hepatitis C treatment slows or halts liver disease progression and lowers the risk of hepatocellular carcinoma (HCC), a type of primary liver cancer. Most experts now agree that an earlier suggestion of a higher risk of HCC recurrence among people cured with DAAs was due to the treatment of sicker people after these drugs became available.
Nonetheless, while the risk of liver cancer is reduced after treatment, it is not eliminated, especially in people with cirrhosis. These people should undergo regular HCC surveillance in areas where HCC treatment is available.
Geoffrey Dusheiko of University College London suggested that people with advanced (stage F3) fibrosis, those with metabolic syndrome (who are at risk for fatty liver disease) and those with other risk factors should be under surveillance for HCC as well.