treatment

Last edited 07/2020

Treatment of the acute attack is supportive. Measures include abstinence from alcohol, bed-rest, and a low fat, high carbohydrate diet.

Treatment of hepatitis C

Direct acting antivirals (DAAs) are the most effective treatment option for people with hepatitis C and are the NICE and NHS England recommended medications.

• choice of DAA is dependent on the type of hepatitis c genotype, past treatment response, the level of active virus in your body (viral load) and if there is cirrhosis
• Ribavirin may be added to the treatment to increase the chance of achieving a cure when there is a high viral load or more advanced liver disease
• Drug interactions are very important to consider in people receiving DAA therapy, as they can sometimes affect how well the treatment works (eg oral contraceptives) or contribute to side effects
• essential that all co-prescribed medication is first checked for drug to drug interactions using https://www.hep-druginteractions.org/
• DAAs and ribavirin
cannot be prescribed safely during pregnancy and some drugs can affect conception also

Common Medications

Elbasvir/Grazoprevir 50mg/100mg (Zepatier®)

• Zepatier is a two-drug combination
• treatment durations are 12 or 16 weeks depending on viral load and genotype
• side effects are minimal but some people experience headache, nausea, diarrhoea, insomnia and fatigue
• drug may not be suitable if you are taking anticoagulants (such as rivaroxaban or apixaban), epilepsy medications or statins

Glecaprevir/Pibrentasvir 100mg/40mg (Maviret®)

• a two-drug combination in a single tablet
• treatment duration is usually 8 weeks; courses up to 16 weeks are needed occasionally
• side effects are minimal but some people experience headache, nausea and fatigue (lack of energy).
• drug may not be suitable if you are taking anticoagulants (such as rivaroxaban or apixaban), epilepsy medications or statins

Sofosbuvir/Ledipasvir 400mg/90mg (Harvoni®)

• a two-drug combination in a single tablet
• treatment durations are 8 or 12 weeks depending on viral load, genotype and past treatment response
• side effects are minimal but some people experience headaches and fatigue (lack of energy).
• drug may not be suitable if you are taking amiodarone, anticoagulants (such as rivaroxaban or apixaban), epilepsy medications or statins

Sofosbuvir/Velpatasvir 400mg/100mg (Epclusa®)

• a two-drug combination in a single tablet
• treatment duration is usually 12 weeks depending on viral load, genotype and past treatment response
• side effects are minimal but some people experience headaches and fatigue (lack of energy)
• drug may not be suitable if you are taking amiodarone, anticoagulants (such as rivaroxaban or apixaban), epilepsy medications or statins

Ribavirin

• ribavirin alone does not cure hepatitis C but is used in combination with other DAAs to increase their effect
• side effects include fatigue (lack of energy), insomnia and headache
• ribavirin can cause birth defects in animals and will not be prescribed

Liver transplantation:

• considered for patients with decompensated cirrhosis; also for those who develop hepatocellular carcinoma

Surveillance for hepatocellular carcinoma - this is achieved by ultrasound and measurement of alpha-feto protein - this is undertaken every three or four months and is part of the care of patients with cirrhosis associated with chronic hepatitis C virus infection

Advice to patients should cover areas such as (3):

• alcohol advice
  • not known whether there is a safe limit of alcohol consumption in patients with hepatitis C
  • however risk of liver damage is directly proportional to the level of consumption and thus all patients diagnosed with hepatitis C infection should be advised to avoid alcohol or reduce their consumption as much as possible
• hygiene precautions
  • patients should be advised to avoid sharing razors, toothbrushes or any other items that may be contaminated with blood - if a patient adheres to such precautions, patients can be reassured that transmission of hepatitis C virus to household members is very unlikely
  • a patient who is hepatitis C positive should inform their doctor and dentist that they have hepatitis C infection
• sexual relationships
  • sexual intercourse presents a low risk of transmitting the virus - evidence from studies suggest that less than 5% of the regular sexual partners of people with hepatitis C infection will become infected
  • note though that risk of transmission increases with multiple partners
  • patients should be advised to use condoms to reduce the risk of transmission
  • the Department of Health in England recommends that regular sexual partners of patients with hepatitis C should be tested for the infection - however the frequency of testing is unclear
• obesity
  • obesity is an established risk factor for progressive liver disease - however it is not known whether subsequent weight loss reduces the risk
  • in the context of obesity as a risk factor for progressive liver disease, it seems sensible to encourage obese patients with hepatitis C to lose weight
• employment
  • people are not obliged to inform their employer that they have hepatitis C unless they are healthcare professionals who perform exposure-prone procedures

The best treatment is prevention by screening donor blood for anti-HCV. A vaccine is unlikely to be forthcoming in the near future.

The Summary of Product Characteristics (SPCs) of drugs mentioned must be consulted before prescribing any drug mentioned.

Reference:

• PHE (2020). Hepatitis C in England 2020 - Working to eliminate hepatitis C as a major public health threat
• University Hospitals Bristol and Weston NHS Foundation (2020). The Bristol and Severn Hepatitis C Network.
• Drug and Therapeutics Bulletin 43(3):17-24