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Background
Neal Mehta, MD
William Carey, MD Chronic hepatitis C virus (HCV) infection remains one of the most important clinical and public health problems facing modern medicine. In 2015, the Center for Disease Control (CDC) estimates that 170 million people worldwide are living with chronic HCV infection and almost 20,000 died from HCV–related liver disease in 2014. Hepatitis C–related deaths in 2013 surpassed the total combined number of deaths from 60 other infectious diseases reported to the CDC, including HIV, tuberculosis, and pneumococcal disease.
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Ava White 3 minutes ago
In the United States, an estimated 1% of the population is infected. As recently as 2017 an estimate...
In the United States, an estimated 1% of the population is infected. As recently as 2017 an estimated 44,700 new cases occurred.
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Zoe Mueller 1 minutes ago
Those between ages 20-39 are most likely to become infected. Injection drug use is the most common m...
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Lucas Martinez 1 minutes ago
More information is available. (https://www.uspreventiveservicestaskforce.org/uspstf/document/Recomm...
Those between ages 20-39 are most likely to become infected. Injection drug use is the most common mode of acquisition. HCV rate increases are particularly noted in American Indians, Alaskan natives, and non-Hispanic white populations.
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Andrew Wilson 2 minutes ago
More information is available. (https://www.uspreventiveservicestaskforce.org/uspstf/document/Recomm...
More information is available. (https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/hepatitis-c-screening).
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Henry Schmidt 4 minutes ago
Although 15% to 25% of infected individuals spontaneously clear the virus without any treatment, app...
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Mason Rodriguez 3 minutes ago
Cirrhosis–related mortality from HCV ranges from 2% to 5% per year. Finally, in people with HC...
Although 15% to 25% of infected individuals spontaneously clear the virus without any treatment, approximately 75% to 85% will develop chronic HCV infection. The risk of cirrhosis after chronic HCV infection is 20% within 20 years and 30% within 30 years.
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Mia Anderson 8 minutes ago
Cirrhosis–related mortality from HCV ranges from 2% to 5% per year. Finally, in people with HC...
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Andrew Wilson 5 minutes ago
Chronic HCV infection is the leading indication for liver transplantation in the U.S. Various epidem...
Cirrhosis–related mortality from HCV ranges from 2% to 5% per year. Finally, in people with HCV cirrhosis, liver cancer occurs in an estimated 3% to 10% per year.
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Sophie Martin 8 minutes ago
Chronic HCV infection is the leading indication for liver transplantation in the U.S. Various epidem...
Chronic HCV infection is the leading indication for liver transplantation in the U.S. Various epidemiologic risk factors can influence the risk and rate of HCV progression including age at acquisition, male sex, alcohol exposure, genetic factors, coinfection with other viruses, and other comorbidities (Figure 1).
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David Cohen 5 minutes ago
Figure 1 Fortunately, this life–threatening viral infection can now be eradicated in ne...
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Sebastian Silva 18 minutes ago
The World Health Organization proposes elimination of HCV world-wide by 2030. Distinction between HC...
Figure 1 Fortunately, this life–threatening viral infection can now be eradicated in nearly all affected people. It is estimated that by 2025, HCV will be a rare disease.
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Sebastian Silva 15 minutes ago
The World Health Organization proposes elimination of HCV world-wide by 2030. Distinction between HC...
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Aria Nguyen 8 minutes ago
Most people with HCV have little or no visible evidence of liver damage, and if confirmed, managemen...
The World Health Organization proposes elimination of HCV world-wide by 2030. Distinction between HCV as an infection, on the one hand, and a liver disease, on the other, is important.
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Mason Rodriguez 17 minutes ago
Most people with HCV have little or no visible evidence of liver damage, and if confirmed, managemen...
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Sebastian Silva 18 minutes ago
HCV replicates in the liver and in peripheral blood mononuclear cells, and it is detectable in serum...
Most people with HCV have little or no visible evidence of liver damage, and if confirmed, management of the underlying infection is all that needs to concern the clinician. Once cured of HCV no additional follow up is needed in individuals without significant hepatic fibrosis. Those with significant liver damage need both antiviral therapy and attention to the potential consequences of a damaged liver Next: Virology Virology
Virology
HCV is a ribonucleic acid (RNA) virus classified in the Flaviviridae family.
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Zoe Mueller 1 minutes ago
HCV replicates in the liver and in peripheral blood mononuclear cells, and it is detectable in serum...
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Noah Davis 32 minutes ago
During HCV assembly and release from infected cells, virus particles associate with lipids and circu...
HCV replicates in the liver and in peripheral blood mononuclear cells, and it is detectable in serum during acute and chronic infection. The exact mechanism of viral entry into liver cells is not known, but it is associated with several viral and cellular factors.
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Sebastian Silva 28 minutes ago
During HCV assembly and release from infected cells, virus particles associate with lipids and circu...
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Scarlett Brown 3 minutes ago
Genotype does not affect the natural history of the disease. In the U.S., the predominant genotype i...
During HCV assembly and release from infected cells, virus particles associate with lipids and circulate in the blood in the form of triglyceride–rich particles. HCV polymerase is an enzyme encoded in the HCV genome that lacks error–correcting mechanisms, leading to a high mutation rate that likely contributes to the virus' ability to evade the body's immune system. There are six major genotypes of HCV.
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Evelyn Zhang 22 minutes ago
Genotype does not affect the natural history of the disease. In the U.S., the predominant genotype i...
Genotype does not affect the natural history of the disease. In the U.S., the predominant genotype is G1, constituting approximately 70% of individuals, 16% G2, 12% G3, and smaller proportions with genotypes 4, 5, or 6. Figure 2 indicates the geographic prevalence of HCV genotypes.
Currently used antiviral treatments are highly effective against all genotype, although slightly less so against G3. Figure 2.
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Brandon Kumar 32 minutes ago
Geographic prevalence of the 6 major HCV genotypes (G1-G6). Previous: Background
Next: Transmission ...
Geographic prevalence of the 6 major HCV genotypes (G1-G6). Previous: Background
Next: Transmission Transmission
Transmission
In the past, a major route of infection was via blood transfusion; however, effective screening of blood donations for HCV (since 1992) has reduced the risk of transfusion-associated HCV to less than 1 per 2 million units transfused.
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Lucas Martinez 23 minutes ago
Currently, the most common route of transmission is related to intravenous drug use. Other modes of ...
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Aria Nguyen 8 minutes ago
There are no conclusive data to advise against breastfeeding for women with HCV infection. Reports o...
Currently, the most common route of transmission is related to intravenous drug use. Other modes of transmission include having multiple sexual partners, tattooing, body piercing, and sharing straws during intranasal cocaine use. Mother–child vertical transmission occurs in approximately 5% to 10% of cases and is more likely to occur in a mother co-infected with HIV.
There are no conclusive data to advise against breastfeeding for women with HCV infection. Reports of infection rates after an HCV–contaminated needle–stick injury range from 0% to 10.3%, with an average rate of 0.5%, although not all infections lead to long–term infection.
Transmission to a sexual partner in a monogamous relationship is uncommon with rates as low as 0.07% per year. Accordingly, the Centers for Disease Control and Prevention (CDC) does not suggest any change in sexual practice among monogamous couples.
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Brandon Kumar 6 minutes ago
Previous: Virology
Next: Screening Screening
Screening
Because the presence of hepatitis ...
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Chloe Santos 18 minutes ago
Clustering of infected individuals and the age cohort born between 1945 – 1965 led to recommen...
Previous: Virology
Next: Screening Screening
Screening
Because the presence of hepatitis C is most often asymptomatic, most infected individuals are unaware. This creates an environment for inadvertent spread of disease.
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Nathan Chen 15 minutes ago
Clustering of infected individuals and the age cohort born between 1945 – 1965 led to recommen...
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Lucas Martinez 1 minutes ago
Since implementation of age cohort testing, an estimated $1.5 to $1.7 billion dollars has been saved...
Clustering of infected individuals and the age cohort born between 1945 – 1965 led to recommendations of age cohort screening. One–time testing for antibodies to HCV (anti–HCV) by age–cohort was estimated to identify 800,000 more HVC infections. With subsequent treatment, testing by age cohort was estimated to avoid nearly 120,000 HCV–related deaths.
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Liam Wilson 23 minutes ago
Since implementation of age cohort testing, an estimated $1.5 to $1.7 billion dollars has been saved...
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Amelia Singh 32 minutes ago
Table 1: Hepatitis C screening Recommendations from the Centers for Disease Control (CDC) Universal ...
Since implementation of age cohort testing, an estimated $1.5 to $1.7 billion dollars has been saved in liver disease–related costs. The US Preventive Task Force recommends hepatitis C screening for all between 18 -79 year of age. The CDC also recommends wide spread testing (Table 1).
Table 1: Hepatitis C screening Recommendations from the Centers for Disease Control (CDC) Universal hepatitis C screening Once in a lifetime for all 18 years and older
All pregnant women during each pregnancy One‑time hepatitis C testing regardless of age or setting prevalence among people with recognized conditions or exposures
HIV positive
Ever injected drugs, shared needles, syringes, other drug preparation equipment
Ever received maintenance hemodialysis; or people with persistently abnormal ALT levels Transfusions or organ transplants, including: Clotting factor concentrates produced before 1987
Transfusion of blood or blood components before July 1992
Organ transplant before July 1992
Those notified that they received blood from a donor who later tested positive for HCV infection Routine periodic testing for people with ongoing risk factors
Injection drug use
Hemodialysis Any person who requests hepatitis C testing Source (https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm) Previous: Transmission
Next: Signs and Symptoms Signs and Symptoms
Signs and Symptoms
Acute HCV infection is uncommonly recognized because it is usually asymptomatic or accompanied by mild flu–like symptoms. Fatigue is the most common symptom.
Other complaints include weight loss, muscle or joint pain, irritability, nausea, malaise, anorexia, depression, abdominal discomfort, difficulty concentrating, and jaundice. These symptoms occur 2 to 24 weeks after exposure.
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Oliver Taylor 69 minutes ago
Many people with chronic HCV infection have no specific symptoms, and the finding of abnormal hepati...
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Henry Schmidt 16 minutes ago
Extrahepatic manifestations of hepatitis C. Image Courtesy of Cleveland Clinic Journal of Medicine....
Many people with chronic HCV infection have no specific symptoms, and the finding of abnormal hepatic transaminase levels on routine testing often prompts specific testing for hepatitis C. Associated extrahepatic manifestations of HCV infection may include mixed cryoglobulinemia, arthralgias, porphyria cutanea tarda, and membranoproliferative glomerulonephritis (Figure 3). Figure 3.
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Sophie Martin 23 minutes ago
Extrahepatic manifestations of hepatitis C. Image Courtesy of Cleveland Clinic Journal of Medicine....
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Hannah Kim 5 minutes ago
Diagnosis of HCV infection is usually a two–step process: Identification of HCV antibodies the...
Extrahepatic manifestations of hepatitis C. Image Courtesy of Cleveland Clinic Journal of Medicine.
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Andrew Wilson 79 minutes ago
Diagnosis of HCV infection is usually a two–step process: Identification of HCV antibodies the...
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Victoria Lopez 17 minutes ago
A positive test, particularly if the person has a risk factor for transmission, almost always repres...
Diagnosis of HCV infection is usually a two–step process: Identification of HCV antibodies then
Demonstration of viremia and genotype. The most common serologic test used to detect HCV antibodies is the enzyme–linked immunosorbent assay (ELISA), which has a 95% sensitivity and specificity.
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William Brown 52 minutes ago
A positive test, particularly if the person has a risk factor for transmission, almost always repres...
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Natalie Lopez 77 minutes ago
HCV RNA appears in the blood and can be detected 2 to 3 weeks after infection. There are two circums...
A positive test, particularly if the person has a risk factor for transmission, almost always represents either active viral infection or resolved HCV. The assay can detect HCV antibodies 4 to 10 weeks after infection. Confirmation of active infection in any person with a positive anti–HCV assay requires the detection of HCV RNA by PCR.
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Dylan Patel 24 minutes ago
HCV RNA appears in the blood and can be detected 2 to 3 weeks after infection. There are two circums...
HCV RNA appears in the blood and can be detected 2 to 3 weeks after infection. There are two circumstances in which an individual infected with HCV may have a negative anti–HCV assay (a false negative result): Early, acute HCV infection in a person who has not developed antibody levels high enough to be detected;
Individuals unable to mount an immune response and does not produce measurable antibody levels, such as those with HIV coinfection, renal failure, or HCV–associated mixed cryoglobulinemia.
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James Smith 60 minutes ago
A high clinical suspicion is important if the first situation arises. Acute hepatitis C should be su...
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Jack Thompson 57 minutes ago
In most cases, HCV RNA can be detected during the acute phase and should be checked if clinical susp...
A high clinical suspicion is important if the first situation arises. Acute hepatitis C should be suspected if clinical signs and symptoms (eg, jaundice and ALT elevation) are compatible with infection.
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Dylan Patel 17 minutes ago
In most cases, HCV RNA can be detected during the acute phase and should be checked if clinical susp...
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Sophia Chen 28 minutes ago
Again, if clinical suspicion is high, the HCV RNA level should be checked to confirm infection. An H...
In most cases, HCV RNA can be detected during the acute phase and should be checked if clinical suspicion is high. In the second circumstance, an immunosuppressed patient may not be able to mount an antibody response.
Again, if clinical suspicion is high, the HCV RNA level should be checked to confirm infection. An HCV viral quantitative assay ("viral load") defines the presence and amount of virus.
The viral load does not define the likelihood of disease progression, severity of disease, or degree of liver damage. It is not necessary to check the viral load repeatedly.
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Audrey Mueller 64 minutes ago
People infected with HCV may have normal or elevated ALT values, limiting the value of this test in ...
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Scarlett Brown 30 minutes ago
In one study of non–cirrhotic individuals with HCV infection, 56.2% had evidence of fibrosis o...
People infected with HCV may have normal or elevated ALT values, limiting the value of this test in the diagnosis of HCV. Although most HCV–infected individuals with persistently normal ALT values have no hepatic fibrosis, it may be present in up to 25% of this population. Previous: Screening
Next: Assessment of Hepatic Fibrosis Assessment of Hepatic Fibrosis
Assessment of Hepatic Fibrosis
There is a surprisingly high incidence of advanced hepatic fibrosis in HCV–infected people.
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Victoria Lopez 49 minutes ago
In one study of non–cirrhotic individuals with HCV infection, 56.2% had evidence of fibrosis o...
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Isabella Johnson 81 minutes ago
The role of hepatic fibrosis in HCV treatment decision–making is discussed later. Of note, non...
In one study of non–cirrhotic individuals with HCV infection, 56.2% had evidence of fibrosis on liver biopsy. Identifying people with advanced fibrosis (F3 or F4) is important as it determines prognosis and need for further monitoring after infection treated. Individuals with advanced fibrosis need surveillance for hepatocellular carcinoma and routine blood work for the detection of progressive disease or complications related to their underlying cirrhosis.
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Sebastian Silva 16 minutes ago
The role of hepatic fibrosis in HCV treatment decision–making is discussed later. Of note, non...
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Evelyn Zhang 116 minutes ago
Thus, they are best for people with a very low probability of significant fibrosis or those with a h...
The role of hepatic fibrosis in HCV treatment decision–making is discussed later. Of note, noninvasive markers may be very good at separating out the extremes, but are limited in distinguishing specific levels of fibrosis between the extremes.
Thus, they are best for people with a very low probability of significant fibrosis or those with a high likelihood of cirrhosis. When common laboratory tests, imaging, and physical exam findings point to cirrhosis, additional testing is often unnecessary.
Absence of such findings, however, does not provide evidence for absence of hepatic fibrosis or even cirrhosis. Therefore, for many with HCV infection, additional assessment is advised. The two types of noninvasive tests most often used are serum–based tests and imaging studies.
Serum&ndash Based Testing
There are both proprietary and nonproprietary serum–based tests to detect hepatic fibrosis. The nonproprietary models are just as useful as the proprietarily ones and are recommended.
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Chloe Santos 20 minutes ago
One commonly used nonproprietary serum marker model is the aspartate aminotransferase (AST) to plate...
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Sophie Martin 6 minutes ago
An APRI score greater than 0.7 had a sensitivity of 77% and specificity of 72% for predicting signif...
One commonly used nonproprietary serum marker model is the aspartate aminotransferase (AST) to platelet ratio index (APRI). In a meta–analysis of 40 studies, an APRI score ([AST level/upper limit of normal AST]/platelet count) greater than 1.0 had a 76% specificity and 72% sensitivity for predicting cirrhosis.
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Julia Zhang 44 minutes ago
An APRI score greater than 0.7 had a sensitivity of 77% and specificity of 72% for predicting signif...
An APRI score greater than 0.7 had a sensitivity of 77% and specificity of 72% for predicting significant hepatic fibrosis. Some evidence suggests that using multiple indices in combination or an algorithmic approach may result in higher diagnostic accuracy than using APRI alone. Another commonly used indirect serologic marker of fibrosis in Hepatitis C is the FibroSure® assay, a proprietary assay that classifies the degree of fibrosis using the following variables: alpha–2 macroglobulin, haptoglobin, gamma globulin, apolipoprotein A1, GGT, total bilirubin, patient age, and sex.
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Oliver Taylor 56 minutes ago
Results classify people from F0 to F4. This test has 60% to 75% sensitivity and 80% to 90% specifici...
Results classify people from F0 to F4. This test has 60% to 75% sensitivity and 80% to 90% specificity for detecting significant hepatic fibrosis.
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William Brown 167 minutes ago
Other indirect serologic markers of fibrosis include the HepaScore®, AST/ALT ratio, FibroIndex&r...
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Noah Davis 160 minutes ago
It is painless, risk free, and lends itself to repeated measurement over time. FibroScan ® is th...
Other indirect serologic markers of fibrosis include the HepaScore®, AST/ALT ratio, FibroIndex®, and ActiTest®.
Transient Elastography
Transient elastography is increasingly used for staging hepatic fibrosis.
It is painless, risk free, and lends itself to repeated measurement over time. FibroScan ® is the most widely available device; the majority of studies have employed this particular tool, and data from this are increasing woven into national and international practice guidelines.
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Thomas Anderson 126 minutes ago
Elastography measures hepatic tissue stiffness using shear waves. Measurement of shear waves c...
Elastography measures hepatic tissue stiffness using shear waves. Measurement of shear waves can be also done using MRI. There is great experience with transient elastography in staging hepatic fibrosis in hepatitis C.
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Aria Nguyen 4 minutes ago
In one typical study elastography had an 87% sensitivity and 91% specificity for the diagnosis of ci...
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Dylan Patel 27 minutes ago
Elastography provides technically unreliable results in up to 15% of cases, and is especially unsuit...
In one typical study elastography had an 87% sensitivity and 91% specificity for the diagnosis of cirrhosis. In 7 of 9 studies in a meta–analysis, transient elastography diagnosed stage F2 to F4 fibrosis with 70% sensitivity and 84% specificity. The major limitation of elastography is that results can be skewed in morbidly obese individuals.
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Christopher Lee 96 minutes ago
Elastography provides technically unreliable results in up to 15% of cases, and is especially unsuit...
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Amelia Singh 121 minutes ago
Liver Biopsy
Liver biopsy was formerly an important method for determining the degree of he...
Elastography provides technically unreliable results in up to 15% of cases, and is especially unsuited for use in obese people. Fibroscan ® is contraindicated in those with pacemakers or defibrillators. As in serum based testing, elastography is most reliable when used either in people with no fibrosis or cirrhosis.
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Hannah Kim 21 minutes ago
Liver Biopsy
Liver biopsy was formerly an important method for determining the degree of he...
Liver Biopsy
Liver biopsy was formerly an important method for determining the degree of hepatic fibrosis in certain situations and has been considered the gold standard. Liver biopsy is associated with significant risk. Nearly 84% report pain after liver biopsy.
Although much rarer, some patients have even worse complications: Severe bleeding occurs in 0.35% to 0.5%, perforation in 0.57%, and even death in approximately 0.03%. Not only do patients find liver biopsy anxiety–provoking, but physicians are averse to performing it.
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Scarlett Brown 93 minutes ago
A recent survey of 104 physicians found that only 46.2% of them perform liver biopsy as the primary ...
A recent survey of 104 physicians found that only 46.2% of them perform liver biopsy as the primary diagnostic tool. We no longer perform liver biopsies in most patients with HCV.
Previous: Signs and Symptoms
Next: Treatment Treatment
Treatment
Considered through the prism of individual and public health, even considering total societal costs, the most effective strategy is clearly to treat all HCV–infected people despite the high cost of medication. All individuals at any stage of hepatitis C should be considered for treatment. Higher overall cure rates improve patient–related outcomes, increase worker productivity, and ultimately lessen the economic burden of chronic HCV on society.
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Lucas Martinez 12 minutes ago
Chronic HCV–related liver disease puts a tremendous economic burden on infected individuals, t...
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Charlotte Lee 4 minutes ago
From an economic standpoint, successfully treating this disease positively affects the entire commun...
Chronic HCV–related liver disease puts a tremendous economic burden on infected individuals, their families, and society as a whole. In addition, as chronic HCV is a systemic disease with the potential to affect not only the liver but other organ systems, the disease burden can be enormous.
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James Smith 77 minutes ago
From an economic standpoint, successfully treating this disease positively affects the entire commun...
From an economic standpoint, successfully treating this disease positively affects the entire community. Those cured of chronic HCV have a reduction in liver inflammation.
There is clear evidence that hepatic fibrosis and even cirrhosis is reversible when HCV is eliminated. This, in turn, is associated with a more than 70% reduction in the risk of hepatocellular carcinoma and 90% reduction in the risk of liver–related death and liver transplantation. Achieving cure has been shown to improve social, physical, and emotional health of those infected with HCV.
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Victoria Lopez 18 minutes ago
In a large study of 4,781 people with chronic HCV infection, both depression (found in 30%) and poor...
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Audrey Mueller 30 minutes ago
Even people with advanced fibrosis or cirrhosis realize as much as an 80% reduction in the risk of d...
In a large study of 4,781 people with chronic HCV infection, both depression (found in 30%) and poor physical health (found in 25%) were associated with unemployment, higher stressful events, and lower social support. Cure of HCV was associated with a lower risk of depression and with better physical health. Benefits of cure accrue regardless of the stage of fibrosis at baseline.
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Sophie Martin 50 minutes ago
Even people with advanced fibrosis or cirrhosis realize as much as an 80% reduction in the risk of d...
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Emma Wilson 97 minutes ago
Fibrosis may also improve. Among those with lesser degrees of liver damage, studies suggest a decrea...
Even people with advanced fibrosis or cirrhosis realize as much as an 80% reduction in the risk of developing clinical decompensation. A number of studies have also shown a decrease in the risk of specific complications, including a decrease of as much as 77% in the risk of development of hepatocellular carcinoma.
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Luna Park 44 minutes ago
Fibrosis may also improve. Among those with lesser degrees of liver damage, studies suggest a decrea...
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Sophia Chen 69 minutes ago
The ideal treatment for HCV would have the following attributes: Highly effective
Low cost
Few side ...
Fibrosis may also improve. Among those with lesser degrees of liver damage, studies suggest a decrease in the degree of liver fibrosis in treated individuals and, in a minority of people, regression of cirrhosis.
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Isaac Schmidt 10 minutes ago
The ideal treatment for HCV would have the following attributes: Highly effective
Low cost
Few side ...
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Christopher Lee 38 minutes ago
Because of limited resources, insurers have established a triage strategy. These vary between compan...
The ideal treatment for HCV would have the following attributes: Highly effective
Low cost
Few side effects
Easy to administer
Lack of significant drug – drug interactions
No need for treatment monitoring
Cost
All treatments for Hepatitis C are expensive. Typical costs are indicated below. As most people cannot cover these costs, payment and authorization for treatment falls to insurance companies.
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Joseph Kim 38 minutes ago
Because of limited resources, insurers have established a triage strategy. These vary between compan...
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Hannah Kim 69 minutes ago
Absence of virus in the blood 12 weeks after ending treatment is referred to as sustained virologic ...
Because of limited resources, insurers have established a triage strategy. These vary between companies.
General Treatment Principles
The goal of treatment is permanent elimination of virus.
Absence of virus in the blood 12 weeks after ending treatment is referred to as sustained virologic response (SVR). Increasingly, SVR and "cure" are used interchangeably and will be so used in this chapter. By convention, SVR determination is made 12 (or more) weeks after cessation of antiviral treatment.
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Sophie Martin 88 minutes ago
This is sometimes called SVR 12. Those who achieve an SVR have HCV antibodies but no longer have det...
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David Cohen 40 minutes ago
Immunization against hepatitis A should be considered if negative
Hepatitis B markers (hepatitis B s...
This is sometimes called SVR 12. Those who achieve an SVR have HCV antibodies but no longer have detectable levels of HCV RNA.
Patient Assessment
Pretreatment assessment of the patient with chronic hepatitis C should include the following: HCV viral load
HCV genotype (once per lifetime)
Complete blood count (CBC) including platelet count, hepatic function panel, international normalization ratio, basic metabolic panel
Assessment of the level of liver fibrosis
Anti–HAV (total).
Immunization against hepatitis A should be considered if negative
Hepatitis B markers (hepatitis B surface antigen [HBsAg], hepatitis B core antibody [anti-HBc], hepatitis B surface antibody [anti–HBs]) (Immunize those with negative markers. In people with serologic evidence of HBV infection, measure a baseline HBV DNA prior to treatment.)
HIV status Previous: Assessment of Hepatic Fibrosis
Next: Treatment Regimens Treatment Regimens
Treatment Regimens
It is highly recommended that the full prescribing information packet be reviewed before prescribing any drug, including those discussed here.
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Thomas Anderson 24 minutes ago
There are many FDA–approved medications for treatment of HCV. Most combine two or more antivir...
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Ethan Thomas 39 minutes ago
to treat people without decompensated cirrhosis, advanced renal insufficiency (eGFR >30), or coin...
There are many FDA–approved medications for treatment of HCV. Most combine two or more antivirals targeting different steps in the viral replication process. This chapter focuses on those regimens that make the most sense for general practitioners in the U.S.
to treat people without decompensated cirrhosis, advanced renal insufficiency (eGFR >30), or coinfection with hepatitis B or HIV. Individuals with advanced cirrhosis or with a coinfection (HIV or HBV) should be seen by a healthcare provider with special expertise in gastroenterology, hepatology, or infectious disease. Those with significant renal insufficiency (eGFR <30) also should be treated by a specialist.
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Ava White 161 minutes ago
First&ndash Line Therapy
The three pan-genotypic hepatitis drugs are described here, in des...
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Elijah Patel 93 minutes ago
Mavyret ® (Maviret ® in European Union) is a combination of glecaprevir (100 mg) and pibrent...
First&ndash Line Therapy
The three pan-genotypic hepatitis drugs are described here, in descending order of value. Prices cited are from (https://www.verywellhealth.com/list-of-approved-hepatitis-c-drugs-3576465) accessed on February 7, 2021. Considerable negotiation between insurers and pharmaceutical manufacturers makes actual costs opaque and subject to frequent change.
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Charlotte Lee 20 minutes ago
Mavyret ® (Maviret ® in European Union) is a combination of glecaprevir (100 mg) and pibrent...
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Alexander Wang 29 minutes ago
It is highly effective against all 6 hepatitis c genotypes. The rate of cure is > 98%....
Mavyret ® (Maviret ® in European Union) is a combination of glecaprevir (100 mg) and pibrentasvir (40 mg). Three tablets are taken all at once each day for 8 weeks (12 weeks if cirrhosis is present). This drug is not approved for those with decompensated cirrhosis.
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James Smith 301 minutes ago
It is highly effective against all 6 hepatitis c genotypes. The rate of cure is > 98%....
It is highly effective against all 6 hepatitis c genotypes. The rate of cure is > 98%.
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Hannah Kim 98 minutes ago
Based on public prices, this if the least costly treatment for hepatitis C. As of January 2020 the a...
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Nathan Chen 95 minutes ago
One tablet per day is taken for 12 weeks. It is approved for those with and without cirrhosis....
Based on public prices, this if the least costly treatment for hepatitis C. As of January 2020 the average wholesale price (AWP) of Mavyret was $26,400 for an 8-week course and $39,600 for a 12-week course. Epclusa ® is a combination of sofusbuvir and velpatasvir.
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Aria Nguyen 37 minutes ago
One tablet per day is taken for 12 weeks. It is approved for those with and without cirrhosis....
One tablet per day is taken for 12 weeks. It is approved for those with and without cirrhosis.
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Lucas Martinez 212 minutes ago
This drug is not approved for those with decompensated cirrhosis. It is highly effective against all...
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Mason Rodriguez 52 minutes ago
The rate of cure is > 98%. As of January 2020 the average wholesale price (AWP) of Epclusa ® ...
This drug is not approved for those with decompensated cirrhosis. It is highly effective against all 6 hepatitis c genotypes.
The rate of cure is > 98%. As of January 2020 the average wholesale price (AWP) of Epclusa ® was $89,700 for an 8-week course.
A generic formulation of this combination is available that is cost-competitive with Mavyret ®. Vosevi ® is a combination of sofosbuvir (400 mg), velpatasvir (100 mg) and voxilaprevir (100 mg).
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Natalie Lopez 79 minutes ago
One tablet per day is taken for 12 weeks. It is approved for treatment of those who have failed prev...
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Sophie Martin 126 minutes ago
This drug is not approved for those with decompensated cirrhosis. Those without cirrhosis and with c...
One tablet per day is taken for 12 weeks. It is approved for treatment of those who have failed previous hepatitis C treatment, regardless of genotype. The cure rate in these difficult to treat patients is 91% for those with genotype 3, and > 95% for other genotypes.
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Christopher Lee 98 minutes ago
This drug is not approved for those with decompensated cirrhosis. Those without cirrhosis and with c...
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William Brown 143 minutes ago
As of January 2020 the average wholesale price (AWP) of Vosevi ® was $74,760 for a 12-week cours...
This drug is not approved for those with decompensated cirrhosis. Those without cirrhosis and with compensated cirrhosis may use this agent. This drug is not approved for those with decompensated cirrhosis.
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Victoria Lopez 53 minutes ago
As of January 2020 the average wholesale price (AWP) of Vosevi ® was $74,760 for a 12-week cours...
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Thomas Anderson 256 minutes ago
Those without cirrhosis and with compensated cirrhosis may use this agent. This drug is not approved...
As of January 2020 the average wholesale price (AWP) of Vosevi ® was $74,760 for a 12-week course. A previously top-selling drug, Harvoni ® (sofosbuvir 400 mg, ledipasvir 90 mg) is also highly effective but not for genotype 2 or genotype 3 hepatitis C.
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Dylan Patel 182 minutes ago
Those without cirrhosis and with compensated cirrhosis may use this agent. This drug is not approved...
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Mia Anderson 206 minutes ago
This drug is not approved for those with decompensated cirrhosis. The cure rate is > 95%....
Those without cirrhosis and with compensated cirrhosis may use this agent. This drug is not approved for those with decompensated cirrhosis. One pill is taken daily for 8 weeks in those without cirrhosis; 12 weeks for those with compensated cirrhosis.
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Isaac Schmidt 42 minutes ago
This drug is not approved for those with decompensated cirrhosis. The cure rate is > 95%....
This drug is not approved for those with decompensated cirrhosis. The cure rate is > 95%.
As of January 2020 the average wholesale price (AWP) of Harvoni was $94,500 for a 12-week course. Because of the small risk of reactivation of hepatitis B in those treated for HCV, care must be taken to obviate this risk. A positive hepatitis B c antibody (anti HBc) defines a person exposed to hepatitis B virus and therefore at risk for reactivation.
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Lily Watson 182 minutes ago
Those who are, in addition, positive for hepatitis B surface antigen (HbsAg) are at more risk.
S...
Those who are, in addition, positive for hepatitis B surface antigen (HbsAg) are at more risk.
Second&ndash Line Therapy
Drugs effective against only selected genotypes include Zepatier ® (grazoprevir, elbasvir) effective against HCV genotype 1a, 1b, and 4 Technivie ® (partaprevir, ritonavir, ombitsavir) effective against HCV genotype 4 These drugs are seldom prescribed.
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Nathan Chen 130 minutes ago
Side Effects and Drug&ndash Drug Interactions
The direct–acting antivirals have an ex...
Side Effects and Drug&ndash Drug Interactions
The direct–acting antivirals have an excellent side effect profile and are generally well tolerated. The most common side effects of are headache (22%), fatigue (15%), nausea (9%), asthenia A major drug interaction with both of these drugs occurs with amiodarone.
Serious symptomatic bradycardia (slow heart rate) has been associated with velpatasvir–sofosbuvir and amiodarone, especially in those with advanced liver disease or underlying heart disease. Therefore, co-administration of velpatasvir–sofosbuvir or amiodarone is not recommended for people without alternative treatment options.
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Ethan Thomas 103 minutes ago
In addition, drugs that are inducers of P–glycoprotein and/or inducers of certain cytochrome P...
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Lucas Martinez 193 minutes ago
Monitoring During Treatment
Confirmation of treatment success is demonstrated by the absenc...
In addition, drugs that are inducers of P–glycoprotein and/or inducers of certain cytochrome P enzymes may decrease the serum concentrations of sofosbuvir and/or velpatasvir resulting in a decreased potency of the combination. Certain established clinically significant drug interactions have also been described. Statins and proton pump inhibitors are generally held during treatment of hepatitis C.
Monitoring During Treatment
Confirmation of treatment success is demonstrated by the absence of HCV virus in the blood 12 or more weeks after completion of therapy. This has been termed sustained virologic response.
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Ella Rodriguez 6 minutes ago
(SVR). Such represents a cure....
(SVR). Such represents a cure.
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Isabella Johnson 17 minutes ago
An individual with no- or minimal fibrosis who achieves an SVR needs no further follow-up. The rare ...
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Emma Wilson 162 minutes ago
The individual who has cirrhosis should be monitored even after cure for possible progression, decom...
An individual with no- or minimal fibrosis who achieves an SVR needs no further follow-up. The rare individual who fails to achieve an SVR is most often referred to a gastroenterologist, hepatologist, or infectious disease specialist to consider retreatment.
The individual who has cirrhosis should be monitored even after cure for possible progression, decompensation, etc. It is becoming apparent that a minority of individuals with cirrhosis from hepatitis C may undergoing significant improvement in the degree of hepatic fibrosis, and even disappearance of cirrhosis.
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Sophie Martin 196 minutes ago
In the absence of liver biopsy, cirrhosis is presumed in the presence of otherwise unexplained throm...
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Natalie Lopez 413 minutes ago
Those with the next lowest fibrosis score (F-3) implies bridging fibrosis. Together, F-3 and F-4 fib...
In the absence of liver biopsy, cirrhosis is presumed in the presence of otherwise unexplained thrombocytopenia, or the presence of ascites, esophageal varices, or other markers of cirrhosis. Increasingly, elastography (e.g., by Fibroscan ®) is employed as non-invasive method of staging hepatic fibrosis. Cirrhosis is termed F-4. Fibroscan ® revealing > 15 KPA liver stiffness is highly associated with cirrhosis.
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Ava White 294 minutes ago
Those with the next lowest fibrosis score (F-3) implies bridging fibrosis. Together, F-3 and F-4 fib...
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Henry Schmidt 318 minutes ago
Hepatocellular carcinoma is a risk for those with advanced fibrosis. Importantly, this risk diminish...
Those with the next lowest fibrosis score (F-3) implies bridging fibrosis. Together, F-3 and F-4 fibrosis are termed advanced fibrosis.
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Scarlett Brown 64 minutes ago
Hepatocellular carcinoma is a risk for those with advanced fibrosis. Importantly, this risk diminish...
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James Smith 10 minutes ago
Acute Hepatitis C
Acute HCV infection is frequently undiagnosed due to lack of specific sym...
Hepatocellular carcinoma is a risk for those with advanced fibrosis. Importantly, this risk diminishes but does not disappear even after HCV cured. Such individuals should be screened for hepatocellular carcinoma every 6 months with a right upper quadrant ultrasound.
Contraindications
The only contraindication to current chronic HCV treatment is in a patient with a short–life expectancy that cannot be lengthened with treatment, with liver transplant, or with any other treatments.
Acute Hepatitis C
Acute HCV infection is frequently undiagnosed due to lack of specific symptoms. Because up to 50% of acutely infected individuals will spontaneously clear the infection, a balance must be struck between watchful waiting and treatment. At minimum, monitoring for HCV RNA for at least 3 months before starting treatment is recommended to allow for spontaneous clearance; however, delaying for 6 months is also acceptable.
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Isaac Schmidt 30 minutes ago
In people who are anti–HCV positive and HCV RNA negative (ie, spontaneous clearance of infecti...
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Henry Schmidt 74 minutes ago
There is no value to administration of either serum immune globulin or prophylactic antiviral treatm...
In people who are anti–HCV positive and HCV RNA negative (ie, spontaneous clearance of infection), HCV RNA should be tested again in 3 months to confirm true clearance. Healthcare workers accidentally exposed to HCV-infected blood via a needle–stick injury should immediately report the exposure. They should have immediate testing for anti–HCV antibodies to establish the absence of pre–existing infection.
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Lucas Martinez 50 minutes ago
There is no value to administration of either serum immune globulin or prophylactic antiviral treatm...
There is no value to administration of either serum immune globulin or prophylactic antiviral treatment. The average incidence of anti–HCV seroconversion after needle–stick from a known anti–HCV positive source is 0% to 10.3%.
For individuals diagnosed with acute HCV infection (i.e., positive anti–HCV antibodies and positive HCV RNA), there is no clear benefit to early treatment. Monitoring for 6 months is acceptable as most cases will spontaneously clear without intervention.
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Brandon Kumar 393 minutes ago
When the decision is made to initiate treatment after 6 months, treating as described for chronic he...
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Scarlett Brown 267 minutes ago
Studies of the predictors of spontaneous clearance of HCV infection have suggested that clearance ma...
When the decision is made to initiate treatment after 6 months, treating as described for chronic hepatitis C is recommended, given its high efficacy and safety. In addition, insurance reimbursement plans have not made an exception to the general requirement that significant fibrosis must be present for payment, making the issue of early treatment essentially moot.
Studies of the predictors of spontaneous clearance of HCV infection have suggested that clearance may be more likely to occur in younger people and in those with a more symptomatic presentation, particularly with jaundice. Transplantation using HCV-infected donor organs.
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Andrew Wilson 53 minutes ago
Patients awaiting organ transplantation of experience very long delays caused by a shortage or organ...
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Ella Rodriguez 21 minutes ago
The success in elimination of HCV is organ recipients is > 98%. Some centers have adopted an appr...
Patients awaiting organ transplantation of experience very long delays caused by a shortage or organs. To increase supply, and in recognition of the ease of treatment of HCV, organs from infected donors are now offered to those who indicate a willingness to accept such. Treatment is initiated as soon after transplantation as virus is detected and continued for 12 weeks.
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Alexander Wang 111 minutes ago
The success in elimination of HCV is organ recipients is > 98%. Some centers have adopted an appr...
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Amelia Singh 69 minutes ago
In the few who acquire HCV despite pre-emptive treatment, and additional 12 weeks of therapy elimina...
The success in elimination of HCV is organ recipients is > 98%. Some centers have adopted an approach of not waiting for HCV to emerge in the recipient but to give antivirals at the time of transplant and for a period as short as one week after. In these programs, success in preventing HCV is > 97%.
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Ethan Thomas 102 minutes ago
In the few who acquire HCV despite pre-emptive treatment, and additional 12 weeks of therapy elimina...
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Noah Davis 125 minutes ago
Decompensated Cirrhosis
Decompensated cirrhosis is defined as Child–Pugh Classificati...
In the few who acquire HCV despite pre-emptive treatment, and additional 12 weeks of therapy eliminates the infection. Previous: Treatment
Next: Difficult–to–Treat Populations Difficult–to–Treat Populations
Difficult–to–Treat Populations
These individuals are best managed by specialists, so they are only briefly described here.
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Charlotte Lee 240 minutes ago
Decompensated Cirrhosis
Decompensated cirrhosis is defined as Child–Pugh Classificati...
Decompensated Cirrhosis
Decompensated cirrhosis is defined as Child–Pugh Classification B or C. It also can be defined clinically by the development of liver decompensation, such as jaundice, or complications of portal hypertension, such as ascites, variceal hemorrhage, or hepatic encephalopathy Treatment decisions for people with decompensated cirrhosis should be made by a hepatologist, preferably in the context of a liver transplant program.
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Ava White 28 minutes ago
HCV Following Liver Transplant
Infection of the new liver is almost universal post-transpla...
HCV Following Liver Transplant
Infection of the new liver is almost universal post-transplant, and the subsequent rate of hepatic fibrosis can be quite rapid. The likelihood of a patient developing cirrhosis in the newly transplanted liver over the course of 3 to 5 years post-transplant, is as high as 10% to 30%.
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Henry Schmidt 87 minutes ago
In a small subgroup of individuals following liver transplant with HCV (27 of 179), the pattern of r...
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William Brown 290 minutes ago
In addition, HCV seems to play a role in the rate of progression of kidney disease. Drug metabolism ...
In a small subgroup of individuals following liver transplant with HCV (27 of 179), the pattern of recurrence, with mainly cholestatic features (fibrosing cholestatic hepatitis), and the rate of disease progression is much more aggressive, leading to death in 1 to 3 years in up to 60% of these individuals.
HCV in Chronic Kidney Disease
Hepatitis C adversely affects survival in those with chronic kidney disease, especially those on dialysis.
In addition, HCV seems to play a role in the rate of progression of kidney disease. Drug metabolism of many of the drugs used for HCV is altered in people with severe renal impairment and those on dialysis.
Sufficient data is available for the following statement to be made by the American Association for the Study of Liver Disease and the Infectious Disease Society of America: No dose adjustment in direct-acting antivirals is required when using recommended regimens Excellent cure rates have been shown for direct acting agents in chronic kidney disease including those on dialysis.
HIV&ndash Hepatitis C Coinfection
Patients with HCV infection often share risk factors for coinfection with both hepatitis B virus (HBV) and HIV. HIV is known to accelerate HCV disease progression.
With the use of direct–acting antivirals, those co-infected with HIV and HCV can be reliably treated with a traditional 12-week course. The importance of treatment is clear – those successfully treated are at a substantially lower risk of developing liver disease, complications of liver disease, or suffering a liver–related death.
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Julia Zhang 188 minutes ago
However, there are major issues with drug–drug interactions with direct-acting-agents and seve...
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Nathan Chen 14 minutes ago
Those with chronic HCV and active HBV coinfection have a more severe degree of liver fibrosis and a ...
However, there are major issues with drug–drug interactions with direct-acting-agents and several of the medications used to control HIV. These are outlined in the AASLD/IDA practice guideline (HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis (https://www.hcvguidelines.org/) .
Hepatitis B&ndash Hepatitis C Coinfection
The clinical course of HCV is thought to be worsened by HBV coinfection.
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Dylan Patel 11 minutes ago
Those with chronic HCV and active HBV coinfection have a more severe degree of liver fibrosis and a ...
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Henry Schmidt 251 minutes ago
One study in anti–HCV positive subjects found a significantly lower prevalence of HCV RNA (41%...
Those with chronic HCV and active HBV coinfection have a more severe degree of liver fibrosis and a higher risk of developing hepatocellular carcinoma than with HCV alone. Some studies, however, have suggested that an active HBV infection, but not previous infection, actually suppresses the replication of H.
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Andrew Wilson 209 minutes ago
One study in anti–HCV positive subjects found a significantly lower prevalence of HCV RNA (41%...
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Ryan Garcia 15 minutes ago
Because of this, we recommend referral of these people to a specialist for HCV treatment whenever an...
One study in anti–HCV positive subjects found a significantly lower prevalence of HCV RNA (41%) in those with active HBV infection than in those who had recovered from HBV infection (82%). Several cases of reactivation of dormant hepatitis B have been reported when treatment of HCV is undertaken, including a few with severe liver injury requiring urgent liver transplantation. Those who are anti–HBc positive (whether they have HBsAg and even when HBV DNA levels are undetectable) are at risk.
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Chloe Santos 386 minutes ago
Because of this, we recommend referral of these people to a specialist for HCV treatment whenever an...
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Noah Davis 23 minutes ago
Because alcohol intake varies over time and affects individuals differently, it has been difficult t...
Because of this, we recommend referral of these people to a specialist for HCV treatment whenever anti–HBc or HBsAg is present.
Hepatitis C and Alcohol Use
Currently, alcohol use and HCV infection are the two primary causes of cirrhosis and liver transplantation in the U.S. Concurrent alcohol use is a common occurrence in people with chronic HCV.
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Harper Kim 159 minutes ago
Because alcohol intake varies over time and affects individuals differently, it has been difficult t...
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Audrey Mueller 275 minutes ago
In a study of 6,600 people with HCV, higher alcohol intake was associated with significantly more ci...
Because alcohol intake varies over time and affects individuals differently, it has been difficult to find an exact threshold for the risk to a person with HCV infection and concomitant alcohol use. It is clear, however, that heavy alcohol use (defined as 5 or more drinks per day) contributes to HCV–associated liver disease.
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Julia Zhang 485 minutes ago
In a study of 6,600 people with HCV, higher alcohol intake was associated with significantly more ci...
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Isaac Schmidt 106 minutes ago
As cirrhosis is the primary risk factor for hepatocellular carcinoma, alcohol use is associated with...
In a study of 6,600 people with HCV, higher alcohol intake was associated with significantly more cirrhosis compared with lower alcohol intake. Moreover, studies have shown that even lower amounts of alcohol were associated with fibrosis, although to a lesser extent than heavy alcohol use. Therefore, it is quite clear that alcohol intake increases the risk of cirrhosis alone and particularly in combination with HCV.
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Daniel Kumar 238 minutes ago
As cirrhosis is the primary risk factor for hepatocellular carcinoma, alcohol use is associated with...
As cirrhosis is the primary risk factor for hepatocellular carcinoma, alcohol use is associated with this cancer risk through its cirrhosis effect. According to the U.S. Department of Veteran's Affairs, those with chronic HCV likely should not drink alcohol as any amount can contribute to worsening liver disease.
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Elijah Patel 115 minutes ago
Heavy alcohol use, in particular, has been linked with fibrosis progression and cirrhosis although e...
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Sebastian Silva 230 minutes ago
Women who test positive for hepatitis C do not need to be treated while pregnant. The average rate o...
Heavy alcohol use, in particular, has been linked with fibrosis progression and cirrhosis although even light and moderate amounts do so to a lesser degree. People with established cirrhosis should definitely abstain from alcohol use.
Hepatitis C and Pregnancy
It is now recommended that women be tested for hepatitis C during each pregnancy.
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Christopher Lee 62 minutes ago
Women who test positive for hepatitis C do not need to be treated while pregnant. The average rate o...
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Dylan Patel 24 minutes ago
Luckily, spontaneous resolution of HCV occurs in approximately 50% of HCV–infected infants wit...
Women who test positive for hepatitis C do not need to be treated while pregnant. The average rate of HCV transmission from a HCV–infected mother to child is 5% to 6% if the mother is HIV–negative and up to 14% if the mother is HIV–positive. There is no known method of preventing perinatal transmission of HCV.
Luckily, spontaneous resolution of HCV occurs in approximately 50% of HCV–infected infants within the first 3 years of life, so HCV treatment should not be considered before 3 years of age. Children who do not clear the virus should be closely followed by a specialist.
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Sophia Chen 16 minutes ago
Hepatitis C virus is not spread through breast milk. The Centers for Disease Control endorses breast...
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Sebastian Silva 84 minutes ago
Occasionally, a woman being treated for HCV will become pregnant. It is unknown whether or not Mavyr...
Hepatitis C virus is not spread through breast milk. The Centers for Disease Control endorses breast feeding in HCV infected women unless her nipples are cracked and bleeding, or in the event of HIV–HCV coinfection. Typically, pregnant woman are not offered hepatitis C treatment.
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Charlotte Lee 27 minutes ago
Occasionally, a woman being treated for HCV will become pregnant. It is unknown whether or not Mavyr...
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Julia Zhang 34 minutes ago
Animal studies suggest lack of risk, but human data are scant. Any combination that contains ribavir...
Occasionally, a woman being treated for HCV will become pregnant. It is unknown whether or not Mavyret ®, Epclusa ®, or Vosevi ® poses a risk to the developing human fetus, is excreted in human milk, or poses adverse effect on nursing infants.
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Madison Singh 393 minutes ago
Animal studies suggest lack of risk, but human data are scant. Any combination that contains ribavir...
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Christopher Lee 550 minutes ago
At least 2 reliable methods of birth control are recommended for any individual who is receiving rib...
Animal studies suggest lack of risk, but human data are scant. Any combination that contains ribavirin, a known teratogenic agent, must be assiduously avoided in both female and male partners.
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David Cohen 168 minutes ago
At least 2 reliable methods of birth control are recommended for any individual who is receiving rib...
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Christopher Lee 84 minutes ago
Serum aminotransferase levels reflecting hepatocellular injury can fluctuate, as does the viral load...
At least 2 reliable methods of birth control are recommended for any individual who is receiving ribavirin or who has done so within the preceding 6 months. Previous: Treatment Regimens
Next: Conclusions Conclusions
Conclusions
HCV infection becomes chronic in most and it can lead to cirrhosis in as many as 20% over a 20–year period.
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Liam Wilson 204 minutes ago
Serum aminotransferase levels reflecting hepatocellular injury can fluctuate, as does the viral load...
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Daniel Kumar 301 minutes ago
The pathologic course is affected by various factors, such as the patient's age at onset of infectio...
Serum aminotransferase levels reflecting hepatocellular injury can fluctuate, as does the viral load, making them unreliable markers of disease severity. As the disease evolves, hepatocytes are progressively destroyed, often replaced by fibrosis, slowly leading to the development cirrhosis unless it is treated.
The pathologic course is affected by various factors, such as the patient's age at onset of infection, sex, coinfection with other viruses, other medical conditions, and risk behaviors. The risk of developing hepatocellular carcinoma in people with chronic HCV plus cirrhosis is as high as 4% per year. HCV–infected individuals with cirrhosis should be followed by a liver specialist.
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Lily Watson 381 minutes ago
Direct–acting antiviral agents have made it possible to cure most cases of HCV infection. Alth...
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Ava White 201 minutes ago
Although HCV remains a major global health problem, significant advances in the understanding of its...
Direct–acting antiviral agents have made it possible to cure most cases of HCV infection. Although successful treatment with these regimens is associated with a lower rate of liver–related complications, and perhaps even regression of fibrosis/cirrhosis, those successfully treated may still be at risk for hepatocellular carcinoma if they have cirrhosis.
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Sophie Martin 245 minutes ago
Although HCV remains a major global health problem, significant advances in the understanding of its...
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Andrew Wilson 422 minutes ago
In the U.S., an estimated 3.5 million people are infected with HCV, and roughly half do not know the...
Although HCV remains a major global health problem, significant advances in the understanding of its basic biology have allowed improvements in treatment. Given the pace of discovery in this field, it may one day be possible to eradicate this deadly virus. Previous: Difficult–to–Treat Populations
Next: Key Points Key Points
Key Points
Hepatitis C infection remains one of the most important clinical and public health problems facing modern medicine.
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Ella Rodriguez 475 minutes ago
In the U.S., an estimated 3.5 million people are infected with HCV, and roughly half do not know the...
In the U.S., an estimated 3.5 million people are infected with HCV, and roughly half do not know they are infected. Approximately 75% to 85% of infected individuals will develop chronic HCV infection. Currently, the most common route of transmission is related to intravenous drug use.
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Isaac Schmidt 403 minutes ago
Other modes of transmission include having multiple sexual partners, tattooing, body piercing, and s...
Other modes of transmission include having multiple sexual partners, tattooing, body piercing, and sharing straws during intranasal cocaine use. All adults should be screened for HCV. Diagnosis of HCV infection is usually a two–step process.
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Sofia Garcia 501 minutes ago
First, identify HCV antibodies with an anti–HCV lab test, and second, confirm the diagnosis wi...
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Charlotte Lee 344 minutes ago
Most people with HCV have little or no visible evidence of liver damage, and if infection is confirm...
First, identify HCV antibodies with an anti–HCV lab test, and second, confirm the diagnosis with demonstration of viremia by checking the HCV viral load. Distinction between HCV as an infection, on the one hand, and a liver disease, on the other, is important.
Most people with HCV have little or no visible evidence of liver damage, and if infection is confirmed, management of the underlying infection is all that needs to concern the clinician. Once cured of infection, no additional follow up is needed in this subset of patients. We recommend assessing liver fibrosis in patients with HCV by using noninvasive radiologic modalities or serum–based markers.
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Charlotte Lee 106 minutes ago
The only contraindication to current chronic HCV treatment is in a patient with a short life expecta...
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Brandon Kumar 20 minutes ago
Those with decompensated cirrhosis, post–liver transplant HCV, chronic kidney disease, HCV&nda...
The only contraindication to current chronic HCV treatment is in a patient with a short life expectancy that cannot be lengthened with treatment, with liver transplant, or with any other treatments. Currently, the major barrier to treatment is the financial cost of the medication. Patients with stage F3 or F4 liver fibrosis should be followed by a specialist for liver–related complications.
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Thomas Anderson 373 minutes ago
Those with decompensated cirrhosis, post–liver transplant HCV, chronic kidney disease, HCV&nda...
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Evelyn Zhang 192 minutes ago
https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf?sequence=1 Additiona...
Those with decompensated cirrhosis, post–liver transplant HCV, chronic kidney disease, HCV–HIV coinfection, HCV–HBV coinfection, or who are pregnant should have their HCV infection managed by a specialist. Previous: Conclusions
Next: Suggested Reading Suggested Reading
Suggested Reading
HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis https://www.hcvguidelines.org/
Global Health Sector Strategy on viral hepatitis. Towards ending viral hepatitis.
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Natalie Lopez 67 minutes ago
https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf?sequence=1 Additiona...
https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf?sequence=1 Additional Reading Centers for Disease Control and Prevention. Hepatitis C FAQs for health professionals.
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Victoria Lopez 41 minutes ago
Available at: http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed October 27, 2016. Centers for Di...
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Sebastian Silva 104 minutes ago
Hepatitis C kills more Americans than any other infectious disease. Available at: http://www.cdc.gov...
Available at: http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed October 27, 2016. Centers for Disease Control and Prevention.
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James Smith 79 minutes ago
Hepatitis C kills more Americans than any other infectious disease. Available at: http://www.cdc.gov...
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Lucas Martinez 47 minutes ago
Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chron...
Hepatitis C kills more Americans than any other infectious disease. Available at: http://www.cdc.gov/media/releases/2016/p0504-hepc-mortality.html. Accessed November 2, 2016.
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Scarlett Brown 525 minutes ago
Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chron...
Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C: the OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups.
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Natalie Lopez 488 minutes ago
Lancet 1997; 349:825–832. Marcolongo M, Young B, Dal Pero F, et al....
Lancet 1997; 349:825–832. Marcolongo M, Young B, Dal Pero F, et al.
A seven–gene signature (cirrhosis risk score) predicts liver fibrosis progression in patients with initially mild chronic hepatitis C. Hepatology 2009; 50:1038–1044.
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Ava White 58 minutes ago
Pawlotsky JM, Chevaliez S, McHutchison JG. The hepatitis C virus life cycle as a target for new anti...
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David Cohen 393 minutes ago
Gastroenterology 2007; 132:1979–1998. Burlone ME, Budkowska A....
Pawlotsky JM, Chevaliez S, McHutchison JG. The hepatitis C virus life cycle as a target for new antiviral therapies.
Gastroenterology 2007; 132:1979–1998. Burlone ME, Budkowska A.
Hepatitis C virus cell entry: role of lipoproteins and cellular receptors. J Gen Virol 2009; 90:1055–1070.
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Ethan Thomas 3 minutes ago
Martell M, Esteban JI, Quer J, et al. Hepatitis C virus (HCV) circulates as a population of differen...
Martell M, Esteban JI, Quer J, et al. Hepatitis C virus (HCV) circulates as a population of different but closely related genomes: quasispecies nature of HCV genome distribution.
J Virol 1992; 66:3225–3229. Manos MM, Shvachko VA, Murphy RC, Arduino JM, Shire NJ. Distribution of hepatitis C virus genotypes in a diverse U.S.
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Luna Park 253 minutes ago
integrated health care population. J Med Virol 2012; 84:1744–1750....
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Henry Schmidt 164 minutes ago
Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion–transmitted viral in...
integrated health care population. J Med Virol 2012; 84:1744–1750.
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Sofia Garcia 49 minutes ago
Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion–transmitted viral in...
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Victoria Lopez 112 minutes ago
Karmochkine M, Carrat F, Dos Santos O, Cacoub P, Raguin G. A case–control study of risk factor...
Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion–transmitted viral infections: the Retrovirus Epidemiology Donor Study. N Engl J Med 1996; 334:1685–1690.
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Sophia Chen 240 minutes ago
Karmochkine M, Carrat F, Dos Santos O, Cacoub P, Raguin G. A case–control study of risk factor...
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Jack Thompson 119 minutes ago
European Paediatric Hepatitis C Virus Network. A significant sex–but not elective cesarean sec...
Karmochkine M, Carrat F, Dos Santos O, Cacoub P, Raguin G. A case–control study of risk factors for hepatitis C infection in patients with unexplained routes of infection. J Viral Hepat 2006; 13:775–782.
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Noah Davis 254 minutes ago
European Paediatric Hepatitis C Virus Network. A significant sex–but not elective cesarean sec...
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Christopher Lee 309 minutes ago
Cottrell EB, Chou R, Wasson N, Rahman B, Guise JM. Reducing risk for mother–to–infant tr...
European Paediatric Hepatitis C Virus Network. A significant sex–but not elective cesarean section–effect on mother–to–child transmission of hepatitis C virus infection. J Infect Dis 2005; 192:1872–1879.
Cottrell EB, Chou R, Wasson N, Rahman B, Guise JM. Reducing risk for mother–to–infant transmission of hepatitis C virus: a systematic review for the U.S. Preventive Services Task Force.
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Julia Zhang 378 minutes ago
Ann Intern Med 2013; 158:109–113. Yazdanpanah Y, De Carli G, Migueres B, et al....
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Lucas Martinez 84 minutes ago
Risk factors for hepatitis C virus transmission to health care workers after occupational exposure: ...
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