Hepatitis C: Diagnosis and Management
Am Fam Physician. 2021 Dec ;104(6):626-635.
Patient information: A handout on this topic is available at https://familydoctor.org/condition/hepatitis-c.
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Screening recommendations and treatment guidelines for hepatitis C virus (HCV) infection have been updated. People at the greatest risk of HCV infection are those between 18 and 39 years of age and those who use injection drugs. Universal screening with an anti-HCV antibody test with follow-up reflex HCV RNA polymerase chain reaction testing for positive results to confirm active disease is recommended at least once for all adults 18 years and older and during each pregnancy. Any person with ongoing risk factors should be screened periodically as long as the at-risk behavior persists. One-time screening is recommended for patients younger than 18 years with risk factors. For treatment-naive adults without cirrhosis or with compensated cirrhosis, a simplified treatment regimen consisting of eight weeks of glecaprevir/pibrentasvir or 12 weeks of sofosbuvir/velpatasvir results in greater than 95% cure rates. Undetectable HCV RNA 12 weeks after completing therapy is considered a virologic cure (i.e., sustained virologic response). A sustained virologic response is associated with lower all-cause mortality and improves hepatic and extrahepatic manifestations, cognitive function, physical health, work productivity, and quality of life. In patients with compensated cirrhosis, posttreatment surveillance for hepatocellular carcinoma and esophageal varices should include abdominal ultrasonography (with or without alpha fetoprotein) every six months and upper endoscopy every two to three years. In the absence of cirrhosis, no liver-related follow-up is recommended.
Hepatitis C virus (HCV) infection, an underdiagnosed and undertreated multifaceted systemic disease, has a protracted chronic phase with hepatic and extrahepatic manifestations that affects an estimated 3.7 million people in the United States.1–5 From 2010 to 2018, the incidence of acute HCV infection among people 18 to 39 years of age quadrupled because of the opioid epidemic and the associated increase in people who inject drugs.1–8 Globally, less than 5% of people with HCV have been diagnosed, and less than 1% have received treatment.1,6,7
WHAT'S NEW ON THIS TOPIC
From 2010 to 2018, the incidence of acute HCV infection among people 18 to 39 years of age quadrupled because of the opioid epidemic and the associated increase in people who inject drugs.
Only 52% of the 3.7 million people in the United States with chronic HCV infection are aware of their disease, and only 37% have received treatment.
The U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention recommend one-time screening for HCV infection in adults 18 to 79 years of age, and periodic screening in adults with ongoing risk factors.
The American College of Obstetricians and Gynecologists recommends screening all pregnant people for HCV infection during each pregnancy.
HCV = hepatitis C virus.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Centers for Disease Control and Prevention, U.S. Preventive Services Task Force, and American College of Obstetricians and Gynecologists
Accurate tests for detecting HCV
Hepatitis A and hepatitis B vaccinations should be administered to people with HCV. A pneumococcal polysaccharide vaccine is indicated for adults 19 to 64 years of age with chronic hepatic disease and cirrhosis.8,15,17,18
Expert opinion and consensus guideline from the Advisory Committee on Immunization Practices and Centers for Disease Control and Prevention
Adults with HCV infection who meet criteria for treatment with a simplified regimen should be treated with eight weeks of glecaprevir/pibrentasvir (Mavyret) or 12 weeks of sofosbuvir/velpatasvir (Epclusa), regardless of the HCV genotype.8,15,18,40,54
Placebo-controlled trials show a > 95%sustained viral response at 12 weeks posttreatment; sustained virologic response is associated with improved patient-oriented outcomes in long-term cohort studies
Expert opinion and consensus guideline
HCV = hepatitis C virus.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
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