Most of us are anxiously awaiting the FDA’s announcement approving the newest hepatitis C medication Harvoni. Gilead’s once-daily combination pill sofosbuvir/ledipasvir is a significant achievement. However, it isn’t the only news. Yesterday, AASLD/IDSA/IAS-USA updated their Recommendations to include information on the management of acute hepatitis C.
Acute hepatitis C virus (HCV) infection occurs in the first six months. People with acute HCV have a 20 to 50 percent chance of clearing the virus on their own, without treatment. The majority will clear HCV in the six months following exposure, but up to 11 percent may clear it after that point. A viral load (HCV RNA) at six months after the time of infection will identify most of those who have chronic HCV. However, sometimes a viral load is suppressed in the acute phase; thus, a single undetectable viral load is not enough to determine spontaneous clearance.
Those who are most likely to clear HCV on their own are those who are female and younger. Jaundice, elevated ALT level, hepatitis B virus surface antigen (HBsAg) positivity, HCV genotype 1, and host genetic factors are also predictors of spontaneous clearance.
The symptoms of acute HCV infection include fatigue, loss of appetite, abdominal pain, nausea, vomiting, and low-grade fever. Some patients will not have symptoms or will assume their symptoms have another cause, such as the flu. Less than 25 percent will develop jaundice. Liver enzymes (ALT, etc) are usually elevated, but not always.
Avoid acetaminophen and alcohol during acute HCV infection. Practice precautions that may reduce HCV transmission. Patients suspected of having acute HCV should also be tested for HIV, hepatitis B, and other liver diseases, such as hepatitis A or autoimmune hepatitis. When there is a known exposure, there are no recommendations for pre or post-exposure prophylaxis of HCV infection.
Treating Acute HCV
In the past, acute HCV treatment was initiated early, using peginterferon. The timing was important because of the low efficacy rates that occurred with chronic HCV treatment. However, now that HCV treatment is easier to tolerate and the cure rates are high, it makes sense to wait to see if a person clears HCV spontaneously. However, the Recommendations leave the timing up to the medical provider. They do encourage using the same HCV medications that are being used on chronic HCV conditions. Genotype determines the treatment choice.
And soon we will have more HCV drugs to choose from…