Hepatitis C Management

Note: Every Hep C patient needs to be discussed with an attending real-time.

** If the patient is experiencing homelessness, contact Dr. Khan to consider enrollment in the homeless HCV study.

Labs must be completed within 6 months before prescribing.

1. Confirm active hepatitis C infection

Order:

• HCV RNA viral load with reflex to genotype

2. Confirm the patient is appropriate for simplified treatment

If any of the following are present, stop and refer to Dr. Khan:

• Prior treatment with a direct-acting antiviral (DAA)

• HIV coinfection

• Pregnancy

• Cirrhosis or any history of hepatic decompensation, including:

  • Ascites

  • Hepatic encephalopathy

  • Varices

3. Order baseline tests

Order:

• HBsAg

  • If positive, refer to Dr. Khan, but treatment may still proceed

• CBC

  • If platelets <150, refer to Dr. Khan, but treatment may still proceed

• CMP

• FibroTest

  • If FibroTest = F4, refer to Dr. Khan, but treatment may still proceed

4. Additional baseline tasks

• Start Hepatitis A and B vaccination if due

• Review medications using a drug-drug interaction checker such as Liverpool:

  https://www.hep-druginteractions.org/

  • If interactions are found, mitigate them if possible

  • If they cannot be safely mitigated, stop and refer to Dr. Khan

5. Start treatment

Complete the CVS Specialty Pharmacy form for the selected medication and give it to Yasmin Cano, who will coordinate delivery, counseling, and tracking.

Choose one:

• Mavyret for 8 weeks

• Epclusa for 12 weeks

Also:

• Discuss common side effects with the patient:

  • Headache

  • Fatigue

  • Nausea

  • Diarrhea

• Send a Cerner message to Dr. Khan and Yasmin Cano confirming treatment initiation

• Add the selected medication to the medication list

  • Do not send an electronic prescription

  • The CVS specialty form serves as the prescription and will be faxed by Yasmin with the required paperwork

6. Follow-up during treatment

• Follow up with the patient at 4 weeks to assess adherence, tolerance, and side effects

• Order HCV RNA quantitative to be drawn at the 4-week treatment mark

7. Confirm cure

• After treatment is completed, order HCV RNA for 12 weeks after the final dose

• This is the SVR12 (sustained virologic response at 12 weeks)

• Patients are considered cured only if this result is undetectable

If any of the following occur, refer to Dr. Khan:

• Detectable HCV RNA at SVR12

• Significant nonadherence or interrupted treatment course

Flow Diagram