Clinical Commander

All dossiers
hep.viral-hepatitis-c.core.v1

Chronic Hepatitis C

hepatologychronicadultoutpatient
Start encounter →Print handoutPRODUCTION

Fresh hep.* prefix dossier; manifest binds to existing hcv_initial batch23 workup scaffold. Pan-genotypic DAA era (AASLD/IDSA HCV 2023 Update - Bhattacharya PMID 37229695); genotype testing de-emphasised. Mavyret (glecaprevir/pibrentasvir) RxCUI 1940702 + Epclusa (sofosbuvir/velpatasvir) RxCUI 1799211 + Vosevi (sofosbuvir/velpatasvir/voxilaprevir) RxCUI 1939328 all RxNav-verified live; these are combination DAA RxCUIs distinct from component CUIs. HBV reactivation prophylaxis mandatory in HBsAg+ during DAA - entecavir or TAF. Decompensated cirrhosis (CTP B/C) - protease inhibitors CONTRAINDICATED; sofosbuvir/velpatasvir + ribavirin 12 wk. DAA-experienced salvage - sofosbuvir/velpatasvir/voxilaprevir (Vosevi) 12 wk. Post-SVR HCC surveillance only continues for F3-F4 fibrosis; reinfection annual RNA in ongoing-risk PWID/MSM.

Entry points (5)

  • lab_abnormality
    Anti-HCV antibody positive (screening or reflex) (AASLD/IDSA HCV 2023)
    anti_hcv_positive
  • lab_abnormality
    HCV RNA detectable - confirmed chronic infection (AASLD/IDSA HCV 2023)
    hcv_rna_detectable
  • history
    Universal one-time screening adults >=18 + pregnancy + risk factors (PWID, HIV, dialysis, MSM) (AASLD/IDSA HCV 2023)
    risk_factor_screening
  • lab_abnormality
    Unexplained ALT/AST elevation - workup includes HCV (AASLD/IDSA HCV 2023)
    unexplained_transaminitis
  • imaging
    Cirrhotic liver on imaging - HCV workup (AASLD/IDSA HCV 2023)
    cirrhotic_morphology

Required inputs (20)

  • agerequired
    demographic • used at CONTEXT
    Pediatric DAA regimens differ; pregnancy DAA contraindicated outside ribavirin-free regimens (AASLD/IDSA HCV 2023)
  • sexrequired
    demographic • used at CONTEXT
    Pregnancy screening universal in pregnancy per AASLD/IDSA 2023
  • hcv_rna_quantitativerequired
    lab • used at INITIAL_WORKUP
    Confirms active chronic infection; baseline for SVR12 endpoint (AASLD/IDSA HCV 2023)
  • hcv_genotype
    lab • used at INITIAL_WORKUP
    De-emphasised in pan-genotypic era but still useful for retreatment or unusual regimens (AASLD/IDSA HCV 2023)
  • ast_altrequired
    lab • used at INITIAL_WORKUP
    Baseline hepatic injury; FIB-4 component (AASLD/IDSA HCV 2023)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    FIB-4 + APRI components; cirrhosis surrogate (AASLD/IDSA HCV 2023)
  • total_bilirubinrequired
    lab • used at INITIAL_WORKUP
    Cirrhosis severity; MELD if decompensated (AASLD/IDSA HCV 2023)
  • inrrequired
    lab • used at INITIAL_WORKUP
    Cirrhosis severity; MELD; decompensation screen (AASLD/IDSA HCV 2023)
  • albuminrequired
    lab • used at INITIAL_WORKUP
    Cirrhosis severity; Child-Pugh + MELD3 (AASLD/IDSA HCV 2023)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    eGFR drives DAA selection (no longer needs adjustment most regimens; specific consideration for ESRD) (AASLD/IDSA HCV 2023)
  • hbsag_anti_hbcrequired
    lab • used at INITIAL_WORKUP
    HBV reactivation screen before DAA initiation - mandatory; HBV DNA if HBsAg+ or anti-HBc+ (AASLD/IDSA HCV 2023)
  • hiv_screenrequired
    lab • used at INITIAL_WORKUP
    Co-infection common; alters DAA selection (drug-drug interactions with ART) (AASLD/IDSA HCV 2023)
  • pregnancy_test
    lab • used at INITIAL_WORKUP
    Pregnancy + reproductive potential - ribavirin contraindicated (DAAs alone generally OK but data limited) (AASLD/IDSA HCV 2023)
  • liver_us_dopplerrequired
    imaging • used at INITIAL_WORKUP
    Cirrhosis screen; HCC surveillance baseline (AASLD/IDSA HCV 2023)
  • fibroscan_transient_elastography
    imaging • used at BRANCHING_WORKUP
    Fibrosis staging (LSM >=12.5 kPa = advanced/cirrhotic) (AASLD/IDSA HCV 2023)
  • prior_daa_exposurerequired
    history • used at CONTEXT
    DAA-experienced needs sofosbuvir/velpatasvir/voxilaprevir salvage (AASLD/IDSA HCV 2023)
  • current_medications_DDI_checkrequired
    medication • used at CONTEXT
    Major DAA DDIs: amiodarone (BRADYCARDIA - especially with sofosbuvir), strong CYP3A inducers (rifampin, phenytoin, carbamazepine, St Johns wort), some statins, PPIs (with elbasvir-grazoprevir) (AASLD/IDSA HCV 2023)
  • decompensation_historyrequired
    history • used at CONTEXT
    Decompensated cirrhosis (CTP B/C) - avoid protease inhibitors (glecaprevir, voxilaprevir); use sofosbuvir/velpatasvir +/- ribavirin (AASLD/IDSA HCV 2023)
  • alcohol_use_disorderrequired
    history • used at CONTEXT
    Concurrent ALD; counseling but does NOT preclude DAA (AASLD/IDSA HCV 2023)
  • injection_drug_use_historyrequired
    history • used at CONTEXT
    PWID full eligibility for DAA + harm reduction + syringe access; reinfection education (AASLD/IDSA HCV 2023)

12-phase flow (8)

  1. 1FRAME
    Confirm chronic HCV scope (RNA detectable + chronicity); plan simplified vs full evaluation (AASLD/IDSA HCV 2023)
    inputs: hcv_rna_quantitative
    advance: chronic HCV confirmed
  2. 2ENTRY
    Recognize positive HCV Ab or RNA via universal screening, risk-based screening, or incidental transaminitis (AASLD/IDSA HCV 2023)
    advance: HCV diagnosis established
  3. 3CONTEXT
    Risk factors (PWID, HIV, dialysis, MSM), DAA-experience, current medications + DDIs (amiodarone, anticonvulsants, rifampin, St Johns wort), pregnancy status, decompensation history, alcohol use, mental health, social support (AASLD/IDSA HCV 2023)
    inputs: age, sex, prior_daa_exposure, current_medications_DDI_check, decompensation_history, alcohol_use_disorder, injection_drug_use_history
    advance: context captured
  4. 4INITIAL_WORKUP
    HCV RNA quantitative, genotype (optional pan-genotypic era), CBC, CMP (AST/ALT/bili/INR/albumin/Cr), HBsAg + anti-HBc total + anti-HBs, HIV Ag/Ab, pregnancy test if reproductive potential, liver US (HCC baseline), FibroScan/FIB-4/APRI for fibrosis staging (AASLD/IDSA HCV 2023)
    inputs: hcv_rna_quantitative, ast_alt, platelets, total_bilirubin, inr, albumin, creatinine, hbsag_anti_hbc, hiv_screen, liver_us_doppler
    actions: panel.lft, panel.cbc, panel.renal
    advance: core labs back
  5. 5BRANCHING_WORKUP
    FibroScan / FIB-4 / APRI; if cirrhotic - Child-Pugh + MELD + EGD for varices (Baveno VII) + HCC surveillance plan + transplant referral if MELD >=15; if DAA-experienced - resistance testing optional (AASLD/IDSA HCV 2023)
    inputs: fibroscan_transient_elastography
    actions: hcv_initial
    advance: fibrosis staged + cirrhosis status determined
  6. 6TREATMENT
    DAA selection by treatment-experience + cirrhosis status: treatment-naive non-cirrhotic - glecaprevir/pibrentasvir 8 wk OR sofosbuvir/velpatasvir 12 wk; compensated cirrhosis (CTP A) - glecaprevir/pibrentasvir 8 wk OR sofosbuvir/velpatasvir 12 wk; decompensated cirrhosis (CTP B/C) - sofosbuvir/velpatasvir 12 wk + low-dose ribavirin (NO protease inhibitors); DAA-experienced - sofosbuvir/velpatasvir/voxilaprevir 12 wk salvage; HBV reactivation prophylaxis if HBsAg+ (entecavir or TAF) (AASLD/IDSA HCV 2023)
    inputs: hcv_rna_quantitative, creatinine, decompensation_history
    advance: DAA regimen selected + initiated
  7. 7MONITORING
    On-treatment: clinical check at week 4 (adherence, AEs, simplified monitoring); HCV RNA NOT required mid-treatment if simplified eligible; SVR12 = HCV RNA undetectable >=12 weeks after treatment completion (cure); LFT q1mo if cirrhotic; monitor HBV reactivation in HBsAg+; INR + bilirubin q2-4 wk in CTP B/C (AASLD/IDSA HCV 2023)
    inputs: hcv_rna_quantitative, ast_alt
    advance: SVR12 documented or non-response identified
  8. 8FOLLOWUP
    Post-SVR: cured HCV - continue HCC surveillance q6mo (US +/- AFP) ONLY if fibrosis F3-F4 (cirrhosis persists despite cure); EGD per Baveno VII if cirrhotic; reinfection monitoring (annual HCV RNA in PWID/ongoing risk); alcohol cessation; vaccinations (HAV/HBV/influenza/PCV20/COVID); harm reduction; mental health and addiction support (AASLD/IDSA HCV 2023)
    advance: long-term plan in place