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hep.viral-hepatitis-c.core.v1PRODUCTION
hep.viral-hepatitis-c.core.v1

Chronic Hepatitis C

hepatologychronicadult
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Encounter flow

8/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm chronic HCV scope (RNA detectable + chronicity); plan simplified vs full evaluation (AASLD/IDSA HCV 2023)

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chronic HCV confirmed

Patient inputs (20)

Pediatric DAA regimens differ; pregnancy DAA contraindicated outside ribavirin-free regimens (AASLD/IDSA HCV 2023)

Pregnancy screening universal in pregnancy per AASLD/IDSA 2023

DAA-experienced needs sofosbuvir/velpatasvir/voxilaprevir salvage (AASLD/IDSA HCV 2023)

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)

Decompensated cirrhosis (CTP B/C) - avoid protease inhibitors (glecaprevir, voxilaprevir); use sofosbuvir/velpatasvir +/- ribavirin (AASLD/IDSA HCV 2023)

Concurrent ALD; counseling but does NOT preclude DAA (AASLD/IDSA HCV 2023)

PWID full eligibility for DAA + harm reduction + syringe access; reinfection education (AASLD/IDSA HCV 2023)

Confirms active chronic infection; baseline for SVR12 endpoint (AASLD/IDSA HCV 2023)

Baseline hepatic injury; FIB-4 component (AASLD/IDSA HCV 2023)

FIB-4 + APRI components; cirrhosis surrogate (AASLD/IDSA HCV 2023)

Cirrhosis severity; MELD if decompensated (AASLD/IDSA HCV 2023)

Cirrhosis severity; MELD; decompensation screen (AASLD/IDSA HCV 2023)

Cirrhosis severity; Child-Pugh + MELD3 (AASLD/IDSA HCV 2023)

eGFR drives DAA selection (no longer needs adjustment most regimens; specific consideration for ESRD) (AASLD/IDSA HCV 2023)

HBV reactivation screen before DAA initiation - mandatory; HBV DNA if HBsAg+ or anti-HBc+ (AASLD/IDSA HCV 2023)

Co-infection common; alters DAA selection (drug-drug interactions with ART) (AASLD/IDSA HCV 2023)

Cirrhosis screen; HCC surveillance baseline (AASLD/IDSA HCV 2023)

Fibrosis staging (LSM >=12.5 kPa = advanced/cirrhotic) (AASLD/IDSA HCV 2023)

De-emphasised in pan-genotypic era but still useful for retreatment or unusual regimens (AASLD/IDSA HCV 2023)

Pregnancy + reproductive potential - ribavirin contraindicated (DAAs alone generally OK but data limited) (AASLD/IDSA HCV 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

No severity triggers declared for this engine.

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Recommended regimen

Chronic HCV - pan-genotypic DAA by treatment experience + cirrhosis status (AASLD/IDSA HCV 2023)
axis: hcv_daa_treatment_axisstep 1 - Step 1 - Treatment-naive non-cirrhotic or compensated cirrhotic (CTP A) - pan-genotypic 8 or 12 weeks
Selected step "Step 1 - Treatment-naive non-cirrhotic or compensated cirrhotic (CTP A) - pan-genotypic 8 or 12 weeks" — No prior DAA + (no cirrhosis OR compensated CTP A cirrhosis) + no decompensation history
  • glecaprevir_pibrentasvir
    first line
    DAA_NS3_4A_protease_inhibitor_NS5A_inhibitor_combination
    300/120 mg (3 tablets) PO once daily with food x 8 weeks • PO • once daily
    triggers: treatment_naive, no_cirrhosis_or_CTP_A, no_HIV_or_compatible_ART
    AASLD/IDSA HCV 2023 (PMID 37229695) - Mavyret 8 wk pan-genotypic for treatment-naive without decompensation; SVR12 >95%
    rxcui 1940702
  • sofosbuvir_velpatasvir
    first line
    DAA_NS5B_polymerase_NS5A_combination
    400/100 mg (1 tablet) PO once daily x 12 weeks • PO • once daily
    triggers: treatment_naive, compensated_or_no_cirrhosis, PPI_user_alternative
    AASLD/IDSA HCV 2023 - Epclusa 12 wk pan-genotypic; preferred when amiodarone-co-prescribed avoided OR shorter regimen contraindicated
    rxcui 1799211

outpatient playbook — drug actions (5)

  1. 1. glecaprevir/pibrentasvir 8 wk treatment-naive non-cirrhotic OR CTP A
    300/120 mg PO once daily with food x 8 weeks • PO • once daily
    trigger: Treatment-naive, no decompensation (AASLD/IDSA HCV 2023)
    Mavyret 8 wk pan-genotypic SVR12 >95% (PMID 37229695)
  2. 2. sofosbuvir/velpatasvir 12 wk alternative or PPI co-prescription
    400/100 mg PO once daily x 12 weeks • PO • once daily
    trigger: Treatment-naive, alternative to Mavyret (AASLD/IDSA HCV 2023)
    Epclusa 12 wk pan-genotypic; flexible with PPIs vs Mavyret
  3. 3. sofosbuvir/velpatasvir + ribavirin 12 wk for CTP B/C
    Epclusa 400/100 mg PO daily + RBV 600-1200 mg PO daily titrated • PO • daily
    trigger: Decompensated cirrhosis CTP B or C (AASLD/IDSA HCV 2023)
    Protease inhibitors contraindicated; RBV adds 5-10% SVR12 benefit
  4. 4. sofosbuvir/velpatasvir/voxilaprevir 12 wk salvage
    400/100/100 mg PO once daily with food x 12 weeks • PO • once daily
    trigger: DAA-experienced (prior NS5A failure) (AASLD/IDSA HCV 2023)
    Vosevi salvage POLARIS-1 SVR12 ~96%
  5. 5. entecavir or TAF HBV prophylaxis during DAA if HBsAg+
    Entecavir 0.5 mg PO daily OR TAF 25 mg PO daily during DAA + 12 weeks post • PO • daily
    trigger: HBsAg+ at baseline (AASLD/IDSA HCV 2023)
    Prevents HBV reactivation - can be fulminant during DAA

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Anti-HCV antibody positive (screening or reflex) (AASLD/IDSA HCV 2023); HCV RNA detectable - confirmed chronic infection (AASLD/IDSA HCV 2023); Universal one-time screening adults >=18 + pregnancy + risk factors (PWID, HIV, dialysis, MSM) (AASLD/IDSA HCV 2023).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic Hepatitis C** (hep.viral-hepatitis-c.core.v1).
Scope: Confirm chronic HCV scope (RNA detectable + chronicity); plan simplified vs full evaluation (AASLD/IDSA HCV 2023)

Plan

Regimen axis: **Chronic HCV - pan-genotypic DAA by treatment experience + cirrhosis status (AASLD/IDSA HCV 2023)** — step "Step 1 - Treatment-naive non-cirrhotic or compensated cirrhotic (CTP A) - pan-genotypic 8 or 12 weeks".
1. glecaprevir_pibrentasvir 300/120 mg (3 tablets) PO once daily with food x 8 weeks PO once daily (DAA_NS3_4A_protease_inhibitor_NS5A_inhibitor_combination, first line) — AASLD/IDSA HCV 2023 (PMID 37229695) - Mavyret 8 wk pan-genotypic for treatment-naive without decompensation; SVR12 >95%
2. sofosbuvir_velpatasvir 400/100 mg (1 tablet) PO once daily x 12 weeks PO once daily (DAA_NS5B_polymerase_NS5A_combination, first line) — AASLD/IDSA HCV 2023 - Epclusa 12 wk pan-genotypic; preferred when amiodarone-co-prescribed avoided OR shorter regimen contraindicated

Setting playbook (outpatient) — Achieve SVR12 with simplified DAA regimen, prevent HBV reactivation, link to addiction/harm reduction, manage cirrhosis longitudinally with HCC surveillance (AASLD/IDSA HCV 2023)
3. glecaprevir/pibrentasvir 8 wk treatment-naive non-cirrhotic OR CTP A 300/120 mg PO once daily with food x 8 weeks PO once daily — Treatment-naive, no decompensation (AASLD/IDSA HCV 2023) (Mavyret 8 wk pan-genotypic SVR12 >95% (PMID 37229695))
4. sofosbuvir/velpatasvir 12 wk alternative or PPI co-prescription 400/100 mg PO once daily x 12 weeks PO once daily — Treatment-naive, alternative to Mavyret (AASLD/IDSA HCV 2023) (Epclusa 12 wk pan-genotypic; flexible with PPIs vs Mavyret)
5. sofosbuvir/velpatasvir + ribavirin 12 wk for CTP B/C Epclusa 400/100 mg PO daily + RBV 600-1200 mg PO daily titrated PO daily — Decompensated cirrhosis CTP B or C (AASLD/IDSA HCV 2023) (Protease inhibitors contraindicated; RBV adds 5-10% SVR12 benefit)
6. sofosbuvir/velpatasvir/voxilaprevir 12 wk salvage 400/100/100 mg PO once daily with food x 12 weeks PO once daily — DAA-experienced (prior NS5A failure) (AASLD/IDSA HCV 2023) (Vosevi salvage POLARIS-1 SVR12 ~96%)
7. entecavir or TAF HBV prophylaxis during DAA if HBsAg+ Entecavir 0.5 mg PO daily OR TAF 25 mg PO daily during DAA + 12 weeks post PO daily — HBsAg+ at baseline (AASLD/IDSA HCV 2023) (Prevents HBV reactivation - can be fulminant during DAA)

Non-pharmacologic actions:
- Alcohol cessation counseling + addiction medicine referral (AASLD/IDSA HCV 2023)
- Harm reduction (syringe access, naloxone, MAT) for PWID (AASLD/IDSA HCV 2023)
- Vaccinations - HAV, HBV (if not immune), influenza, PCV20, COVID (AASLD/IDSA HCV 2023)
- HCC surveillance US +/- AFP q6mo if F3 or F4 (AASLD/IDSA HCV 2023)
- EGD for varices if cirrhotic per Baveno VII (AASLD/IDSA HCV 2023)
- Reinfection education and annual HCV RNA in ongoing-risk patients (AASLD/IDSA HCV 2023)
- Mental health + social work + peer navigator support (AASLD/IDSA HCV 2023)
- Transplant evaluation if MELD >=15 OR persistent decompensation despite SVR (AASLD/IDSA HCV 2023)

AVOID / contraindication checks:
- Amiodarone_with_sofosbuvir_BRADYCARDIA_check_DDI (AASLD/IDSA HCV 2023)
- Rifampin_phenytoin_carbamazepine_St_Johns_wort_CYP3A_inducers_avoid_all_DAA (AASLD/IDSA HCV 2023)
- Protease_inhibitor_CONTRAINDICATED_decompensated_CTP_B_C (AASLD/IDSA HCV 2023)
- Ribavirin_teratogenic_pregnancy_absolute_contraindication_both_partners_strict_contraception_6_months_post (AASLD/IDSA HCV 2023)
- HBV_reactivation_screen_mandatory_before_DAA_HBsAg_AND_anti_HBc (AASLD/IDSA HCV 2023)
- PPI_with_velpatasvir_or_ledipasvir_limit_to_low_dose_omeprazole_20_with_food (AASLD/IDSA HCV 2023)
- Atorvastatin_rosuvastatin_pravastatin_dose_adjustment_with_DAA (AASLD/IDSA HCV 2023)
- No_calc_inducers_grapefruit_juice_with_DAA (AASLD/IDSA HCV 2023)

Monitoring

Regimen monitoring:
- baseline HCV RNA genotype optional LFTs CBC BMP HBsAg anti HBc HIV (AASLD/IDSA HCV 2023)
- on treatment simplified monitoring clinical visit week 4 or per pathway (AASLD/IDSA HCV 2023)
- SVR12 HCV RNA undetectable 12 weeks post treatment completion (AASLD/IDSA HCV 2023)
- LFTs q1mo if cirrhotic (AASLD/IDSA HCV 2023)
- HBV DNA q4 8w during DAA if HBsAg positive (AASLD/IDSA HCV 2023)
- CBC for ribavirin anemia q2 4w (AASLD/IDSA HCV 2023)
- INR bilirubin q2 4w in decompensated cirrhosis (AASLD/IDSA HCV 2023)
- post SVR HCC surveillance q6mo only if F3 or F4 (AASLD/IDSA HCV 2023)
- reinfection annual HCV RNA in ongoing risk PWID MSM (AASLD/IDSA HCV 2023)

Setting (outpatient) monitoring:
- On-treatment simplified monitoring - clinical visit week 4 + adherence + AE check (AASLD/IDSA HCV 2023)
- SVR12 HCV RNA undetectable 12 weeks post-treatment = cure (AASLD/IDSA HCV 2023)
- LFTs monthly if cirrhotic during DAA + 3 months post (AASLD/IDSA HCV 2023)
- CBC q2-4w if on ribavirin (anemia monitoring) (AASLD/IDSA HCV 2023)
- HBV DNA q4-8w during DAA if HBsAg+ (AASLD/IDSA HCV 2023)
- Annual HCV RNA in PWID/MSM/ongoing risk to detect reinfection (AASLD/IDSA HCV 2023)
- q6mo HCC surveillance US +/- AFP if F3-F4 post-cure (AASLD/IDSA HCV 2023)

Follow-up plan: 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)
- Close-out criterion: long-term plan in place

Monitoring phase: 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)

Disposition

Current setting: outpatient — Achieve SVR12 with simplified DAA regimen, prevent HBV reactivation, link to addiction/harm reduction, manage cirrhosis longitudinally with HCC surveillance (AASLD/IDSA HCV 2023)

Disposition criteria:
- Maintain outpatient hepatology / primary care management - DAA cure pathway is fully outpatient (AASLD/IDSA HCV 2023)
- Inpatient admission only for decompensation events (variceal bleed, SBP, HE, HRS-AKI) - route to cirrhosis/SBP/HRS engines (AASLD/IDSA HCV 2023)
- Transplant center referral if MELD >=15 OR persistent decompensation despite SVR (AASLD/IDSA HCV 2023)

Escalation triggers (move to higher acuity):
- Decompensation during DAA - hold protease inhibitor and switch to sofosbuvir/velpatasvir +/- RBV; hepatology urgent (AASLD/IDSA HCV 2023)
- HBV reactivation during DAA - start entecavir or TAF immediately; hepatology urgent (AASLD/IDSA HCV 2023)
- Severe ribavirin anemia (Hb <8.5) - reduce dose or hold; transfuse if symptomatic (AASLD/IDSA HCV 2023)
- Treatment failure (detectable RNA at SVR12) - retreatment with sofosbuvir/velpatasvir/voxilaprevir + resistance testing (AASLD/IDSA HCV 2023)
- New HCC on surveillance - tumor board + multidisciplinary care (AASLD/IDSA HCV 2023)

Earlier-Return Triggers

- No severity triggers declared for this engine.

Citations

- AASLD/IDSA Hepatitis C Guidance 2023 Update (Bhattacharya, Clinical Infectious Diseases 2023) - current floor; living document at hcvguidelines.org [PMID:37229695](https://pubmed.ncbi.nlm.nih.gov/37229695/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AASLD/IDSA Hepatitis C Guidance 2023 Update (Bhattacharya, Clinical Infectious Diseases 2023) - current floor; living document at hcvguidelines.org — PMID:37229695