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id.hcv-initial.chronic.v1PRODUCTION
id.hcv-initial.chronic.v1

Hepatitis C — initial evaluation & DAA

infectious_diseasechronicadult
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11/12 authored

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

Current phase

Frame

Detailed

Chronic HCV initial evaluation; acute HCV / treatment-experienced / decompensated cirrhosis covered by sibling engines (IDSA 2024)

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scope confirmed (chronic, treatment-naive, compensated by default)

Patient inputs (11)

HBV co-infection screen — DAA can reactivate HBV; FDA boxed warning (IDSA 2024)

Co-infection alters regimen choice + drug-drug interactions (IDSA 2024)

Treatment-experienced affects regimen + duration (IDSA 2024)

Compensated vs decompensated drives regimen + HCC surveillance (IDSA 2024)

Confirms active infection vs cleared exposure (IDSA 2024)

Baseline ALT/AST + bilirubin; drives Child-Pugh staging if cirrhotic (IDSA 2024)

FIB-4 + APRI inputs; portal HTN marker (IDSA 2024)

eGFR for sofosbuvir-based regimen choice (now safe at all eGFR) (IDSA 2024)

DAA drug-drug interactions (PPI with velpatasvir, statins, amiodarone) (IDSA 2024)

Pan-genotypic DAAs apply but genotype 3 affects regimen + duration in cirrhotics (IDSA 2024)

Stage liver fibrosis (F0-F4); HCC screening if cirrhotic (IDSA 2024)

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

Severity triggers (10)

10 need judgement
  • informationallife_threateninghbv_reactivation_during_daa
    HBsAg+ OR anti-HBc+ alone patient about to start DAA, OR HBV-DNA rise + ALT rise during DAA — life-threatening reactivation risk (FDA boxed warning 2016; AASLD/IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdecompensated_cirrhosis_emergence
    Ascites / variceal bleed / hepatic encephalopathy / SBP / Child-Pugh B or C emergence during evaluation or DAA — life-threatening hepatic decompensation (AASLD/IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghcc_emergence_post_svr
    Hepatocellular carcinoma detected on surveillance imaging in cirrhotic patient EVEN after SVR12 cure — life-threatening, requires emergent multidisciplinary coordination (AASLD HCC Surveillance Guidance 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredaa_treatment_failure_resistance
    Detectable HCV-RNA at week 4 of DAA, end-of-treatment, or SVR12 (12 weeks post-EOT) — DAA failure with potential NS5A resistance-associated substitutions (AASLD/IDSA 2024; POLARIS-1 / -4)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereextrahepatic_manifestations
    Cryoglobulinemia / vasculitis / glomerulonephritis / B-cell lymphoma in HCV+ patient (AASLD/IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_hcv
    HCV+ patient with current pregnancy OR pregnancy occurring during DAA (especially ribavirin-containing regimen) — defer DAA until postpartum; Category X ribavirin teratogenicity (AASLD/IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehiv_hcv_hbv_triple_coinfection
    Triple co-infection: HIV+ AND HCV-RNA+ AND HBsAg+ — complex DDI screening + multi-specialty coordination required (AASLD/IDSA 2024; AASLD HBV; DHHS HIV)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereidu_relapse_during_daa
    Active injection drug use relapse during DAA treatment — adherence intervention + harm reduction; DO NOT discontinue DAA solely for IDU relapse (C-EDGE Co-STAR; SIMPLIFY; AASLD/IDSA 2024 universal-treatment paradigm)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransplant_recipient_hcv
    HCV+ patient who is a current organ-transplant recipient (liver, kidney, heart, lung) OR pre-transplant candidate — DAA selection per organ + immunosuppressant-DAA DDI management (AST-IDSA transplant ID; AASLD/IDSA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemajor_drug_interaction
    Concurrent amiodarone (bradycardia with sof-containing), strong CYP3A4 inducer (rifampin, carbamazepine, St Johns Wort) → reduces DAA exposure, OR PPI requiring spacing with velpatasvir, OR statin DDI (gleca + rosuvastatin → cap dose), OR efavirenz reduces sof/vel (AASLD/IDSA 2024; Liverpool HEP DDI checker)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

HCV pan-genotypic DAA — treatment-naive, compensated (AASLD/IDSA + EASL 2025)
axis: hcv_pan_genotypic_daa
Selected axis "HCV pan-genotypic DAA — treatment-naive, compensated (AASLD/IDSA + EASL 2025)" by default fallback (first axis)
  • glecaprevir-pibrentasvir
    first line
    NS3_4A_NS5A_protease_polymerase_inhibitor
    300/120 mg PO daily (3 tablets of 100/40) • PO with food • daily × 8 weeks
    triggers: treatment_naive, no_cirrhosis_or_compensated_cirrhosis
    AASLD/IDSA + EASL 2025 — Mavyret 8-week pan-genotypic; non-inferior to 12 weeks (EXPEDITION-8); avoid in decompensated cirrhosis (protease inhibitor)
    rxcui 1940702
  • sofosbuvir-velpatasvir
    first line
    NS5B_NS5A_polymerase_inhibitor
    400/100 mg PO daily • PO • daily × 12 weeks
    triggers: treatment_naive, all_genotypes, compensated_or_decompensated_cirrhosis
    AASLD/IDSA + EASL 2025 — Epclusa 12-week pan-genotypic; safe in all eGFR (post-EXPEDITION-4/5); preferred in decompensated cirrhosis with ribavirin
    rxcui 1799211
  • sofosbuvir-velpatasvir-voxilaprevir
    second line
    NS5B_NS5A_NS3_inhibitor
    400/100/100 mg PO daily • PO • daily × 12 weeks
    triggers: DAA_failure_NS5A_inhibitor_experienced
    AASLD/IDSA + EASL 2025 — Vosevi salvage for treatment-experienced; not first-line
    rxcui 1939328
  • ledipasvir-sofosbuvir
    second line
    NS5A_NS5B_inhibitor
    90/400 mg PO daily • PO • daily × 8-12 weeks
    triggers: genotype_1_4_5_6, older_regimen_alternative
    AASLD/IDSA — older but still effective for non-3 genotypes
    rxcui 1591942

outpatient playbook — drug actions (6)

  1. 1. glecaprevir-pibrentasvir (Mavyret)
    rxcui 1940702
    300/120 mg PO daily (3 tabs of 100/40) • PO with food • daily × 8 weeks (12 wk if compensated cirrhosis)
    trigger: Treatment-naive, no decompensated cirrhosis (compensated cirrhosis OK per EXPEDITION-8)
    AASLD/IDSA 2024 + EASL 2025 — pan-genotypic 8 wk first-line in treatment-naive non-cirrhotic OR compensated cirrhotic per EXPEDITION-8 (Brown Hepatology 2020 NEEDS_SOURCE_REVIEW); avoid in decompensated cirrhosis (protease inhibitor → hepatic toxicity)
  2. 2. sofosbuvir-velpatasvir (Epclusa)
    rxcui 1799211
    400/100 mg PO daily • PO • daily × 12 weeks (24 wk OR + ribavirin × 12 wk if decompensated cirrhosis)
    trigger: Treatment-naive; first-line equivalent to Mavyret; preferred in decompensated cirrhosis (with ribavirin) and in eGFR < 30 (per EXPEDITION-4/-5)
    AASLD/IDSA 2024 + EASL 2025 + ASTRAL-1 (Feld NEJM 2015 PMID 26571066) — pan-genotypic 12 wk; safe across all eGFR including dialysis
  3. 3. sofosbuvir-velpatasvir-voxilaprevir (Vosevi)
    rxcui 1939328
    400/100/100 mg PO daily • PO • daily × 12 weeks
    trigger: Prior DAA failure (NS5A-inhibitor-experienced); resistance testing optional
    AASLD/IDSA 2024 + POLARIS-1 / -4 (Bourlière NEJM 2017 NEEDS_SOURCE_REVIEW) — salvage for DAA-experienced; AVOID in decompensated cirrhosis (protease inhibitor)
  4. 4. HBV antiviral — entecavir
    rxcui 306266
    0.5 mg PO daily • PO • daily during DAA + 12 weeks post-DAA-EOT
    trigger: HBsAg+ patient OR anti-HBc+ alone before/concurrent with DAA
    FDA boxed warning 2016 — DAA can reactivate HBV; prophylactic anti-HBV mandatory in HBsAg+; consider in anti-HBc+ alone with HBV-DNA monitoring
  5. 5. HBV antiviral — tenofovir-disoproxil-fumarate
    rxcui 322248
    300 mg PO daily • PO • daily during DAA + 12 weeks post-DAA-EOT
    trigger: HBsAg+ patient OR anti-HBc+ alone; alternative to entecavir; preferred if HIV co-infection (also covers HIV)
    FDA boxed warning 2016 + AASLD/IDSA HBV; preferred ARV-overlap option if HIV co-infected
  6. 6. ribavirin (RBV — only for select decompensated cirrhotic)
    rxcui 9344
    Weight-based: <75 kg 1000 mg/day OR ≥75 kg 1200 mg/day, divided BID • PO with food • divided BID × 12 weeks (only with sof/vel in decompensated cirrhosis)
    trigger: Decompensated cirrhosis + sof/vel × 12 wk regimen (alternative to sof/vel × 24 wk)
    AASLD/IDSA 2024 — RBV-shortened sof/vel for decompensated cirrhosis; Category X — counsel + pregnancy test + contraception × 6 mo washout

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: HCV antibody positive (IDSA 2024); HCV RNA detectable on screening (IDSA 2024); Unexplained ALT elevation in at-risk individual (IDSA 2024).

Objective

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

Assessment

**Hepatitis C — initial evaluation & DAA** (id.hcv-initial.chronic.v1).
Phenotype framing: Confirm HCV as primary driver vs alcohol / MASLD / other viral; cryoglobulinemia / vasculitis / GN extrahepatic flags (IDSA 2024)
Scope: Chronic HCV initial evaluation; acute HCV / treatment-experienced / decompensated cirrhosis covered by sibling engines (IDSA 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **HCV pan-genotypic DAA — treatment-naive, compensated (AASLD/IDSA + EASL 2025)**.
1. glecaprevir-pibrentasvir 300/120 mg PO daily (3 tablets of 100/40) PO with food daily × 8 weeks (NS3_4A_NS5A_protease_polymerase_inhibitor, first line) — AASLD/IDSA + EASL 2025 — Mavyret 8-week pan-genotypic; non-inferior to 12 weeks (EXPEDITION-8); avoid in decompensated cirrhosis (protease inhibitor)
2. sofosbuvir-velpatasvir 400/100 mg PO daily PO daily × 12 weeks (NS5B_NS5A_polymerase_inhibitor, first line) — AASLD/IDSA + EASL 2025 — Epclusa 12-week pan-genotypic; safe in all eGFR (post-EXPEDITION-4/5); preferred in decompensated cirrhosis with ribavirin
3. sofosbuvir-velpatasvir-voxilaprevir 400/100/100 mg PO daily PO daily × 12 weeks (NS5B_NS5A_NS3_inhibitor, second line) — AASLD/IDSA + EASL 2025 — Vosevi salvage for treatment-experienced; not first-line
4. ledipasvir-sofosbuvir 90/400 mg PO daily PO daily × 8-12 weeks (NS5A_NS5B_inhibitor, second line) — AASLD/IDSA — older but still effective for non-3 genotypes

Setting playbook (outpatient) — Universal screening per USPSTF 2020 → confirmation → pre-treatment workup → pan-genotypic DAA delivery via specialty pharmacy → SVR12 cure documentation → post-SVR surveillance per cirrhosis status with lifelong HCC surveillance for cirrhotics; co-management for HBV/HIV co-infection, IDU, pregnancy, transplant recipients (AASLD/IDSA 2024 web edition; EASL 2025; USPSTF 2020 PMID 32119076)
5. glecaprevir-pibrentasvir (Mavyret) 300/120 mg PO daily (3 tabs of 100/40) PO with food daily × 8 weeks (12 wk if compensated cirrhosis) — Treatment-naive, no decompensated cirrhosis (compensated cirrhosis OK per EXPEDITION-8) (AASLD/IDSA 2024 + EASL 2025 — pan-genotypic 8 wk first-line in treatment-naive non-cirrhotic OR compensated cirrhotic per EXPEDITION-8 (Brown Hepatology 2020 NEEDS_SOURCE_REVIEW); avoid in decompensated cirrhosis (protease inhibitor → hepatic toxicity))
6. sofosbuvir-velpatasvir (Epclusa) 400/100 mg PO daily PO daily × 12 weeks (24 wk OR + ribavirin × 12 wk if decompensated cirrhosis) — Treatment-naive; first-line equivalent to Mavyret; preferred in decompensated cirrhosis (with ribavirin) and in eGFR < 30 (per EXPEDITION-4/-5) (AASLD/IDSA 2024 + EASL 2025 + ASTRAL-1 (Feld NEJM 2015 PMID 26571066) — pan-genotypic 12 wk; safe across all eGFR including dialysis)
7. sofosbuvir-velpatasvir-voxilaprevir (Vosevi) 400/100/100 mg PO daily PO daily × 12 weeks — Prior DAA failure (NS5A-inhibitor-experienced); resistance testing optional (AASLD/IDSA 2024 + POLARIS-1 / -4 (Bourlière NEJM 2017 NEEDS_SOURCE_REVIEW) — salvage for DAA-experienced; AVOID in decompensated cirrhosis (protease inhibitor))
8. HBV antiviral — entecavir 0.5 mg PO daily PO daily during DAA + 12 weeks post-DAA-EOT — HBsAg+ patient OR anti-HBc+ alone before/concurrent with DAA (FDA boxed warning 2016 — DAA can reactivate HBV; prophylactic anti-HBV mandatory in HBsAg+; consider in anti-HBc+ alone with HBV-DNA monitoring)
9. HBV antiviral — tenofovir-disoproxil-fumarate 300 mg PO daily PO daily during DAA + 12 weeks post-DAA-EOT — HBsAg+ patient OR anti-HBc+ alone; alternative to entecavir; preferred if HIV co-infection (also covers HIV) (FDA boxed warning 2016 + AASLD/IDSA HBV; preferred ARV-overlap option if HIV co-infected)
10. ribavirin (RBV — only for select decompensated cirrhotic) Weight-based: <75 kg 1000 mg/day OR ≥75 kg 1200 mg/day, divided BID PO with food divided BID × 12 weeks (only with sof/vel in decompensated cirrhosis) — Decompensated cirrhosis + sof/vel × 12 wk regimen (alternative to sof/vel × 24 wk) (AASLD/IDSA 2024 — RBV-shortened sof/vel for decompensated cirrhosis; Category X — counsel + pregnancy test + contraception × 6 mo washout)

Non-pharmacologic actions:
- Specialty pharmacy delivery + adherence monitoring + co-pay assistance — required for all DAAs (AASLD/IDSA 2024 + CMS coverage policy 2024 universal access)
- HAV + HBV vaccination if non-immune (anti-HBs negative) — AASLD/IDSA 2024
- Pneumococcal vaccine if cirrhotic (PCV20 per ACIP 2024)
- Influenza vaccine annual + COVID-19 per current ACIP
- Alcohol cessation counseling — synergistic hepatotoxicity (AASLD/IDSA 2024)
- Harm reduction (needle exchange, MAT for OUD — methadone / buprenorphine / naltrexone) — do NOT discontinue DAA for IDU relapse (C-EDGE Co-STAR Dore Ann Intern Med 2016 NEEDS_SOURCE_REVIEW; AASLD/IDSA 2024 universal-treatment paradigm)
- Addiction-medicine linkage if IDU — routes to psych.opioid_use_disorder.core.v1
- Cirrhotic patients: variceal screening EGD q1-3 yr + HCC US ± AFP q6 months lifelong EVEN after SVR (AASLD HCC Surveillance Guidance 2023 NEEDS_SOURCE_REVIEW)
- Reinfection prevention education — sexual transmission low except MSM with HIV; needle-sharing major risk; routine re-screening if at-risk (AASLD/IDSA 2024)
- Pregnancy planning + postpartum DAA initiation — counsel perinatal transmission ~5%; test infant at 18 mo for HCV-RNA (AASLD/IDSA 2024 perinatal)
- Partner-care services — HCV testing for sexual / needle-sharing partners (AASLD/IDSA 2024)
- HIV PrEP if HIV-negative with risk (CDC PrEP guidance)
- Lifestyle counseling — alcohol cessation, hepatotoxic-drug review (acetaminophen ≤ 2 g/day if cirrhotic), weight management for MASLD comorbid driver (AASLD/IDSA 2024)

AVOID / contraindication checks:
- DAA HBV screen pre treatment FDA boxed warning for HBV reactivation (IDSA 2024)
- Protease inhibitor block in decompensated cirrhosis (IDSA 2024)
- DAA amiodarone block bradycardia (IDSA 2024)
- DAA PPI spacing velpatasvir with acid suppression (IDSA 2024)
- DAA statin DDI rosuvastatin dose cap with glecaprevir (IDSA 2024)
- DAA carbamazepine rifampin st johns wort block CYP inducers (IDSA 2024)

Monitoring

Regimen monitoring:
- on treatment LFT at week 4 if baseline abnormal (IDSA 2024)
- on treatment HCV RNA optional at week 4 (IDSA 2024)
- SVR12 HCV RNA at 12 weeks post treatment = cure (IDSA 2024)
- cirrhotic lifelong HCC surveillance q6mo US AFP despite cure (IDSA 2024)

Setting (outpatient) monitoring:
- Week 4 on-treatment LFT only if baseline ALT/AST elevated (AASLD/IDSA 2024)
- Week 4 on-treatment HCV-RNA optional — undetectable predicts SVR12 cure (AASLD/IDSA 2024)
- End-of-treatment HCV-RNA optional — most data drive from SVR12
- SVR12 (12 weeks post-EOT HCV-RNA) = cure (definitional; AASLD/IDSA 2024)
- HBsAg+ or anti-HBc+ alone patients: HBV-DNA + LFT monthly during DAA + 3 months post-EOT (FDA boxed warning 2016)
- Cirrhotic patients post-SVR: lifelong HCC surveillance — US ± AFP q6 months + EGD q1-3 yr (AASLD HCC Surveillance Guidance 2023)
- Non-cirrhotic post-SVR: routine primary care + reinfection screening per risk (annual rescreening in PWID, MSM with HIV) (AASLD/IDSA 2024)
- Pregnancy: defer DAA until postpartum; document for postpartum re-initiation; test infant at 18 mo (AASLD/IDSA 2024)

Follow-up plan: Cirrhotic → lifelong HCC surveillance US ± AFP q6 months despite cure; reinfection education / harm reduction; hepatology continuity (IDSA 2024)
- Close-out criterion: long-term plan documented

Monitoring phase: On-treatment LFT week 4 if abnormal baseline; SVR12 (HCV RNA) 12 weeks after end of therapy (IDSA 2024)

Disposition

Current setting: outpatient — Universal screening per USPSTF 2020 → confirmation → pre-treatment workup → pan-genotypic DAA delivery via specialty pharmacy → SVR12 cure documentation → post-SVR surveillance per cirrhosis status with lifelong HCC surveillance for cirrhotics; co-management for HBV/HIV co-infection, IDU, pregnancy, transplant recipients (AASLD/IDSA 2024 web edition; EASL 2025; USPSTF 2020 PMID 32119076)

Disposition criteria:
- Outpatient throughout DAA treatment unless decompensation (AASLD/IDSA 2024)
- Specialty-pharmacy continuity for DAA refills + adherence monitoring
- Post-SVR cirrhotic: continue indefinitely in HCV-care clinic OR hepatology for lifelong HCC + variceal surveillance (AASLD HCC Surveillance Guidance 2023)
- Post-SVR non-cirrhotic: discharge from HCV-care clinic back to primary care after SVR12 confirmed + reinfection-risk plan documented (AASLD/IDSA 2024)

Escalation triggers (move to higher acuity):
- Cirrhotic decompensation (ascites / variceal bleed / HE / SBP) emergence during evaluation or treatment → hepatology + admit + sof/vel × 24 wk OR sof/vel + ribavirin × 12 wk OR delay DAA until liver transplant evaluation; routes to gi.cirrhosis.core.v1 + gi.variceal_bleed.v1 (AASLD/IDSA 2024)
- HBV reactivation during DAA — HBV-DNA rise + ALT rise → confirm prophylactic entecavir/tenofovir; ID consult; FDA boxed warning (FDA 2016)
- DAA treatment failure — HCV-RNA detectable at week 4 or SVR12 → resistance testing + Vosevi salvage 12 wk (POLARIS-1 / -4 NEEDS_SOURCE_REVIEW)
- HCC detected on surveillance (even after SVR) → hepatology + oncology coordination; routes to gi.hcc.core.v1 (AASLD HCC Surveillance Guidance 2023)
- On-treatment ALT > 10× ULN → stop DAA + hepatology consult (AASLD/IDSA 2024)
- New pregnancy during DAA (especially ribavirin) → stop ribavirin immediately + OB/MFM + hepatology consult; 6-mo washout for ribavirin teratogenicity (AASLD/IDSA 2024)
- IDU relapse during DAA — adherence intervention; harm reduction; do NOT discontinue DAA solely for IDU relapse; addiction-medicine linkage (C-EDGE Co-STAR + AASLD/IDSA 2024)
- Triple co-infection HIV/HCV/HBV detected → ID + hepatology + pharmacy consult; coordinate ART + DAA + HBV-prophylaxis (AASLD/IDSA 2024)
- Transplant recipient on DAA — manage immunosuppressant-DAA DDIs (cyclosporine/tacrolimus + protease inhibitors → adjust doses; sof/vel preferred minimal CNI interaction) (AST-IDSA transplant ID; AASLD/IDSA 2024)
- Extrahepatic manifestation (cryoglobulinemia / vasculitis / GN / lymphoma) → expedite DAA + rheumatology/oncology consult (AASLD/IDSA 2024)

Patient Action Plan

**HCV treatment + post-cure plan (IDSA 2024)**
Personalised values: daa_regimen, cirrhosis_status, hbv_status, reinfection_risk_factors (IDSA 2024).

**On treatment / SVR12 achieved — staying on track (IDSA 2024)** (green):
Triggers:
- Taking DAA every day at the same time, with food if Mavyret
- No new symptoms; LFTs stable
- Vaccinations up to date (HAV, HBV)
Actions:
- Take medication every day; do not skip doses
- Bring all OTC and prescription medication lists to every visit (DDIs are common)
- Avoid alcohol; reduce reinfection risk (no needle sharing, safer sex if MSM)
- Get hepatitis A and B vaccines if not immune
- Keep liver imaging appointments q6 months if you have cirrhosis (lifelong, even after cure)

**Side effects or new symptoms — call your provider (IDSA 2024)** (yellow):
Triggers:
- Nausea, headache, fatigue, mild rash
- Missed doses
- Started a new medication or supplement
- New jaundice, dark urine, or right upper-quadrant discomfort
Actions:
- Continue medication unless told to stop
- Call your provider for guidance — drug interaction or side effect can usually be managed
- Do not start new herbal supplements (St Johns Wort) without checking
Contact provider when:
- Any new jaundice or dark urine
- Missed >2 doses
- New medication or supplement

**Stop and seek care immediately (IDSA 2024)** (red):
Triggers:
- Severe abdominal pain, confusion, encephalopathy, vomiting blood, black stool (decompensation)
- Rapid jaundice progression
- Severe rash with fever (DRESS-like)
- Pregnancy occurring on regimen including ribavirin
Actions:
- Go to the emergency department now
- Bring a list of all current medications including DAA
Contact provider when:
- Always go to ED for these symptoms — urgent hepatology evaluation required

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] HBsAg+ OR anti-HBc+ alone patient about to start DAA, OR HBV-DNA rise + ALT rise during DAA — life-threatening reactivation risk (FDA boxed warning 2016; AASLD/IDSA 2024)
- [LIFE_THREATENING] Ascites / variceal bleed / hepatic encephalopathy / SBP / Child-Pugh B or C emergence during evaluation or DAA — life-threatening hepatic decompensation (AASLD/IDSA 2024)
- [LIFE_THREATENING] Hepatocellular carcinoma detected on surveillance imaging in cirrhotic patient EVEN after SVR12 cure — life-threatening, requires emergent multidisciplinary coordination (AASLD HCC Surveillance Guidance 2023)

Citations

- AASLD/IDSA HCV Guidance (continuously updated, 2024-2025 web edition) + EASL 2025 HCV Recommendations [PMID:37229695](https://pubmed.ncbi.nlm.nih.gov/37229695/)
- Cited evidence (PMID 32956768) [PMID:32956768](https://pubmed.ncbi.nlm.nih.gov/32956768/)
- Cited evidence (PMID 26571066) [PMID:26571066](https://pubmed.ncbi.nlm.nih.gov/26571066/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AASLD/IDSA HCV Guidance (continuously updated, 2024-2025 web edition) + EASL 2025 HCV Recommendations — PMID:37229695
  • Cited evidence (PMID 32956768) — PMID:32956768
  • Cited evidence (PMID 26571066) — PMID:26571066