How Is Hepatitis C Treated?

Across the globe, some 71 million people are living with a chronic hepatitis C infection, according to the World Health Organization (WHO). (1)

Though no vaccine exists for hepatitis C, medications are available to treat and potentially cure liver disease. According to WHO, antiviral medicines can cure more than 95 percent of people infected with hepatitis C, by attacking the virus. These medicines only became available within the past decade, ushering in a huge positive change in the treatment of hepatitis C. But they can be costly, which limits their accessibility for many patients. (1)

A person is considered “cured” of hepatitis C if they’re declared to have a sustained virologic response (SVR), which means their HCV viral load is undetectable 12 weeks or more after treatment. (2)

Though highly unlikely, it’s possible for some of the virus to survive and replicate after a patient achieves SVR. Furthermore, surviving hepatitis C doesn’t make you immune, and it’s possible to contract the illness again if you are re-exposed to the virus.

Along with abstinence from alcohol (drinking has been shown to accelerate the progression of liver disease), the standard treatment for chronic hepatitis C used to be a combination antiviral therapy consisting of a pegylated interferon and ribavirin, sometimes called PEG/riba therapy. (3,4)

A pegylated interferon is a long-acting form of an interferon, a synthetic copy of an infection-fighting protein secreted by immune system cells in response to pathogens. Ribavirin is a drug that interferes with HCV's ability to replicate. In some cases, pegylated interferon was used without ribavirin, but ribavirin alone isn't effective against hepatitis C.

To treat hepatitis C, doctors prescribed weekly injections of the pegylated interferons along with twice-daily oral doses of ribavirin. PEG/riba therapy was not a cure-all.

Interferon is not an option for people with liver failure, autoimmune diseases, and psychiatric illness. It can also cause a range of life-threatening complications that prevent many people from completing their therapy. (5)

Newer drug regimens that can cure hepatitis C have forced a change in the standard treatment for the disease, and in the United States, these medications have largely replaced interferon. But, although it is rarely used, pegylated interferon with or without ribavirin may still be used in combination with newer antiviral drugs. (6)

In the last decade, the Food and Drug Administration (FDA) has approved a number of new oral drugs to help treat hepatitis C, called direct-acting antiviral medicines.

Which medication you’re prescribed and the length of your treatment will depend on:

• Which hepatitis C genotype you have
• How much liver damage you have
• Whether you have been treated for hepatitis C in the past (6)

These medications include the following:

Sofosbuvir (Sovaldi) is part of a class of drugs called polymerase inhibitors, which block the key protein that mediates HCV replication. It’s approved to treat genotypes 1, 2, 3, and 4. In clinical trials, regimens containing sofosbuvir had cure rates ranging from 56 percent to more than 90 percent. A study from 2017 found comparable real-world cure rates for these regimens. (8) Depending on the needs of the patient, sofosbuvir is taken in combination with other antiviral drugs. In rare cases, it is taken in combination with pegylated interferon and ribavirin or with ribavirin alone. (9)

Ledipasvir and sofosbuvir (Harvoni) was approved by the FDA in 2014. It’s a combination drug for hepatitis C genotype 1, 4, 5, or 6 that includes sofosbuvir and ledipasvir. Most patients take a 12-week course of pills, but some may be prescribed in 8-week or 24-week courses. In clinical studies, cure rates ranged from 93 to 100 percent. (10)

Elbasvir and grazoprevir (Zepatier) is a once-daily pill to treat genotypes 1 and 4 that was approved by the FDA in 2016. (12) In studies, patients with genotype 1 chronic hepatitis C had a 94 to 97 percent cure rate, and 96 to 100 percent of patients with genotype 4 chronic hepatitis C infection were cured. (13)

Sofosbuvir and velpatasvir (Epclusa) is a once-daily, fixed-dose combination tablet that was approved in 2016 for treatment of all genotypes, 1 through 6. A 12-week treatment was approved in patients without cirrhosis or with compensated cirrhosis, and in combination with ribavirin for patients with advanced cirrhosis. In clinical trials of patients without cirrhosis or compensated cirrhosis, 98 percent were considered cured after treatment with Epclusa. In patients with decompensated cirrhosis, those that received 12 weeks of Epclusa with ribavirin had a cure rate of 94 percent, compared with 83 percent for those who received Epclusa alone for 12 weeks. Those who received Epclusa alone for 24 weeks had an 86 percent cure rate. (12)

Sofosbuvir, velpatasvir, and voxilaprevir (Vosevi) is a combination drug that was approved by the FDA in 2017. It contains sofosbuvir and velpatasvir, as well as the drug voxilaprevir to treat adults with chronic HCV genotypes 1 through 6 without cirrhosis or with mild cirrhosis. Vosevi is the first treatment approved for patients who have been previously treated with sofosbuvir or other drugs for HCV that inhibit a protein called NS5A. Clinical trials demonstrated that 96 to 97 percent of patients had no virus detected in the blood 12 weeks after finishing treatment. (14)

Glecaprevir and pibrentasvir (Mavyret) was approved by the FDA in 2017 as the first treatment of eight weeks’ duration for all HCV genotypes in adults without cirrhosis who have not been previously treated. Before then, standard treatment length was 12 weeks or more. In clinical trials, 92 to 100 percent of patients who received Mavyret for 8, 12, or 16 weeks had no virus detected in the blood 12 weeks after finishing treatment. (15)

Though the latest generation of hepatitis C drugs can effectively cure the disease, patients whose hepatitis C infection has progressed to the point of causing advanced cirrhosis or liver failure may require a liver transplant to fully recover.

It’s important to let your doctor know what other medications and supplements you’re taking so you can avoid harmful interactions. If you’re nursing or pregnant, you’ll also want to let your healthcare provider know, as this can affect your treatment options. (16)

The newer direct-acting antiviral medicines for hepatitis C can be very expensive — listed at tens of thousands of dollars.

While pricing is often negotiated by insurance companies and other agencies, the process is not especially transparent and can be confusing. (17)

If you need help paying for medicines, speak with your doctor. For more information about available financial assistance, visit the American Liver Foundation.

Additional reporting by Deborah Shapiro.