Hepatitis C

Presentation

• Acute (<6 months), chronic (>6 months)

• Non-specific abdominal pain, jaundice, nausea/vomiting, myalgia

• Chronic infection is often asymptomatic until complications (e.g., cirrhosis, hepatocellular carcinoma)

Screening

• IVDU (including previous use)

• Incarceration

• Elevated LFTs

• Healthcare workers performing exposure-prone procedures

• Tattoos/piercings

• Migrants – esp Africa, SEA

• Note: Patients with unexplained cirrhosis or extrahepatic manifestations (e.g., cryoglobulinaemia, porphyria cutanea tarda)

Diagnosis

• Positive Hep C antibodies (anti-HCV)

• Confirm active infection: HCV RNA test

  • Anti-HCV positive, HCV RNA positive → current infection

  • Anti-HCV positive, HCV RNA negative → resolved infection

• Persistent positive anti-HCV: lifelong marker

• HCV viral load (RNA): indicates current infection or cure

Notes: Reflex RNA testing is recommended when anti-HCV antibodies are positive, to streamline diagnosis

Investigations

• HCV genotype

• HCV viral load

• Disease screen: Hep A/B, HIV

• LFTs, US abdomen, liver elastography (cirrhosis)

• INR (synthetic liver function)

• APRI (AST to platelet ratio index): score for cirrhosis if liver elastography unavailable

• Consider full blood count (anaemia, thrombocytopenia), renal function, and albumin to assess disease severity

Referral Criteria

• Refer or seek expert advice for:

  • Children with Hep C

  • Patients with suspected or confirmed cirrhosis

  • Complex comorbidities (e.g., hepatitis B or HIV co-infection, kidney impairment)

  • Previous treatment failure with DAAs

  • Potential drug interactions that cannot be managed in primary care

  • Patients with decompensated liver disease (Child-Pugh class B/C or MELD >13)

Note: Referral is also recommended for pregnant patients, as DAAs are contraindicated during pregnancy

Pre-Treatment Assessment

• Confirm current infection: HCV RNA testing

• Assess for cirrhosis:

  • Transient elastography (FibroScan): liver stiffness ≥12.5 kPa → cirrhosis

  • APRI score <1.0 excludes cirrhosis

• Screen for co-infections: Hepatitis B, HIV

• Review meds for potential drug interactions with DAAs

• Consider pregnancy (avoid treatment during pregnancy)

• Assess for decompensated liver disease (e.g. ascites, jaundice, MELD >13)

Note: Ensure Hepatitis A and B vaccination for non-immune patients to prevent co-infection

Monitoring During and After Treatment

During Treatment

• Most patients do not require routine monitoring

• Arrange follow-up on a case-by-case basis:

  • Monitor adherence or address drug interactions

  • Monitor for adverse effects (rare with DAAs)

  • Patients with decompensated liver disease or complex comorbidities → require specialist care

After Treatment

• Confirm Cure:

  • HCV RNA test 12 weeks after treatment completion → undetectable HCV RNA confirms sustained virological response (SVR = cure)

• Long-Term Monitoring (as required):

  • Cirrhosis:

    • 6-monthly surveillance for HCC

    • Monitor for oesophageal varices and osteoporosis

  • Abnormal LFTs: Investigate other causes of liver disease

  • Ongoing Risk Factors for Reinfection:

    • Annual HCV RNA testing

    • Offer harm reduction strategies (e.g. needle programs)

• No follow-up required for patients with:

  • No cirrhosis

  • Normal LFTs (ALT <30 U/L males, <19 U/L females)

  • No ongoing risk factors

Management

Non-Pharmacological:

• Cease alcohol, smoking, weight loss (if obese)

• Ensure vaccination against Hepatitis A and B if non-immune

Education

• Cure rate >90% with DAAs; 25% resolve spontaneously

• Reinfection possible → annual HCV RNA testing for high-risk individuals

• Do not share razors/toothbrushes

• Screen for reinfection annually if at risk

• Encourage harm reduction practices for IVDU patients to minimise reinfection risk

Pharm

• Direct-acting antivirals (DAAs): e.g. sofosbuvir, glecaprevir, pibrentasvir

• Specialist guidance for cirrhosis, drug interactions, comorbidities

Note: DAAs are well tolerated, but baseline renal function testing is essential as some DAAs (e.g., sofosbuvir) are contraindicated in severe renal impairment