Case Spotlight

I would wait for the US and elastography findings but there is high suspicion this patient has cirrhosis and for purposes of HCV treatment should be treated as cirrhotic. I’m attaching the PDF handout for treating HCV in a compensated cirrhotic from the HCC guidelines website which reviews pre-treatment testing – depending on which medication regimen you use, genotype testing may be needed. Other laboratory testing prior to initiating antiviral therapy includes Quantitative HCV RNA (HCV viral load), HIV antigen/antibody test, Hepatitis B surface antigen, HCV genotype (if treating with sofosburvir/velpatasvir) and pregnancy test (if treating a female). Within 3 months of starting medication, CBC, INR, LFTs, and eGFR should be checked. 

Compensated cirrhotic patients initiating treatment should also have a calculated FIB-4 score, CTP score, ultrasound to evaluate for HCC and subclinical ascites, a complete medication reconciliation with assessment on potential drug-drug interactions, and education on medication administration, adherence, and prevention of reinfection. In terms of drug interactions, I would suggest checking the University of Liverpool website as recommended in the attached handout (www.hep-druginteractions.org/checker). Finally, the patient will probably need EGD to assess for varices and ongoing HCC screening and referral to GI/hepatology would likely be helpful given the concern for cirrhosis.