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<!DOCTYPE html> <html xmlns="http://www.w3.org/1999/xhtml" lang="en" xml:lang="en"> <head>  <script async src="https://www.googletagmanager.com/gtag/js?id=G-WVK41JBQ8K"></script> <script> window.dataLayer = window.dataLayer || []; function gtag(){dataLayer.push(arguments);} gtag('js', new Date()); gtag('config', 'G-WVK41JBQ8K'); </script> <meta http-equiv="Content-Type" content="text/html;charset=utf-8" /> <title>Core Concepts - Treatment of HCV in Persons with Cirrhosis - Treatment of Hepatitis C Infection - Hepatitis C Online</title>  <link href="https://fonts.googleapis.com/css?family=Open+Sans:400,400i,600,600i,700,700i&subset=latin-ext" rel="stylesheet"> <link rel="stylesheet" href="//cdn.hepatitisc.uw.edu/css/vendors.css?v=bmhjdmMtbWFzdGVyLWM4ODQzNjczLTIwMjQtMTEtMTMtMjA1NjI0Cg" type="text/css" media="screen,print" /> <link rel="stylesheet" href="//cdn.hepatitisc.uw.edu/css/dynamic.css.php?v=bmhjdmMtbWFzdGVyLWM4ODQzNjczLTIwMjQtMTEtMTMtMjA1NjI0Cg" type="text/css" 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glyphicon-remove" aria-hidden="true"></span> <span class="hidden">Site Navigation</span></div></li><li class="section home-section"><a href="/" title="Hepatitis C Online" class=" link"></a></li><li class="section biology"><a href="/page/hcv/biology" class="link ">HCV <br />Biology</a></li><li class="section treatments nhcvc-medications has-submenu"><a href="/page/treatment/drugs" class=" link ">HCV <br />Medications<span class="submenu-trigger"></span></a><div class="submenu medications"><div class="description description-default">Listed in <strong>alphabetical</strong> order.</div><ul><li class="treatment treatment-7"><a href="/page/treatment/drugs/elbasvir-grazoprevir"><img class="drug-preview" src="//cdn.hepatitisc.uw.edu/css/images/drugs/7.png" alt="Elbasvir-Grazoprevir (Zepatier) Pill Preview" />Elbasvir-Grazoprevir <em>Zepatier</em></a></li><li class="treatment treatment-22"><a href="/page/treatment/drugs/glecaprevir-pibrentasvir"><img class="drug-preview" src="//cdn.hepatitisc.uw.edu/css/images/drugs/22.png" alt="Glecaprevir-Pibrentasvir (Mavyret) Pill Preview" />Glecaprevir-Pibrentasvir <em>Mavyret</em></a></li><li class="treatment treatment-11"><a href="/page/treatment/drugs/ledipasvir-sofosbuvir"><img class="drug-preview" src="//cdn.hepatitisc.uw.edu/css/images/drugs/11.png" alt="Ledipasvir-Sofosbuvir (Harvoni) Pill Preview" />Ledipasvir-Sofosbuvir <em>Harvoni</em></a></li><li class="treatment treatment-3"><a href="/page/treatment/drugs/ribavirin-drug"><img class="drug-preview" src="//cdn.hepatitisc.uw.edu/css/images/drugs/3.png" alt="Ribavirin (Copegus, Rebetol, Ribasphere) Pill Preview" />Ribavirin <em>Copegus, Rebetol, Ribasphere</em></a></li><li class="treatment treatment-1"><a href="/page/treatment/drugs/sofosbuvir-drug"><img class="drug-preview" src="//cdn.hepatitisc.uw.edu/css/images/drugs/1.png" alt="Sofosbuvir (Sovaldi) Pill Preview" />Sofosbuvir <em>Sovaldi</em></a></li><li class="treatment treatment-20"><a href="/page/treatment/drugs/epclusa"><img class="drug-preview" src="//cdn.hepatitisc.uw.edu/css/images/drugs/20.png" alt="Sofosbuvir-Velpatasvir (Epclusa) Pill Preview" />Sofosbuvir-Velpatasvir <em>Epclusa</em></a></li><li class="treatment treatment-21"><a href="/page/treatment/drugs/sofosbuvir-velpatasvir-voxilaprevir"><img class="drug-preview" src="//cdn.hepatitisc.uw.edu/css/images/drugs/21.png" alt="Sofosbuvir-Velpatasvir-Voxilaprevir (Vosevi) Pill Preview" />Sofosbuvir-Velpatasvir-Voxilaprevir <em>Vosevi</em></a></li></ul></div></li><li class="section modules active-trail has-submenu"><a href="/alternate" class="link active-trail">Course <br /> Modules<span class="submenu-trigger"></span></a><div class="submenu modules"><ul><li class="level1 level1-all "><a href="/alternate"><span class="caption">View all Course Modules</span></a></li><li class="level1 level1-31 has-subsubmenu"><a href="/go/screening-diagnosis"><span class="num">1</span><span class="caption">Screening and Diagnosis of Hepatitis C Infection</span><span class="submenu-trigger"></span></a><div class="subsubmenu custom"><a class="description" href="/custom/screening-diagnosis"><h3>Self-Study Module<span class="edition-tag edition-tag-4">4th Edition</span><span class="cme-tag cme-tag-available">CNE/CME Available</span></h3> Track your progress and receive CE credit</a><ul><li><a href="/custom/screening-diagnosis">Screening and Diagnosis: Self-Study <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-108"><a href="/custom/screening-diagnosis/epidemiology-us"><span class="caption">HCV Epidemiology in the United States</span></a></li><li class="level2 level2-109"><a href="/custom/screening-diagnosis/recommendations-screening"><span class="caption">Recommendations for Hepatitis C Screening</span></a></li><li class="level2 level2-110"><a href="/custom/screening-diagnosis/diagnostic-testing"><span class="caption">Hepatitis C Diagnostic Testing</span></a></li><li class="level2 level2-111"><a href="/custom/screening-diagnosis/counseling-prevention"><span class="caption">Counseling for Prevention of HCV Transmission</span></a></li><li class="level2 level2-112"><a href="/custom/screening-diagnosis/acute-diagnosis"><span class="caption">Diagnosis of Acute HCV Infection</span></a></li></ol><ul><li><a href="/custom/screening-diagnosis/certificate">Certificate Requirements <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul></div><div class="subsubmenu level2s"><a class="description" href="/go/screening-diagnosis"><h3>Quick Reference<span class="edition-tag edition-tag-4">4th Edition</span></h3> Rapidly access information in this module</a><ul><li><a href="/go/screening-diagnosis">Screening and Diagnosis of Hepatitis C Infection: Overview</a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-153"><a href="/go/screening-diagnosis/epidemiology-us/core-concept/all"><span class="caption">HCV Epidemiology in the United States</span></a></li><li class="level2 level2-157"><a href="/go/screening-diagnosis/recommendations-screening/core-concept/all"><span class="caption">Recommendations for Hepatitis C Screening</span></a></li><li class="level2 level2-154"><a href="/go/screening-diagnosis/diagnostic-testing/core-concept/all"><span class="caption">Hepatitis C Diagnostic Testing</span></a></li><li class="level2 level2-155"><a href="/go/screening-diagnosis/counseling-prevention/core-concept/all"><span class="caption">Counseling for Prevention of HCV Transmission</span></a></li><li class="level2 level2-156"><a href="/go/screening-diagnosis/acute-diagnosis/core-concept/all"><span class="caption">Diagnosis of Acute HCV Infection</span></a></li></ol></div></li><li class="level1 level1-34 has-subsubmenu"><a href="/go/evaluation-staging-monitoring"><span class="num">2</span><span class="caption">Evaluation, Staging, and Monitoring of Chronic Hepatitis C</span><span class="submenu-trigger"></span></a><div class="subsubmenu custom"><a class="description" href="/custom/evaluation-staging-monitoring"><h3>Self-Study Module<span class="edition-tag edition-tag-4">4th Edition</span><span class="cme-tag cme-tag-available">CNE/CME Available</span></h3> Track your progress and receive CE credit</a><ul><li><a href="/custom/evaluation-staging-monitoring">Evaluation, Staging, and Monitoring: Self-Study <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-124"><a href="/custom/evaluation-staging-monitoring/initial-evaluation-chronic"><span class="caption">Initial Evaluation of Persons with Chronic HCV</span></a></li><li class="level2 level2-125"><a href="/custom/evaluation-staging-monitoring/natural-history"><span class="caption">Natural History of HCV Infection</span></a></li><li class="level2 level2-126"><a href="/custom/evaluation-staging-monitoring/counseling-liver-health"><span class="caption">Counseling Persons with Chronic HCV Infection</span></a></li><li class="level2 level2-127"><a href="/custom/evaluation-staging-monitoring/evaluation-staging"><span class="caption">Evaluation and Staging of Liver Fibrosis</span></a></li><li class="level2 level2-128"><a href="/custom/evaluation-staging-monitoring/evaluation-prognosis-cirrhosis"><span class="caption">Evaluation and Prognosis of Persons with Cirrhosis</span></a></li><li class="level2 level2-129"><a href="/custom/evaluation-staging-monitoring/surveillance-hepatocellular-carcinoma"><span class="caption">Surveillance for Hepatocellular Carcinoma</span></a></li><li class="level2 level2-130"><a href="/custom/evaluation-staging-monitoring/extrahepatic-conditions"><span class="caption">Extrahepatic Conditions Related to HCV Infection</span></a></li></ol><ul><li><a href="/custom/evaluation-staging-monitoring/certificate">Certificate Requirements <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul></div><div class="subsubmenu level2s"><a class="description" href="/go/evaluation-staging-monitoring"><h3>Quick Reference<span class="edition-tag edition-tag-4">4th Edition</span></h3> Rapidly access information in this module</a><ul><li><a href="/go/evaluation-staging-monitoring">Evaluation, Staging, and Monitoring of Chronic Hepatitis C: Overview</a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-169"><a href="/go/evaluation-staging-monitoring/initial-evaluation-chronic/core-concept/all"><span class="caption">Initial Evaluation of Persons with Chronic HCV</span></a></li><li class="level2 level2-170"><a href="/go/evaluation-staging-monitoring/natural-history/core-concept/all"><span class="caption">Natural History of HCV Infection</span></a></li><li class="level2 level2-171"><a href="/go/evaluation-staging-monitoring/counseling-liver-health/core-concept/all"><span class="caption">Counseling Persons with Chronic HCV Infection</span></a></li><li class="level2 level2-172"><a href="/go/evaluation-staging-monitoring/evaluation-staging/core-concept/all"><span class="caption">Evaluation and Staging of Liver Fibrosis</span></a></li><li class="level2 level2-175"><a href="/go/evaluation-staging-monitoring/evaluation-prognosis-cirrhosis/core-concept/all"><span class="caption">Evaluation and Prognosis of Persons with Cirrhosis</span></a></li><li class="level2 level2-173"><a href="/go/evaluation-staging-monitoring/surveillance-hepatocellular-carcinoma/core-concept/all"><span class="caption">Surveillance for Hepatocellular Carcinoma</span></a></li><li class="level2 level2-174"><a href="/go/evaluation-staging-monitoring/extrahepatic-conditions/core-concept/all"><span class="caption">Extrahepatic Conditions Related to HCV Infection</span></a></li></ol></div></li><li class="level1 level1-33 has-subsubmenu"><a href="/go/management-cirrhosis-related-complications"><span class="num">3</span><span class="caption">Management of Cirrhosis-Related Complications</span><span class="submenu-trigger"></span></a><div class="subsubmenu custom"><a class="description" href="/custom/management-cirrhosis-related-complications"><h3>Self-Study Module<span class="edition-tag edition-tag-4">4th Edition</span><span class="cme-tag cme-tag-available">CNE/CME Available</span></h3> Track your progress and receive CE credit</a><ul><li><a href="/custom/management-cirrhosis-related-complications">Management of Cirrhosis-Related Complications: Self-Study <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-119"><a href="/custom/management-cirrhosis-related-complications/ascites-diagnosis-management"><span class="caption">Diagnosis and Management of Ascites</span></a></li><li class="level2 level2-120"><a href="/custom/management-cirrhosis-related-complications/spontaneous-bacterial-peritonitis-recognition-management"><span class="caption">Recognition and Management of Spontaneous Bacterial Peritonitis</span></a></li><li class="level2 level2-121"><a href="/custom/management-cirrhosis-related-complications/varices-screening-prevention-bleeding"><span class="caption">Screening for Varices and Prevention of Bleeding</span></a></li><li class="level2 level2-122"><a href="/custom/management-cirrhosis-related-complications/hepatic-encephalopathy-diagnosis-management"><span class="caption">Diagnosis and Management of Hepatic Encephalopathy</span></a></li><li class="level2 level2-123"><a href="/custom/management-cirrhosis-related-complications/liver-transplantation-referral"><span class="caption">Referral for Liver Transplantation</span></a></li></ol><ul><li><a href="/custom/management-cirrhosis-related-complications/certificate">Certificate Requirements <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul></div><div class="subsubmenu level2s"><a class="description" href="/go/management-cirrhosis-related-complications"><h3>Quick Reference<span class="edition-tag edition-tag-4">4th Edition</span></h3> Rapidly access information in this module</a><ul><li><a href="/go/management-cirrhosis-related-complications">Management of Cirrhosis-Related Complications: Overview</a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-164"><a href="/go/management-cirrhosis-related-complications/ascites-diagnosis-management/core-concept/all"><span class="caption">Diagnosis and Management of Ascites</span></a></li><li class="level2 level2-165"><a href="/go/management-cirrhosis-related-complications/spontaneous-bacterial-peritonitis-recognition-management/core-concept/all"><span class="caption">Recognition and Management of Spontaneous Bacterial Peritonitis</span></a></li><li class="level2 level2-166"><a href="/go/management-cirrhosis-related-complications/varices-screening-prevention-bleeding/core-concept/all"><span class="caption">Screening for Varices and Prevention of Bleeding</span></a></li><li class="level2 level2-167"><a href="/go/management-cirrhosis-related-complications/hepatic-encephalopathy-diagnosis-management/core-concept/all"><span class="caption">Diagnosis and Management of Hepatic Encephalopathy</span></a></li><li class="level2 level2-168"><a href="/go/management-cirrhosis-related-complications/liver-transplantation-referral/core-concept/all"><span class="caption">Referral for Liver Transplantation</span></a></li></ol></div></li><li class="level1 level1-35 has-subsubmenu"><a href="/go/evaluation-treatment"><span class="num">4</span><span class="caption">Evaluation and Preparation for Hepatitis C Treatment</span><span class="submenu-trigger"></span></a><div class="subsubmenu custom"><a class="description" href="/custom/evaluation-treatment"><h3>Self-Study Module<span class="edition-tag edition-tag-4">4th Edition</span><span class="cme-tag cme-tag-available">CNE/CME Available</span></h3> Track your progress and receive CE credit</a><ul><li><a href="/custom/evaluation-treatment">Evaluation and Preparation for Treatment: Self-Study <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-131"><a href="/custom/evaluation-treatment/treatment-goals-predicting-response"><span class="caption">Goals and Benefits with HCV Treatment</span></a></li><li class="level2 level2-132"><a href="/custom/evaluation-treatment/treatment-initiation-decision"><span class="caption">Making a Decision on When to Initiate HCV Therapy</span></a></li><li class="level2 level2-133"><a href="/custom/evaluation-treatment/addressing-structural-barriers-to-treatment"><span class="caption">Addressing Structural Barriers to HCV Treatment</span></a></li></ol><ul><li><a href="/custom/evaluation-treatment/certificate">Certificate Requirements <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul></div><div class="subsubmenu level2s"><a class="description" href="/go/evaluation-treatment"><h3>Quick Reference<span class="edition-tag edition-tag-4">4th Edition</span></h3> Rapidly access information in this module</a><ul><li><a href="/go/evaluation-treatment">Evaluation and Preparation for Hepatitis C Treatment: Overview</a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-176"><a href="/go/evaluation-treatment/treatment-goals-predicting-response/core-concept/all"><span class="caption">Goals and Benefits with HCV Treatment</span></a></li><li class="level2 level2-177"><a href="/go/evaluation-treatment/treatment-initiation-decision/core-concept/all"><span class="caption">Making a Decision on When to Initiate HCV Therapy</span></a></li><li class="level2 level2-178"><a href="/go/evaluation-treatment/addressing-structural-barriers-to-treatment/core-concept/all"><span class="caption">Addressing Structural Barriers to HCV Treatment</span></a></li></ol></div></li><li class="level1 level1-30 has-subsubmenu hovered active-trail"><a href="/go/treatment-infection" class="active-trail"><span class="num">5</span><span class="caption">Treatment of Hepatitis C Infection</span><span class="submenu-trigger"></span></a><div class="subsubmenu custom"><a class="description" href="/custom/treatment"><h3>Self-Study Module<span class="edition-tag edition-tag-4">4th Edition</span><span class="cme-tag cme-tag-available">CNE/CME Available</span></h3> Track your progress and receive CE credit</a><ul><li><a href="/custom/treatment">Treatment of HCV: Self-Study <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-102"><a href="/custom/treatment/multi-genotype-treatment-new-lesson"><span class="caption">Simplified HCV Treatment for All HCV Genotypes</span></a></li><li class="level2 level2-103"><a href="/custom/treatment/retreatment-patients-prior-treatment-experience"><span class="caption">Retreatment of Patients with Prior HCV Treatment Experience</span></a></li><li class="level2 level2-101"><a href="/custom/treatment/monitoring"><span class="caption">Monitoring During and After HCV Treatment</span></a></li><li class="level2 level2-105"><a href="/custom/treatment/treatment-cirrhosis"><span class="caption">Treatment of HCV in Persons with Cirrhosis</span></a></li><li class="level2 level2-104"><a href="/custom/treatment/treatment-acute-infection"><span class="caption">Treatment of Acute HCV Infection</span></a></li></ol><ul><li><a href="/custom/treatment/certificate">Certificate Requirements <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul></div><div class="subsubmenu level2s"><a class="description" href="/go/treatment-infection"><h3>Quick Reference<span class="edition-tag edition-tag-4">4th Edition</span></h3> Rapidly access information in this module</a><ul><li><a href="/go/treatment-infection">Treatment of Hepatitis C Infection: Overview</a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-149"><a href="/go/treatment-infection/multi-genotype-treatment-new-lesson/core-concept/all"><span class="caption">Simplified HCV Treatment for All HCV Genotypes</span></a></li><li class="level2 level2-150"><a href="/go/treatment-infection/retreatment-patients-prior-treatment-experience/core-concept/all"><span class="caption">Retreatment of Patients with Prior HCV Treatment Experience</span></a></li><li class="level2 level2-143"><a href="/go/treatment-infection/monitoring/core-concept/all"><span class="caption">Monitoring During and After HCV Treatment</span></a></li><li class="level2 level2-152 class="active-trail hovered""><a href="/go/treatment-infection/treatment-cirrhosis/core-concept/all" active-trail hovered><span class="caption">Treatment of HCV in Persons with Cirrhosis</span></a></li><li class="level2 level2-151"><a href="/go/treatment-infection/treatment-acute-infection/core-concept/all"><span class="caption">Treatment of Acute HCV Infection</span></a></li></ol></div></li><li class="level1 level1-32 has-subsubmenu"><a href="/go/key-populations-situations"><span class="num">6</span><span class="caption">Treatment of Key Populations and Unique Situations</span><span class="submenu-trigger"></span></a><div class="subsubmenu custom"><a class="description" href="/custom/key-populations-unique-situations"><h3>Self-Study Module<span class="edition-tag edition-tag-4">4th Edition</span><span class="cme-tag cme-tag-available">CNE/CME Available</span></h3> Track your progress and receive CE credit</a><ul><li><a href="/custom/key-populations-unique-situations">Treatment of Key Populations and Unique Situations: Self-Study <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-113"><a href="/custom/key-populations-unique-situations/treatment-hiv-coinfection"><span class="caption">Treatment of HCV in Persons with HIV Coinfection</span></a></li><li class="level2 level2-114"><a href="/custom/key-populations-unique-situations/treament-renal-impairment"><span class="caption">Treatment of HCV in Persons with Renal Impairment</span></a></li><li class="level2 level2-115"><a href="/custom/key-populations-unique-situations/treatment-substance-use"><span class="caption">Treatment of HCV in Persons with Substance Use</span></a></li><li class="level2 level2-116"><a href="/custom/key-populations-unique-situations/treatment-corrections"><span class="caption">Treatment of HCV in a Correctional Setting</span></a></li><li class="level2 level2-117"><a href="/custom/key-populations-unique-situations/management-health-care-workers-potentially-exposed-to-hcv"><span class="caption">Management of Health Care Personnel Exposed to HCV</span></a></li><li class="level2 level2-118"><a href="/custom/key-populations-unique-situations/perinatal-hcv-transmission"><span class="caption">Perinatal HCV Transmission</span></a></li></ol><ul><li><a href="/custom/key-populations-unique-situations/certificate">Certificate Requirements <span class="cme-tag cme-tag-available">CNE/CME</span></a></li></ul></div><div class="subsubmenu level2s"><a class="description" href="/go/key-populations-situations"><h3>Quick Reference<span class="edition-tag edition-tag-4">4th Edition</span></h3> Rapidly access information in this module</a><ul><li><a href="/go/key-populations-situations">Treatment of Key Populations and Unique Situations: Overview</a></li></ul><h4>Lessons</h4><ol><li class="level2 level2-158"><a href="/go/key-populations-situations/treatment-hiv-coinfection/core-concept/all"><span class="caption">Treatment of HCV in Persons with HIV Coinfection</span></a></li><li class="level2 level2-159"><a href="/go/key-populations-situations/treament-renal-impairment/core-concept/all"><span class="caption">Treatment of HCV in Persons with Renal Impairment</span></a></li><li class="level2 level2-160"><a href="/go/key-populations-situations/treatment-substance-use/core-concept/all"><span class="caption">Treatment of HCV in Persons with Substance Use</span></a></li><li class="level2 level2-161"><a href="/go/key-populations-situations/treatment-corrections/core-concept/all"><span class="caption">Treatment of HCV in a Correctional Setting</span></a></li><li class="level2 level2-162"><a href="/go/key-populations-situations/management-health-care-workers-potentially-exposed-to-hcv/core-concept/all"><span class="caption">Management of Health Care Personnel Exposed to HCV</span></a></li><li class="level2 level2-163"><a href="/go/key-populations-situations/perinatal-hcv-transmission/core-concept/all"><span class="caption">Perinatal HCV Transmission</span></a></li></ol></div></li></ul></div></li><li class="section tools has-submenu"><a href="/page/clinical-calculators/apri" class="link ">Tools &<br /> Calculators<span class="submenu-trigger"></span></a><div class="submenu tools"><ul><li 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<em>CAGE Alcohol Questionnaire</em></a></li><li class="tool"><a href="/page/substance-use/opioid" class="">Opioid: Risk Tool <em>Opioid Risk Tool (ORT)</em></a></li></ul></div></li></ul></div></li><li class="section ccn"><a href="/page/site/clinical-consultation" class="link has-tooltip">Clinical <br />Consultation</a></li><li class="section expert-opinions"><a href="/page/challenges/expert-opinions" class=" link "><span class="icon"><span class="glyphicon glyphicon-link"></span></span>Clinical <br />Challenges</a></li><li class="section mini-lectures"><a href="/mini-lectures" class="link">Mini-<br>Lectures</a></li><li class="section glossary"><a href="javascript:void(0)" title="Search for any topic" class="link ">Search</a><div id="search-minimal" class="search-interface"><div class="close"></div><div class="search-controls"><label for="search-q">Search for</label><input type="text" name="search-q" id="search-q" class="search-input" placeholder="Terms, medications, lectures, core concepts, etc..." /></div><div class="search-results-container"></div><div class="search-notice"><strong>Use this Search to quickly find items or navigate the site.</strong></div></div></li></ul><div class="user-status"><a class="loggedout" href="https://www.hepatitisC.uw.edu/alternate" title="Sign In for registered users"><span class="glyphicon glyphicon-log-in"></span><span class="label-text"> Sign In</span></a><span class="hidden-xs"> or <a class="loggedout" href="https://www.hepatitisC.uw.edu/page/account/register" title="Create an account">Register</a></span></div></div></div></div></section><div id="wrap" class="content-wrap"> <div id="content"> <div id="notifications"></div><div class="page-titles"><h2 class="main-title level130"><a href="/go/treatment-infection"><span class="heading">Treatment of Hepatitis C Infection</span></a></h2><h2 class="main-subtitle level130"><a href="/go/treatment-infection/treatment-cirrhosis"><span class="heading">Treatment of HCV in Persons with Cirrhosis</span></a></h2></div><div id="page" class="levels level130 menu-closed-forced menu-closed level4"><div class="inner"><div id="sidebar" class=""><span class="menu-toggle"><span class="icon_open glyphicon glyphicon-menu-hamburger title-extra" title="Open the navigation menu"></span><span class="icon_closed glyphicon glyphicon-remove" title="Hide the navigation menu"></span><span class="button-description">Section Navigation</span></span><div class="header">Section Navigation</div><div class="inner"><ul class="overview"><li class="page page-overview level1 first not-started"><a href="/go/treatment-infection" class="title-extra level1 " title="Treatment of Hepatitis C Infection"><span class="type">Module 5 Overview</span><br /><span class="title">Treatment of Hepatitis C Infection</span></a></li><li class="level2 not-started"><a href="/go/treatment-infection/multi-genotype-treatment-new-lesson" title="Simplified HCV Treatment for All HCV Genotypes" class="title-extra level2"><span class="progress-container level130" title="Progress of this Lessons"><span class="progress-bar progress-bar-0" style="width: 0%"><span class="percent less">0%</span></span></span><span class="type">Lesson 1</span><br /><span class="title">Simplified HCV Treatment for All HCV Genotypes</span></a><div class="level3s" ><span class="title">Activities</span><ol><li class="level3 active-trail"><a href="/go/treatment-infection/multi-genotype-treatment-new-lesson/core-concept/all" class="title-extra active-trail" title="Core Concepts"><span class="ui-icon ui-icon-note"></span><span class="num">1A.</span>Core Concepts</a></li></ol><li class="level2 not-started"><a href="/go/treatment-infection/retreatment-patients-prior-treatment-experience" title="Retreatment of Patients with Prior HCV Treatment Experience" class="title-extra level2"><span class="progress-container level130" title="Progress of this Lessons"><span class="progress-bar progress-bar-0" style="width: 0%"><span class="percent less">0%</span></span></span><span class="type">Lesson 2</span><br /><span class="title">Retreatment of Patients with Prior HCV Treatment Experience</span></a><div class="level3s" ><span class="title">Activities</span><ol><li class="level3 active-trail"><a href="/go/treatment-infection/retreatment-patients-prior-treatment-experience/core-concept/all" class="title-extra active-trail" title="Core Concepts"><span class="ui-icon ui-icon-note"></span><span class="num">2A.</span>Core Concepts</a></li></ol><li class="level2 not-started"><a href="/go/treatment-infection/monitoring" title="Monitoring During and After HCV Treatment" class="title-extra level2"><span class="progress-container level130" title="Progress of this Lessons"><span class="progress-bar progress-bar-0" style="width: 0%"><span class="percent less">0%</span></span></span><span class="type">Lesson 3</span><br /><span class="title">Monitoring During and After HCV Treatment</span></a><div class="level3s" ><span class="title">Activities</span><ol><li class="level3 active-trail"><a href="/go/treatment-infection/monitoring/core-concept/all" class="title-extra active-trail" title="Core Concepts"><span class="ui-icon ui-icon-note"></span><span class="num">3A.</span>Core Concepts</a></li></ol><li class="level2 active-trail expanded not-started"><a href="/go/treatment-infection/treatment-cirrhosis" title="Treatment of HCV in Persons with Cirrhosis" class="title-extra level2 active-trail expanded"><span class="progress-container level130" title="Progress of this Lessons"><span class="progress-bar progress-bar-0" style="width: 0%"><span class="percent less">0%</span></span></span><span class="type">Lesson 4</span><br /><span class="title">Treatment of HCV in Persons with Cirrhosis</span></a><span class="active-trail-indicator"></span><div class="level3s" ><span class="title">Activities</span><ol><li class="level3 active-trail"><a href="/go/treatment-infection/treatment-cirrhosis/core-concept/all" class="title-extra active-trail" title="Core Concepts"><span class="ui-icon ui-icon-note"></span><span class="num">4A.</span>Core Concepts</a></li><li class="level3"><a href="/go/treatment-infection/treatment-cirrhosis/understanding-liver-biopsy" title="Understanding Liver Biopsy Results" class="title-extra"><span class="ui-icon ui-icon-extlink"></span><span class="num">4B.</span>Understanding Liver Biopsy Results</a></li></ol><li class="level2 not-started"><a href="/go/treatment-infection/treatment-acute-infection" title="Treatment of Acute HCV Infection" class="title-extra level2"><span class="progress-container level130" title="Progress of this Lessons"><span class="progress-bar progress-bar-0" style="width: 0%"><span class="percent less">0%</span></span></span><span class="type">Lesson 5</span><br /><span class="title">Treatment of Acute HCV Infection</span></a><div class="level3s" ><span class="title">Activities</span><ol><li class="level3 active-trail"><a href="/go/treatment-infection/treatment-acute-infection/core-concept/all" class="title-extra active-trail" title="Core Concepts"><span class="ui-icon ui-icon-note"></span><span class="num">5A.</span>Core Concepts</a></li></ol></div></li></ul><ul class="progress-tracker"><li class="progress-tracker last"><a href="javascript:void(0)" onclick="progressTracker()" class="progress-tracker title-extra" title="Progress Tracker"><i class="glyph-tasks"></i> Progress Tracker</a></li></ul></div></div><div id="page-content"><h1 class="title" id="page-title"><span class="type">Lesson 4.</span> Treatment of HCV in Persons with Cirrhosis</h1><div id="page-navigation-top" class="page-navigation "><div class="content"><span class="left"><a class="button button-instructions left" alt="Self-Study Module" title="Treatment of Hepatitis C Infection" href="https://www.hepatitisC.uw.edu/custom/treatment/treatment-cirrhosis"><span class="cme-tag cme-tag-available">CME/CNE</span> Earn CE credit for this module</a> </span><span class="reading-pane"><a class="button button-print left" title="PDF" href="//cdn.hepatitisc.uw.edu/pdf/treatment-infection/treatment-cirrhosis/core-concept/all" target="_blank"><span class="glyphicon glyphicon-print"></span> PDF</a><a class="button button-share left" title="Share page" href="https://www.hepatitisC.uw.edu/go/treatment-infection/treatment-cirrhosis/core-concept/all" onclick="return sharePage()" target="_blank"><span class="glyphicon glyphicon-envelope"></span> Share</a></span><span class="right next"></div></div><div class="section section-popup section-instructions-popup"><a class="close" onclick="toggleInstructions()"></a><div class="section section-objectives"><h3 class="title" id="objectives">Learning Objective Performance Indicators</h3><div class="content"><ul> <li>Distinguish persons with compensated cirrhosis from those with decompensated cirrhosis</li> <li>Summarize the impact of treating HCV in persons with cirrhosis</li> <li>Discuss major studies involving regimens with pangenotypic activity used to treat HCV in persons with compensated cirrhosis</li> <li>Provide appropriate HCV treatment options for persons with compensated cirrhosis</li> <li>List approaches to treatment of HCV in persons with decompensated cirrhosis</li> </ul></div></div></div><div class="inner"><div class="major-section major-section-core-concepts"><div class="section section-core-concepts"><div class="content"><div class="core-concepts-info"><div class="last-updated"><strong>Last Updated:</strong> <span class="date">October 5th, 2023</span></div><div class="contributor-blurbs speaker-info-level1"><strong>Authors:</strong> <div class="contributor-blurb"><a href="javascript:void(0)">H. Nina Kim, MD, MSc</a><div class="data-content"><strong>H. Nina Kim, MD, MSc</strong><br /> Professor of Medicine<br /> Division of Allergy & Infectious Diseases<br /> University of Washington<div class="disclosures"><em>Disclosures</em>: None</div></div></div>, <div class="contributor-blurb"><a href="javascript:void(0)">Paula P. Cox-North, PhD, APRN</a><div class="data-content"><strong>Paula P. Cox-North, PhD, MN, ARNP</strong><br /> Hepatitis and Liver Clinic<br /> Harborview Medical Center<br /> University of Washington<div class="disclosures"><em>Disclosures</em>: Speaking Fee: Gilead Sciences</div></div></div></div><div class="contributor-blurbs speaker-info-level1"><strong>Reviewers:</strong> <div class="contributor-blurb"><a href="javascript:void(0)">Maria A. Corcorran, MD, MPH</a><div class="data-content"><strong>Maria A. Corcorran, MD, MPH</strong><br /> Assistant Professor<br /> Division of Allergy & Infectious Diseases<br /> University of Washington<div class="disclosures"><em>Disclosures</em>: None</div></div></div>, <div class="contributor-blurb"><a href="javascript:void(0)">David H. Spach, MD</a><div class="data-content"><strong>David H. Spach, MD</strong><br /> Professor of Medicine<br /> Division of Allergy & Infectious Diseases<br /> University of Washington<div class="disclosures"><em>Disclosures</em>: None</div></div></div></div></div></div></div><div id="page-toc" class="page-toc"><div class="header" title="Click to Pin/Unpin"><span class="heading">Table of Contents</span></div><ul class="nav nav-tabs"><li class="page-title nav-item"><a class="nav-link" href="#page-title">Treatment of HCV in Persons with Cirrhosis</a></li><li class="nav-item"><a class="nav-link" href="#background">Background</a><ul class="subtoc"><li><a href="#background-introduction">Introduction</a></li><li><a href="#background-distinguishing-compensated-decompensated-cirrhosis">Distinguishing Compensated and Decompensated Cirrhosis</a></li></ul></li><li class="nav-item"><a class="nav-link" href="#impact-treating-hcv-persons-cirrhosis">Impact of Treating HCV in Persons with Cirrhosis</a><ul class="subtoc"><li><a href="#impact-treating-hcv-persons-cirrhosis-reduction-cirrhosis-related-complications-after-hcv-treatment">Reduction in Cirrhosis-related Complications After HCV Treatment</a></li><li><a href="#impact-treating-hcv-persons-cirrhosis-regression-reversal-hepatic-fibrosis-after-hcv-treatment">Regression and Reversal of Hepatic Fibrosis after HCV Treatment</a></li></ul></li><li class="nav-item"><a class="nav-link" href="#treating-hcv-persons-compensated-cirrhosis">Treating HCV in Persons with Compensated Cirrhosis</a><ul class="subtoc"><li><a href="#treating-hcv-persons-compensated-cirrhosis-hcv-treatment-goals-persons-compensated-cirrhosis">HCV Treatment Goals in Persons with Compensated Cirrhosis</a></li><li><a href="#treating-hcv-persons-compensated-cirrhosis-hcv-treatment-data-persons-compensated-cirrhosis">HCV Treatment Data in Persons with Compensated Cirrhosis</a></li><li><a href="#treating-hcv-persons-compensated-cirrhosis-recommended-hcv-treatment-compensated-cirrhosis">Recommended HCV Treatment with Compensated Cirrhosis</a></li></ul></li><li class="nav-item"><a class="nav-link" href="#treating-hcv-persons-decompensated-cirrhosis">Treating HCV in Persons with Decompensated Cirrhosis</a><ul class="subtoc"><li><a href="#treating-hcv-persons-decompensated-cirrhosis-definition-decompensated-cirrhosis">Definition of Decompensated Cirrhosis</a></li><li><a href="#treating-hcv-persons-decompensated-cirrhosis-hcv-treatment-goals-persons-decompensated-cirrhosis">HCV Treatment Goals in Persons with Decompensated Cirrhosis</a></li><li><a href="#treating-hcv-persons-decompensated-cirrhosis-hcv-treatment-regimens-persons-decompensated-cirrhosis">HCV Treatment Regimens for Persons with Decompensated Cirrhosis</a></li><li><a href="#treating-hcv-persons-decompensated-cirrhosis-guidance-hcv-treatment-decompensated-cirrhosis">Guidance for HCV Treatment with Decompensated Cirrhosis</a></li></ul></li><li class="nav-item"><a class="nav-link" href="#summary-points">Summary Points</a></li><li role="separator" class="divider"></li><li class="nav-item"><a class="nav-link" href="#citations">Citations</a></li><li class="nav-item"><a class="nav-link" href="#references-unassigned">Additional References</a></li><li class="nav-item"><a class="nav-link" href="#figures">Figures</a></li></ul></div><div class="core-concepts-text"><div class="content"><div class="core-concept-subsection"><h2 class="section-title" id="background">Background</h2><div class="level4s level4s-full-text section-content"><!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <html><body><h3 id="background-introduction">Introduction</h3> <p>Individuals with chronic hepatitis C virus (HCV) infection and cirrhosis have an increased risk of developing severe liver-related complications, including hepatic decompensation, hepatocellular cancer, and death. Accordingly, any person with chronic HCV infection who is diagnosed with cirrhosis should be considered a high priority for HCV treatment. When considering the general approach to the treatment of hepatitis C in persons with cirrhosis, it is essential to determine (1) whether the individual received prior HCV treatment and experienced virologic failure and (2) whether their cirrhosis is compensated or decompensated (<a title="Figure 1 - General Approach to Hepatitis C Treatment in Adults with Cirrhosis" data-doc-scroll="0" data-doc-source-format="0" data-doc-id="499" data-doc-weight="1" data-doc-source="png" data-doc-info-width="1398" data-doc-info-height="715" alt="Abbreviation: American Association for the Study of the Liver (AASLD) and Infectious Disease Society of America (IDSA)<div></div>" class="linked-doc-1 style-text-width-below document has-link-relation link-relation-below" href="//cdn.hepatitisc.uw.edu/doc/499-2/general-approach-to-hepatitis-c-treatment-adults-cirrhosis.jpg">Figure 1</a>). For persons with chronic HCV infection and decompensated cirrhosis, HCV treatment plans and goals are more complicated and require management by a liver specialist.</p> <h3 id="background-distinguishing-compensated-decompensated-cirrhosis">Distinguishing Compensated and Decompensated Cirrhosis</h3> <p>One important step in treating HCV in persons with cirrhosis is to determine whether the cirrhosis is compensated or decompensated.<span class="reference-group reference-inline">[<a href="#reference-963" class="ref no-popup">1</a>,<a href="#reference-2486" class="ref no-popup">2</a>]</span> The <a href="https://www.hepatitisc.uw.edu/page/clinical-calculators/ctp">Child-Turcotte-Pugh score</a> is an important component of determining the severity of cirrhosis and predicts morbidity and mortality (<a title="Figure 2 - Child-Turcotte-Pugh Classification for Severity of Cirrhosis" data-doc-scroll="0" data-doc-source-format="0" data-doc-id="239" data-doc-weight="2" data-doc-source="png" data-doc-info-width="1082" data-doc-info-height="620" alt="The Child-Turcotte-Pugh (CTP) classification system utilizes two clinical parameters (encephalopathy and ascites) and three laboratory values (bilirubin, albumin, and prothrombin time). Patients are classified as class A, B, or C based on their total points.<div>Source: Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646-9.</div>" class="linked-doc-2 style-text-width-below document has-link-relation link-relation-bottom" href="//cdn.hepatitisc.uw.edu/doc/239-5/child-turcotte-pugh-classification-severity-cirrhosis.jpg">Figure 2</a>).<span class="reference-group reference-inline">[<a href="#reference-515" class="ref no-popup">3</a>,<a href="#reference-480" class="ref no-popup">4</a>]</span> The treatment approach and goals are divergent based on the classification of compensated versus decompensated cirrhosis. In particular, HCV protease inhibitor-based regimens are not recommended for use in persons with decompensated cirrhosis due to the risk of hepatotoxicity with some direct-acting antiviral (DAA) medications and lack of data with other DAAs.<span class="reference-group reference-inline">[<a href="#reference-1437" class="ref no-popup">5</a>]</span></p> <ul> <li><strong>Compensated Cirrhosis</strong>: In general, individuals with compensated cirrhosis have mild hepatic impairment (Child-Turcotte-Pugh class A) and generally do not have clinical manifestations of decompensated disease, specifically jaundice, ascites, variceal hemorrhage, or hepatic encephalopathy.</li> <li><strong>Decompensated Cirrhosis</strong>: Individuals should be considered to have decompensated cirrhosis if they have moderate or severe liver disease (Child-Turcotte-Pugh class B or C, or a score of 7 or higher). Individuals with decompensated cirrhosis often have experienced one or more of the following: ascites, jaundice, variceal hemorrhage, or hepatic encephalopathy.<span class="reference-group reference-inline">[<a href="#reference-963" class="ref no-popup">1</a>,<a href="#reference-515" class="ref no-popup">3</a>]</span> Individuals who have significant clinical improvement after experiencing one feature of hepatic decompensation should be evaluated on a case-by-case basis to determine whether they could be considered for treatment similar to patients with compensated cirrhosis. Even if they recover from the acute event, they are still considered to have decompensated cirrhosis.</li> </ul></body></html> </div></div><div class="core-concept-subsection"><h2 class="section-title" id="impact-treating-hcv-persons-cirrhosis">Impact of Treating HCV in Persons with Cirrhosis</h2><div class="level4s level4s-full-text section-content"><!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <html><body><h3 id="impact-treating-hcv-persons-cirrhosis-reduction-cirrhosis-related-complications-after-hcv-treatment">Reduction in Cirrhosis-related Complications After HCV Treatment</h3> <p>Multiple studies, most from the interferon era, have shown that successful treatment of HCV in persons with compensated cirrhosis will decrease the incidence of subsequent cirrhosis-related complications, including hepatic failure, hepatocellular carcinoma, and liver-related deaths.<span class="reference-group reference-inline">[<a href="#reference-2054" class="ref no-popup">6</a>,<a href="#reference-1757" class="ref no-popup">7</a>,<a href="#reference-1756" class="ref no-popup">8</a>,<a href="#reference-1766" class="ref no-popup">9</a>]</span> In one international, multicenter study, investigators followed 530 adults with chronic hepatitis C and advanced fibrosis or cirrhosis after treatment with interferon-based therapy and found that patients who achieved a sustained virologic response (SVR) had substantially lower hepatic-related complications and lower mortality (<a title="Figure 3 - Clinical Events Related to HCV Treatment Response" data-doc-scroll="0" data-doc-source-format="0" data-doc-id="236" data-doc-weight="3" data-doc-source="png" data-doc-info-width="1279" data-doc-info-height="569" alt="Abbreviations: HCC = hepatocellular cancer<div>Source: van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA. 2012;308:2584-93.</div>" class="linked-doc-3 style-text-width-below document has-link-relation link-relation-below" href="//cdn.hepatitisc.uw.edu/doc/236-4/clinical-events-related-to-hcv-treatment-response.jpg">Figure 3</a>).<span class="reference-group reference-inline">[<a href="#reference-1757" class="ref no-popup">7</a>]</span></p> <h3 id="impact-treating-hcv-persons-cirrhosis-regression-reversal-hepatic-fibrosis-after-hcv-treatment">Regression and Reversal of Hepatic Fibrosis after HCV Treatment</h3> <p>Multiple studies have shown that persons with chronic HCV and cirrhosis have significant improvement in inflammatory grade and fibrosis severity following HCV therapy and achievement of a sustained virologic response (SVR) (<a title="Figure 4 - Regression of Liver Cirrhosis Following Hepatitis C Treatment" data-doc-scroll="0" data-doc-source-format="0" data-doc-id="500" data-doc-weight="4" data-doc-source="png" data-doc-info-width="1330" data-doc-info-height="623" alt="This graphic shows progression of hepatic fibrosis in persons with untreated chronic hepatitis C, which can regress and reverse following treatment with direct-acting antiviral agents. <div>Illustration: David H. Spach, MD</div>" class="linked-doc-4 style-text-width-below document has-link-relation link-relation-bottom" href="//cdn.hepatitisc.uw.edu/doc/500-1/regression-liver-cirrhosis-following-hepatitis-c-treatment.jpg">Figure 4</a>).<span class="reference-group reference-inline">[<a href="#reference-1757" class="ref no-popup">7</a>,<a href="#reference-1396" class="ref no-popup">10</a>]</span> Several studies have shown regression in hepatic fibrosis following the achievement of an SVR with DAA-based treatments, in addition to improvements in laboratory parameters for hepatic function.<span class="reference-group reference-inline">[<a href="#reference-3325" class="ref no-popup">11</a>,<a href="#reference-2597" class="ref no-popup">12</a>,<a href="#reference-2844" class="ref no-popup">13</a>,<a href="#reference-2607" class="ref no-popup">14</a>,<a href="#reference-2843" class="ref no-popup">15</a>,<a href="#reference-3328" class="ref no-popup">16</a>,<a href="#reference-3329" class="ref no-popup">17</a>]</span></p></body></html> </div></div><div class="core-concept-subsection"><h2 class="section-title" id="treating-hcv-persons-compensated-cirrhosis">Treating HCV in Persons with Compensated Cirrhosis</h2><div class="level4s level4s-full-text section-content"><!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <html><body><h3 id="treating-hcv-persons-compensated-cirrhosis-hcv-treatment-goals-persons-compensated-cirrhosis">HCV Treatment Goals in Persons with Compensated Cirrhosis</h3> <p>The most important immediate goal of treatment is to achieve a sustained virologic response, which is required before observing the subsequent benefit in liver-related and other outcomes. The next intermediate-term priority with treatment is to decrease the patient’s risk of developing hepatic decompensation. The long-term goals are to diminish the risk of developing HCV-related hepatocellular carcinoma and death.</p> <h3 id="treating-hcv-persons-compensated-cirrhosis-hcv-treatment-data-persons-compensated-cirrhosis">HCV Treatment Data in Persons with Compensated Cirrhosis</h3> <p>The following is a summary of clinical trials involving persons with compensated cirrhosis. This summary illustrates the high effectiveness of DAA regimens even among patients with cirrhosis.</p> <p><u><span style="color:#666666;"><strong>PANGENOTYPIC REGIMENS</strong></span></u></p> <h4><span class="inline-treatments drug-22" title="Mavyret" data-toggle="tooltip" data-placement="top">Glecaprevir-Pibrentasvir</span></h4> <ul> <li><span class="trial trial-with-presentation layout-inline" id="trial-148"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/148" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">Glecaprevir-Pibrentasvir in Cirrhosis: Pooled Analysis</span></a></span>: The efficacy of <span class="inline-treatments drug-22" title="Mavyret" data-toggle="tooltip" data-placement="top">glecaprevir-pibrentasvir</span> for 12 or 16 weeks was evaluated in a pooled analysis of 308 adults with HCV genotypes 1, 2, 3, 4, 5, and 6 and compensated cirrhosis.<span class="reference-group reference-inline">[<a href="#reference-2845" class="ref no-popup">18</a>]</span> Cirrhosis status was determined by FibroScan in 70% of the study subjects, and 41% were treatment-experienced with prior peginterferon-based therapy. The Child-Turcotte-Pugh score was 5 in 86% of those enrolled. Using an intent-to-treat analysis, SVR12 was achieved in 96% (297/308) of the study participants.<span class="reference-group reference-inline">[<a href="#reference-2845" class="ref no-popup">18</a>]</span> The SVR12 rates by HCV genotype showed 94% with HCV genotype 1, 97% with genotype 3, and 100% with genotypes 2, 4, 5, or 6.<span class="reference-group reference-inline">[<a href="#reference-2845" class="ref no-popup">18</a>]</span> There were no DAA-associated serious adverse events and no grade 3-4 elevations in hepatic aminotransferase levels. Grade 3 hyperbilirubinemia developed in 3 study participants; this occurred without associated abnormalities in other liver parameters, and it resolved without treatment discontinuation.<span class="reference-group reference-inline">[<a href="#reference-2845" class="ref no-popup">18</a>]</span></li> <li><span class="trial trial-with-presentation layout-inline" id="trial-142"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/142" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">EXPEDITION-8</span></a></span>: In this single-arm trial, <span class="inline-treatments drug-22" title="Mavyret" data-toggle="tooltip" data-placement="top">glecaprevir-pibrentasvir</span> was administered for 8 weeks to 343 treatment-naïve adults with compensated cirrhosis and HCV genotypes 1, 2, 3, 4, 5, or 6.<span class="reference-group reference-inline">[<a href="#reference-3001" class="ref no-popup">19</a>]</span> By intention-to-treat analysis, the SVR12 response rates were 98% overall.<span class="reference-group reference-inline">[<a href="#reference-3001" class="ref no-popup">19</a>]</span></li> </ul> <h4><span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">Sofosbuvir-Velpatasvir</span></h4> <ul> <li><span class="trial trial-with-presentation layout-inline" id="trial-112"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/112" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">ASTRAL-1</span></a></span>: The ASTRAL-1 trial enrolled treatment-naïve and treatment-experienced adults with genotype 1, 2, 4, 5, or 6.<span class="reference-group reference-inline">[<a href="#reference-1825" class="ref no-popup">20</a>]</span> Individuals with compensated cirrhosis were not excluded.<span class="reference-group reference-inline">[<a href="#reference-1825" class="ref no-popup">20</a>]</span> The SVR12 rate with 12 weeks of <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> treatment in participants with cirrhosis was 99% (120 of the 121), and the SVR12 rate was identical to participants without cirrhosis.<span class="reference-group reference-inline">[<a href="#reference-1825" class="ref no-popup">20</a>]</span></li> <li><span class="trial trial-with-presentation layout-inline" id="trial-113"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/113" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">ASTRAL-2</span></a></span>: In this randomized, placebo-controlled trial, participants with HCV genotype 2 received a 12-week treatment course with <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> or <span class="inline-treatments drug-1" title="Sovaldi" data-toggle="tooltip" data-placement="top">sofosbuvir</span> plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>.<span class="reference-group reference-inline">[<a href="#reference-1795" class="ref no-popup">21</a>]</span> Individuals with cirrhosis were not excluded.<span class="reference-group reference-inline">[<a href="#reference-1795" class="ref no-popup">21</a>]</span> All 19 participants with cirrhosis and HCV genotype 2 achieved an SVR12 with <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> treatment.<span class="reference-group reference-inline">[<a href="#reference-1795" class="ref no-popup">21</a>]</span></li> <li><span class="trial trial-with-presentation layout-inline" id="trial-114"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/114" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">ASTRAL-3</span></a></span>: The ASTRAL-3 study enrolled persons with HCV genotype 3, and among the 80 participants with cirrhosis who received <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span>, the SVR12 rates were 93% for treatment-naïve and 89% for treatment-experienced participants.<span class="reference-group reference-inline">[<a href="#reference-1795" class="ref no-popup">21</a>]</span></li> <li><span class="trial trial-with-presentation layout-inline" id="trial-145"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/145" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">Sofosbuvir-Velpatasvir in Patients with Compensated Cirrhosis and HCV Genotype 3 (Spain)</span></a></span>: Additional data from Spain suggest that persons with HCV genotype 3 and cirrhosis should undergo baseline NS5A resistance testing and those with pretreatment NS5A resistance-associated substitutions may benefit from the addition of <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> to reduce the risk of viral relapse.<span class="reference-group reference-inline">[<a href="#reference-2846" class="ref no-popup">22</a>]</span></li> </ul> <h4><span class="inline-treatments drug-21" title="Vosevi" data-toggle="tooltip" data-placement="top">Sofosbuvir-Velpatasvir-Voxilaprevir</span></h4> <ul> <li><span class="trial trial-with-presentation layout-inline" id="trial-118"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/118" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">POLARIS-2</span></a></span>: In this phase 3, active-comparator, open-labeled trial, 314 patients with chronic hepatitis C genotypes 1, 2, or 3 with prior direct-acting antiviral (DAA) therapy without an NS5A inhibitor were randomized to receive either <span class="inline-treatments drug-21" title="Vosevi" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir-voxilaprevir</span> or <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> for 12 weeks.<span class="reference-group reference-inline">[<a href="#reference-1956" class="ref no-popup">23</a>]</span> Compensated cirrhosis was present in 46% and prior <span class="inline-treatments drug-1" title="Sovaldi" data-toggle="tooltip" data-placement="top">sofosbuvir</span> exposure in 80% of patients.<span class="reference-group reference-inline">[<a href="#reference-1956" class="ref no-popup">23</a>]</span> The overall sustained virologic response rates were 98% and 90% for the <span class="inline-treatments drug-21" title="Vosevi" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir-voxilaprevir</span> and <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> arms, respectively; among those participants with cirrhosis, 98% (82 of 84) achieved an SVR12 in the <span class="inline-treatments drug-21" title="Vosevi" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir-voxilaprevir</span> arm compared with 86% (59 of 69) in the <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> arm.<span class="reference-group reference-inline">[<a href="#reference-1956" class="ref no-popup">23</a>]</span> Virologic relapse was confirmed at week 4 for one <span class="inline-treatments drug-21" title="Vosevi" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir-voxilaprevir</span> patient and 14 <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> participants, of whom 8 had genotype 3a.<span class="reference-group reference-inline">[<a href="#reference-1956" class="ref no-popup">23</a>]</span></li> </ul> <p><u><strong><span style="color:#666666;">NON-PANGENOTYPIC REGIMENS</span></strong></u></p> <h4><span class="inline-treatments drug-7" title="Zepatier" data-toggle="tooltip" data-placement="top">Elbasvir-Grazoprevir</span></h4> <ul> <li><span class="trial trial-with-presentation layout-inline" id="trial-151"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/151" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">Integrated Analysis of Treatment in Persons with Compensated Cirrhosis</span></a></span>: In this study, investigators performed an integrated analysis of 6 <span class="inline-treatments drug-7" title="Zepatier" data-toggle="tooltip" data-placement="top">elbasvir-grazoprevir</span> phase 2/3 clinical trials to determine SVR12 treatment responses in 402 study participants with HCV genotypes 1, 4, or 6 and compensated cirrhosis.<span class="reference-group reference-inline">[<a href="#reference-1974" class="ref no-popup">24</a>]</span> Participants received treatment with <span class="inline-treatments drug-7" title="Zepatier" data-toggle="tooltip" data-placement="top">elbasvir-grazoprevir</span>, with or without weight-based <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>; the treatment duration was 12 weeks for treatment-naïve participants (n = 169) and 12, 16, or 18 weeks for treatment-experienced subjects (n = 233).<span class="reference-group reference-inline">[<a href="#reference-1974" class="ref no-popup">24</a>]</span> Notably, platelet counts of less than 100,000 cells/mm<sup>3</sup> and serum albumin of less than 3.5 g/dL were present in only 25% and 6% of participants, respectively. Overall, using an intention-to-treatment analysis, SVR12 occurred in 96% of treatment-naïve participants and ranged from 89 to 100% among treatment-experienced subjects.<span class="reference-group reference-inline">[<a href="#reference-1974" class="ref no-popup">24</a>]</span> Genotype 1a patients were most likely to experience viral relapse, with the strongest predictor for treatment failure being the presence of baseline NS5A resistance-associated substitutions. Asymptomatic grade 3-4 increases in hepatic aminotransferase levels were observed in 2.3%.<span class="reference-group reference-inline">[<a href="#reference-1974" class="ref no-popup">24</a>]</span></li> </ul> <h4><span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">Ledipasvir-Sofosbuvir</span></h4> <ul> <li><span class="trial trial-with-presentation layout-inline" id="trial-59"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/59" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">ION-1</span></a></span>: The ION-1 trial enrolled HCV treatment-naïve adults, with and without compensated cirrhosis, to receive 12 or 24 weeks of <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span>.<span class="reference-group reference-inline">[<a href="#reference-1330" class="ref no-popup">25</a>]</span> Among the subjects enrolled with compensated cirrhosis, 97% (63 of 65) achieved an SRV12; the results were similar with 12 or 24 weeks of therapy.<span class="reference-group reference-inline">[<a href="#reference-1330" class="ref no-popup">25</a>]</span> In this study, the addition of <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> did not significantly improve SVR12 rates.</li> <li><span class="trial trial-with-presentation layout-inline" id="trial-60"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/60" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">ION-2</span></a></span>: In this trial, treatment-experienced adults with HCV genotype 1 were treated with 12 or 24 weeks of <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span>, with or without <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>.<span class="reference-group reference-inline">[<a href="#reference-1331" class="ref no-popup">26</a>]</span> Among those individuals with cirrhosis, SVR12 rates were lower if they received <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span> for 12 weeks (86%) versus 24 weeks (100%).<span class="reference-group reference-inline">[<a href="#reference-1331" class="ref no-popup">26</a>]</span> In this study, the addition of <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> did not significantly improve SVR12 rates.<span class="reference-group reference-inline">[<a href="#reference-1331" class="ref no-popup">26</a>]</span></li> <li><span class="trial trial-with-presentation layout-inline" id="trial-79"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/79" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">SIRIUS</span></a></span>: In the SIRIUS trial, 155 treatment-experienced adults with HCV genotype 1 and compensated cirrhosis received 12 weeks of <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span> plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> or 24 weeks of <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span>; the SVR12 rates were 96% for participants in the 12-week group and 97% in the 24-week group.<span class="reference-group reference-inline">[<a href="#reference-1617" class="ref no-popup">27</a>]</span> In a post-hoc analysis of 7 clinical trials, investigators analyzed data from 513 adults with HCV genotype 1 and compensated cirrhosis who received <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span>, with or without <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>.<span class="reference-group reference-inline">[<a href="#reference-1624" class="ref no-popup">28</a>]</span> The treatment-naïve subjects did equally well with either a 12- or 24-week treatment course, but treatment-experienced individuals had lower response rates with 12 compared with 24 weeks; <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> did not significantly improve SVR rates.<span class="reference-group reference-inline">[<a href="#reference-1624" class="ref no-popup">28</a>]</span></li> </ul> <h3 id="treating-hcv-persons-compensated-cirrhosis-recommended-hcv-treatment-compensated-cirrhosis">Recommended HCV Treatment with Compensated Cirrhosis</h3> <p>For individuals with compensated cirrhosis (Child-Turcotte-Pugh Class A) the <span class="guideline layout-inline" id="guideline-1"><span class="inline-guidelines inline-highlight guideline-1" title="American Association for the Study of Liver Diseases (AASLD)-Infectious Diseases Society of America (IDSA) HCV Guidance" data-guideline-id="1"><span class="field field-title">AASLD-IDSA HCV Guidance</span></span></span> provides recommendations for initial treatment and retreatment (when prior therapy has failed).<span class="reference-group reference-inline">[<a href="#reference-1769" class="ref no-popup">29</a>,<a href="#reference-2038" class="ref no-popup">30</a>]</span> Treatment of persons with decompensated cirrhosis should be managed by a liver specialist.</p> <ul> <li>Treatment-naïve persons with compensated cirrhosis should undergo screening to see if they are eligible for the simplified treatment approach for persons with compensated cirrhosis as outlined in the <span class="guideline layout-inline" id="guideline-1"><span class="inline-guidelines inline-highlight guideline-1" title="American Association for the Study of Liver Diseases (AASLD)-Infectious Diseases Society of America (IDSA) HCV Guidance" data-guideline-id="1"><span class="field field-title">AASLD-IDSA HCV Guidance</span></span></span>.<span class="reference-group reference-inline">[<a href="#reference-3125" class="ref no-popup">31</a>]</span> The recommended pangenotypic DAA regimens for simplified therapy—<span class="inline-treatments drug-22" title="Mavyret" data-toggle="tooltip" data-placement="top">glecaprevir-pibrentasvir</span> or <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span>—are effective in patients with or without cirrhosis.<span class="reference-group reference-inline">[<a href="#reference-3125" class="ref no-popup">31</a>,<a href="#reference-3124" class="ref no-popup">32</a>,<a href="#reference-3295" class="ref no-popup">33</a>]</span> When treating with <span class="inline-treatments drug-22" title="Mavyret" data-toggle="tooltip" data-placement="top">glecaprevir-pibrentasvir</span>, the dosing and duration of treatment are the same when treating persons without cirrhosis and those with compensated cirrhosis.<span class="reference-group reference-inline">[<a href="#reference-3125" class="ref no-popup">31</a>]</span> If, however, treatment with <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> is being considered for a person with compensated cirrhosis, a baseline HCV genotype should be obtained, since this treatment regimen may need to be adjusted if the person has HCV genotype 3.<span class="reference-group reference-inline">[<a href="#reference-3125" class="ref no-popup">31</a>]</span> Further, in this situation, if this baseline genotype screening identifies HCV genotype 3, then resistance-associated substitution (RAS) testing is recommended, and the regimen may require adjustment based on this result.<span class="reference-group reference-inline">[<a href="#reference-3125" class="ref no-popup">31</a>]</span></li> <li>Treatment-experienced persons with compensated cirrhosis should be managed based on the prior treatment received as outlined in the <span class="guideline layout-inline" id="guideline-1"><span class="inline-guidelines inline-highlight guideline-1" title="American Association for the Study of Liver Diseases (AASLD)-Infectious Diseases Society of America (IDSA) HCV Guidance" data-guideline-id="1"><span class="field field-title">AASLD-IDSA HCV Guidance</span></span></span>.<span class="reference-group reference-inline">[<a href="#reference-2038" class="ref no-popup">30</a>]</span> In this context, treatment-experienced refers to individuals who did not achieve an SVR12 with prior treatment or had virologic relapse shortly after completing therapy (i.e., prior therapy failed). Persons who achieve an SVR12 with prior treatment but later reacquires HCV should be managed the same as treatment-naïve individuals.</li> </ul> <p>Although the treatment recommendations for persons with and without cirrhosis have significant overlap, there are, in some instances, key differences in the recommended regimens, duration of therapy, or inclusion of <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>.<span class="reference-group reference-inline">[<a href="#reference-1769" class="ref no-popup">29</a>,<a href="#reference-2038" class="ref no-popup">30</a>]</span> Thus, when treating HCV in persons with compensated cirrhosis (particularly if they are treatment experienced), the <span class="guideline layout-inline" id="guideline-1"><span class="inline-guidelines inline-highlight guideline-1" title="American Association for the Study of Liver Diseases (AASLD)-Infectious Diseases Society of America (IDSA) HCV Guidance" data-guideline-id="1"><span class="field field-title">AASLD-IDSA HCV Guidance</span></span></span> should be reviewed to ensure that the regimen is appropriate for that particular patient with cirrhosis.<span class="reference-group reference-inline">[<a href="#reference-1769" class="ref no-popup">29</a>,<a href="#reference-2038" class="ref no-popup">30</a>,<a href="#reference-3125" class="ref no-popup">31</a>,<a href="#reference-3295" class="ref no-popup">33</a>]</span></p></body></html> </div></div><div class="core-concept-subsection"><h2 class="section-title" id="treating-hcv-persons-decompensated-cirrhosis">Treating HCV in Persons with Decompensated Cirrhosis</h2><div class="level4s level4s-full-text section-content"><!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <html><body><h3 id="treating-hcv-persons-decompensated-cirrhosis-definition-decompensated-cirrhosis">Definition of Decompensated Cirrhosis</h3> <p>Individuals with cirrhosis should have a <a href="https://www.hepatitisc.uw.edu/page/clinical-calculators/ctp">Child-Turcotte-Pugh score</a> calculated; they are considered to have decompensated cirrhosis if the score is 7 or higher (Child-Turcotte-Pugh class B or C).<span class="reference-group reference-inline">[<a href="#reference-963" class="ref no-popup">1</a>,<a href="#reference-2486" class="ref no-popup">2</a>,<a href="#reference-515" class="ref no-popup">3</a>]</span></p> <h3 id="treating-hcv-persons-decompensated-cirrhosis-hcv-treatment-goals-persons-decompensated-cirrhosis">HCV Treatment Goals in Persons with Decompensated Cirrhosis</h3> <p>The treatment of persons with decompensated cirrhosis (Child-Turcotte-Pugh class B or C) can be potentially challenging given the high rate of clinical events and complications that may occur in persons with decompensated cirrhosis.</p> <ul> <li><strong>Immediate Treatment Goal</strong>: The immediate treatment goal for individuals with decompensated cirrhosis differs based on candidacy for liver transplantation. For those who are not a candidate for liver transplantation, the short-term goal of therapy is to achieve an SVR, with the hope that some degree of liver decompensation will reverse as a result of therapy, which could then stabilize or improve their clinical condition.</li> <li><strong>Intermediate Treatment Goal</strong>: For persons with chronic HCV infection and decompensated cirrhosis who are candidates for liver transplantation, there are a variety of factors to consider in the decision on timing of DAA therapy.<span class="reference-group reference-inline">[<a href="#reference-3330" class="ref no-popup">34</a>]</span> The primary rationale for pretransplantation treatment of HCV is to reduce the risk of liver disease progression and the risk of HCV reinfection of the new liver—thus improving posttransplantation outcomes. Pretransplantation HCV treatment has been shown to be a cost-effective strategy in the United States.<span class="reference-group reference-inline">[<a href="#reference-3075" class="ref no-popup">35</a>]</span> In addition, for some individuals with decompensated cirrhosis, HCV treatment may prevent the need for a liver transplant.<span class="reference-group reference-inline">[<a href="#reference-3076" class="ref no-popup">36</a>]</span> In a European study that evaluated 103 persons with chronic HCV who were on an active liver transplant list due to decompensated cirrhosis, treatment with DAA therapy resulted in delisting 19% at 60 weeks after treatment.<span class="reference-group reference-inline">[<a href="#reference-2815" class="ref no-popup">37</a>]</span> However, HCV treatment is not recommended in all patients prior to transplantation, particularly if their liver disease is severe and transplantation is urgent. The goal in this scenario would be to shorten organ wait times, opening up the possibility of receipt from a donor who has HCV infection, as DAA therapy has been shown to have comparable efficacy posttransplantation.<span class="reference-group reference-inline">[<a href="#reference-3326" class="ref no-popup">38</a>]</span></li> </ul> <h3 id="treating-hcv-persons-decompensated-cirrhosis-hcv-treatment-regimens-persons-decompensated-cirrhosis">HCV Treatment Regimens for Persons with Decompensated Cirrhosis</h3> <p>The efficacy of DAAs in patients with decompensated cirrhosis is lower than in those with compensated disease, ranging from 70 to 90% depending on the study size and the severity of liver disease. In a multicenter study from Canada, among 868 patients with cirrhosis who underwent DAA therapy, 81% of those with Child-Turcotte-Pugh class B or C disease achieved an SVR12 compared with 90% of individuals with Child-Turcotte-Pugh class A disease.<span class="reference-group reference-inline">[<a href="#reference-3327" class="ref no-popup">39</a>]</span> Clinical progression was defined as liver failure, hepatocellular carcinoma, liver transplantation, or death.<span class="reference-group reference-inline">[<a href="#reference-3327" class="ref no-popup">39</a>]</span> Achieving an SVR was associated with event-free survival in those with Child-Turcotte-Pugh class A disease but not in those with Child-Pugh class B or C.<span class="reference-group reference-inline">[<a href="#reference-3327" class="ref no-popup">39</a>]</span> Real-world data suggest that although DAA therapy can reduce the risk of clinical progression in patients with cirrhosis, it may not provide sufficient, timely benefit for patients with severe liver disease who may need to consider liver transplantation in addition to antiviral therapy.</p> <p>The following summarizes the existing clinical trial data that have evaluated the efficacy of NS5A-NS5B inhibitor combinations in patients with decompensated liver disease.</p> <h4><span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">Ledipasvir-Sofosbuvir</span> plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">Ribavirin</span></h4> <ul> <li><span class="trial trial-with-presentation layout-inline" id="trial-76"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/76" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">SOLAR-1: (Cohorts A and B)</span></a></span>: In Cohort A of the phase 2 SOLAR-1 study, investigators prospectively enrolled 108 adults with hepatitis C genotype 1 or 4 infection and decompensated liver disease (Child-Turcotte-Pugh class B or C).<span class="reference-group reference-inline">[<a href="#reference-1550" class="ref no-popup">40</a>]</span> A total of 108 participants were randomized to receive either a 12-week or 24-week course of <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span> plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>; the <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> dose started at 600 mg per day and then was titrated up as tolerated.<span class="reference-group reference-inline">[<a href="#reference-1550" class="ref no-popup">40</a>]</span> Overall, 65% of patients were HCV treatment experienced. Patients receiving the 12-week regimen had an SVR12 rate of 87%, which was similar to the SVR12 rate of 89% in the 24-week regimen; these data excluded 6 patients who underwent liver transplantation.<span class="reference-group reference-inline">[<a href="#reference-1550" class="ref no-popup">40</a>]</span> The results were similar in the Child-Turcotte-Pugh class B and C groups. Overall, the regimen of <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span> plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> was safe and well tolerated.</li> <li><span class="trial trial-with-presentation layout-inline" id="trial-149"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/149" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">SOLAR-2</span></a></span>: In a similar phase 2 trial (SOLAR 2), investigators evaluated 12 or 24 weeks of <span class="inline-treatments drug-11" title="Harvoni" data-toggle="tooltip" data-placement="top">ledipasvir-sofosbuvir</span> plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> in adults with HCV genotype 1 or 4 and advanced liver disease.<span class="reference-group reference-inline">[<a href="#reference-1852" class="ref no-popup">41</a>]</span> The study cohort A included adults with Child-Turcotte-Pugh class A, B, or C who had not undergone liver transplantation.<span class="reference-group reference-inline">[<a href="#reference-1852" class="ref no-popup">41</a>]</span> In participants with Child-Turcotte-Pugh class B, the SVR12 rates were 87% with 12 weeks of treatment and 96% with 24 weeks. For those with Child-Turcotte-Pugh class C, the SVR12 rates were 85% with 12 weeks of treatment and 78% with 24 weeks.<span class="reference-group reference-inline">[<a href="#reference-1852" class="ref no-popup">41</a>]</span></li> </ul> <h4>Sofosbuvir-Based Regimens</h4> <ul> <li><strong><span class="inline-treatments drug-1" title="Sovaldi" data-toggle="tooltip" data-placement="top">Sofosbuvir</span> Plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">Ribavirin</span> in Decompensated Cirrhosis</strong>: In an open-label, nonrandomized, phase 2 trial, 50 adults with Child-Turcotte-Pugh class A or B cirrhosis and portal hypertension were randomized to receive immediate or deferred HCV treatment with <span class="inline-treatments drug-1" title="Sovaldi" data-toggle="tooltip" data-placement="top">sofosbuvir</span> 400 mg once daily plus weight-based <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> 1,000 to 1,200 mg divided twice daily.<span class="reference-group reference-inline">[<a href="#reference-1438" class="ref no-popup">42</a>]</span> The immediate group received treatment for 48 weeks; the deferred group was observed during the first 24 weeks and then received 48 weeks of therapy.<span class="reference-group reference-inline">[<a href="#reference-1438" class="ref no-popup">42</a>]</span> Overall, 72% (33 of 46) of the participants achieved an SVR12. The results were better in those with Child-Turcotte-Pugh class A (78%) than in those with Child-Turcotte-Pugh class B (68%). For the 37 participants who had paired baseline and end-of-treatment hepatic venous gradient measurements, those who achieved an SVR12 had clinically meaningful reductions in portal pressure.<span class="reference-group reference-inline">[<a href="#reference-1438" class="ref no-popup">42</a>]</span></li> </ul> <h4><span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">Sofosbuvir-Velpatasvir</span></h4> <ul> <li><span class="trial trial-with-presentation layout-inline" id="trial-115"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/115" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">ASTRAL-4</span></a></span>: The ASTRAL-4 trial was a randomized, open-label, phase 3 trial designed to examine the safety and efficacy of the fixed-dose combination of <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> with or without <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> in adults with HCV genotypes 1, 2, 3, 4, or 6 and decompensated cirrhosis.<span class="reference-group reference-inline">[<a href="#reference-1826" class="ref no-popup">43</a>]</span> Treatment-naïve and treatment-experienced individuals with Child-Pugh-Turcotte class B disease were randomized to one of three arms: (1) <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> for 12 weeks (n = 90), (2) <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> plus <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> for 12 weeks (n=87), or (3) <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> for 24 weeks (n = 90). All three regimens were highly efficacious among participants with HCV genotypes 1, 2, 4, and 6.<span class="reference-group reference-inline">[<a href="#reference-1826" class="ref no-popup">43</a>]</span> Among participants with HCV genotype 3, the treatment groups without <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> had lower SVR12 rates (50%, 85%, and 50%, respectively).<span class="reference-group reference-inline">[<a href="#reference-1826" class="ref no-popup">43</a>]</span> The MELD scores improved over baseline in those with a baseline MELD score of less than 15 and in those with a baseline MELD score of 15 or greater (<a title="Figure 5 - ASTRAL4: Change in MELD Score in Adults with Baseline MELD Score Less than 15" data-doc-scroll="0" data-doc-source-format="0" data-doc-id="428" data-doc-weight="5" data-doc-source="png" data-doc-info-width="1301" data-doc-info-height="583" alt="Abbreviations: MELD = Model for End-Stage Liver Disease (MELD)<div>Source: Curry MP, O'Leary JG, Bzowej N, et al. Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis. N Engl J Med. 2015;373:2618-28.</div>" class="linked-doc-5 style-text-width-below document document-series has-link-relation link-relation-below" href="//cdn.hepatitisc.uw.edu/doc/428-2/astral4-change-meld-score-adults-baseline-meld-score-less-than-15.jpg" onclick="return openFigure(5,this)">Figure 5</a>).<span class="reference-group reference-inline">[<a href="#reference-1826" class="ref no-popup">43</a>]</span> </li> <li><span class="trial trial-with-presentation layout-inline" id="trial-146"><a href="https://www.hepatitisC.uw.edu/page/treatment/clinical-trials/146" class="no-popup trial-link reading-pane" target="_blank"><span class="field field-title">Sofosbuvir-Velpatasvir in Patients with Decompensated Cirrhosis Study (Japan)</span></a></span>: Another open-label trial that enrolled patients with decompensated cirrhosis randomized 102 participants 1:1 to <span class="inline-treatments drug-20" title="Epclusa" data-toggle="tooltip" data-placement="top">sofosbuvir-velpatasvir</span> with or without <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>.<span class="reference-group reference-inline">[<a href="#reference-3077" class="ref no-popup">44</a>]</span> Most (77%) had CTP class B disease and 78% had HCV genotype 1 infection.<span class="reference-group reference-inline">[<a href="#reference-3077" class="ref no-popup">44</a>]</span> The SVR12 rates were the same, 92% (47 of 51) in both groups.<span class="reference-group reference-inline">[<a href="#reference-3077" class="ref no-popup">44</a>]</span> Of 91 patients who achieved SVR, 26% demonstrated improvement in their CTP score from baseline to post-treatment week 12. Most adverse events were attributed to progression of liver disease or <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span> toxicity.<span class="reference-group reference-inline">[<a href="#reference-3077" class="ref no-popup">44</a>]</span></li> </ul> <h3 id="treating-hcv-persons-decompensated-cirrhosis-guidance-hcv-treatment-decompensated-cirrhosis">Guidance for HCV Treatment with Decompensated Cirrhosis</h3> <p>The <span class="guideline layout-inline" id="guideline-1"><span class="inline-guidelines inline-highlight guideline-1" title="American Association for the Study of Liver Diseases (AASLD)-Infectious Diseases Society of America (IDSA) HCV Guidance" data-guideline-id="1"><span class="field field-title">AASLD-IDSA HCV Guidance</span></span></span> addresses this group of patients in the section <a href="http://www.hcvguidelines.org/full-report/unique-patient-populations-patients-decompensated-cirrhosis">Unique Patient Populations: Patients with Decompensated Cirrhosis</a>.<span class="reference-group reference-inline">[<a href="#reference-1437" class="ref no-popup">5</a>]</span> The key recommendation from the guidance is that general management and treatment of all patients with decompensated cirrhosis should be performed by a medical practitioner highly experienced in managing persons with chronic HCV infection and decompensated cirrhosis. Accordingly, referral of these patients to an expert, ideally at a transplant center, is strongly recommended. Patients with decompensated cirrhosis include patients who may or may not be a candidate for liver transplantation and may include patients with hepatocellular carcinoma.</p></body></html> </div></div><div class="core-concept-subsection"><h2 class="section-title" id="summary-points">Summary Points</h2><div class="level4s level4s-full-text section-content"><!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <html><body><ul> <li>For all patients with chronic hepatitis C and cirrhosis, it is important to determine whether they have compensated cirrhosis or decompensated cirrhosis.</li> <li>Treatment of HCV in persons with compensated cirrhosis (Child-Turcotte-Pugh class A) is a high priority because of the risk of developing severe liver-related complications.</li> <li>For persons with HCV-related cirrhosis, treatment of HCV with an SVR is associated with significant reversal in hepatic fibrosis and reduced risk of developing hepatocellular carcinoma.</li> <li>For persons with HCV and compensated cirrhosis, the regimen choice and duration is generally similar to those without cirrhosis, except for a longer duration, and in select circumstances, the addition of <span class="inline-treatments drug-3" title="Copegus, Rebetol, Ribasphere" data-toggle="tooltip" data-placement="top">ribavirin</span>.</li> <li>With the use of HCV DAA treatment, individuals with HCV and compensated cirrhosis can have comparable SVR12 rates as those without cirrhosis, especially with adjustments in therapy duration when indicated.</li> <li>Treatment of HCV is recommended in persons with decompensated cirrhosis who are eligible for liver transplantation, since the transplanted liver will become infected with HCV in all patients who have detectable HCV RNA levels at the time of liver transplantation. In addition, posttransplantation HCV infection is associated with an accelerated course of liver disease.</li> <li>Treatment of HCV in persons with decompensated cirrhosis should be performed only by a medical provider who has experience in treating HCV in persons with decompensated cirrhosis.</li> </ul></body></html> </div></div><div id="page-navigation-middle" class="page-navigation "><div class="content"><span class="left"> </span><span class="reading-pane"><a class="button button-print left" title="PDF" href="//cdn.hepatitisc.uw.edu/pdf/treatment-infection/treatment-cirrhosis/core-concept/all" target="_blank"><span class="glyphicon glyphicon-print"></span> PDF</a><a class="button button-share left" title="Share page" href="https://www.hepatitisC.uw.edu/go/treatment-infection/treatment-cirrhosis/core-concept/all" onclick="return sharePage()" target="_blank"><span class="glyphicon glyphicon-envelope"></span> Share</a></span><span class="right next"></div></div><div class="core-concept-subsection"><h2 class="section-title" id="citations">Citations</h2><ol class="refs section-content ref-citations" start="1"><li class="ref" id="reference-963"><span class="weight">1.</span>Garcia-Tsao G, Friedman S, Iredale J, Pinzani M. 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Ann Intern Med. 2013;158:329-37.<div>[<a class="link" href="http://www.ncbi.nlm.nih.gov/pubmed/23460056">PubMed Abstract</a>]<span class="highlight-controls"> - </span></div></li><li class="ref" id="reference-1396"><span class="weight">10.</span>Akhtar E, Manne V, Saab S. Cirrhosis regression in hepatitis C patients with sustained virological response after antiviral therapy: a meta-analysis. Liver Int. 2014;35:30-6.<div>[<a class="link" href="http://www.ncbi.nlm.nih.gov/pubmed/24766091">PubMed Abstract</a>]<span class="highlight-controls"> - </span></div></li><li class="ref" id="reference-3325"><span class="weight">11.</span>Rockey DC, Friedman SL. Fibrosis Regression After Eradication of Hepatitis C Virus: From Bench to Bedside. 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Ann Intern Med. 2015;163:1-13.<div>[<a class="link" href="http://www.ncbi.nlm.nih.gov/pubmed/25909356">PubMed Abstract</a>]<span class="highlight-controls"> - </span></div></li></ul></div><div class="core-concept-subsection section section-figures "><h2 class="section-title" id="figures">Figures</h2><div class="content section-content"><div class="documents"><div data-doc-id="499" data-doc-scroll="0" data-doc-weight="1" data-doc-info-width="1398" data-doc-info-height="715" class="document doc-1"><div class="inner"><a target="_blank" rel="" alt="Abbreviation: American Association for the Study of the Liver (AASLD) and Infectious Disease Society of America (IDSA)<div></div>" title="Figure 1 - General Approach to Hepatitis C Treatment in Adults with Cirrhosis" class="image" href="//cdn.hepatitisc.uw.edu/doc/499-2/general-approach-to-hepatitis-c-treatment-adults-cirrhosis.jpg"><img src="//cdn.hepatitisc.uw.edu/doc/499-2/thumb/general-approach-to-hepatitis-c-treatment-adults-cirrhosis.jpg" alt="Abbreviation: American Association for the Study of the Liver (AASLD) and Infectious Disease Society of America (IDSA)" srcset="//cdn.hepatitisc.uw.edu/doc/499-2/thumb/general-approach-to-hepatitis-c-treatment-adults-cirrhosis.jpg 100w, //cdn.hepatitisc.uw.edu/doc/499-2/third/general-approach-to-hepatitis-c-treatment-adults-cirrhosis.png 320w, //cdn.hepatitisc.uw.edu/doc/499-2/text/general-approach-to-hepatitis-c-treatment-adults-cirrhosis.png 800w, //cdn.hepatitisc.uw.edu/doc/499-2/full/general-approach-to-hepatitis-c-treatment-adults-cirrhosis.png 1280w" sizes="(max-width: 200px) 100px, (max-width: 320px) 320px, (max-width: 800px) 800px, 1280px" /> <div class="field field-name"><span class="short">Figure 1.</span> <span class="long">General Approach to Hepatitis C Treatment in Adults with Cirrhosis</span></div></a><div class="field field-caption">Abbreviation: American Association for the Study of the Liver (AASLD) and Infectious Disease Society of America (IDSA)</div><div style="clear: both;"></div></div></div><div data-doc-id="239" data-doc-scroll="0" data-doc-weight="2" data-doc-info-width="1082" data-doc-info-height="620" class="document doc-2"><div class="inner"><a target="_blank" rel="" alt="The Child-Turcotte-Pugh (CTP) classification system utilizes two clinical parameters (encephalopathy and ascites) and three laboratory values (bilirubin, albumin, and prothrombin time). Patients are classified as class A, B, or C based on their total points.<div>Source: Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646-9.</div>" title="Figure 2 - Child-Turcotte-Pugh Classification for Severity of Cirrhosis" class="image" href="//cdn.hepatitisc.uw.edu/doc/239-5/child-turcotte-pugh-classification-severity-cirrhosis.jpg"><img src="//cdn.hepatitisc.uw.edu/doc/239-5/thumb/child-turcotte-pugh-classification-severity-cirrhosis.jpg" alt="The Child-Turcotte-Pugh (CTP) classification system utilizes two clinical parameters (encephalopathy and ascites) and three laboratory values (bilirubin, albumin, and prothrombin time). Patients are classified as class A, B, or C based on their total points." srcset="//cdn.hepatitisc.uw.edu/doc/239-5/thumb/child-turcotte-pugh-classification-severity-cirrhosis.jpg 100w, //cdn.hepatitisc.uw.edu/doc/239-5/third/child-turcotte-pugh-classification-severity-cirrhosis.png 320w, //cdn.hepatitisc.uw.edu/doc/239-5/text/child-turcotte-pugh-classification-severity-cirrhosis.png 800w, //cdn.hepatitisc.uw.edu/doc/239-5/full/child-turcotte-pugh-classification-severity-cirrhosis.png 1280w" sizes="(max-width: 200px) 100px, (max-width: 320px) 320px, (max-width: 800px) 800px, 1280px" /> <div class="field field-name"><span class="short">Figure 2.</span> <span class="long">Child-Turcotte-Pugh Classification for Severity of Cirrhosis</span></div></a><div class="field field-caption">The Child-Turcotte-Pugh (CTP) classification system utilizes two clinical parameters (encephalopathy and ascites) and three laboratory values (bilirubin, albumin, and prothrombin time). Patients are classified as class A, B, or C based on their total points.</div><div class="field field-source">Source: Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646-9.</div><div style="clear: both;"></div></div></div><div data-doc-id="236" data-doc-scroll="0" data-doc-weight="3" data-doc-info-width="1279" data-doc-info-height="569" class="document doc-3"><div class="inner"><a target="_blank" rel="" alt="Abbreviations: HCC = hepatocellular cancer<div>Source: van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA. 2012;308:2584-93.</div>" title="Figure 3 - Clinical Events Related to HCV Treatment Response" class="image" href="//cdn.hepatitisc.uw.edu/doc/236-4/clinical-events-related-to-hcv-treatment-response.jpg"><img src="//cdn.hepatitisc.uw.edu/doc/236-4/thumb/clinical-events-related-to-hcv-treatment-response.jpg" alt="Abbreviations: HCC = hepatocellular cancer" srcset="//cdn.hepatitisc.uw.edu/doc/236-4/thumb/clinical-events-related-to-hcv-treatment-response.jpg 100w, //cdn.hepatitisc.uw.edu/doc/236-4/third/clinical-events-related-to-hcv-treatment-response.png 320w, //cdn.hepatitisc.uw.edu/doc/236-4/text/clinical-events-related-to-hcv-treatment-response.png 800w, //cdn.hepatitisc.uw.edu/doc/236-4/full/clinical-events-related-to-hcv-treatment-response.png 1280w" sizes="(max-width: 200px) 100px, (max-width: 320px) 320px, (max-width: 800px) 800px, 1280px" /> <div class="field field-name"><span class="short">Figure 3.</span> <span class="long">Clinical Events Related to HCV Treatment Response</span></div></a><div class="field field-caption">Abbreviations: HCC = hepatocellular cancer</div><div class="field field-source">Source: van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA. 2012;308:2584-93.</div><div style="clear: both;"></div></div></div><div data-doc-id="500" data-doc-scroll="0" data-doc-weight="4" data-doc-info-width="1330" data-doc-info-height="623" class="document doc-4"><div class="inner"><a target="_blank" rel="" alt="This graphic shows progression of hepatic fibrosis in persons with untreated chronic hepatitis C, which can regress and reverse following treatment with direct-acting antiviral agents. <div>Illustration: David H. Spach, MD</div>" title="Figure 4 - Regression of Liver Cirrhosis Following Hepatitis C Treatment" class="image" href="//cdn.hepatitisc.uw.edu/doc/500-1/regression-liver-cirrhosis-following-hepatitis-c-treatment.jpg"><img src="//cdn.hepatitisc.uw.edu/doc/500-1/thumb/regression-liver-cirrhosis-following-hepatitis-c-treatment.jpg" alt="This graphic shows progression of hepatic fibrosis in persons with untreated chronic hepatitis C, which can regress and reverse following treatment with direct-acting antiviral agents. " srcset="//cdn.hepatitisc.uw.edu/doc/500-1/thumb/regression-liver-cirrhosis-following-hepatitis-c-treatment.jpg 100w, //cdn.hepatitisc.uw.edu/doc/500-1/third/regression-liver-cirrhosis-following-hepatitis-c-treatment.png 320w, //cdn.hepatitisc.uw.edu/doc/500-1/text/regression-liver-cirrhosis-following-hepatitis-c-treatment.png 800w, //cdn.hepatitisc.uw.edu/doc/500-1/full/regression-liver-cirrhosis-following-hepatitis-c-treatment.png 1280w" sizes="(max-width: 200px) 100px, (max-width: 320px) 320px, (max-width: 800px) 800px, 1280px" /> <div class="field field-name"><span class="short">Figure 4.</span> <span class="long">Regression of Liver Cirrhosis Following Hepatitis C Treatment</span></div></a><div class="field field-caption">This graphic shows progression of hepatic fibrosis in persons with untreated chronic hepatitis C, which can regress and reverse following treatment with direct-acting antiviral agents. </div><div class="field field-source">Illustration: David H. Spach, MD</div><div style="clear: both;"></div></div></div><div data-doc-id="428" data-doc-scroll="0" data-doc-weight="5" data-doc-info-width="1301" data-doc-info-height="583" class="document doc-5"><div class="inner"><a target="_blank" rel="image-series-428" alt="Abbreviations: MELD = Model for End-Stage Liver Disease (MELD)<div>Source: Curry MP, O'Leary JG, Bzowej N, et al. Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis. N Engl J Med. 2015;373:2618-28.</div>" title="Figure 5 (Image Series) - ASTRAL4: Change in MELD Score in Adults with Baseline MELD Score Less than 15" class="image-series image-series-428" image-series-title="Figure 5 (Image Series) - Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis: ASTRAL4" href="//cdn.hepatitisc.uw.edu/doc/428-2/astral4-change-meld-score-adults-baseline-meld-score-less-than-15.jpg"><img src="//cdn.hepatitisc.uw.edu/doc/428-2/thumb/astral4-change-meld-score-adults-baseline-meld-score-less-than-15.jpg" alt="Abbreviations: MELD = Model for End-Stage Liver Disease (MELD)" srcset="//cdn.hepatitisc.uw.edu/doc/428-2/thumb/astral4-change-meld-score-adults-baseline-meld-score-less-than-15.jpg 100w, //cdn.hepatitisc.uw.edu/doc/428-2/third/astral4-change-meld-score-adults-baseline-meld-score-less-than-15.png 320w, //cdn.hepatitisc.uw.edu/doc/428-2/text/astral4-change-meld-score-adults-baseline-meld-score-less-than-15.png 800w, //cdn.hepatitisc.uw.edu/doc/428-2/full/astral4-change-meld-score-adults-baseline-meld-score-less-than-15.png 1280w" sizes="(max-width: 200px) 100px, (max-width: 320px) 320px, (max-width: 800px) 800px, 1280px" /> <div class="field field-name"><span class="short">Figure 5 (Image Series).</span> <span class="long">Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis: ASTRAL4</span></div></a><div class="field field-caption">Abbreviations: MELD = Model for End-Stage Liver Disease (MELD)</div><div class="field field-source">Source: Curry MP, O'Leary JG, Bzowej N, et al. Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis. N Engl J Med. 2015;373:2618-28.</div><div style="clear: both;"></div></div></div><div class="doc-series doc-series-428"><div data-doc-id="512" data-doc-scroll="0" data-doc-weight="5B" data-doc-info-width="1305" data-doc-info-height="576" class="document doc-428-5B"><div class="inner"><a target="_blank" rel="image-series-428" alt="Abbreviations: MELD = Model for End-Stage Liver Disease (MELD)<div>Source: Curry MP, O'Leary JG, Bzowej N, et al. Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis. N Engl J Med. 2015;373:2618-28.</div>" title="Figure 5B - ASTRAL4: Change in MELD Score in Adults with Baseline MELD Score of 15 or Greater" class="image-series image-series-428" href="//cdn.hepatitisc.uw.edu/doc/512-2/astral4-change-meld-score-adults-baseline-meld-score-15-or-greater.jpg"><img src="//cdn.hepatitisc.uw.edu/doc/512-2/thumb/astral4-change-meld-score-adults-baseline-meld-score-15-or-greater.jpg" alt="Abbreviations: MELD = Model for End-Stage Liver Disease (MELD)" srcset="//cdn.hepatitisc.uw.edu/doc/512-2/thumb/astral4-change-meld-score-adults-baseline-meld-score-15-or-greater.jpg 100w, //cdn.hepatitisc.uw.edu/doc/512-2/third/astral4-change-meld-score-adults-baseline-meld-score-15-or-greater.png 320w, //cdn.hepatitisc.uw.edu/doc/512-2/text/astral4-change-meld-score-adults-baseline-meld-score-15-or-greater.png 800w, //cdn.hepatitisc.uw.edu/doc/512-2/full/astral4-change-meld-score-adults-baseline-meld-score-15-or-greater.png 1280w" sizes="(max-width: 200px) 100px, (max-width: 320px) 320px, (max-width: 800px) 800px, 1280px" /> <div class="field field-name"><span class="short">Figure 5B.</span> <span class="long">ASTRAL4: Change in MELD Score in Adults with Baseline MELD Score of 15 or Greater</span></div></a><div class="field field-caption">Abbreviations: MELD = Model for End-Stage Liver Disease (MELD)</div><div class="field field-source">Source: Curry MP, O'Leary JG, Bzowej N, et al. 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