EASL 2018 – HCV: How to manage treatment failures in 2018 ?


  • HCV Conference Roundups
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Takeaway 

  • Although rare, HCV treatment failure can occur. International retreatment strategies have been published in order to address such problems. Treatment options mainly depend on prior NS5A, PI or both regimen, and on prior 1st or 2nd generation drug exposure.
  • There is no strategic consensus in the occurrence of salvage regimens failure yet.

Why this matters

  • Phase 3 clinical trials show a 4% HCV treatment failure rate but this percentage ranges from 4 to 10% in real-world cohorts1.

Key points

  • Most failures are seen in Genotype 1a or 1b HCV patients treated with Sofosbuvir/Ledipasvir for 8 weeks, or in cirrhotic patients with any direct-acting antivirals treatment. This latter group has been reported to develop multi-class resistance, making retreatment more challenging even though resistance profile may not influence choice of therapy or outcome.
  • Failure must be confirmed prior to retreatment therapy. Reinfection and all other potential causative factors must also be reviewed.
  • Retreatment options depend on prior regimen:
    • Sofosbuvir/Velpatasvir/Voxilaprevir (SOF/VEL/VOX) for all patients with prior NS5A exposure (as per EASL guidance)
    • SOF/VEL and Glecaprevir/Pibrentasvir (G/P) only for patients with non-NS5A exposure (as per AASLD/IDSA guidance)
    • SOF/VEL + RBV for 24 weeks for decompensated patients (options are limited as PI is needed to treat these patients. SOF/VEL/VOX can be used but with extreme precautions)
  • Failure of salvage regimens may occur and no treatment option has been clearly defined. However, SOF + G/P or SOF/VEL/VOX + Ribavirin for 24 weeks are likely candidates