Let's Talk About Treatment for Hepatitis C
You have some seriously effective options for managing symptoms—and a darn good chance at reaching remission, too.by Sarah Fielding Health Writer
While there’s no vaccine for hepatitis C (like there is for hepatitis A and B), treatment has come a long way in recent years. Nowadays, there are more options available than ever before to help you get your hep C under control or even cure it. But navigating the choices can also be overwhelming and confusing. How do you know which treatment route is right for you? Your doctor will recommend treatment based on your specific symptoms and other information about your health and your overall needs. From anti-virals to surgical options, we’ll break down all your treatment possibilities—along with benefits, side effects, and more.
Our Pro Panel
We went to some of the nation’s top hep C experts to bring you the most up-to-date information possible.
Jesse P. Houghton, M.D.
Senior Medical Director of Gastroenterology
SOMC Gastroenterology Associates at Southern Ohio Medical Center
Suman Radhakrishna, M.D.
Infectious Disease Physician
CHA Hollywood Presbyterian Medical Center
Lanla Conteh, M.D.
Clinical Assistant Professor of Hepatology and Gastroenterology
The Ohio State University Wexner Medical Center
Hep C is classified into six strains known as genotypes with several subtypes. Your doctor selects a treatment regimen based on your genotype, existing health conditions (diabetes, heart condition, etc.), and the medication you already take. Thanks to advancements in treatment research, there are some classes of medications (like DAAs) that work across all six genotypes.
While most of the new medicines used to treat hep C have the potential for common side effects like fatigue, headache, and nausea, some people report having no side effects at all. This is a huge step forward. Early treatments often caused side effects so severe they were comparable with chemotherapy.
Most of the new DAA (direct-acting anti-viral) treatments last 8 to 12 weeks. But depending on your level of liver damage, you may need routine follow-up care to screen for liver disease and/or cancer.
It’s very possible that sticking to a treatment regimen will cure your hep C infection. For example, direct-acting antivirals (DAAs) have been found to cure patients with the hepatitis C virus at a rate of more than 90%.
What Is Hepatitis C Again?
Hepatitis C is a viral liver infection that's classified into six strains known as genotypes. Each can help predict distinctly different treatment outcomes. Genotype 1 is the most prevalent in the United States followed by types 2, 3, and 4. Type 5 is almost always found in South Africa, while type 6 is commonly found in Southeast Asia.
If you have been diagnosed with hepatitis C, know that you’re far from alone. According to the U.S. Department of Health and Human Services, nearly 4 million people in America currently live with chronic hepatitis C. Many of these people, however, are asymptomatic and unaware that they are even infected.
Hep C is blood-borne, which means in order to contract it, your blood needs to come in direct contact with blood tainted with the virus. The risk factors for getting hep C include being over age 50 (you could have been exposed via a blood transfusion before routine screening began); sharing needles; and, less frequently, through having sex with an infected individual. Most patients with an acute hepatitis C infection are asymptomatic. However, between 50% and 85% of these acutely infected patients progress to chronic hepatitis C, meaning that the virus has been present for more than six months. Individuals that have additional diseases such as diabetes, alcoholism, HIV, and obesity, have an increased risk of liver damage.
The symptoms of hepatitis C are often quite generic, including:
tingling on arms and legs
So yeah, you just don't feel great. (Specific, right?) Left untreated, chronic hepatitis C patients infection are at risk for liver failure and should be aware of those symptoms as well:
yellowing of the skin and whites of the eyes
While these symptoms are much more obvious, they're also quite serious. If you notice any, call your doctor ASAP.
If you have been diagnosed with chronic hepatitis C, there are quite a few tests that you should undergo to assess your condition before and after treatment. These include testing for hepatitis A, hepatitis B, and HIV, as well as getting additional blood tests and scans to assess the level of liver damage. Anyone found to have significant liver damage will require ongoing, periodic ultrasound monitoring for liver cancer even after treatment for hep c is complete. These patients, if found to have cirrhosis, will require an upper endoscopy to screen for esophageal varices.
Medications for Hep C
Science has come a long, long way. Recent progress has allowed for more targeted and effective medicine, meaning that there are more options for you and a higher chance beating hep c altogether. While genotype is used as a guide for docs to choose the best medication for you, most new meds are pan-genotypic (translation: they treat any of the common genotypes).
Like linebackers in football, direct-acting antivirals (DAAs) are medicines that zero in on specific parts of the hepatitis C virus to block replication. DAAs—first introduced in 2011—have been found to cure patients with the hepatitis C virus at a rate of more than 90%. The goal of this treatment is to reduce the length of therapy and intensity of side effects while achieving higher sustained virologic response (SVR), which means that fewer people relapse. In a 2018 study of 108 patients, most with liver or kidney transplants, 98% of patients achieved SVR. To achieve SVR, the virus needs to remain undetected via a blood test for 12 weeks after therapy has ended.
What to expect? Your doctor selects a treatment regimen based on your genotype (1-6) and any comorbidities (diabetes, heart condition, etc.) that you have, and additional medication you take. Most treatments last eight to 12 weeks and are often tolerated well.
Daklinza (daclatasvir): 12-week oral therapy that is used in combination with other medications, like Solvadi (sofosbuvir)
Epclusa (sofosbuvir/velpatasvir): Taken daily for 12 weeks
Harvoni (ledipasvir/sofosbuvir): One daily pill for 12 weeks
Mavyret (glecapravir, pibrentasvir): One daily tablet for 8 to 16 weeks
Sovaldi (sofosbuvir): Only recommended when used with other medications such as ribavirin (see below) or Daklinza.
Vosevi (sofosbuvir, velpatasvir, voxilaprevir): Taken daily for 12 weeks; often prescribed to people who didn't respond to other meds
Zepatier (grazoprevir, elbasvir): Taken daily, sometimes in conjunction with ribavirin.
One downside, however, is that DAAs used to treat hepatitis C are very expensive. An eight- to 12-week treatment regimen can cost between $26,500 and $94,000 before potential insurance coverage or discounts kick in. For many providers, obtaining coverage for DAAs has proved to be quite difficult and often comes only after some delay. This is due in part to the newness of the medication and limited sources from which to get it. (Need help paying for your med? We've got 10 ways to save.)
If your provider has experienced issues getting coverage for DAAs or if you're among the 10% of people who don't respond to them, your doctor may likely prescribe ribavirin. This oral medication—patented in 1971—helps to stop the virus, which replicates very quickly, from spreading in the liver.
Before DAAs hit the scene, ribavirin plus interferon (see below) was the treatment dujour. While the dual therapy was able to cure roughly 50% of patients, it came with some intolerable side effects, including anemia, memory loss, insomnia, anxiety, and anorexia. For that reason, and the fact that DAAs are so effective, ribavirin use has decreased significantly (aside from being prescribed in some combination therapies).
Peginterferon is a chemically modified version of interferon, which had to be injected three times a week. By adding a molecule called polyethylene glycol (aka PEG) to the interferon, the medication stays in the body longer and only needs to be injected once a week.
Interferons are proteins that can occur naturally in the body; they pump out of cells when the body is being ambushed by a virus (i.e. hep C). Peginterferon is given to boost the immune system and force-stop the hepatitis virus from reproducing itself. But today, since DAAs are so effective and some of the common side effects of peginterferon include depression, flu-like symptoms, and extreme lethargy, the treatment is rarely prescribed anymore. So consider this section a bit of a history lesson.
Other Types of Therapy That Can Help With Hep C
As with any medical condition, complementary therapies can be used to potentially relieve some of the symptoms that come with a hep C infection. The Liver Foundation reports that people have used relaxation techniques like meditation and visualization, as well as physical techniques like massages, yoga, and tai chi. Overall, these two forms of complementary treatment come without much risk and may prove to help individuals deal with pain and distress, especially when combined with prescription medication.
In contrast, common herbal medicines and supplements often suggested to hepatitis c patients, such as milk thistle and zinc, must be examined much more carefully. Research on the impact of dietary supplements in treating hepatitis C patients is still in the early stages and has not yet proven to help in any way. What's more, supplements aren't regulated by the Food and Drug Administration. If you're interested in trying something, always speak with your doctor first.
For the estimated 5% to 30% of patients with chronic hepatitis C who progress to cirrhosis (chronic liver disease), liver failure, or hepatocellular carcinoma (the most common liver cancer), there are other treatment methods that need to be considered. In severe cases such as these, a liver transplant may even be discussed. What's important to know is that surgery, whether to removed damaged tissue or to replace the liver entirely, treats only the organ itself. It's not a cure for the infection, and continued anti-viral medication will be required to prevent further damage and/or protect the new liver.
Liver Transplant: Mayo Clinic. (2019). “Hepatitis C”. mayoclinic.org
Total People with Hepatitis C: U.S. Department of Health and Human Services. (2019). “How Common Is Hepatitis C?” hhs.gov
Complementary Treatment: Liver Foundation. “What About Complementary Therapies?” liverfoundation.org
Medication Options: Liver Foundation. (2018). “Medication Regimens According to HCV Genotype”. liverfoundation.org
Cost Concerns of DAAs: University of Washington. (2018). “Cost and Access to Direct-Acting Antiviral Agents”. hepatitisc.uw.edu
Effectiveness of DAAs: NCBI. (2018). “Safety and Effectiveness of Direct Acting Antivirals”. ncbi.nlm.nih.gov