Hepatitis medical therapy

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Classification Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Alcoholic Hepatitis Autoimmune Hepatitis
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

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Medical Therapy

Hepatitis A

• Preferred regimen: Usually require only supportive care, with no restrictions in diet or activity.

Hepatitis B

• Acute Hepatitis B

• Preferred regimen: No specific therapy is available for persons with acute hepatitis B; treatment is supportive.

• Prevention

• Vaccination (available since the early 1980s) continues to be the best way for dealing with the condition. Hepatitis B is preventable, and universal vaccination is probably best soloution in countries with a high prevalence.

• 1. Preexposure vaccination

• This is especially relevant in high-risk groups. There are a number of recombinant vaccines with similar efficacy, although the dosage may differ — for example:

• Recombivax HB (10 µg of HBsAg)

• Child < 11 y with an HbsAg-negative mother: 2.5 µg (babies at birth)
• Child < 11 y with an HBsAg-positive mother: 5 µg
• Child 11–19: 5 µg
• Immunocompetent adult: 10 µg
• Immunosuppressed person: 40 µg
• Renal dialysis patient: 40 µg

• Engerix-B (20 µg of HBsAg)

• Child < 10 y: 10 µg (babies at birth)
• Child > 10 y: 20 µg
• Adult: 20 µg
• Immunosuppressed person: 40 µg
• Dialysis patient: 40 µg 4.6.2

• 2. Postexposure vaccination

• A combination of hepatitis B immunoglobulin (HBIg), when available, and HBV vaccine is recommended. If HBIg is available (in most countries it is not), it should be given to all children of HBs-positive mothers at the time of delivery. This is particularly important in neonates, in whom an immediate start of postexposure immunization will prevent infection in infants of HBV-infected mothers. It is important to vaccinate within 24 hours. There is no evidence of a protective effect if the vaccine is given more than 7 days after delivery.

• Direct exposure (percutaneous inoculation or transmucosal exposure) to HBsAg positive body fluid (e.g., needlestick injury):

• Hepatitis B immunoglobulin (HBIg) single intramuscular dose of 0.06 mL/kg (as soon as possible)
• Followed by a complete course of HBV vaccination (initiated within 7 days)

• Direct exposure following sexual contact with an individual with HBV:

• HBIg single intramuscular dose of 0.06 mL/kg (within 14 days; very expensive and not affordable in most places)
• Accompanied by a complete course of HBV vaccination (do not wait!).

• Chronic Hepatitis B

• 1. Patients with HBeAg-positive chronic hepatitis B

• 1.1. HBV DNA >20,000, ALT <2 times upper limit normal (ULN)

• Observe; consider treatment when ALT becomes elevated.
• Consider biopsy in persons 40 years, ALT persistently high normal >2 times upper limit normal (ULN), or with family history of HCC.
• Consider treatment if HBV DNA >20,000 IU/mL and biopsy shows moderate/severe inflammation or significant fibrosis.

• 1.2. HBV DNA >20,000, ALT >2 times upper limit normal (ULN)

• Preferred regimen (1): Pegylated IFN-alpha 180 mcg weekly SC for 48 weeks
• Preferred regimen (2): Tenofovir (TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
• If creatinine clearance 30–49 give 300 mg q48 hrs
• If creatinine clearance 10–29 give 300 mg q72-96 hrs
• If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
• If creatinine clearance <10 without dialysis there is no recommendation
• Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion

• Preferred regimen (3): Entecavir (ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
• If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
• If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
• If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
• Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion

• Alternative regimen (1): Interferon alpha (IFNα) 5 MU daily or 10 MU thrice weekly SC for 16 weeks
• Alternative regimen (2): Lamivudine (LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 100 mg PO qd
• If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
• If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
• If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
• If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
• The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.
• Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion

• Alternative regimen (3): Adefovir (ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 10 mg PO daily
• If creatinine clearance 30–49 give 10 mg PO every other day
• If creatinine clearance 10–19 10 mg PO every third day
• If hemodialysis patients give 10 mg PO every week following dialysis
• Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion

• Alternative regimen (4): Telbivudine (LdT) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 600 mg PO once daily
• If creatinine clearance 30–49 600 give mg PO once every 48 hours
• If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
• If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis

• Note (1): duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion
• Note (2): Observe for 3-6 months and treat if no spontaneous HBeAg loss.
• Note (3): Consider liver biopsy prior to treatment if compensated.
• Note (4): Immediate treatment if icteric or clinical decompensation.
• Note (5): Interferon alpha (IFNα)/ pegylated interferon-alpha (peg-IFNα), Lamivudine (LAM), Adefovir (ADV), Entecavir (ETV), tenofovir disoproxil fumarate (TDF) or telbivudine (LdT) may be used as initial therapy.
• Note (6): Adefovir (ADV) not preferred due to weak antiviral activity and high rate of resistance after 1st year.
• Note (7): Lamivudine (LAM) and Telbivudine (LdT) not preferred due to high rate of drug resistance.
• Note (8): End-point of treatment – Seroconversion from HBeAg to anti-HBe.
• Note (9): Interferon alpha (IFNα) non-responders / contraindications to IFNα change to Tenofovir (TDF)/Entecavir (ETV).

• 1.3. Children with elevated ALT greater than 2 times normal

• Preferred regimen(1): Interferon alpha (IFNα) 6 MU/m2 SC thrice weekly with a maximum of 10 MU
• Preferred regimen(2): Lamivudine (LAM) 3 mg/kg/d PO with a maximum of 100 mg/d.

• 2. Patients with HBeAg-negative chronic hepatitis B

• 2.1. HBV DNA >2,000 IU/mL and elevated ALT >2 times normal

• Preferred regimen (1): Pegylated IFN-alpha 180 mcg weekly SC for 1 year
• Preferred regimen (2): Tenofovir (TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
• If creatinine clearance 30–49 give 300 mg q48 hrs
• If creatinine clearance 10–29 give 300 mg q72-96 hrs
• If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
• If creatinine clearance <10 without dialysis there is no recommendation
• Note: duration of treatment is more than 1 year

• Preferred regimen (3): Entecavir (ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine
• If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine
• If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine
• If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine.
• Note: duration of treatment is more than 1 year

• Alternative regimen (1): Interferon alpha (IFNα) 5 MU daily or 10 MU thrice weekly SC for 1 year
• Alternative regimen (2): Lamivudine (LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 100 mg PO qd
• If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
• If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
• If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
• If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
• The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.
• Note: duration of treatment is more than 1 year

• Alternative regimen (3): Adefovir (ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 10 mg PO daily
• If creatinine clearance 30–49 give 10 mg PO every other day
• If creatinine clearance 10–19 10 mg PO every third day
• If hemodialysis patients give 10 mg PO every week following dialysis
• Note: duration of treatment is more than 1 year

• Alternative regimen (4): Telbivudine (LdT)Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 600 mg PO once daily
• If creatinine clearance 30–49 600 give mg PO once every 48 hours
• If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
• If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis

• Note (1): duration of treatment is more than 1 year
• Note (2): Interferon alpha (IFNα)/ pegylated interferon-alpha (peg-IFNα), Lamivudine (LAM), Adefovir (ADV), Entecavir (ETV), tenofovir disoproxil fumarate (TDF) or telbivudine (LdT) may be used as initial therapy.
• Note (3): Adefovir (ADV) not preferred due to weak antiviral activity and high rate of resistance after 1st year.
• Note (4): Lamivudine (LAM) and Telbivudine (LdT) not preferred due to high rate of drug resistance.
• Note (5): End-point of treatment – not defined
• Note (6): Interferon alpha (IFNα) non-responders / contraindications to IFNα change to Tenofovir (TDF)/Entecavir (ETV).

• 3. HBV DNA >2,000 IU/mL and elevated ALT 1->2 times normal

• Consider liver biopsy and treat if liver biopsy shows moderate/severe necroinflammation or significant fibrosis.

• 4. HBV DNA <2,000 IU/mL and ALT < upper limit normal (ULN)

• Observe, treat if HBV DNA or ALT becomes higher.

• 5. +/- HBeAg and detectable HBV DNA with Cirrhosis

• 5.1. Compensated Cirrhosis and HBV DNA >2,000

• Preferred regimen (1): Entecavir (ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine.
• If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine.
• If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine.
• If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine.

• Preferred regimen (2): Tenofovir (TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
• If creatinine clearance 30–49 give 300 mg q48 hrs
• If creatinine clearance 10–29 give 300 mg q72-96 hrs
• If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
• If creatinine clearance <10 without dialysis there is no recommendation

• Alternative regimen (1): Lamivudine (LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 100 mg PO qd
• If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
• If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
• If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
• If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
• The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.

• Alternative regimen (2): Adefovir (ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 10 mg PO daily
• If creatinine clearance 30–49 give 10 mg PO every other day
• If creatinine clearance 10–19 give 10 mg PO every third day
• If hemodialysis patients give 10 mg PO every week following dialysis

• Alternative regimen (3): Telbivudine (LdT) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 600 mg PO once daily
• If creatinine clearance 30–49 600 give mg PO once every 48 hours
• If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
• If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis

• Note (1): LAM and LdT not preferred due to high rate of drug resistance.
• Note (2): ADV not preferred due to weak antiviral activity and high risk of resistance after 1st year.
• Note (3): These patients should receive long-term treatment. However, treatment may be stopped in HBeAg-positive patients if they have confirmed HBeAg seroconversion and have completed at least 6 months of consolidation therapy and in HBeAg-negative patients if they have confirmed HBsAg clearance.

• 5.2. Compensated Cirrhosis and HBV DNA <2,000

• Consider treatment if ALT elevated.

• 5.3. Decompensated Cirrhosis

• Preferred regimen (1): Tenofovir (TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
• If creatinine clearance 30–49 give 300 mg q48 hrs
• If creatinine clearance 10–29 give 300 mg q72-96 hrs
• If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
• If creatinine clearance <10 without dialysis there is no recommendation

• Preferred regimen (2): Entecavir (ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine.
• If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine.
• If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine.
• If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine.

• Preferred regimen (3): Lamivudine (LAM) AND Adefovir (ADV)

• Lamivudine (LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 100 mg PO qd
• If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
• If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
• If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
• If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
• The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.

• Adefovir (ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 10 mg PO daily
• If creatinine clearance 30–49 give 10 mg PO every other day
• If creatinine clearance 10–19 give 10 mg PO every third day
• If hemodialysis patients give 10 mg PO every week following dialysis

• Preferred regimen (4): Telbivudine (LdT) AND Adefovir (ADV)

• Telbivudine (LdT) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 600 mg PO once daily
• If creatinine clearance 30–49 600 give mg PO once every 48 hours
• If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
• If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis

• Adefovir (ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:

• If creatinine clearance >50 or normal renal function give 10 mg PO daily
• If creatinine clearance 30–49 give 10 mg PO every other day
• If creatinine clearance 10–19 give 10 mg PO every third day
• If hemodialysis patients give 10 mg PO every week following dialysis

• Note: coordinate treatment with transplant center and refer for liver transplant.
• Life-long treatment is recommended.

• 6. +/- HBeAg and undetectable HBV DNA with Cirrhosis

• Compensated Cirrhosis: Observe
• Uncompensated Cirrhosis: Refer for liver transplant

Hepatitis C

Acute Hepatitis C

• Recommendations:

• Regular laboratory monitoring is recommended in the setting of acute HCV infection. Monitoring HCV RNA (eg, every 4 weeks to 8 weeks) for 6 months to 12 months is also recommended to determine spontaneous clearance of HCV infection versus persistence of infection.
• Counseling is recommended for patients with acute HCV infection to avoid hepatotoxic insults, including hepatotoxic drugs (eg, acetaminophen) and alcohol consumption, and to reduce the risk of HCV transmission to others.
• Referral to an addiction medicine specialist is recommended for patients with acute HCV infection related to substance use.
• If the practitioner and patient have decided that a delay in treatment initiation is acceptable, monitoring for spontaneous clearance is recommended for a minimum of 6 months. When the decision is made to initiate treatment after 6 months, treating as described for chronic hepatitis C is recommended.
• If a decision has been made to initiate treatment during the acute infection period, monitoring HCV RNA for at least 12 weeks to 16 weeks before starting treatment is recommended to allow for spontaneous clearance.
• Owing to high efficacy and safety, the same regimens that are recommended for chronic HCV infection are recommended for acute infection.

Chronic Hepatitis C

• 1. Treatment regimens for chronic hepatitis C virus genotype 1

• 1.1. Treatment regimens for genotype 1a:

• Preferred regimen (1): Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 1a infection
• Preferred regimen (2): Daily fixed-dose combination of Paritaprevir 150 mg AND Ritonavir 100 mg AND Ombitasvir 25 mg plus twice-daily dosed Dasabuvir 250 mg AND weight-based Ribavirin(RBV) ([1000 mg <75 kg] to [1200 mg >75 kg]) for 12 weeks (no cirrhosis) OR 24 weeks (cirrhosis) is recommended for treatment-naive patients with HCV genotype 1a infection.
• Preferred regimen (3): Daily Sofosbuvir 400 mg plus Simeprevir 150 mg ± weight-based Ribavirin(RBV) ([1000 mg <75 kg] to [1200 mg >75 kg]) for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) is recommended for treatment-naive patients with HCV genotype 1a infection.

• 1.2. Treatment regimens for genotype 1b:

• Preferred regimen (1): Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection.
• Preferred regimen (2): Daily fixed-dose combination of Paritaprevir 150 mg AND Ritonavir 100 mg AND Ombitasvir 25 mg plus twice-daily dosed Dasabuvir 250 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection. The addition of weight-based RBV (1000 mg [<75kg] to 1200 mg [>75 kg]) is recommended in patients with cirrhosis.
• Preferred regimen (3): Daily Sofosbuvir 400 mg plus Simeprevir 150 mg for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) is recommended for treatment-naive patients with HCV genotype 1b infection.

• 2. Treatment regimens for chronic hepatitis C virus genotype 2

• Preferred regimen: Daily sofosbuvir 400 mg AND weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 12 weeks is recommended for treatment-naive patients with HCV genotype 2 infection. Extending treatment to 16 weeks is recommended in patients with cirrhosis.

• 3. Treatment regimens for chronic hepatitis C virus genotype 3

• Preferred regimen: Daily sofosbuvir (400 mg) and weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 24 weeks is recommended for treatment-naive patients with HCV genotype 3 infection.
• Alternative regimen: Daily sofosbuvir 400 mg and weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is an acceptable regimen for IFN-eligible, treatment-naive patients with HCV genotype 3 infection.

• 4. Treatment regimens for chronic hepatitis C virus genotype 4

• Preferred regimen (1): Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 4 infection.
• Preferred regimen (2): Daily fixed-dose combination of Paritaprevir 150 mg AND Ritonavir 100 mg AND Ombitasvir 25 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 12 weeks is recommended for treatment-naive patients with HCV genotype 4 infection.
• Preferred regimen (3): Daily Sofosbuvir 400 mg AND weight-based RibavirinRBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 24 weeks is recommended for treatment-naive patients with HCV genotype 4 infection.
• Alternative regimen (1): Daily Sofosbuvir 400 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is an acceptable regimen for treatment-naive patients with HCV genotype 4 infection.
• Alternative regimen (2): Daily Sofosbuvir 400 mg plus Simeprevir 150 mg ± weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 12 weeks is an acceptable regimen for treatment-naive patients with HCV genotype 4 infection.

• 5. Treatment regimens for chronic hepatitis C virus genotype 5

• Preferred regimen: Daily Sofosbuvir 400 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is recommended for treatment-naive patients with HCV genotype 5 infection.
• Alternative regimen: Weekly PEG-IFN plus weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 48 weeks is an alternative regimen for IFN-eligible, treatment-naive patients with HCV genotype 5 infection.

• 6. Treatment regimens for chronic hepatitis C virus genotype 6

• Preferred regimen: Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 6 infection.
• Alternative regimen: Daily Sofosbuvir 400 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is an alternative regimen for IFN-eligible, treatment-naive patients with HCV genotype 6 infection.

Hepatitis D

• Preferred regimen: Interferon alpha(IFNα) 5 MU daily OR 9 MU three times a week for 6–12 months

Hepatitis E

• Preferred regimen: Treatment is supportive only.