20-Year HCV Infection Cured After Multiple Treatment Failures

Significant strides have been made in the treatment of hepatitis C virus (HCV) with the introduction of direct-acting antiviral agents (DAAs), however there is limited data on how to treat patients who have failed treatment with multiple DAAs. This case, published in the Journal of Clinical Pharmacy and Therapeutics, discusses a patient with a 20-year-long HCV infection that was finally cured after failing treatment with five different HCV regimens.

The patient, a 60-year-old white woman, had been diagnosed with HCV genotype 1a in 1995 and had been unsuccessfully treated with five different treatment regimens.  These included:

1. Interferon for 24 weeks: null responder
2. Interferon + ribavirin for 48 weeks: null responder
3. Pegylated-interferon + ribavirin for 20 weeks: null responder (discontinued due to leukopenia)
4. Pegylated-interferon + ribavirin + telaprevir for 9 weeks: partial responder (discontinued after detectable viral load of 5830 IU/mL at 4 weeks and 5470 IU/mL at 9 weeks)
5. Simeprevir + sofosbuvir for 12 weeks: partial responder

Genotypic resistance testing was conducted after she had failed her fourth regimen; testing showed resistance to telaprevir and boceprevir with resistance-associated variants V36M and R155K.

In March 2015, she presented to her clinic to initiate a sixth course of therapy at which point her baseline workup was as follows:

• Viral load: 995,810 IU/mL
• Fibrosis stage F4 (diagnosed with compensated cirrhosis in 2012)
• AST: 115 IU/L
• ALT: 124 IU/L
• INR: 1.0
• AFP: 19.8ng/mL
• CrCl >70mL/min

She was not co-infected with HIV or hepatitis B and had no other significant medical history; adherence to previous regimens was found to be excellent. Taking into account previous treatment failures,clinicians started her on ledipasvir/sofosbuvir without ribavirin (due to possible prior intolerance) for a 24 week period.