Treatment of hepatitis C: the use of the new pangenotypic direct-acting antivirals in "special populations"

Background & AimsThe recommended combination of pangenotypic direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) associates the co-formulation of 2 or 3 second-generation DAAs. In the so-called special populations defined as patients with chronic kidney disease (CKD), HCV/HIV co-infection, HCV/HBV co-infection and an unsuccessful previous DAA regimen, these combinations have a high antiviral potency (sustained virologic response (SVR) > 95%), fair tolerance and a reduced pill burden. MethodsWe have taken into account the scientific evidence on the treatment of special populations, in particular from the RUBY 1-2 trials, EXPEDITION 2-4 study, C-WORTHY trial, ASTRAL 5, POLARIS 1-4 studies, MAGELLAN 1 and REVENGE study. ResultsCKD and HCV/HIV co-infection are not predictors of a non-viral response. The glecaprevir/pibentrasvir (Maviret) combination appears to be the first-line therapy for CKD patients while the sofosbuvir/vlpatasvir/voxaliprevir (Sovesi) combination is the first-line option for DAAs failures. Both are effective in patients with HIV-or HBV-HCV co-infection and should be chosen according to the potential drug-drug interaction profile. ConclusionsThe notion of special populations is no longer pertinent with pangenotypic DAAs combinations. International guidelines recommend treating all infected patients and the next challenge is not the therapeutic choice, but to improve the limitations for screening and access to care in HCV infection.