Skill Checkup: A Man With Itching and Abdominal Pain 

Alastair O'Brien, MBBS, BSc, PhD


March 18, 2021

According to EASL 2020 guidelines, determination of HCV genotype and subtype is a recommended part of the workup for a person diagnosed with HCV infection to help guide the duration and choice of treatment. Although treatment with pangenotypic direct-acting antiviral (DAA) therapy can be initiated without determination of the genotype and subtype because of accessibility or affordability reasons, the guidelines state that it is still useful to ascertain the genotype to guide treatment for all patients — treatment-naive and treatment-experienced patients with recently acquired or chronic HCV infection.

Routine resistance testing is not recommended as part of the workup in DAA treatment-naive patients with HCV infection. A standardized resistance test for CE-IVD-marked for resistance testing in the NS3 (protease), NS5A and NS5B (polymerase) regions of HCV genotypes 1a, 1b and 3a is available. Sequencing and interpretation of information can be obtained for other genotypes. However, since DAAs are highly efficacious in patients with detectable preexisting resistance-associated substitutions at baseline, the EASL guidelines state that it is not necessary to perform HCV resistance testing before administering first-line therapy.

A positive HCV antibody result remains positive for life, so repeat antibody testing adds no clinical benefit. In this patient, a prior HCV antibody test already showed positive results. Instead, HCV RNA should be measured at baseline (as was performed in this patient) and at 12 or 24 weeks following therapy completion to determine whether treatment has been successful.

Liver biopsy should be reserved for cases when the diagnosis is uncertain or there is a possibility of mixed etiologies (eg, metabolic syndrome, nonalcoholic steatohepatitis [NASH], alcoholism, or autoimmunity).


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