Challenges and Controversies

Given her age, duration of infection and current labs, I have a very strong suspicion that she has cirrhosis. If I did not have access to a FibrosScan, I would assume she has cirrhosis and proceed with treatment. If I had access to FibroScan, I would go ahead and get one as it could influence my treatment choice. According to the AASLD/IDSA HCV Guidance, patients with genotype 3 and cirrhosis require baseline resistance testing for NS5A RAS Y93H if sofosbuvir/velpatasvir is being considered for treatment. If they have NS5A RAS Y93H, sofosbuvir/velpatasvir is not a good choice for them (without the addition of ribavirin).

In addition, if the she meets criteria for cirrhosis by FibroScan, she will need HCC surveillance with ultrasound +/- AFP every 6 months.

Bottom line, if FibroScan is available, it would be very helpful. If it is not available, I would assume she has cirrhosis and proceed with treatment and HCC surveillance.

She has had HCV for 20 years so there is plenty of time to have developed cirrhosis. The presence of cirrhosis or not might drive which antiviral I'd select, and it would also drive whether I'd recommend lifelong HCC surveillance with ultrasound and AFP. Genotype 3 patients in particular have had higher failure rates with sofosbuvir-velpatasvir such that pre-treatment RAS testing is often performed and if a Y93H mutation is present, then ribavirin should be added. In that case, I might think more about glecaprevir-pibrentasvir. Lastly, another option if you didn't have a Fibroscan would be ultrasound or liver biopsy. If the ultrasound showed cirrhosis definitively, then you've got tie-breaker. Note: in this case, the FIB-4 is 1.88, so in the indeterminate range, which doesn't really help that much. But in general, I like the FIB-4 better because it accounts for age.