Challenges and Controversies

The patient should be sent for an HCC screening ultrasound (US) prior to starting any treatment.

Current AASLD/IDSA guidelines recommend 8 weeks of glecaprevir-pibrentasvir (G/P) for patients with compensated cirrhosis and genotype 3. The recommendation is based on findings from the EXPEDITION-8 study which evaluated 8 weeks of G/P in 343 patients with GT1-6 and compensated cirrhosis. Overall, 98% of the entire cohort achieved an SVR12. In a subgroup of in 63 patients with genotype 3 (n=63), 95% achieved SVR12 (60/63). Of the 3 treatment failures, one was virologic failure (relapse) and 2 were lost to follow-up (per-protocol SVR 98%). Subsequent real world studies have found similar SVRs rates for this group. Some clinicians are reluctant to embrace an 8 week treatment duration, citing limited data and modestly reduced SVR rates. Faced with the available data, treatment with 8 weeks of therapy appears adequate. Assuming that this patient's US does not identify an HCC or ascites, I would offer 8 weeks of G/P, per current AASLD/IDSA guidelines.