Treatment of HCV and compensated liver disease after transplantation

Recommendations for the treatment of HCV after liver transplantation are based on clinical trial data where available. We have tried to avoid extrapolation from studies performed in non-liver transplant patients, given the complexity associated with post-transplant immunosuppression. Therefore, treatment recommendations may differ from those for the non-transplant population and may differ from the treatment regimens currently eligible for prescription under the PBS (Table 6). None of the currently available DAAs in Australia include a specific indication for treating HCV after liver transplantation.

Clinical trial data are limited. The safety and efficacy of sofosbuvir plus velpatasvir has not been formally evaluated in the post-transplant setting but should be safe and effective. The role of ribavirin combined with sofosbuvir plus velpatasvir in the post-transplant setting is not clear, but it should be considered.

The combination of glecaprevir plus pibrentasvir has been evaluated in the post-transplant setting. In the MAGELLAN-2 study, 80 liver transplant recipients and 20 kidney transplant recipients without cirrhosis were treated with glecaprevir plus pibrentasvir for 12 weeks.[84] Patients with Gt 1, 2, 3, 4 and 6 HCV were included. SVR was observed in 98%, with one post-treatment relapse and one loss to follow-up. Treatment was well tolerated. One episode of mild rejection occurred that was assessed to be unrelated to drug–drug interactions. There are limited data available evaluating glecaprevir plus pibrentasvir for 8 weeks versus 12 weeks after liver transplantation. In one small multicentre study in Japan, 24 liver transplant recipients with recurrent HCV infection were treated with 8 weeks or 12 weeks of glecaprevir plus pibrentasvir; 96% achieved SVR12. All 13 patients treated for 8 weeks achieved SVR.[85] Until more data become available, we continue to recommend a 12-week treatment duration. However, an 8-week treatment duration may be considered for some people without cirrhosis on a case-by-case basis.

Sofosbuvir plus velpatasvir plus voxilaprevir has not specifically been studied in post-transplant patients but should be used for people who did not respond to a prior DAA regimen, particularly one containing an NS5A inhibitor. As with all other DAA regimens in post-transplant patients, drug–drug interactions should be taken into consideration.