A 45-year-old man with compensated cirrhosis from chronic HCV infection is started on sofosbuvir/velpatasvir (pangenotypic DAA) for 12 weeks. Four weeks into treatment he remains undetectable on HCV RNA PCR. Which monitoring parameter is MOST critical during DAA treatment in a cirrhotic patient?
- A HCV genotype confirmation weekly
- B HBsAg and HBV DNA to screen for HBV reactivation ✓
- C Thyroid function tests monthly
- D Serum ammonia levels
Explanation
FDA issued a black box warning in 2016 regarding HBV reactivation (including fulminant hepatitis and death) during or after DAA therapy for HCV. The mechanism involves loss of immune suppression against HBV as HCV immune interference resolves. All patients should be screened for HBV (HBsAg, anti-HBc) before starting DAAs. HBsAg-positive patients require concurrent HBV antiviral therapy. Anti-HBc-positive/HBsAg-negative patients need monitoring with HBsAg and HBV DNA during and for several months after treatment. Thyroid monitoring is relevant for ribavirin/interferon therapy, not pure DAA regimens.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.