Purpose of review: This article reviews treatment options of the approved and soon-to-be approved direct-acting antivirals (DAA)-based therapies in individuals with hepatitis C virus (HCV) cirrhosis.
Recent findings: DAA-based therapies have been shown to be well tolerated and effective in achieving viral cure in individuals with compensated and decompensated cirrhosis. Preliminary studies suggest that viral eradication arrests fibrosis progression and could lead to fibrosis regression. Long-term benefits of successful HCV treatment in this population translate into less frequent hepatic decompensation and hepatocellular carcinoma development, improvements in liver disease severity, reduction of liver-related mortality, and potential obviation of the need for transplantation. The optimization of viral eradication rates requires longer duration therapy and/or more complex combinations of drugs, including ribavirin. Treatment decisions are guided by HCV genotype, renal function, drug-drug interactions, and the severity of cirrhosis. Safety concerns are paramount in individuals with advanced liver disease and continued vigilance for hepatotoxicity and other complications is warranted, especially in those with decompensated cirrhosis.
Summary: The availability of high potency DAA-based therapies with excellent safety profiles has transformed the HCV-infected cirrhotic population into a group that is no longer 'difficult-to-treat'. Understanding the pretreatment factors that predict clinical benefits vs. harm remains key in treating this population.