Hello hovis,

In terms of the treatment testing makes no difference to the outcome.

In terms of predicting if longer than 12 weeks would be beneficial, the only solid data relates to being undetected/detected at 4 weeks. The ~ 20% of people still detected at 4 weeks are 2-2.5x as likely to fail treatment so, if a patient falls into this group it is worth considering extending the treatment past12 weeks.

If you test at 6 weeks you will almost certainly be undetected but that’s all it tells us. If it was still detected that would be a “better do something” kind of a moment, but it’s highly unlikely that this will be the case.

If the weeks 4 viral load result is <12IU/ml but not mention undetected. This means still got small amount of virus?
If refer to this assay provides quantitative results over a wide range of 12~100,000,000 IU/ml. Is it <12 IU/ml is means virus undetected? I'm genotypes 3 n decompensated liver cirrhosis. Do I need to extend my treatment if first weeks 4 viral load result is <12IU/ml?

Hello Carolwinnie,

Yes, the second test says <12 but still detected (so we can still see a trace).

The <12 test is more sensitive than the <15 and <25 and <30 tests so is the "least worrying" of the

Hello Carolwinnie,

Your father is on a good treatment, however, if it was my father we would be treating for longer than 12 weeks. Most of the extra benefit is adding 4 weeks (maybe 4% extra cure @16 weeks) with another 4 weeks adding 2% extra cure and an extra 4 weeks adding another 1%. The point is that most of the cure is in the first 8-12 weeks, with less and less extra cure the longer we treat.

Your father may have to stop the Ribavirin if his platelets continue to fall.

If this happens he should definitely do more than 12 weeks (I would suggest 24 weeks total if we drop back to just using Sof/Vel)

So 12 weeks with Ribavirin is a good treatment for him. He has a good doctor.

Adding extra weeks is good insurance if he is tolerating the drugs well and can be thought of as being like insurance – probably not required, but nice to have if you need it.

The main benefits of Ribavirin are at the start of treatment so my suggestion would be to use it while side effects can be tolerated (and haemoglobin and platelets remain ok).

If there are problems we can reduce the dose or stop it.

The extra treatment duration is much more valuable to success than ribavirin.

There is not a lot of good data about how successful treatment is in really sick patients (like Child Pugh

https://www.hcvguidelines.org/unique-populations/decompensated-cirrhosis

The main guidance is from ASTRAL-4, where we saw:

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1512614

You will find this table in that paper from NEJM

As you can see from the GT3 patients the numbers are small so the confidence interval (margin for error) is quite wide.

For 12 weeks Sof/Vel without ribavirin success was 7/14 patients (50%)

With ribavirin that rose to 11/13 (85%) which is certainly better.

Unfortunately, Gilead did not do 24 weeks either with or without ribavirin but we know from experience what I have already told you – extra treatment duration provides a small, but very real, extra benefit.

https://www.clinicaloptions.com/hepatitis/conference-coverage/aasld-2015/highlights/capsules/206/page-1

I would estimate that with 24 weeks of treatment and at least 12 weeks with Ribavirin we can expect at least a 90% success rate – so 9 chances of success and only 1 chance of failure.

There is nothing better we could be giving. The NS3/4 boosters in Vosevii or Maviret (if combined with Sofosbuvir) or Zepatier (if combined with Sofosbuvir) can not be used in Child Pugh B or C.

You are, in short, doing everything that can possibly be done to maximise the chance of cure.