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. 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. 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.