Hepatitis C Blog
Greg Jefferys Hepatitis C blog deals with all the issues associated with hepatitis C
Treatment of Hepatitis C Genotype 3 Relapse
Treatment for Hepatitis C Genotype 3 Relapse after treatment
Hepatitis C genotype 3 is the genotype of Hep C that does the most damage to the patient’s health and is the most difficult to treat, particularly if the patient has liver cirrhosis.
There are more post-treatment relapses from the incorrect treatment of Genotype 3 than any other type of Hepatitis C.
Whilst treatment of HCV Genotype 3 has improved over the last 6 six years there are still many instances of doctors prescribing the wrong treatment for genotype 3.
The most common error resulting in relapse is too short a treatment time. Hep C genotype 3 needs a longer treatment time than all other genotypes of Hepatitis C to achieve comparable cure rates.
The second most common cause of relapse comes from the use of Mavyret in the treatment of people infected with Hep C G3 who have liver cirrhosis.
Mavyret should not be used to treat people who have liver cirrhosis (F4) as Mavyret gives a significantly lower cure rate than Sofosbuvir-based treatments such as Sofosbuvir + Daclatasvir and Epclusa if cirrhosis is present. This is demonstrated in the graph below comparing Mavyret (GLE/PIB) with Epclusa, this is a part of a graph from the European Journal of Hospital Pharmacy
This graph shows that Hepatitis C patients with a fibrosis level of F4 (liver cirrhosis) have less than a 67% chance of being cured by Mavyret compared with 88% for Epclusa
Relapse from G3, Retreatment options.
Every few weeks I am contacted by someone who has relapsed after treatment with DAAs. More than 90% of these cases are from people who have Hep C genotype 3.
In these cases, the person, and their family, are always devastated by the news that the treatment has been unsuccessful.
If they have very good insurance or access to free public health care there are several treatment options that an expert in the area of Hepatitis C re-treatment can prescribe. However, if a person is in a situation where access to free treatment and treatment advice is not available then dealing with Hepatitis C treatment relapse becomes a nightmare. Firstly because of the cost of re-treatment and secondly because access to good advice is expensive.
The first option for people who have failed treatment is usually the Gilead drug combination called Vosevi. Vosevi is the same drug combination as Epclusa (Sofosbuvir + Velpatasvir) but with an additional drug called Voxilaprevir.
The problem with Vosevi is that it is very expensive and there is no generic version of Vosevi. A lot of health insurance services will not cover the cost of Vosevi re-treatment.
For people who have failed treatment with Mavyret Vosevi is a good treatment, however, for people who have relapsed with G3 a minimum of 16 weeks of treatment is advisable. But generally, insurance companies will only cover a 12-week treatment of Vosevi because of the cost.
A better option for people who have failed an 8-week treatment with Mavyret is to use the combination of Sofosbuvir + Daclatasvir for 24 weeks. This drug combination has a higher cure rate than Epclusa for people who have failed previous treatments and has a higher cure rate than Mavyret. The additional advantage of Sofosbuvir + Daclatasvir is that it is available in generic form and is relatively cheap, with a 24-week treatment costing not more than US$1,000.
In the six years I have been helping people who have failed previous treatment I have seen a 100% cure rate from people doing the 24 week treatment with Sofosbuvir + Daclatasvir.
This graph, from a study of more than 5,000 patients in the USA, shows that Sofosbuvir + Daclatasvir is superior to Epclusa for patients who have failed a previous treatment
Hep C Genotype 3 Relapse: The Real World
Below I will share the story of a woman from Florida in the USA whose son approached me to help him get generic Epclusa last year (March 2020) just as the COVID 19 pandemic was sweeping the planet.
Because she had genotype 3 and liver cirrhosis I suggested a minimum of 16 weeks of treatment with Sofosbuvir + Velaptasvir (Epclusa).
After some discussion with his mother and their family, he agreed to follow this course and I organized the generic Epclusa for them.
However, the shipment of the generic Epclusa from India was delayed because of the COVID 19 disruption to international air freight and in the period of delayed delivery this woman’s family doctor convinced her not to take the generic Epclusa and instead organised the family to pay almost US$15,000 for an 8 week treatment with Mavyret.
When I received the news that the family had decided to follow this path I was a little upset but suggested that it would still probably be fine as long as they followed up the 8 weeks of Mavyret immediately with 8 weeks of the generic Epclusa. In other words, still doing the 16 weeks treatment. The son agreed to this as being sensible and I did not hear much more until the SVR 12 tests were completed.
Here is how this played out.
S### sent April 22
I have bad news greg
I am shaking
I don’t know what to do.
My mother has relapsed after completing the treatment with Mavyret.
See the results And tell me about it.
Hep C relapse Genotype 3
S###33 sent April 22
Greg, message me as soon as possible
My mother did 8 weeks of Mavyret and she has genotype 3 with cirrhosis
She is still is not aware of the result
I don’t know how to tell her
Greg, I am super devastated. I am crying from the inside
Waiting for you to see and respond!
Greg, are you there?
You sent April 22
Hi S####… This is very strange
As well as the 8 weeks of Mavyret did she also take the Epclusa I sent you? Yes or no?
No Greg, she did not.
The family went along with the doctor, the doctor advised her to only do the 8 weeks treatment with Mavyret and not to use the generic Epclusa you sent.
That was a mistake
We should have listened to you
Greg, now what to do now
I am devastated and ashamed that we didn’t listen to you.
April 23. Original message:
This is very strange if she reached SVR 12
Reply by S####:
She did. We did test the 12 weeks post-treatment. It came negative. But now it’s back.
Greg, I am waiting for your advice
April 23. Original message:
So that I am sure I am understanding the situation correctly please confirm if, as well as the Mavyret she also took the Epclusa I sent?
Yes or No?
Reply by S#####:
The elder people in my family wanted to go along with the doctor. But I tried to oppose that but in the end, I couldn’t.
Greg, now I am clueless about what to do for my mother!
My father is not here. He is in his home country and he will be mentally devastated if he hears about this.
I have to deal with this alone
Please tell me what can we do now
Every minute of my life is now painful…I am waiting for your recommendation in this situation.
You sent April 23
Well S#### I am sad and disappointed that you did not follow my advice If you had followed the advice I gave you Your mother would definitely be cured, I gave all this advice for free, and answered so many of your questions and gave you so much support, just from only the kindness of my heart and your family repaid my kindness by ignoring me.
It’s a very sad situation, actually, words fail me
Reply by S####:
Greg, I totally understand your feeling. I fought with my family over this and now they don’t have any words. I am truly sorry to you, Greg.
Greg, now we are in a cave. Please help us. Tell us if there’s any way now
Greg, now what can we do????
You sent April 23
It’s a very very difficult position that your mother is now in. I have to admit being angry at the stupidity of her doctor because every doctor should know that 8 weeks Mavyret is not enough for someone with G3 and liver cirrhosis.
Before I offer any advice I will need to know that your family are agreeing to follow the guidelines I will give I don’t want to waste my time again
S#### sent April 23
I will do that truly. Whatever it takes.
I swear it on my mother
We will strictly follow everything you say
Everything, Greg
You sent April 23
I need you to speak to your family and your mother to get assurances that this is not going to happen again
I already talked with her but I am doing again
I just talked with my mother and family
We are ready to go, Greg.
To strictly follow your guidelines
We will definitely not waste your time, Greg.
Apr 24, 2021, 11:21AM
Hi S#####
I have been thinking about your mother’s situation in some detail. Because your mother failed the Mavyret the virus will have built up no immunity to Sofosbuvir we do not need to go to the Zepatier as was my first thought. My suggestion would be 24 weeks of Sofosbuvir + Daclatasvir. This has a higher treatment success than Epclusa for people who have failed previous treatments.
S#### sent April 26
Okay, Greg. So, then we have to ship those through you from India.
You can make the order.
I am with your guidelines 100% without a point of doubt, Greg.
After Treatment … the waiting
Re-treatment, after a person has failed previous treatment, is always difficult.
Firstly there is the worry during the treatment, wondering if it is working or not.
Then when the treatment is complete there is a 12 week wait until the SVR 12 test is done.
Then there is another wait for SVR24.
Its a lot of anxiety and waiting.
In the case above the treatment has just begun. so the final result will not be 100% certain until April next year.
The moral of the story is to treat correctly the first time and not risk relpase.
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