Table 1:

Suggested work-up before beginning HCV therapy

CategoryInvestigationConsiderations
Routine bloodwork

  • Complete blood count

  • Liver enzymes (alanine transaminase, aspartate transaminase, alkaline phosphatase)

  • Liver function (bilirubin, INR, albumin)

  • Creatinine

  • Low platelets and elevated bilirubin or INR are suggestive of cirrhosis

  • Renal function is important to determine safety of some regimens

Serology to exclude other infections

  • HIV

  • Hepatitis B (HBsAg, anti-HBs, anti-HBc)

  • If HIV-positive, treatment for HIV must take drug interactions into consideration

  • If HBsAg-positive or anti-HBc-positive, see section on HBV coinfection (risk of HBV reactivation) (Appendix 1)

Serology to exclude other common liver diseases

  • Transferrin saturation (hemochromatosis)

  • IgG

  • Elevated immunoglobulin G may reflect cirrhosis or possibly autoimmune hepatitis

Staging of liver disease

  • APRI*

  • FibroTest (serum panel)†

  • Ultrasound*

  • Transient elastography†

  • All persons with HCV must have evaluation of fibrosis to exclude cirrhosis.

  • Normal ultrasound does not exclude cirrhosis.21

  • APRI < 0.7 has a very high negative predictive value to exclude cirrhosis22

HCV-specific

  • HCV genotype and HCV RNA

  • Resistance testing (may be useful in select circumstances)

  • To select appropriate regimen, and consideration for addition of ribavirin.

  • Note: anti-HBc = hepatitis B core antibody, anti-HBs = hepatitis B surface antibody, APRI = Aspartate Aminotransferase to Patelet Ratio Index, HBsAg = hepatitis B virus surface antigen, HBV = hepatitis B virus, HCV = hepatitis C virus, HIV = human immunodeficiency virus, IgG = immunoglobulin G, INR = international normalized ratio.

  • ↵* All persons with HCV should have a baseline ultrasound and evaluation of fibrosis.

  • ↵† Where available, use noninvasive technologies (e.g., transient elastography [FIbroscan], shear-wave elastography, MR-Elastography, or FibroTest).