The currently approved direct-acting antivirals (DAAs) can be used to treat a great majority of hepatitis C-infected patients. |
Some of the last remaining issues regarding DAA therapy are how to treat patients who have not responded to DAA therapy who have severe resistance associated-substitution, how to manage drug interactions with strong enzyme inducers, and how to treat patients with both decompensated cirrhosis and renal impairment. |
1 Introduction
2 Methods
3 Pharmacokinetics
Drug | Brand name | Pharmaceutical form | Dose | Genotypes | Remarks | References |
---|---|---|---|---|---|---|
Daclatasvir | Daklinza® | Film-coated tablet | 60 mg qd | 1a, 1b, 2, 3, 4 | Available in tablets of 30, 60, and 90 mg | |
Sofosbuvir/ledipasvir | Harvoni® | Film-coated tablet | 400 mg/90 mg qd | 1a, 1b, 4, 5, 6 | ||
Elbasvir/grazoprevir | Zepatier® | Film-coated tablet | 50 mg/100 mg qd | 1a, 1b, 4 | ||
Sofosbuvir/velpatasvir | Epclusa® | Film-coated tablet | 400 mg/100 mg | 1a, 1b, 2, 3, 4, 5, 6 | ||
Glecaprevir/pibrentasvir | Maviret®/Mavyret® | Film-coated tablet | 100 mg/40 mg qd | 1a, 1b, 2, 3, 4, 5, 6 | ||
Sofosbuvir/velpatasvir/voxilaprevir | Vosevi® | Film-coated tablet | 400 mg/100 mg/100 mg | 1a, 1b, 2, 3, 4, 5, 6 |
Drug | tmax (h) | Cmax (ng/mL) | Cmin (ng/mL) | AUC (ng∙h/mL) | Vd/F | t½ (h) | Protein binding (%) | References |
---|---|---|---|---|---|---|---|---|
Protease inhibitors | ||||||||
Glecaprevir | 5.0 | 597 | NR | 4800 | NR | 6–9 | 97 | |
Grazoprevir | 2 | 165 | 18.0 | 1420 | 1250 | 24 | > 98.8 | |
Voxilaprevir | 4 | 192 | 47 | 2577 | NR | 33 | > 99 | |
NS5A inhibitors | ||||||||
Daclatasvir | 1–2 | 1534 | 232 | 14,122 | 47 | 12–15 | ± 99 | |
Elbasvir | 3 | 121 | 48.4 | 1920 | 680 | 31 | > 99.9 | |
Ledipasvir | 4.0 | 323 | NR | 7290 | 47 | > 99.8 | ||
Pibrentasvir | 5.0 | 110 | NR | 1430 | NR | 23–29 | > 99.9 | |
Velpatasvir (Epclusa®) | 3 | 259 | 51 | 2970 | NR | 15 | > 99.5 | |
Velpatasvir (Vosevi®) | 4 | 311 | NR | 4041 | NR | 17 | > 99 | |
NS5B inhibitors | ||||||||
Sofosbuvir/GS-331007 (Sovaldi®) | 0.5–2/2 | NR | NR | 1010/7200 | NR | 0.4/27 | 61–65/minimal | |
Sofosbuvir/GS-331007 (Harvoni®) | ~ 1/4 | 618/707 | NR | 1320/12,000 | NR | 0.5/27 | 61–65/minimal | |
Sofosbuvir/GS-331007 (Epclusa®) | 0.5–1/3 | 566/868 | NR | 1260/13,970 | NR | 0.5/25 | 61–65/minimal | |
Sofosbuvir/GS-331007 (Vosevi®) | 2/4 | 678/744 | NR | 1665/12,834 | NR | 0.5/29 | 61–65/minimal |
3.1 Daclatasvir (DCV)
3.1.1 Absorption
3.1.2 Distribution
3.1.3 Metabolism
3.2 Sofosbuvir (SOF)/Ledipasvir (LDV)
3.2.1 Absorption
3.2.2 Distribution
3.2.3 Metabolism
3.3 Elbasvir (EBR)/Grazoprevir (GZR)
3.3.1 Absorption
3.3.2 Distribution
3.3.3 Metabolism
3.4 SOF/Velpatasvir (VEL)
3.4.1 Absorption
3.4.2 Distribution
3.4.3 Metabolism
3.4.4 Excretion
3.5 Glecaprevir (GLE)/Pibrentasvir (PIB)
3.5.1 Absorption
3.5.2 Distribution
3.5.3 Metabolism
3.6 SOF/Velpatasvir (VEL)/Voxilaprevir (VOX)
3.6.1 Absorption
3.6.2 Distribution
3.6.3 Metabolism
3.6.4 Excretion
4 Drug–Drug Interactions
4.1 HIV Drugs
4.2 Immunosuppressive Drugs
4.3 Cardiovascular Drugs
4.4 Anticonvulsant Drugs
4.5 Tuberculosis Drugs
4.6 Acid-Reducing Agents
5 Efficacy and Toxicity
5.1 SOF/DCV
5.1.1 Efficacy
5.1.2 Toxicity
5.2 SOF/LDV
5.2.1 Efficacy
5.2.2 Toxicity
5.3 EBR/GZR
5.3.1 Efficacy
5.3.2 Toxicity
5.4 SOF/VEL
5.4.1 Efficacy
5.4.2 Toxicity
5.5 GLE/PIB
5.5.1 Efficacy
5.5.2 Toxicity
5.6 SOF/VEL/VOX
5.6.1 Efficacy
5.6.2 Toxicity
6 Special Populations
Population/drug | SOF/DCV | SOF/LDV | EBR/GZR | SOF/VEL | GLE/PIB | SOF/VEL/VOX |
---|---|---|---|---|---|---|
HCV genotype | ||||||
Genotype 1 | ||||||
Genotype 1a | 96 [125] | |||||
Genotype 1b | ||||||
Genotype 2 | 77a [197] | |||||
Genotype 3 | ||||||
Genotype 4 | 100 [92] | |||||
Genotype 5 | 100 [110] | 95 [67] | 25–100a,b [197] | 97 [81] | 100 [92] | 100 [98] |
Genotype 6 | 100a [55] | 96 [147] | 100 [81] | 100 [92] | ||
HCV treatment experience | ||||||
Treatment naïve | ||||||
Treatment experienced | ||||||
Cirrhosis | ||||||
Without cirrhosis | ||||||
With cirrhosis | ||||||
Special populations | ||||||
Transplant | 96 [104] | 98–100 [131] | ||||
Renal impairment | 91 [170] | |||||
HBV co-infection | 86a [99] | 100 [70] | ||||
HIV co-infection | 98 [131] | |||||
Bleeding disorder | 100 [178] | 94 [122] | ||||
Children |
6.1 Hard to Cure Patients
6.1.1 Genotype 3
6.1.2 Treatment-Experienced Patients
6.1.3 Patients with Resistance-Associated Substitutions
6.2 Liver Cirrhosis
Drug | Normal dose | Child–Pugh score A | Child–Pugh score B | Child–Pugh score C | References |
---|---|---|---|---|---|
Daclatasvir | 60 mg qd | 60 mg qd | 60 mg qd | 60 mg qd | |
Sofosbuvir/ledipasvir | 400 mg/90 mg qd | 400 mg/90 mg qd | 400 mg/90 mg qd | 400 mg/90 mg qd | |
Elbasvir/grazoprevir | 50 mg/100 mg qd | 50 mg/100 mg qd | Contraindicate | Contraindicated | |
Sofosbuvir/velpatasvir | 400 mg/100 mg qd | 400 mg/100 mg qd | 400 mg/100 mga | 400 mg/100 mga | |
Glecaprevir/pibrentasvir | 100 mg/40 mg qd | 100 mg/40 mg qd | Not recommendedb | Contraindicated | |
Sofosbuvir/velpatasvir/voxilaprevir | 400 mg/100 mg/100 mg qd | 400 mg/100 mg/100 mg qd | Not recommended | Not recommended |
6.3 Transplant Patients
6.4 Renal Impairment
Drug | Normal dose | eGFR | Removed by hemodialysis | References | ||
---|---|---|---|---|---|---|
30–50 mL/min | 10–30 mL/min | < 10 mL/min | ||||
Daclatasvir | 60 mg qd | 60 mg qd | 60 mg qd | 60 mg qd | Unlikely, high protein binding | |
Sofosbuvir/ledipasvir | 400 mg/90 mg qd | 400 mg/90 mg qd | Not recommendeda | Not recommendeda | Ledipasvir: unlikely GS-331007: yes, 53% | |
Elbasvir/grazoprevir | 50 mg/100 mg qd | 50 mg/100 mg qd | 50 mg/100 mg qd | 50 mg/100 mg qd | No | |
Sofosbuvir/velpatasvir | 400 mg/100 mg qd | 400 mg/100 mg qd | Not recommendeda | Not recommendeda | Velpatasvir: unlikely GS-331007: yes, 53% | |
Glecaprevir/pibrentasvir | 100 mg/40 mg qd | 100 mg/40 mg qd | 100 mg/40 mg qd | 100 mg/40 mg qd | No | |
Sofosbuvir/velpatasvir/voxilaprevir | 400 mg/100 mg/100 mg qd | 400 mg/100 mg/100 mg qd | Not recommended | Not recommended | Velpatasvir and voxilaprevir: unlikely GS-331007: yes, 53% |