Direct Acting Antiviral Therapy After Liver Transplantation

Paul Y. Kwo


Curr Opin Gastroenterol. 2016;32(3):152-158. 

In This Article

Treatment Options for Patients Postorthotopic Liver Transplant

Prior to the era of all oral DAA agents SVR rates after transplant were markedly reduced compared to nontransplant patients because of the inability of the patients posttransplant to tolerate the interferon-based regimen and the reduced renal function leading to greater anemia with ribavirin.[10] However, the era of oral DAA agents has changed this, and at this time, those who are post-OLT with hepatitis C should be expected to achieve sustained response rate at similar rates as those who have not undergone OLT. Moreover, DAA agents now serve as a rescue therapy for the dreaded complication of fibrosing cholestatic hepatitis C, which has been associated with a poor prognosis.[11]

Sofosbuvir and Ribavirin

Sofosbuvir and ribavirin was the first all oral combination that was reported to be effective after transplantation. The safety and efficacy of 24 weeks of sofosbuvir with ribavirin has been in 40 patients post-OLT of whom 80% were men, 85% white, and 83% genotype 1 with 40% having advanced fibrosis.[12] The majority of individuals have been previously treated with interferon-based therapies. An overall sustained response rate was noted in 28 of 40 patients (70%) with relapse accounting for all cases of virologic failure and all six genotype 3 individuals achieving SVR. The initial ribavirin dose was 400 mg and was subsequently titrated. Importantly, unlike interferon-based therapies, no graft losses or episodes of rejection occurred given there was no immune modulation with this strategy. Finally, a broad range of antirejection regimens were allowed, including tacrolimus, cyclosporine, mycophenolate, and azathioprine. Although the addition of other DAAs to sofosbuvir improves the SVR rate, this combination may be used with all genotypes without adjustments for drug–drug interactions.