First-Hand Insights into Treating Hepatitis C in Pregnancy

At IDWeek, the session "Should HCV Be Treated in Pregnant Persons?" featured Catherine Chappell, MD, MSc, assistant professor at the University of Pittsburgh. Chappell, an obstetrician-gynecologist with training in reproductive infectious disease, family planning, and addiction medicine, discussed ongoing studies on direct-acting antivirals for treating hepatitis C in pregnancy.

The session aimed to equip participants with key learning objectives, including applying data regarding the safety and effectiveness of HCV antivirals in pregnant individuals, the role of shared decision-making in HCV treatment, and how HCV treatment can enhance self-efficacy and engagement in care for other health challenges.

Chappell emphasized the current evidence supporting the treatment of HCV in pregnant persons, stating, “We have conducted two studies involving pregnant individuals with hepatitis C, evaluating the pharmacokinetics of ledipasvir and sofosbuvir during pregnancy. Our findings indicated that no dose adjustments are necessary, as the concentrations in pregnant individuals were comparable to those in non-pregnant individuals. Currently, we are also conducting a large prospective cohort study of sofosbuvir in pregnant people.”

Chappell summarized her key takeaways: "No dose adjustments are needed. We have the most robust data for the sofosbuvir-based regimen, but significant data gaps remain, particularly regarding the safety of the cabotegravir-prep regimen. There is also very limited data on the safety of breastfeeding, indicating that we still have areas to explore further.”

Turning to the potential risks and benefits of treating HCV during pregnancy, Chappell highlighted, “The potential benefits of treating hepatitis C during pregnancy include achieving a maternal cure while the patient is engaged in care and has insurance coverage, allowing for treatment during antenatal care. Hepatitis C treatment has significant benefits, including preventing morbidity and mortality from liver complications, reducing community transmission, and providing psychological benefits for patients. Additionally, there is evidence suggesting that treatment may mitigate risks associated with hepatitis C in pregnancy, such as cholestasis, preterm birth, and fetal growth restriction.”

Chappell also addressed the risks associated with treatment, stating, “The risks associated with hepatitis C treatment in pregnancy depend on the gestational age at the time of exposure. Currently, there is no evidence suggesting increased risk to the mother or fetus based on the limited data available. Theoretically, treatment initiated after organogenesis, which is completed by 16 weeks, should not increase the risk of birth defects. However, there may be concerns regarding an increased risk of preterm birth or fetal growth restriction if treatment occurs later in pregnancy. Despite this, the available data does not indicate an increased risk.”

When discussing practical applications, she advised, “When considering treatment, I recommend starting after the anatomy ultrasound is completed to ensure that there are no birth defects present that a patient might mistakenly attribute to the treatment. The 20-week ultrasound is critical in this regard. We have the most data on sofosbuvir-based regimens; however, insurance coverage may sometimes restrict the ability to prescribe these regimens. Therefore, it’s important to consider whatever treatment the insurance supports. Ideally, treatment should begin late in the second trimester or early in the third trimester, with the goal of completing the course before delivery.

Finally, Chappell highlighted the patient perspective, stating, “In my experience, patients often want the opportunity to discuss treatment options during pregnancy and to have ownership over their decision-making. They can't make informed choices unless we present the options to them. Therefore, I encourage healthcare providers to talk to their pregnant patients with hepatitis C about potential treatment options during pregnancy.”

Overall, no dose adjustments are necessary for direct-acting antivirals in pregnant individuals, with strong support for the sofosbuvir-based regimen. Benefits include maternal cure, prevention of liver complications, and reduced perinatal transmission, with minimal risks after 16 weeks gestation. Guidelines recommend starting treatment after the 20-week ultrasound through shared decision-making. Collaboration with high-risk OBs and perinatal addiction specialists is important, and patients want the option to discuss treatment during pregnancy.

Reference

Chappell, C. Should HCV Be Treated in Pregnant Persons?- What We Know So Far. Session 17; poster #1884, presented at IDWeek 2024. October 16-19, 2024. Los Angeles, CA.