Consider whether the patient has decompensated liver disease

Patients with hepatitis C who have decompensated liver disease (Child–Pugh class B or C cirrhosis, a Model for End-stage Liver Disease [MELD] score over 13¹, or ascites) should be managed by a specialist. Treatment regimens and monitoring in this group are more complex.

The recommended antiviral regimen for patients with decompensated liver disease is sofosbuvir+velpatasvir plus ribavirin; close monitoring may be required. The NS3/4A protease inhibitors (eg glecaprevir, grazoprevir, voxilaprevir) are not recommended in patients with Child–Pugh class B cirrhosis, and are contraindicated in patients with Child–Pugh class C cirrhosis, because of the risk of liver toxicity.