Sofosbuvir with velpatasvir and voxilaprevir

How it works

Sofosbuvir inhibits the NS5B polymerase, velpatasvir inhibits the NS5A protein, and voxilaprevir inhibits the NS3/4A protease — three complementary targets that provide a high barrier to resistance for treatment-experienced infection.

Prescribing in practice

• Co-administration with amiodarone risks serious symptomatic bradycardia and should generally be avoided; review for this and other significant interactions before starting.
• The voxilaprevir protease-inhibitor component means it is not recommended in moderate-to-severe hepatic impairment (decompensated cirrhosis), and acid-suppressing drugs and potent enzyme inducers can reduce efficacy.
• Screen for hepatitis B before treatment owing to the risk of HBV reactivation during HCV direct-acting antiviral therapy.

Monitoring

Monitor HCV viral load to confirm response and assess hepatic function, reserving this regimen for appropriate compensated liver disease and watching for hepatitis B reactivation.

Counselling the patient

• Take one tablet once daily with food for the full prescribed course.
• Share a complete list of your medicines, including indigestion remedies and herbal products such as St John's wort.
• Report any fainting or very slow heartbeat, especially if you take medicines for heart rhythm.

Evidence & guidelines

Sofosbuvir with velpatasvir and voxilaprevir is recommended by NICE as a salvage regimen for chronic hepatitis C in patients previously treated with direct-acting antivirals, supported by the POLARIS trials.