Shorter direct-acting antiviral courses have been tested in people without cirrhosis, and missing cirrhosis can lead to undertreatment. APRI and FIB-4 are useful first steps but miss some patients with cirrhosis; transient elastography, where available, is more accurate. Clinical signs of portal hypertension, low platelets or nodular liver on ultrasound should also prompt caution. If in doubt, treat as cirrhotic and arrange hepatocellular carcinoma surveillance.
- Calculate APRI and FIB-4 before treatment.
- Use transient elastography where available to confirm absence of cirrhosis.
- Check platelets and ultrasound for signs of portal hypertension.
- When uncertain, use the cirrhosis regimen and start liver cancer surveillance.
Why it matters
Short-course evidence only holds for patients who truly have no cirrhosis.
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