Treatment of HCV infection in the setting of cirrhosis remains a challenge. In patients with compensated cirrhosis, combination therapy is the preferable choice, although the optimal regimen has not been defined. Some general recommendations can be made. Patients with genotype 1 should be treated for a total of 48 weeks with high doses of RBV and high doses of either PEG-IFN α-2a or PEG-IFN α-2b. There is no difference in efficacy between the two regimens, although it is important to consider that patients with cirrhosis are more likely to suffer from hematological adverse effects, which are more common with PEG-IFN. Patients with genotype non-1 may require lower doses of RBV, and 24 weeks of treatment duration might be enough. In cases where RBV is contraindicated, patients should be treated with PEG-IFN alone. The treatment for patients with decompensated cirrhosis remains controversial, and antiviral therapy should not be used outside a clinical trial, and then only with very close monitoring by experts in the field. Management of hepatitis C after liver transplant is also an area to be explored. Although treatment should be offered to patients, the ideal regimen and dosage remain undefined. Combination therapy with PEG-IFN and RBV along with judicious growth factor use appears to hold the greatest promise.
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