FDA Warns of Liver Injury with Mavyret, Zepatier, Vosevi

The Food and Drug Administration (FDA) has received reports that the use of Mavyret, Zepatier, or Vosevi to treat chronic hepatitis C in patients with moderate to severe liver impairment has resulted in rare cases of worsening liver function or liver failure. All these medicines contain a hepatitis C virus (HCV) protease inhibitor and are not indicated for use in patients with moderate to severe liver impairment. In most patients, symptoms resolved or new onset worsening of liver function improved after stopping the medicine. These medicines have been widely used and are safe and effective in patients with no or mild liver impairment.

In many of the reported cases, liver failure occurred in patients who had signs and symptoms of moderate to severe liver impairment (Child-Pugh B or C) or other serious liver problems and should not have been treated with these medicines. In some cases, patients were reported to have no cirrhosis or compensated cirrhosis with mild liver impairment (Child-Pugh A) despite having evidence of decreased platelets at baseline or an increase in the pressure within the portal vein that carries blood from the digestive organs to the liver. In addition, some cases had other significant pre-existing risk factors such as liver cancer, alcohol abuse, or serious medical illnesses associated with serious liver problems. These factors may have contributed to clinical worsening of liver function or liver failure during treatment with these hepatitis C medicines. In most cases, liver failure or decompensation typically occurred within the first 4 weeks of starting treatment. We will continue to monitor this safety concern and will communicate any new information to the public if it becomes available.

Mavyret, Zepatier, and Vosevi are FDA-approved to treat chronic hepatitis C in patients without liver impairment or with mild liver impairment (Child-Pugh A). Clinical trials in patients with compensated cirrhosis or mild liver impairment (Child-Pugh A) have shown that these medicines are well tolerated and highly effective. These medicines reduce the amount of HCV in the body by preventing it from multiplying, which over time leads to clearing the virus from the body, or HCV cure, which can prevent or limit liver damage from HCV. HCV is a contagious disease, and without treatment it can lead to serious liver problems, including cirrhosis, liver cancer, and death. When prescribed as indicated, these medicines continue to be safe and effective.

Health care professionals should continue to prescribe Mavyret, Zepatier, or Vosevi as indicated in the prescribing information for patients without liver impairment or with mild liver impairment (Child-Pugh A). Assess severity of liver disease at baseline and closely monitor for signs and symptoms of worsening liver function such as increases in liver enzymes, jaundice, ascites, encephalopathy, and variceal hemorrhage. Assessment of baseline liver disease and close monitoring are especially important in those with pre-existing significant liver problems or risk factors, such as hepatocellular carcinoma or alcohol abuse, which can also contribute to clinical worsening of liver function or liver failure during treatment. Discontinue these medicines in patients who develop signs and symptoms of liver decompensation or as clinically indicated. Mavyret and Zepatier should not be prescribed in patients with any history of prior hepatic decompensation. Vosevi is indicated for patients who have previously failed certain other HCV treatments and is not recommended in patients with any history of hepatic decompensation unless the benefits outweigh the risk of liver injury, liver failure or death.

Patients should be aware that the risk of serious liver injury is rare. However, patients should contact their health care professional right away if fatigue, weakness, loss of appetite, nausea and vomiting, yellow eyes or skin, or light-colored stools develop, as these may be signs of liver injury. If a patients has liver impairment or other pre-existing risk factors that can worsen liver function such as a history of alcohol abuse, the patient should talk with their health care professional about the benefits and risks of the medicine. Patients should not stop taking these medicines without first talking with their health care professionals because stopping treatment early can lead to inadequate treatment, which could allow HCV to come back. Over time, this could result in progression to severe liver disease and its complications, including cirrhosis, liver cancer, and death. These medicines have been widely used and are safe and effective in patients without liver impairment or in those with mild liver impairment for whom they are indicated.

The FDA identified 63 cases of worsening liver function called liver decompensation with regimens Mavyret, Zepatier, and Vosevi to treat hepatitis C. Some of these cases led to liver failure and death. Most of these patients had moderate to severe liver impairment and should not have been prescribed these medicines. This number includes only cases submitted to FDA or those found in the medical literature, so there may be additional cases about which we are unaware. In 2018, an estimated 72,000 patients received dispensed prescriptions for Mavyret, Zepatier, or Vosevi from U.S. outpatient retail and mail-order/specialty pharmacies.

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