skip to main content

Chronic hepatitis C requiring glecaprevir/pibrentasvir — DFSRH MCQ

Instant feedback + full explanation. One question, done properly.

HardHepatologyChronic hepatitis C requiring glecaprevir/pibrentasvirDFSRH

A 28-year-old woman with chronic hepatitis C is due to start an 8-week course of glecaprevir/pibrentasvir in 48 hours. She has compensated liver disease, with normal bilirubin, albumin and INR, no cirrhosis and no hepatic mass. She uses a 21/7 combined oral contraceptive containing ethinylestradiol 30 micrograms and levonorgestrel. She is on day 15 of active tablets and has taken every tablet correctly in this and the preceding packet. There has been no vomiting, severe diarrhoea or interacting medication. She had condomless intercourse yesterday. A high-sensitivity urine pregnancy test today is negative. The hepatology team asks for an urgent contraceptive plan because of the anticipated antiviral interaction. She wants highly effective, user-independent contraception and accepts an etonogestrel implant. There is no contraindication to implant use. Which is the most appropriate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Insert the implant today, stop the combined pill today, give no emergency contraception or additional precautions, and commence glecaprevir/pibrentasvir as planned

Glecaprevir/pibrentasvir must not be co-administered with ethinylestradiol-containing products because this combination increases the risk of ALT elevations. This is a hepatotoxicity interaction, not simply a concern about reduced contraceptive efficacy. Progestogen-only contraceptives, including the etonogestrel implant, have no clinically significant interaction identified in the product information. She is in week 3 of correctly used CHC and has completed more than 7 consecutive active tablets. FSRH guidance therefore permits immediate insertion of the implant with no additional contraceptive precautions. The condomless intercourse occurred while CHC protection was intact, so emergency contraception is not indicated. The negative pregnancy test is too early to assess intercourse yesterday but does not alter management because there was no contraceptive failure. Option D creates prohibited ethinylestradiol exposure during antiviral therapy. Option B incorrectly applies the 7-day implant precaution used when switching from less reliably suppressive situations, such as week 1 after a hormone-free interval. Option C treats protected intercourse as an emergency-contraception indication. Option A unnecessarily prolongs ethinylestradiol exposure and delays effective hepatitis C treatment; neither implant insertion nor antiviral initiation needs to await a withdrawal bleed.

Reference: Glecaprevir/Pibrentasvir 100 mg/40 mg film-coated tablets — Summary of Product Characteristics (11 March 2024) — https://www.medicines.org.uk/emc/product/763/smpc FSRH Clinical Guideline: Progestogen-only Implant (February 2021, amended July 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-progestogen-only-implants.pdf