Background and study aim: Hepatitis C (HCV) affects nearly one in every 5 Egyptians which is the highest incidence allover the world. Most of the Egyptian Chronic Hepatitis (CHC) patients are of genotype 4 where it represents 90% of all Egyptian HCV cases. The clinical utility of antiviral therapy in elderly patients in our locality is not clear, also little information is available in literatures allover the world on treatment of such group of patients with genotype 4. The present study aimed at evaluating the efficacy and safety of combination therapy (pegylated interferon alpha 2a (PegIFN-alph2a) and ribavirin) in treatment of elderly Egyptian patients with HCV genotype 4. Patients and methods: 60 elderly Egyptian patients (more than 55years) with chronic HCV (group 1) and another group of 72 younger (less than 55 years) age patients (group 2) were enrolled in the present study. Both group of patients were compensated and all of genotype 4. Both groups received 180 mcg PegIFN-alpha2a subcutaneously once weekly and ribavirin (1000-1200mg/daily) for 48 weeks. Patients were followed for 48 weeks and sustained virological response and safety were assessed in both groups. Results : A significant improvement in both end of treatment response (ETR) and sustained virologic response (SVR) was noted in both group, where ETR was achieved in 32 (53.3%) and 41 patients (56.9%) in both groups respectively, and 27 patients in group 1 (45.0%) and 38 (52.8%) in group 2 could retain negative viraemia SVR by the end of follow up period. SVR showed a non-significant negative correlation with age. Viral clearance after 4weeks of therapy was associated with high incidence of ETR and SVR (P <0.001), but without significant difference between both groups. Rate of discontinuation and periods of discontinuation and side effect and safety of therapy was not significantly different in both groups. Conclusion : Despite these challenges, the present study showed that HCV treatment was generally well tolerated by the elderly Egyptian patients (55-68 years) with a little or no significant difference in SVR as well as therapy discontinuation rates secondary to adverse effects compared to younger age groups. Therefore, we recommend that chronic HCV Egyptian patients of age 55 years and more should be included in trials of chronic hepatitis C treatment and old age is no more contraindication for interferon/ribavirin therapy and the risk-benefit of antiviral therapy should be assessed on an individual basis.