By Cheryl Lathrop
BOSTON -- November 4, 2009 -- Treatment with pegylated interferon and ribavirin (PEG/RBV) therapy during compensated cirrhosis is the most cost-effective strategy for antiviral administration in the setting of advanced hepatitis C virus (HCV)-related liver disease, researchers noted here at the Liver Meeting 2009, the 60th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD).
This strategy yields the greatest survival benefit with the lowest associated cost; it reverses cirrhosis, and prevents decompensation, transplantation, hepatocellular carcinoma (HCC), and death. Sammy Saab, MD, MPH, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and colleagues reported evidence from their study for treating HCV in patients with compensated cirrhosis before it progresses to more advanced liver disease. The poster presentation was held here on October 31.
Antiviral therapy for the treatment of HCV infection is used both before and after liver transplantation. The objective of this study was to determine the ideal timing for PEG/RBV therapy in patients with advanced liver disease infected with genotype 1 HCV.
The 4 treatment groups were as follows: (1) no antiviral treatment, (2) antiviral therapy in patients with compensated cirrhosis, (3) antiviral therapy in patients with decompensated cirrhosis, and (4) antiviral therapy in patients with recurrent HCV post transplant. A Markov model was constructed comparing treatment strategies. Outcomes of interest were total cost per patient, number of quality-adjusted life-years (QALYs) saved, number of deaths, number of HCCs, and number of transplants required. Each of the 4 treatment arms comprised 1,000 patients.
The total cost per patient for treatment during compensated cirrhosis was $331,425; the total cost per patient for each of the other 3 treatment groups was approximately $152,000 more. The life expectancy for treatment during compensated cirrhosis was almost 10 QALY; for the other 3 groups it was about 7 QALY.
In the 10-year outcome data, a total of approximately 250 patients died in the compensated cirrhosis treatment group; approximately 500 patients died in each of the other 3 groups. A total of approximately 175 patients had a transplant in the compensated cirrhosis treatment group; approximately 200 patients had a transplant in each of the other 3 groups. About 50 patients had regression of cirrhosis in the compensated-cirrhosis treatment group.
Treatment of patients with compensated cirrhosis was the most cost-effective strategy; it resulted in improved survival and decreased cost when compared with the other 3 strategies. Treatment after development of decompensated cirrhosis or post transplant was also cost-effective, but these patients derived less survival benefit at greater cost (when compared with patients treated during compensated cirrhosis). Patients who were allowed to develop more advanced disease had a considerably worse prognosis. All 3 treatment strategies appeared more cost-effective than "no treatment," which suggests that these patients may benefit from antiviral treatment.
"Given these results, we strongly recommend expeditious administration of antiviral therapy to patients with compensated cirrhosis before their disease advances," the authors stated.
These treatment strategies must be studied further, however, before they can be universally recommended, they advised.
[Presentation title: Timing of Hepatitis C Antiviral Therapy Pre and Post Liver Transplantation: A Decision Analysis Model. Abstract 503]
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