In a cohort of patients with CHC, ARFI imaging was more accurate than TE for the non-invasive staging of both significant and severe classes of liver fibrosis.
Modified spleen stiffness measurement by transient elastography is associated with presence of large oesophageal varices in patients with compensated hepatitis C virus cirrhosis 1
on behalf of the WEF Study GroupRandomized controlled trials (RCTs) show that triple therapy (TT) with peginterferon alpha, ribavirin, and boceprevir (BOC) or telaprevir (TVR) is more effective than peginterferon-ribavirin dual therapy (DT) in the treatment of previously untreated patients with genotype 1 (G 1 ) chronic hepatitis C (CHC). We assessed the cost-effectiveness of TT compared to DT in the treatment of untreated patients with G 1 CHC. We created a Markov Decision Model to evaluate, in untreated Caucasian patients age 50 years, weight 70 kg, with G 1 CHC and Metavir F2 liver fibrosis score, for a time horizon of 20 years, the cost-effectiveness of the following five competing strategies: 1) boceprevir response-guided therapy (BOC-RGT); 2) boceprevir IL28B genotype-guided strategy (BOC-IL28B); 3) boceprevir rapid virologic response (RVR)-guided strategy (BOC-RVR); 4) telaprevir response-guided therapy (TVR-RGT); 5) telaprevir IL28B genotype-guided strategy (TVR-IL28B). Outcomes included life-years gained (LYG), costs (in 2011 euros) and incremental cost-effectiveness ratio (ICER). In the base-case analysis BOC-RVR and TVR-IL28B strategies were the most effective and cost-effective of evaluated strategies. LYG was 4.04 with BOC-RVR and 4.42 with TVR-IL28B. ICER compared with DT was €8.304 per LYG for BOC-RVR and €11.455 per LYG for TVR-IL28B. The model was highly sensitive to IL28B CC genotype, likelihood of RVR and sustained virologic response, and BOC/TVR prices. Conclusion: In untreated G 1 CHC patients age 50 years, TT with first-generation protease inhibitors is costeffective compared with DT. Multiple strategies to reduce costs and improve effectiveness include RVR or genotype-guided treatment. (HEPATOLOGY 2012;56:850-860) T he estimated global prevalence of hepatitis C virus (HCV) infection is 2.2%, corresponding to about 130 million HCV-positive persons worldwide, most of whom are chronically infected. 1 A recent revision 2 reported that the estimated prevalence of HCV infection in Europe ranges from 0.6% to 5.6%. This is of increasing interest because HCV is a leading cause of both cirrhosis and hepatocellular carcinoma (HCC) in Western countries. The prevalence of HCV-related cirrhosis and its complications will continue to increase through the next decade, and will mostly affect those above age 60. 3 Considering the burden of HCV-related cirrhosis and its complications, the achievement of a sustained virologic response (SVR) is a very important surrogate outcome in the management of chronic hepatitis C (CHC) patients. In fact, viral eradication prevents the development of cirrhosis 4 and its complications, such as esophageal varices 5 and HCC, 6 and leads to a decrease in liver-related death. 7
P ortal hypertension (PH), defined by a hepatic venous pressure gradient (HVPG) greater than 6 mmHg, 1 is a common complication of cirrhosis. The presence and the development of esophageal varices (EV) is a clinical manifestation of PH, 2,3 with a prevalence that can range from 40% to 80% in patients with cirrhosis. This prevalence increases progressively in relation to the severity of liver damage. 4,5 The presence of EV is also a clear indicator of a certain stage of cirrhosis. 6 The development of EV in patients with cirrhosis occurs when the HVPG is greater than 10 mmHg, 3,7 with an incidence of approximately 5% per year and a yearly rate of progression to larger varices of 5% to 15%. 4,5,8 The clinical relevance of EV is linked to the risk of bleeding that occurs when HVPG is greater than 12 mmHg, 7-9 with a mortality rate that exceeds 20% within 6 weeks from the bleeding episode, despite aggressive treatment. 10 The Baveno IV 2005 Consensus Workshop 11 and the American Association for the Study of Liver Diseases 2007 single-topic symposium on portal hypertension 12 recommended that endoscopic screening for esophageal and gastric varices should always be performed when a diagnosis of cirrhosis is made. Upper endoscopy should be repeated at 2-year to 3-year intervals in patients without varices, and at 1-year to 2-year intervals in those with small varices, to evaluate their development or progression. 11,12 These guidelines might not be ideal for clinical
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