Is it cost-effective to treat recurrent hepatitis C infection in orthotopic liver transplantation patients?

Abstract

Hepatitis C virus (HCV) recurs in the allograft almost universally after orthotopic liver transplantation (OLT), with a variable course ranging from mild hepatitis to frank cirrhosis. The uncertain prognosis after OLT has lead to widely increased use of antiviral therapy in the post-OLT setting. We compared two scenarios (antiviral therapy versus no antiviral therapy) using a Markov-based decision analytic model to simulate costs and health outcomes for recurrent HCV in three age and sex cohorts of post-OLT patients. Efficacy outcomes included total costs, cases of cirrhosis prevented, cases of death prevented, lifeyears gained, and cost per life-year saved. One-way sensitivity analyses were performed for sustained viral response; annual drug cost, discount rate, compliance, cirrhosis rate, decompensation rate, and cost of dying. Two-way sensitivity analyses were performed to compare effects of (1) changing sustained viral response and antiviral therapy costs, and (2) changing the sustained viral response and cirrhosis rate. The incremental cost-effectiveness ratio for the reference patient cohort of 1,000 men aged 55 years was $29,100 per life-year saved. The model was sensitive to drug costs, cirrhosis rate, and sustained viral response. The two-way sensitivity analysis showed that antiviral therapy remained cost-effective even if drug costs increased, as long as these increases were associated with higher sustained viral responses. The costeffectiveness ratio also was sensitive to age and sex of cohort. The decision to treat HCV after OLT with antiviral therapy usually is based on many considerations. O rthotopic liver transplantation (OLT) is definitive therapy for patients with decompensated liver disease. Whereas the 1-year survival rate in patients with decompensated liver disease is between 50% and 70%, OLT increases survival to almost 90%. 1-4 Hepatitis C virus (HCV) is one of the leading causes of cirrhosis in patients undergoing OLT in the United States. It now accounts for the majority of liver transplantations in the United States. 5 As the population of individuals infected with HCV several decades ago begin to develop liver disease, the number and relative proportion of patients who undergo OLT for HCV is likely to increase further. 6 HCV recurrence is almost universal after OLT.After 5 years, approximately 75% of transplant recipients have recurrent HCV. 7 Recurrence does not appear to affect short-term survival. The 5-year survival rate of patients who undergo OLT for HCV is similar to that of patients who undergo OLT for other causes of decompensated liver disease. 1,[8][9][10] However, HCV recurrence may have an adverse impact on long-term survival after OLT. Between 8% and 31% of patients who undergo OLT for HCV develop cirrhosis in 5 to 7 years. 8,9,[11][12][13][14][15][16] Thus, the clinical impact of HCV may not be seen for almost a decade after OLT. However, a subgroup of individuals who undergo OLT for HCV have an accelerated course and develop decompensation within several months of OLT...

Duration of antiviral therapy for cholestatic HCV recurrence may need to be indefinite

“…[1][2][3][4][5] There has been a great deal of interest in antiviral therapy for hepatitis C virus (HCV) recurrence, 6,7 with some studies suggesting that combination therapy with alfa interferon (IFN) and ribavirin (RIB) may be beneficial in preventing the progression to liver allograft failure, 8,9 and, as a result, combination antiviral may be costeffective. 10 However, a number of important questions remain undefined, including for whom and when therapy should be initiated, for how long, what are the endpoints of therapy (eg, biochemical and histologic improvement, sustained virologic clearance), and what factors are predictive of long-term outcome. The augmented side effects and limited efficacy of antiviral therapy underscore the importance of addressing these questions in prospective randomized trials.…”

Cost-effectiveness analysis of antiviral treatment in liver transplant recipients with HCV infection

“…Prior to our analysis, cost-effectiveness of HCV treatment post OLT has only been studied by Saab et al in a North American cohort of patients [42,43]. In his first study [42], antiviral treatment with an estimated SVR of 20% resulted in a gain of 0.41 life-years compared with no treatment.…”

“…In his first study [42], antiviral treatment with an estimated SVR of 20% resulted in a gain of 0.41 life-years compared with no treatment. Quality of life was not considered.…”

Treatment of hepatitis C virus infection in the allograft

“…There have been few studies evaluating costs in this situation. Saab 38 used Markov modeling to assess the cost effectiveness of antiviral therapy after liver transplantation. Costs were estimated using the best available data: antiviral drug costs, $12,700/y; filgastrina and erythropoietin, $300/y; treating cirrhosis, $425, and decompensated cirrhosis, $20,000.…”