Treatment of patients waitlisted for liver transplant with all‐oral direct‐acting antivirals is a cost‐effective treatment strategy in the United States

Ahmed, Aijaz; Gonzalez, Stevan A.; Cholankeril, George; Perumpail, Ryan B.; McGinnis, J.J.; Saab, Sammy; Beckerman, Rachel; Younossi, Zobair M.

doi:10.1002/hep.29137

Cited by 25 publications

(25 citation statements)

References 40 publications

(66 reference statements)

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“…24,29 Pretransplant patients who are pre-cirrhotic or who have well-compensated disease may benefit from early HCV treatment with stabilization or regression of chronic liver disease, potentially avoiding LT entirely. Ahmed et al recently reported a Markov analysis comparing delayed or immediate HCV treatment among patient waiting for LT. 30 The benefit of HCV treatment varied according to clinical condition. Among patients with decompensated liver disease, pre-LT treatment was associated with improved survival (9.3 vs. 8.7 quality-adjusted life-years) but higher costs ($304,800 USD vs. $283,789 USD).…”

Section: Discussionmentioning

confidence: 99%

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes

Axelrod

Schnitzler

Alhamad

et al. 2018

American Journal of Transplantation

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Direct-acting antiviral medications (DAAs) have revolutionized care for hepatitis C positive (HCV+) liver (LT) and kidney (KT) transplant recipients. Scientific Registry of Transplant Recipients registry data were integrated with national pharmaceutical claims (2007-2016) to identify HCV treatments before January 2014 (pre-DAA) and after (post-DAA), stratified by donor (D) and recipient (R) serostatus and payer. Pre-DAA, 18% of HCV+ LT recipients were treated within 3 years and without differences by donor serostatus or payer. Post-DAA, only 6% of D-/R+ recipients, 19.8% of D+/R+ recipients with public insurance, and 11.3% with private insurance were treated within 3 years (P < .0001). LT recipients treated for HCV pre-DAA experienced higher rates of graft loss (adjusted hazard ratio [aHR] 1.85 , P < .0001) and death (aHR 1.68 , P < .0001). Post-DAA, HCV treatment was not associated with death (aHR 0.67 , P = .25) or graft failure (aHR 0.64 , P = .20) in D+R+ LT recipients. Treatment increased in D+R+ KT recipients (5.5% pre-DAA vs 12.9% post-DAA), but did not differ by payer status. DAAs reduced the risk of death after D+/R+ KT by 57% ( 0.43 , P = .04) and graft loss by 46% ( 0.54 , P = .08). HCV treatment with DAAs appears to improve HCV+ LT and KT outcomes; however, access to these medications appears limited in both LT and KT recipients.

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Section: Discussionmentioning

confidence: 99%

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes

Axelrod

Schnitzler

Alhamad

et al. 2018

American Journal of Transplantation

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“…Other studies have investigated the optimal timing of DAA treatment for patients listed for transplant, using a decision analytical model . The first was the study by Njei et al that considered only patients with decompensated cirrhosis without HCC.…”

Section: Discussionmentioning

confidence: 99%

“…Once again, the PRE‐LT treatment emerged as more effective for patients with a MELD score lower than 23. A final study from Ahmed et al considered patients with decompensated cirrhosis or with HCC in the same model and showed that antiviral therapy given PRE‐LT was more cost‐effective than if given post‐LT. In all these studies, the positive effect of treating with DAA prior to LT was ascribed to a reduction in the MELD score and to a consequent lower risk of death while waiting for a LT.…”

Section: Discussionmentioning

confidence: 99%

“…Other studies have investigated the optimal timing of DAA treatment for patients listed for transplant, using a decision analytical model. 9,[12][13][14] The first was the study by Njei model and showed that antiviral therapy given PRE-LT was more cost-effective than if given post-LT. In all these studies, the positive effect of treating with DAA prior to LT was ascribed to a reduction in the MELD score and to a consequent lower risk of death while waiting for a LT.…”

Section: Discussionmentioning

confidence: 99%

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The optimal timing of hepatitis C therapy in liver transplant‐eligible patients: Cost‐effectiveness analysis of new opportunities

Cortesi

Belli

Facchetti

et al. 2018

Journal of Viral Hepatitis

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Different strategies of DAAs treatment are currently possible both pre- and postliver transplantation (LT). Clinical and economic consequences of these strategies still need to be adequately investigated; this study aims at assessing their cost-effectiveness. A decision analytical model was created to simulate the progression of HCV-infected patients listed for decompensated cirrhosis (DCC) or for hepatocellular carcinoma (HCC). Three DAAs treatment strategies were compared: (i) a 12-week course of DAAs prior to transplantation (PRE-LT), (ii) a 4-week course of DAAs starting at the time of transplantation (PERI-LT) and (iii) a 12-week course of DAAs administered at disease recurrence (POST-LT). The population was substratified according to HCC presence and, in those without HCC, according to the MELD score at listing. Data on DAAs effectiveness were estimated using a cohort of patients still followed by 11 transplant centres of the European Liver and Intestine Transplant Association and by data available in the literature. In this study, PRE-LT treatment strategy was dominant for DCC patients with MELD<16 and cost-effective for those with MELD16-20, while POST-LT strategy emerged as cost-effective for DCC patients with MELD>20 and for those with HCC. Sensitivity analyses confirmed PRE-LT as the cost-effective strategy for patients with MELD≤20. In conclusion, PRE-LT treatment is cost-effective for patients with MELD≤20 without HCC, while treatments after LT are cost-effective in cirrhotic patients with MELD>20 and in those with HCC. It is worth reminding, though, that the final choice of a specific regimen at the patient level will have to be personalized based on clinical, social and transplant-related factors.

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“…

We read with interest the study by Ahmed et al (1) identifying the cost-effectiveness of all direct-acting antivirals (DAAs) for patients with hepatitis C virus (HCV) awaiting liver transplant (LT) in the United States.A few things should be considered before applying the findings of Ahmed et al (1) to clinical practice. There are possible selection biases in the base case scenario, for example, the ASTRAL-4 cohort, (2) which may not reflect the full spectrum of the US population.

…”

mentioning

confidence: 99%

Societal perspectives analysis for evaluating direct‐acting antiviral affordability while awaiting liver transplant

et al. 2017

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We read with interest the study by Ahmed et al. (1) identifying the cost-effectiveness of all direct-acting antivirals (DAAs) for patients with hepatitis C virus (HCV) awaiting liver transplant (LT) in the United States.A few things should be considered before applying the findings of Ahmed et al. (1) to clinical practice. There are possible selection biases in the base case scenario, for example, the ASTRAL-4 cohort, (2) which may not reflect the full spectrum of the US population. The ASTRAL-4 study (2) included a predominantly white population (90%) According to the United Network of Organ Sharing database in year 2016, approximately 20% of LT waitlist cases resulted in death or removal from the waitlist. The proportion of DAA users among HCV patients awaiting LT is largely unknown. Uncertainty remains regarding the Trump administration's actions on DAA coverage for patients with HCV waiting LT. In these contexts, Kieslich et al. (5) suggested that both the patient and the public should be proactively engaged to promote DAA coverage for HCV treatment as an urgent agenda for the media and policymakers. Simultaneously, newer costeffectiveness analyses of DAA coverage should be tested again, ideally by two reference case perspectives-the societal and payers' perspectives-and should be put forward to identify the most affordable ways to cover DAAs for US patients with HCV awaiting LT. (6)

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Treatment of patients waitlisted for liver transplant with all‐oral direct‐acting antivirals is a cost‐effective treatment strategy in the United States

Cited by 25 publications

References 40 publications

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes

The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes

The optimal timing of hepatitis C therapy in liver transplant‐eligible patients: Cost‐effectiveness analysis of new opportunities

Societal perspectives analysis for evaluating direct‐acting antiviral affordability while awaiting liver transplant

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