PARIS — The early treatment of hepatitis C infection with a pan-genotypic drug combination is more effective and less expensive than if therapy is delayed until liver fibrosis develops, health economists report.
A health state-transition model of the natural history of hepatitis C shows that early therapy with the combination of glecaprevir and pibrentasvir (Mavyret, AbbVie) results in lower lifetime costs because of reductions in the risk for decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, and liver-related mortality, said researcher Scott Johnson, PhD, from Medicus Economics in Boston.
The findings from this analysis might convince insurers and policy makers to cover the costs of early hepatitis C therapy because it will eliminate expenses down the road, Johnson said here at the International Liver Congress 2018.
“We’re talking here about lifetime benefits, and payers are interested in that,” he told Medscape Medical News.
In Europe, healthcare policy frequently bases the administration of hepatitis C therapy on fibrosis stage, so patients with later-stage disease are often given preference. In the United States, the decision is usually left to third-party payers, Johnson explained.
These policies, aimed at curtailing costs, are short-sighted, he said. They ignore the reality that patients in the later stages of disease are at greater risk for hepatic and extrahepatic complications, even after a sustained viral response is achieved. And patients with later-stage disease usually require a longer course of therapy, which adds to the cost.
We’re talking here about lifetime benefits, and payers are interested in that.
In their model, Johnson and his colleagues used data from the United Kingdom to look at the impact of therapy on both liver-related and extrahepatic complications.
The team extracted modified intent-to-treat efficacy data from clinical trials that examined the combination of glecaprevir and pibrentasvir, and information on aggregated outcomes across patient genotypes, treatment history, and cirrhosis status.
The analysis modeled costs for three disease stages: mild, as indicated by a fibrosis score of F0 or F1; moderate, a score of F2 or F3; and advanced or compensated cirrhosis, a score of F4.
The model shows that the lifetime risk for compensated cirrhosis would be lower if treatment is initiated during the mild stage of disease than if it is initiated during the moderate stage (12.4% vs 23.0%).
And rates of sustained viral response would be virtually identical, regardless of when therapy is initiated. However, quality of life would be better when treatment is initiated during the mild stage of disease than when it is initiated during the moderate or advanced stage (16.2 vs 13.9 vs 10.0 quality-adjusted life years).
Table. Risks Associated With Treatment Start During Different Disease Stages
| Lifetime Risk | Mild, % | Moderate, % | Advanced, % |
|---|---|---|---|
| Decompensated cirrhosis | 4.0 | 8.9 | 11.6 |
| Hepatocellular carcinoma | 1.8 | 4.0 | 35.2 |
| Liver transplantation | 0.4 | 1.0 | 2.6 |
| Liver-related death | 3.8 | 9.1 | 41.1 |
In addition, estimated lifetime direct medical costs would be lower when treatment is initiated during the mild stage of disease than when it is initiated during the moderate or advanced stage (£32,996 vs £35,128 vs £60,963, which converts to roughly US$47,161 vs US$50,208 vs US$87,133).
“What’s new here is that if you’re assuming treatment, the costs are lower to treat earlier, because you move from a 12-week to an 8-week regimen, on average,” Johnson told Medscape Medical News.
The exception is previously treated patients with hepatitis C genotype 3 infection, who appear to require a 12-week course of therapy to achieve a sustained viral response, he noted.
High-Risk Patients
The very early treatment of acute infection in high-risk patients might be especially effective for reducing future problems associated with chronic hepatitis C, said Markus Cornberg, MD, PhD, from Hannover Medical School in Germany.
“Patients in high-risk groups, such as men who have sex with men, have viral loads during this acute infection, but most have no jaundice and don’t feel sick,” he told Medscape Medical News. They might, therefore, transmit the virus when participating in risky behavior during this phase, “so why not just pick them and treat them early?”
When health authorities in the Netherlands granted high-risk patients unrestricted access to hepatitis C therapy, there was an increase in treatment uptake and a rapid decline in new acute hepatitis C infections, Cornberg reported.
This study was supported by AbbVie. Johnson is an employee of Medicus Economics LLC, which was hired by AbbVie to conduct the study. Cornberg reports receiving fees from AbbVie unrelated to the study.
International Liver Congress (ILC) 2018: Abstract PS-058. Presented April 12, 2018.
Follow Medscape Gastro on Twitter @MedscapeGastro and Neil Osterweil @NeilOsterweil
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