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TREATMENT OF HEPATITIS C CIRRHOSIS USING PEGYLATED INTERFERON: MONEY WELL
SPENT?
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W. Ray Kim, John J Poterucha, Mayo Clinic, Rochester, MN
Background: Pegylated interferon (peg-IFN) administered once weekly in
patients with cirrhosis from chronic hepatitis C (HCV) has been shown to be
significantly more effective than standard IFN. Emerging data suggest that
sustained virologic response (SVR) in HCV cirrhosis may prevent hepatic
decompensation or hepatocellular carcinoma (HCC).
Aims:(1) to determine whether peg-IFN treatment of HCV cirrhosis may be
economically justified and (2) to examine factors that influence its
cost-effectiveness.
Methods: Based on (1) data obtained from a randomized trial evaluating the
efficacy of 40 kDa peg-IFN alfa-2a in patients with HCV cirrhosis (NEJM
2000;1673) and (2) our previously published Markov model (Annals Int Med
1997;866), updated with more recent data, incremental cost-effectiveness
analysis was conducted. Our computer simulation included 3000 patients with
compensated HCV cirrhosis (age=45) that were assigned to receive either no
treatment or recommended doses of peg-IFN for 48 weeks.
As time elapsed, patients developed hepatic decompensation (4%/year) or HCC
(1.5%/year), which led to liver transplantation and/or death. Sustained
virologic response (SVR), achieved with peg-IFN in 12% of patients with
genotype 1 and 50% of those with other genotypes, was conservatively assumed
to reduce the risk of hepatic decompensation and HCC by 50%.
No benefit was assumed for patients who did not achieve SVR. editorial note:
this appears to me to be a conservative approach since data from studies
suggest interferon without an SVR may improve histology and outcomes.
Peg-IFN was discontinued prematurely in 25% of patients for reasons such as
intolerance or adverse events (10%).
Results: In the table, at 10 years following therapy, peg-IFN reduced the risk of
hepatic decompensation by 2-7% and that of HCC by up to 3%, depending on the
genotype. Over the lifetime of the patient, peg-IFN was associated with
reduction in mortality from liver disease by 2% (genotype 1) and 10% (others)
and saving of $2,600 (genotype 1) and $10,900 (others) in healthcare costs
for future hepatic decompensation and HCC. Overall, the cost per a year of
life saved was comfortably within established criteria for genotype 1 and
extremely favorable for other genotypes. Of factors that affected the overall
cost-effectiveness of peg-IFN, the degree to which the risk of hepatic
decompensation or HCC was reduced by SVR was most influential. However,
peg-IFN remained cost-effective if the risk reduction was at least 30% for
genotype 1 and 10% for other genotypes. Conclusions: Even using very
conservative estimates for future benefits of SVR, we found the
cost-effectiveness of peg-IFN therapy for compensated HCV cirrhosis well
within the accepted limit. Treatment of compensated HCV cirrhosis with
peg-IFN is strongly supported, particularly in patients with genotypes other
than 1.
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