March 07, 2017
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DAA therapy more cost effective prior to LT than after

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Treating patients with hepatitis C and hepatocellular carcinoma or decompensated cirrhosis with all-oral direct-acting antiviral therapy prior to liver transplantation had highly effective results and was more cost effective than treating post-LT, according to simulated results of a recent study.

“From a cost perspective, while the acquisition cost of DAA treatment is identical in the pre- and post-LT settings, the total per-patient lifetime costs for the patient are higher pre-LT versus post-LT,” Aijaz Ahmed, MD, of the Stanford University School of Medicine, and colleagues wrote. “This is explained by the longer time spent on the [waitlist] for patients treated pre-LT, which is a costly state in our model, relative to patients assumed cured after transplant, where costs are assumed to be negligible. When the total lifetime costs associated with the pre-LT treatment strategy are placed in context with the [quality-adjusted life years (QALYs)] accrued by the patient, the pre-LT strategy is nonetheless cost-effective.”

The researchers designed two models to simulate 1,000 HCV genotype 1 patients with either HCC or decompensated cirrhosis. The mean age of the patients was 50 years. Patients were waitlisted for LT and followed for 30 years to simulate a lifetime horizon.

Sustained virologic response rates for HCV genotype 1 patients undergoing pre-LT treatment were sourced from the ASTRAL-4 study and patients undergoing post-LT treatment were sourced from the SOLAR studies. Treatment costs were based on RedBook pricing, monitoring costs were based on CMS pricing and all health-state costs were based on a study on chronic HCV infection associated costs.

Decompensated cirrhosis

Researchers separated patients in the decompensated cirrhosis model based on MELD score (those with a score 15 vs. < 15). They then analyzed patients in each group based on pre-LT treatment vs. post-LT treatment.

For patients with decompensated cirrhosis and a MELD score of 15 or higher in the post-LT arm, the mean waitlist time was 0.75 years, 15.7% died on the waitlist, 75.6% received LT, 667 achieved SVR, 4.9 had HCC, 447 died from liver-related causes, and follow-up showed an average of 8.69 per patient QALYs, 10.9 per patient life years (LYs) and $283,789 per patient lifetime costs. Comparatively, in the pre-LT arm, results included a mean waitlist time of 2.08 years, 13.3% waitlist deaths, 72.4% received LT, 902 patients achieved SVR, 4.7 had HCC, 447 liver-related deaths, 9.27 QALYs, 11.19 LYs and $304,800 per patient lifetime costs.

Regarding patients with decompensated cirrhosis and a MELD score under 15 in the post-LT arm, the mean waitlist time was 2.05 years, 18.1% died on the waitlist, 65.8% received LT, 580 achieved SVR, 14.1 had HCC, 535 died from liver-related causes, and follow-up showed an average of 8.04 QALYs, 10.31 LYs and $249,025 per patient lifetime costs. In comparison, the pre-LT results included a mean waitlist time of 2.46 years, 10% waitlist deaths, 73.5% received LT, 937 patients achieved SVR, 5.8 had HCC, 534.9 liver-related deaths, 9.55 QALYs, 11.57 LYs and $292,374 per patient lifetime costs.

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HCC review

For patients with HCC in the post-LT arm, the mean waitlist time was 0.74 years, 2.3% died on the waitlist, 93.1% received LT, 806 achieved SVR, 405 died from liver-related causes, and follow-up showed an average of 10.39 QALYs, 13.04 LYs and $283,696 per patient lifetime costs. In comparison, in the pre-LT arm, results included a mean waitlist time of 0.74 years, 1.4% waitlist deaths, 94% receiving LT, 947 patients achieving SVR, 370 liver-related deaths, 11.48 QALYs, 13.61 LYs and $364,948 per patient lifetime costs.

“The timing of antiviral treatment for HCV patients with [decompensated cirrhosis] relative to LT is an important area of clinical and policy research,” the researchers wrote. “Our results indicate that pre-LT treatment with a highly effective, all-oral DAA regimen is the most cost-effective strategy for the treatment of HCV patients with [decompensated cirrhosis] waitlisted for LT, with an estimated [incremental cost-effective ratio (ICER)] of $28,692 to $36,583. Among HCC patients, pre-LT treatment was also found to be the most cost-effective treatment strategy, with an estimated ICER of $74,255.” – by Talitha Bennett

Disclosure : The researchers report no relevant financial disclosures.