icon_folder.gif   Conference Reports for NATAP  
  AASLD ( American Association for the Study of Liver Diseases)
November 9-13, 2001, Dallas
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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.