Treatment options for chronic Hepatitis B virus infection have disparate risks and benefits.
Interferon has clinically significant side effects, and lamivudine is associated with viral resistance.
In contrast, adefovir is safe and has lower viral resistance but is more expensive, but the most cost-effective approach is uncertain.
Dr Kanwal and colleagues from New York determined whether and under what circumstances the improved efficacy of adefovir offsets its increased cost compared with lamivudine or interferon.
The investigators conducted a cost–utility analysis stratified by Hepatitis B e-antigen status and a systematic review of MEDLINE from 1970 to 2005.
|Interferon cost $6337 versus $8446 with adefovir salvage strategy to gain 1 quality-adjusted life-year|
|Annals of Internal Medicine|
The researchers included patients with chronic Hepatits B infection, elevated aminotransferase levels, and no cirrhosis.
The analysis included third-party payer over the lifetime of patients and assessed incremental cost per quality-adjusted life-year gained.
The team classified interventions into 5 groups including no HBV treatment (the “do nothing” strategy) and interferon monotherapy.
The researchers reported that the remaining 3 intervention groups included lamivudine monotherapy, adefovir monotherapy, or lamivudine with crossover to adefovir upon resistance ("adefovir salvage" strategy).
The team found that the "do nothing" strategy was least effective yet least expensive.
The researchers noted that, compared with the "do nothing" strategy, using interferon cost an incremental $6337 to gain 1 additional quality-adjusted life-year.
Compared with interferon, the adefovir salvage strategy cost an incremental $8446 per quality-adjusted life-year gained.
The investigators observed that both the lamivudine and adefovir monotherapy strategies were more expensive yet less effective than the alternative strategies and were therefore dominated.
The team showed in a sensitivity analysis, that interferon was most cost-effective in health care systems with tight budgetary constraints and a high prevalence of Hepatitis B e-antigen-negative patients.
The researchers indicated that these results apply only to patients with chronic Hepatitis B infection with elevated aminotransferase levels, and no clinical or histologic evidence of cirrhosis.
The research team reported that these results do not apply to alternative populations to those with Hepatitis B as described.
Dr Kanwal's team concludes, “Neither lamivudine nor adefovir monotherapy is cost-effective in chronic Hepatitis B infection.”
“However, a hybrid salvage strategy reserving adefovir only for lamivudine-associated viral resistance may be highly cost-effective across most health care settings.”
“Interferon therapy may still be preferred in health care systems with limited resources, especially in those serving populations with a high prevalence of Hepatitis B e antigen-negative.”