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Oral direct-acting antivirals is cost-effective in patients waitlisted for liver transplant in the USA

A study in July's issue of Hepatology examines the treatment of patients waitlisted for liver transplant with all-oral direct-acting antivirals is a cost-effective treatment strategy in the United States.

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All-oral direct acting antivirals have been shown to have high safety and efficacy in treating patients with hepatitis C virus (HCV) awaiting liver transplant. 

However, there is limited empirical evidence comparing the health and economic outcomes associated with treating patients pre-liver transplant versus post-liver transplant. 

Dr Zobair Younossi and colleagues analyzed the cost-effectiveness of pre-liver transplant versus post-liver transplant treatment with an all-oral direct acting antivirals regimen among HCV patients with hepatocellular carcinoma or decompensated cirrhosis. 

The researchers constructed decision-analytic Markov models of the natural disease progression of HCV in hepatocellular carcinoma patients and decompensated cirrhosis patients waitlisted for liver transplant. 

The model followed hypothetical cohorts of 1,000 patients with a mean age of 50 over a 30-year time horizon from a third-party US payer perspective and estimated their health and cost outcomes based on pre-liver transplant versus post-liver transplant treatment with an all-oral direct acting antivirals regimen. 

The pre-liver transplant treatment strategy resulted in 12 per-patient quality-adjusted life years
Hepatology
Transition probabilities and utilities were based on the literature and hepatologist consensus. 

The team sourced sustained virological response rates from ASTRAL-4, SOLAR-1, and SOLAR-2. 

Costs were sourced from RedBook, Medicare fee schedules, and published literature. 

In the hepatocellular carcinoma analysis, the pre-liver transplant treatment strategy resulted in 12 per-patient quality-adjusted life years and $365,948 per patient lifetime costs versus 10 and $283,696, respectively, in the post-liver transplant arm. 

In the decompensated cirrhosis analysis, the pre-liver transplant treatment strategy resulted in 9 per-patient quality-adjusted life years and $304,800 per patient lifetime costs versus 8.7 and $283,789, respectively, in the post-liver transplant arm. 

The researchers found that the pre-liver transplant treatment strategy was the most cost-effective in both populations with an incremental cost-effectiveness ratio of $74,255 in hepatocellular carcinoma, and $36,583 in decompensated cirrhosis. 

Sensitivity and scenario analyses showed that results were most sensitive to the utility of patients post-liver transplant, treatment sustained virological response rates, liver transplant costs, and baseline Model for End-Stage Liver Disease score.

Dr Younossi's team comments, "The timing of initiation of antiviral treatment for HCV patients with hepatocellular carcinoma or decompensated cirrhosis relative to liver transplant is an important area of clinical and policy research."

"Our results indicate that pre-liver transplant treatment with a highly effective, all-oral direct acting antivirals regimen provides the best health outcomes and is the most cost-effective strategy for the treatment of HCV patients with hepatocellular carcinoma or decompensated cirrhosis waitlisted for liver transplant."

Hepatology 2017: 66(1): 46–56
06 July 2017

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