Is it cost-effective to treat recurrent hepatitis C infection in orthotopic liver transplantation patients?

Cost-effectiveness of Ombitasvir/Paritaprevir/Ritonavir, Dasabuvir+Ribavirin for US Post-Liver Transplant Recurrent Genotype 1 HCV

BACKGROUND & AIMS

Orthotopic liver transplant patients with recurrent hepatitis C (HCV) historically have had limited treatment options. Ombitasvir/paritaprevir/ritonavir, dasabuvir and ribavirin (3D+R) was approved by the FDA in December 2014 for liver transplant recipients with recurrent genotype 1 HCV, in whom it is effective and well-tolerated.

METHODS

Using a two-phase Markov model, we analysed the cost-effectiveness of 3D+R in liver transplant recipients, the only HCV treatment with FDA approval in this population. As a sensitivity analysis, we also considered the cost-effectiveness of pegylated interferon plus ribavirin, the only other therapy with data from Phase III trials in this population. Patients were given one of three options: 3D+R for 24 weeks, pegylated interferon and ribavirin for 48 weeks (PR48) or no treatment (NT). Patients were then followed through subsequent disease progression until death. Outcome measures analysed were: lifetime risks of liver morbidity and mortality, treatment costs, non-treatment medical expenditures, and quality-adjusted life years.

RESULTS

Treatment with 3D+R was associated with a significantly lower lifetime risk of liver-related morbidity and mortality than treatment with PR48 or NT. 3D+R also was associated with a higher gain in quality-adjusted life years (11.3 compared to 8.25 with NT) and lower discounted overall costs ($423,585 compared to $724,757 with NT).

CONCLUSIONS

The use of 3D+R for liver transplant recipients with recurrent HCV is an outcome-improving and cost-effective regimen for this population with limited treatment options and large unmet need.

Cost-effectiveness analysis of antiviral treatment in liver transplant recipients with HCV infection

Within 5-10 years, 20-40% of hepatitis C virus (HCV)-infected liver transplant recipients can be expected to develop cirrhosis. Here, cost-effectiveness of antiviral therapy was assessed. A Markov model was developed to simulate disease progression and calculate outcome and costs of treatment. In the baseline analysis, Peg-IFN/RBV treatment prevented organ loss/death, gained quality-adjusted life-years (QALYs) and undercut the limit of cost-effectiveness of €50 000/QALY with an incremental cost-effectiveness ratio of approximately €40 400/QALY and €21 000/QALY for HCV genotype 1 and 2/3 patients, respectively. Furthermore, sensitivity analysis testing modified model parameters according to extreme data described in the literature confirmed cost-effectiveness for a lower or higher rate of fibrosis progression, increased non-HCV-related mortality, lower limits of utilities, a time horizon of 30 years, and additional costs in the year of death. On the other hand, cost-effectiveness was lost for patients with genotype 1 in case of doubled antiviral or life-time costs or an increased discount rate of 7%. New treatment strategies for HCV genotype 1 infected patients remained on the same level cost-effective, if additional costs did not exceed €10 774 per 10% sustained virologic response gain. We conclude that Peg-IFN/RBV treatment is cost-effective post transplant. This may support treatment decision in individual cases.

Management of hepatitis C virus infection recurrence after liver transplantation: an overview

Hepatitis C virus (HCV) infection is the major indication for liver transplantation worldwide. Its recurrence is virtually universal. Once reinfection is established, progression to cirrhosis occurs in 25%-30% of recipients within 5 years. Several studies have attempted to identify the ideal antiviral treatment for liver transplant recipients. At present, the management of recurrent HCV infection in liver transplant recipients is based on widely accepted indications, which represent a reliable guide to identify the "ideal" candidate for therapy, when therapy should be started, and what is to be expected in terms of side effects and response to treatment.

Empirically evaluating decision-analytic models

OBJECTIVES

Model-based cost-effectiveness analyses support decision-making. To augment model credibility, evaluation via comparison to independent, empirical studies is recommended.

METHODS

We developed a structured reporting format for model evaluation and conducted a structured literature review to characterize current model evaluation recommendations and practices. As an illustration, we applied the reporting format to evaluate a microsimulation of human papillomavirus and cervical cancer. The model's outputs and uncertainty ranges were compared with multiple outcomes from a study of long-term progression from high-grade precancer (cervical intraepithelial neoplasia [CIN]) to cancer. Outcomes included 5 to 30-year cumulative cancer risk among women with and without appropriate CIN treatment. Consistency was measured by model ranges overlapping study confidence intervals.

RESULTS

The structured reporting format included: matching baseline characteristics and follow-up, reporting model and study uncertainty, and stating metrics of consistency for model and study results. Structured searches yielded 2963 articles with 67 meeting inclusion criteria and found variation in how current model evaluations are reported. Evaluation of the cervical cancer microsimulation, reported using the proposed format, showed a modeled cumulative risk of invasive cancer for inadequately treated women of 39.6% (30.9-49.7) at 30 years, compared with the study: 37.5% (28.4-48.3). For appropriately treated women, modeled risks were 1.0% (0.7-1.3) at 30 years, study: 1.5% (0.4-3.3).

CONCLUSIONS

To support external and projective validity, cost-effectiveness models should be iteratively evaluated as new studies become available, with reporting standardized to facilitate assessment. Such evaluations are particularly relevant for models used to conduct comparative effectiveness analyses.

Antiviral therapy of chronic hepatitis C in patients with advanced liver disease and after liver transplantation

Chronic infection with the hepatitis C virus (HCV) represents one of the major causes for end-stage liver disease worldwide. Although liver transplantation offers an effective treatment, HCV reinfection of the transplanted graft is a critical and almost inevitable complication with major influence on graft- and patient survival. Pre-transplant antiviral therapy in advanced liver disease is limited by poor tolerance and only applicable to mildly decompensated patients but was able to show promising results in patients reaching negative viral load when undergoing transplantation. Prophylactic therapy with HCV antibodies during the anhepatic phase has not been shown to be effective in studies to date. Antiviral therapy after transplantation but before evidence of reinfection, so called pre-emptive treatment, is limited by frequent complications and a high rate of side effects. The mainstay of management represents directed antiviral therapy after evidence of recurrence of chronic Hepatitis C. With a combination therapy of pegylated interferon and ribavirin, sustained virologic response rates of 25-45% are achieved. However, tolerability is often poor, and the need of dose reduction is frequent. To date, there is no general consensus on modality, timing and dosing of antiviral treatment of HCV in patients with advanced liver disease and after liver transplantation. More randomised, controlled trials are needed. Moreover, upcoming new treatment approaches, e.g. specifically targeted antiviral therapy for hepatitis C (STAT-C) with HCV-specific polymerase and protease inhibitors, may represent a therapeutic alternative.

Addition of adult-to-adult living donation to liver transplant programs improves survival but at an increased cost

Using outcomes data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study, we performed a cost-effectiveness analysis exploring the costs and benefits of living donor liver transplantation (LDLT). A multistage Markov decision analysis model was developed with treatment, including medical management only (strategy 1), waiting list with possible deceased donor liver transplantation (DDLT; strategy 2), and waiting list with possible LDLT or DDLT (strategy 3) over 10 years. Decompensated cirrhosis with medical management offered survival of 2.0 quality-adjusted life years (QALYs) while costing an average of $65,068, waiting list with possible DDLT offered 4.4-QALY survival and a mean cost of $151,613, and waiting list with possible DDLT or LDLT offered 4.9-QALY survival and a mean cost of $208,149. Strategy 2 had an incremental cost-effectiveness ratio (ICER) of $35,976 over strategy 1, whereas strategy 3 produced an ICER of $106,788 over strategy 2. On average, strategy 3 cost $47,693 more per QALY than strategy 1. Both DDLT and LDLT were cost-effective compared to medical management of cirrhosis over our 10-year study period. The addition of LDLT to a standard waiting list DDLT program is effective at improving recipient survival and preventing waiting list deaths but at a greater cost.

Hepatitis C and liver transplantation: enhancing outcomes and should patients be retransplanted

Hepatitis C (HCV)-related end-stage liver disease is the most common indication for liver transplantation. Safe expansion of the donor pool with improved rates of deceased donation and more widespread use of living and extended criteria donation are likely to decrease wait list mortality. In addition, improved antiviral treatments and a better understanding of the delicate balance between under- and over-immunosuppression in this population are needed. Finally, when recurrent advanced fibrosis occurs, the criteria for patient selection for retransplantation remain widely debated. This article reviews the literature on these topics and the work being done in each area to maximize outcomes in patients receiving transplants for HCV-related cirrhosis.

Cost-effectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression

PURPOSE

A recent randomized clinical trial has demonstrated that direct decompressive surgery plus radiotherapy was superior to radiotherapy alone for the treatment of metastatic epidural spinal cord compression. The current study compared the cost-effectiveness of the two approaches.

METHODS AND MATERIALS

In the original clinical trial, clinical effectiveness was measured by ambulation and survival time until death. In this study, an incremental cost-effectiveness analysis was performed from a societal perspective. Costs related to treatment and posttreatment care were estimated and extended to the lifetime of the cohort. Weibull regression was applied to extrapolate outcomes in the presence of censored clinical effectiveness data.

RESULTS

From a societal perspective, the baseline incremental cost-effectiveness ratio (ICER) was found to be $60 per additional day of ambulation (all costs in 2003 Canadian dollars). Using probabilistic sensitivity analysis, 50% of all generated ICERs were lower than $57, and 95% were lower than $242 per additional day of ambulation. This analysis had a 95% CI of -$72.74 to 309.44, meaning that this intervention ranged from a financial savings of $72.74 to a cost of $309.44 per additional day of ambulation. Using survival as the measure of effectiveness resulted in an ICER of $30,940 per life-year gained.

CONCLUSIONS

We found strong evidence that treatment of metastatic epidural spinal cord compression with surgery in addition to radiotherapy is cost-effective both in terms of cost per additional day of ambulation, and cost per life-year gained.

Hepatitis C virus and liver transplantation

Hepatitis C virus (HCV) infection remains the most common cause of hepatic failure requiring orthotopic liver transplantation, and the disparity between the number of patients in need of liver replacement and the number of organs available continues to grow. Unfortunately, without viral eradication before transplantation, HCV recurrence is universal and is associated with poor graft and patient survival. Despite expansion of the donor pool and attempts to suppress HCV activity with various pretransplant and posttransplant antiviral therapies, many questions remain. This article reviews the literature regarding the evaluation of patients for transplantation, the antiviral therapies available in the peritransplant period, the immunosuppressive regimens, used, and the approach to patients with recurrent HCV infection.

Management of Recurrent Hepatitis C in Liver Transplant Recipients

Recurrent HCV infection is universal in liver transplant recipients who are viremic pretransplant. The rate of histologic disease progression after transplantation is more rapid, and the risk of cirrhosis by 5 to 10 years is about 30%. Several donor, recipient, and viral factors have been associated with worse post-transplant outcomes in recipients with recurrent hepatitis C. Whether or not HCV-infected recipients of live donor grafts have worse out-comes compared with deceased donor graft recipients is controversial. To maximize the long-term survival of recipients with HCV infection, eradication of infection is the ultimate goal. Treatment of recurrent HCV after liver transplantation can be undertaken at several different time points: (1) prophylactically, at the time of transplantation; (2) pre-emptively, in the early post-transplant period; and (3) after established recurrent histologic disease is present. Prophylactic therapy for HCV infection has no established role at present, but studies are ongoing. Preemptive therapy using IFN and RBV has resulted in variable SVR rates (9%-43%) and is generally poorly tolerated, especially if the patient has advanced liver disease pretransplantation. Treatment of established recurrent HCV disease with combination PEGIFN and RBV is associated with a SVR in about 30% to 35% of patients overall but is limited by high rates of dose reduction or drug discontinuation. In conclusion, successful HCV eradication in the post-transplant setting is difficult with current treatment options, but it is possible. Determination of the optimal doses of antiviral drugs in transplant patients and improvements in drug tolerability may be important first steps in achieving enhanced response rates. There is a need for new drugs in this population that have greater efficacy and a better safety profile.

Treatment of hepatitis C after liver transplantation

This article summarizes the current therapies, with particular emphasis on antiviral therapy. Because these alternatives have substantial limitations, pretransplant or early post-transplant recognition of patients with high risk of severe post-transplantation outcome is desirable to target these patients for intervention. Alternatively, the implementation of measures aimed at reducing or avoiding factors known to be associated with an aggressive recurrence is an additional strategy that needs to be explored.

Quality assurance, efficiency indicators and cost-utility of the evaluation workup for liver transplantation

We report the results of a retrospective review of the outpatient pretransplantation workup for United Network for Organ Sharing (UNOS) 3 patients adopted at a liver transplantation (LT) center and illustrate the efficiency indicators used for quality evaluation and cost-analysis. A single-center, pre-LT evaluation workup was performed on an outpatient basis at a cost per patient evaluation of 2,770 Euros (). Objective measures were: the number of patients admitted to and excluded from each phase of the algorithm; the rate of patients admitted to pre-LT evaluation out of the total of referred patients (the referral efficiency rate); the rate of waitlisted patients out of those admitted to pre-LT evaluation (the evaluation efficiency rate); the rate of waitlisted patients out of those referred for LT (the process efficiency rate); and the cost per waitlisted patient, as the ratio of the cost per patient evaluation to the evaluation efficiency rate. From January 1, 1996, to October 1, 2004, 1,837 patients were referred for LT on an outpatient basis. Based on preemptive evaluation of the available clinical data, 412 patients (22.4%) were excluded from pre-LT evaluation and 1,425 (77.6%) were admitted to preliminary consultation. Among these, 603 (42.3%) were excluded from and 822 (57.7%) were admitted to pre-LT evaluation with a referral efficiency rate of 44.7% (822 of 1,837). Out of the patients evaluated for LT, 484 were waitlisted with a cost-utility and evaluation efficiency rate of 58.8% each (484 of 822). Of the 1,837 patients originally addressed for LT 484 were waitlisted, yielding a process efficiency rate of 26.3% (484 of 1,837) and a cost per waitlisted patient of 4,710.8. In conclusion, the 3 indicators allowed monitoring of the efficiency of the pre-LT evaluation algorithm. The current process efficiency rate at our center is low (26.3%), but avoiding early referrals we might increase it to 31.6%, with a 12% net saving on costs per waitlisted patient (from 4,710.8 to 4,165.4).

Treatment of recurrent hepatitis C after liver transplantation

Chronic hepatitis C virus (HCV) infection is the most common indication for liver transplantation in the United States and Europe, and more than 20,000 patients worldwide have undergone transplantation for complications of chronic hepatitis C. In North America, HCV accounts for 15% to 50% of the liver transplants performed in United States transplant programs. To maximize the long-term survival of liver transplant recipients who have HCV infection, eradication of infection is the ultimate goal. Pretransplant antiviral therapy with the goal of achieving viral eradication before transplantation is a consideration in some patients, especially those who have mildly decompensated liver disease. This article focuses on the management of liver transplant recipients who have HCV infection at the time of transplantation. Prophylactic and preemptive therapies, as well as treatment of established recurrent disease, are the strategies reviewed.

Management of hepatitis C virus infection in the setting of liver transplantation

1. Posttransplantation recurrence of hepatitis C virus infection is a universal phenomenon with a highly variable natural history. 2. Approximately 10% to 25% of hepatitis C virus- infected recipients of liver allografts will develop cirrhosis within 5 years' after transplantation. 3. The 1-year actuarial risk of hepatic decompensation after recurrence of cirrhosis approximates 42%. 4. Some of the factors associated with aggressive recurrence include donor and recipient age, recent year of transplantation, recipient gender and race, the use of antithymocyte globulin, and high dose of corticosteroids. 5. Highly aggressive recurrent hepatitis C virus infection leading to cirrhosis fares poorly after retransplantation in the presence of hyperbilirubinemia and renal failure, with a 1-year survival of approximately 40%. 6. Elevated serum aminotransferases are a poor indicator or recurrent disease. 7. Current sustained virological response after combination pegylated alpha interferon and ribavirin treatment is approximately 25%. 8. There is no consensus on initiation time point, duration of treatment, or dosage. Given immunosuppression, at least 48 weeks of therapy is a reasonable approach. 9. Treatment for 48 weeks is cost effective. Incremental cost-effectiveness ratio for men aged 55 years is $29,100 per life-year saved.

Hepatitis B and hepatitis C viruses in liver transplantation

Liver transplantation (LT) for end-stage liver disease (ESLD) secondary to hepatitis viruses has evolved rapidly during the last two decades. ESLD secondary to hepatitis C virus (HCV) accounts for approximately 50% of LT in the United States and Europe. Despite the decrease in the number of new HCV infections, the prevalence of advanced HCV-related liver disease is steadily increasing. In light of the near universal recurrence of posttransplantation HCV infection and our limited ability to treat recurrent disease, transplantation is in danger of being overrun by viral hepatitis, unless effective strategies can be used to treat disease, expand the donor pool of available organs, and prevent disease recurrence. In the early 1980s, results of LT for chronic hepatitis B virus infection were hampered by recurrent infection and subsequent allograft failure. However, with the introduction of passive immunoprophylaxis with hepatitis B immunoglobulin and treatment with potent nucleoside analogs, there has been a resurgence of LT for hepatitis B virus-related ESLD. Despite the wide acceptance of LT as a therapy for ESLD, there is little consensus on the appropriate immunosuppressive regimens, and prophylactic and therapeutic treatments vary widely from one center to another. This review summarizes available data and highlights appropriate strategies to improve outcomes.

Recurrent hepatitis C genotype 1b following liver transplantation: treatment with combination interferon-ribavirin therapy

BACKGROUND

Recurrent hepatitis C is very common leading to graft cirrhosis in a significant proportion of patients. Preliminary reports of combination therapy with interferon-ribavirin have been promising but generally applied to selected patients with chronic mild disease. Little is known, however, about the efficacy and risk of adverse effects when it is used in general clinical practice.

AIMS

To analyse the efficacy (biochemical, virological and histological response) and tolerance of combination therapy in patients with recurrent hepatitis C genotype 1b.

METHODS

Twenty-four patients (mean age 54 years; range 37-67 years; 75% male) with recurrent hepatitis C virus (histology at baseline: acute hepatitis (n = 3); chronic hepatitis (n = 21) with F3 or 4 in 77%) were treated with 12 months interferon (1.5-3 MU thrice weekly) + ribavirin (600-1200 mg daily) followed by 6 months ribavirin (58%), at a median of 427 days (56-2812) after transplantation.

RESULTS

Seven patients (29%) discontinued therapy due to side effects, mainly anaemia, at a median of 3 months since initiation. Dose modifications were required in 88% of those completing the whole course of therapy. Overall, the sustained virological and biochemical response was 12.5%. This rate was slightly higher (18%) if only the 17 patients who finished the whole course of therapy were analysed. Histological improvement was achieved in 31.5% of treated patients.

CONCLUSIONS

Combination therapy has a very limited efficacy in the liver transplant setting, although some benefit may be achieved, even in those with advanced graft fibrosis. Tolerance, however, remains a matter of concern.

Treatment of Hepatitis C in Solid Organ Transplantation

Hepatitis C virus (HCV) infection is highly prevalent worldwide, and results in significant morbidity and mortality. HCV frequently infects haemodialysis patients and appears to impact on long-term survival of kidney transplant recipients. Therefore, treatment is recommended for kidney transplant candidates before transplantation and should be avoided following transplantation because of a high risk of allograft rejection. HCV infection does not appear to influence survival in cardiac transplant recipients and cardiac transplant recipients should also not be treated. In general, HCV-infected patients with cirrhosis are not considered as candidates for either kidney or cardiac transplantation given their risk of decompensation. HCV is the most common indication for liver transplantation and re-infection with varying degrees of liver injury is universal. Survival after liver transplantation is reduced among HCV-infected patients when compared with uninfected controls. Therefore, treatment using interferon and ribavirin is advocated; however, such therapy is frequently limited by adverse effects. Thus, improved antiviral treatment modalities are eagerly awaited in the transplant setting.

Treatment of hepatitis C virus infection in the allograft

1. Recurrence of hepatitis C virus (HCV) in the graft is associated with a reduced quality of life and worse graft survival. 2. Pretransplantation, the severity of HCV recurrence may be reduced by reducing the pretransplantation load, by avoiding the use of organs from older donors, and by reducing the ischemic times. The effect of split livers on recurrence rates is uncertain. 3. The optimal immunosuppression regime has not been established but a heavy induction regime and treatment for acute rejection are associated with more viral replication and more graft damage. 4. Presently, there is no convincing evidence for preemptive treatment of HCV. 5. There are many studies on the effect of interferon with and without ribavirin for the treatment of HCV hepatitis. However, few are prospective, randomized, and controlled. 6. The current best treatment is with pegylated interferon and ribavirin; the dose and duration of treatment need to be established. Side-effects of treatment are common and reduction/withdrawal is frequent, but the regime is cost-effective. 7. The role of newer treatments remains to be established.

Outcome and management of hepatitis C in liver transplant recipients

Hepatitis C virus (HCV)-related cirrhosis is the leading indication for liver transplantation. Reinfection of the allograft with HCV is universal in all patients with pretransplantation viremia, and leads to histologically proven hepatitis in 50%-80% of these patients. Recent data have demonstrated significantly higher mortality among HCV-positive liver transplant recipients. For this subgroup of patients, retransplantation remains highly controversial. As current antiviral therapy is limited in efficacy and tolerability, an improved understanding of those patients at greatest risk of developing serious HCV-induced graft injury is necessary to optimize treatment.

Treatment strategies for hepatitis C: intervention prior to liver transplant, pre-emptively or after established disease

Cirrhosis secondary to chronic hepatitis C virus (HCV) infection accounts for most liver transplants performed in the United States and European transplant centers. Given the high prevalence of HCV infection in the general population, the lack of consistently effective antiviral therapy, and the eventual progression to cirrhosis of a subset of those infected, predictions for the future are that the number of patients in need of transplantation will increase in the coming decade. In addition, viral infection recurs nearly universally leading to the development of chronic HCV in most recipients and progression to cirrhosis after a median of 9 to 12 years in a significant proportion of these recipients.

Recurrent hepatitis C following liver transplant: diagnosis, natural history, and therapeutic options

Hepatitis C virus (HCV) related cirrhosis is the most common indication for orthotopic liver transplantation (OLT). Updated data suggest worse long-term outcomes for those transplanted with HCV than those transplanted for other indications. Re-infection with HCV post-OLT is universal, therefore diagnosis of recurrence should be based on histological findings in the setting of persistent viremia. Variables associated with worse outcome of recurrent disease include early recurrence, degree of immunosuppression, and donor age. Antiviral therapy has been used in the prevention and treatment of recurrent disease, and can be initiated prior to transplantation, prophylactically after transplantation, and during recurrence. Preliminary studies of pre-transplantation treatment demonstrate virological responses, but tolerance is common. Higher efficacy has been associated with combination therapy for recurrent disease. Adverse effects limit its widespread use.

Duration of antiviral therapy for cholestatic HCV recurrence may need to be indefinite

Progressive liver allograft injury related to hepatitis C virus (HCV) recurrence occurs in 20% to 30% of liver transplant recipients within the first 5 years. In particular, the subset of patients who develop the severe cholestatic variant has an extremely high mortality. We report our center's experience with 7 cholestatic patients who were treated with interferon alfa-2b (3 million IU three times per week initially) in combination with ribavirin. In 4 of the 7 patients, HCV-RNA in serum became undetectable, and in an additional patient, normalization of serum bilirubin was achieved despite persistent viremia. Discontinuation of antiviral therapy by patient choice, intolerance of side effects, or occurrence of infection were followed temporally by rapid relapses of the cholestatic syndrome, allograft failure, and death. The only 2 patients alive in remission of this syndrome have been maintained on antiviral therapy for an average of 32 months. Thus, based on our experience, we recommend that duration of antiviral therapy in the subset of patients with cholestatic HCV recurrence should be indefinite.