Shorter Duration Hepatitis C Virus Treatment is Associated with Better Persistence to Prescription Refills in People Who Inject Drugs: A Real-World Study

INTRODUCTION

Direct-acting antiviral (DAA) therapy is highly effective in curing hepatitis C virus (HCV) infection in people who inject drugs (PWID). Previous studies showed declining persistence to DAA therapy over the course of treatment. This study compares real-world medication persistence to prescription refills for 8- versus 12-week DAA in treatment-naïve PWID with chronic HCV with compensated cirrhosis or without cirrhosis.

METHODS

Symphony Health's claims database was used to collect data from patients with chronic HCV aged ≥ 12 years who were prescribed 8- or 12-week DAA therapy between August 2017 and November 2020 and had a diagnosis of addicted drug use within 6 months prior to index date. Eligible patients had medical/pharmacy claims in the 6 months before and 3 months after the first index medication fill date (i.e., index date). Patients completing all refills (8-week = 1 refill, 12-week = 2 refills) were deemed persistent. The percentage of persistent patients in each group, and at each refill step, was determined; outcomes were also assessed in a subgroup of Medicaid-insured patients.

RESULTS

This study assessed 7203 PWID with chronic HCV (8-week, 4002; 12-week, 3201). Patients prescribed 8-week DAA treatment were younger (42.9 ± 12.4 vs 47.5 ± 13.2, P < 0.001) and had fewer comorbidities (P < 0.001). Patients receiving 8- versus 12-week DAA had greater refill persistence (87.9% vs 64.4%, P < 0.001). Similar percentages of patients missed their first refill (8-week, 12.1% vs 12-week, 10.8%); nearly 25% of patients receiving 12-week DAA missed their second refill. After baseline characteristics were controlled, patients prescribed 8- versus 12-week DAA were more likely to be persistent (odds ratio [95% confidence interval] 4.3 [3.8, 5.0]). Findings in the Medicaid-insured subgroup were consistent.

CONCLUSION

Patients prescribed 8- vs 12-week DAA therapy had significantly greater prescription refill persistence. Most nonpersistence was due to missed second refills, highlighting the potential benefit of shorter treatment durations in this population.

Premature ovarian senescence and a high miscarriage rate impair fertility in women with HCV

BACKGROUND & AIMS

Premenopausal women who are HCV positive (HCV+) have failing ovarian function, which is likely to impact their fertility. Thus, we investigated the reproductive history, risk of infertility, and pregnancy outcomes in women of childbearing age who were HCV+.

METHODS

Three different groups were studied: (1) Clinical cohort: 100 women who were HCV+ and also had chronic liver disease (CLD), age matched with 50 women who were HBV+ with CLD and with 100 healthy women; all women were consecutively observed in three gastroenterology units in hospitals in Italy; (2) 1,998 women who were HCV+ and enrolled in the Italian Platform for the Study of Viral Hepatitis Therapies (PITER); (3) 6,085 women, who were mono-infected with HCV, and 20,415 women, who were HCV-, from a large de-identified insurance database from the USA.

MEASUREMENTS

total fertility rate (TFR) defined as the average number of children that a woman would bear during her lifetime. To define the reproductive stage of each participant, levels of anti-Müllerian hormone (AMH) and 17β-estradiol were measured.

RESULTS

Clinical cohort: women who were either HCV+ or HBV+ had similar CLD severity and age at first pregnancy. Based on a multivariate analysis, women who were HCV+ had a higher risk of miscarriage than those who were HBV+ (odds ratio [OR] 6,905; 95% CI 1.771-26.926). Among women who were HCV+, incidence of miscarriage was correlated with median AMH level (1.0 ng/ml). Achieving a sustained virologic response (SVR) after antiviral treatment reduced the risk of miscarriage (OR 0.255; 95% CI 0.090-0.723). In the PITER-HCV cohort, miscarriage occurred in 42.0% of women (44.6% had multiple miscarriages). TFR for women who were HCV+ and between 15 and 49 years of age was 0.7 vs. 1.37 of Italian population of the same age range. In the US cohort: compared with women who were HCV-, women who were HCV+ positive were significantly more likely to have infertility (OR 2.439; 95% CI 2.130-2.794), premature birth (OR 1.34; 95% CI 1.060-1.690), gestational diabetes (OR 1.24; 95% CI 1.020-1.510), and pre-eclampsia (OR 1.206; 95% CI 0.935-1.556), and were less likely to have a live birth (OR 0.754; 95% CI 0.622-0.913).

CONCLUSIONS

Ovarian senescence in women of childbearing age who are HCV+ is associated with a lower chance of live birth, greater risk of infertility, gestational diabetes, pre-eclampsia and miscarriage. Such risks could be positively influenced by successful HCV cure.

LAY SUMMARY

Most new cases of HCV infection are among people who inject drugs, many of whom are young women in their childbearing years. Women of reproductive age who are HCV+ display markers of ovarian senescence. This is associated with an increased burden in terms of infertility and adverse pregnancy outcomes, including stillbirth, miscarriage, fewer live births, and gestational diabetes. Early viral suppression with therapy is likely to mitigate these risks.

Abstract 218: Case-mix Analysis of AIM-HIGH Patients in the Real-world

Background: Subjects are enrolled in randomized clinical trials according to strict entry and exclusion criteria. The extent to which these study subjects are similar to or different from ‘real world’ patients importantly impacts the extent to which the results of clinical trials can be generalized

Objectives: To examine the baseline characteristics of AIM-HIGH-like patients identified in real-world practice and compare them to the patients enrolled in the AIM-HIGH clinical trial.

Methods: This was a retrospective claims database study. The earliest complete lipid panel of individuals 45-64 years of age, was identified. The date of the lipid panel was set as index date. Individuals had to be enrolled at least a year prior to the index date and fulfill the cardiovascular disease (CVD) and atherosclerotic dyslipidemia inclusion criteria in AIM-HIGH. Descriptive analyses were conducted to understand the baseline characteristics of these AIM-HIGH-like (A-H-like) patients.

Results: A total of 52,712 patients with a complete lipid panel and previous CVD history, as specified in the inclusion criteria, were identified. Applying the atherosclerotic dyslipidemia criteria, an overall 11,906 (22.6%) patients(A-H) were identified of which 5,645 patients (44.4%) were treated with statin or statin-ezetimibe. These 5,465 statin-treated patients account for 10.4% of the patients with a CVD history. The average LDL-C (±SD), HDL-C(SD) and median TG of the treated A-H patients in the real-world were 74.5mg/dL(16.4), 37.4mg/dL(6.4) and 164.0mg/dL respectively. These values were slightly higher (p<0.0001 for LDL-C and HDL-C) than the average LDL-C (SD), HDL-C (SD) and median TG of patients in AIM-HIGH (95% statin-treated), 71.0mg/dL(18.0), 34.9mg/dL(5.6) and 161.0mg/dL, respectively. In the real-world, while only 63.0% of the A-H-like patients had LDL-C<100mg/dL, 98.2% of the treated A-H-like patients had LDL-C< 100 mg/dL. Likewise, only 21.8% of the A-H-like population in the real-word had LDL-C < 70 mg/dL and 36.3% of the treated A-H-like real-world patients had LDL-C < 70 mg/dL. There was a very small proportion of the treated real-world population (15.0%) that had all lipid values at recommended levels.

Conclusion: In the real-world, A-H like patients with atherosclerotic dyslipidemia represent only 22.6% of the secondary prevention population. Majority of patients in AIM-HIGH trial were statin-treated (95%), and these well-controlled treated A-H-like patients account for only 10.4% of the secondary prevention population in the real-world, indicating that there remains a large secondary prevention population in the real-world that needs further evaluation regarding need for treatment.

Abstract 292: Baseline characteristics of patients starting on Niacin extended-release

Background: The lack of CV benefit in the recent AIM-HIGH clinical trial, where niacin was given on a background of statin treatment in patients with baseline lipids that were already well-controlled, led us to ask the question as to what are the baseline characteristics of real-world patients that physicians were starting on prescription Niacin extended-release (NER).

Objectives: To evaluate, using a real-world database, the baseline characteristics of real-world patients started on niacin monotherapy or combination therapy.

Methods: This was a retrospective analysis using electronic medical records. Individuals receiving the first prescription for NER monotherapy or single pill statin-niacin combination (SPC) between July 2000-September 2011 were identified. The date of the first prescription was set as the index date. Patients were 18 years or older on index date, and during the six months prior to index date they had a lipid panel but had no prescription for NER or statin-niacin SPC. Patients were classified based on therapy: NER monotherapy, statin-niacin (includes SPC), and all other combinations of NER. NCEP guidelines were used to evaluate/classify risk-adjusted optimal lipid levels.

Results: A total of 45,518 patients fulfilled all inclusion criteria. Overall, 58% of the patients had hypertension, 28% had diabetes, and 48% had CHD or CHD risk equivalent. Irrespective of LDL-C levels, 66% had low HDL-C. Among the remaining 34% of the patients with HDL-C at goal, 75.8% had LDL-C>100mg/dL and/or TG >200mg/dL. A total 17,042 patients (37%) were started on niacin extended release monotherapy, 18,782 (41%) were treated with statin-niacin (including SPC), and 9,696 (21%) were treated with all other combinations of niacin extended release. Among the high-risk patients treated with statin-niacin (excluding SPC) 64% had LDL-C<100mg/dL and 54% had non-HDL also at goal; 25% had LDL-C<70mg/dL and 16% had non-HDL also at goal. The baseline average LDL-C and HDL-C and median TG for statin-niacin patients were 93.1 mg/dL(33.5), 39.5mg/dL(11.3) and 165.0mg/dL, respectively.

Conclusion: Half the patients starting on NER have hypertension and/or CHD/CHD risk equivalents and the majority have low HDL-C. While the majority of high risk patients for whom niacin was added to baseline statin, or who were starting statin-niacin combinations had LDL-C<100mg/dL, fewer patients had LDL-C <70mg/dL goal, and even fewer had non-HDL <100mg/dL. In comparison to AIM-HIGH the average LDL-C and non-HDL levels were higher in the real-world, raising the question whether patients enrolled in AIM-HIGH were only the well-controlled patients, and that the sample size had to have been considerably higher for us to see any additional benefit of adding niacin to statin therapy.

Impact of change in high-density lipoprotein cholesterol from baseline on risk for major cardiovascular events

INTRODUCTION

Low concentration of high-density lipoprotein cholesterol (HDL-C) has increasingly been recognized as a strong and independent predictor of cardiovascular risk. The aim of this study was to determine the association between change in HDL-C concentration from baseline and risk of a major cardiovascular event in a commercially insured population cohort with suboptimal HDL-C and low-density lipoprotein cholesterol (LDL-C) concentrations at baseline.

METHODS

A retrospective longitudinal survival analysis was conducted using claims data from a large, commercial US health plan. To be included, patients had to be > or =50 years of age on the index date (laboratory test date between January 1, 2000 and December 31, 2003 on which both their LDL-C and HDL-C were not at goal), be continuously enrolled for a minimum of 6 months prior to and 12 months after the index date, and had to have at least one other laboratory panel result within 1 year prior to the cardiovascular event or study disenrollment. Cox proportional hazards analysis was conducted to assess the association between change in HDL-C concentrations and risk of a major cardiovascular event (defined as a > or =1-day hospitalization for a cardiovascular disease [CVD] diagnosis or an invasive cardiovascular procedure) within 5 years of the index date, after adjusting for covariates.

RESULTS

A 0.026 mmol/L (1 mg/dL) increase in HDL-C from baseline was associated with a statistically significant 1.9% decreased risk of a major cardiovascular event (P<0.0001; hazard ratio: 0.981; 95% CI: 0.974, 0.989), after adjustment for covariates.

CONCLUSION

Our finding of an inverse association between change in HDL-C concentrations and risk of a major cardiovascular event confirms previously reported results. Increasing HDL-C concentrations may serve as an effective measure for preventing future cardiovascular events.

Association between HDL-C concentration and risk for a major cardiovascular event

OBJECTIVE

To determine the association between baseline HDL-C concentrations and risk of a major cardiovascular event (within 5 years) in a large US claims database.

METHODS

A retrospective longitudinal analysis using claims data from the i3 Ingenix LabRx database was conducted. Patients were included if they had complete lipid panel lab results, were continuously enrolled for >or=6 months prior to and >or=12 months following the lab test (index date), and were >or=50 years of age. Cox proportional hazards analysis assessed the association between HDL-C concentrations and risk of a major cardiovascular event within 5 years of the index date, after adjusting for covariates.

RESULTS

There was a statistically significant association between HDL-C and risk of a major cardiovascular event. A 0.026 mmol/L (1 mg/dL) increase in HDL-C from baseline was associated with a 1.3% decreased risk of a major cardiovascular event (e.g., a 0.13 mmol/L [5 mg/dL] increase in HDL-C above baseline concentrations was associated with a 6.5% decrease). This association became evident within 1 year of follow-up.

CONCLUSIONS

HDL-C concentrations were inversely associated with the occurrence of cardiovascular events within 5 years. Women who were >or=0.26 mmol/L (10 mg/dL) below their target concentrations had cardiovascular risk similar to that of women with baseline ischemic heart disease and hypertension, and men who were >or=0.26 mmol/L (10 mg/dL) below their target concentrations had cardiovascular risk similar to that of men with baseline cardiovascular disease, diabetes, or cerebrovascular disease. Limitations inherent to claims-based analyses must be considered when interpreting these findings, such as the potential for miscoding or incomplete data, and the fact that the presence of a diagnosis code on a medical claim is not positive presence of disease. Furthermore, patients who suffered a fatal cardiovascular event at home during the study period, and therefore did not receive treatment, were not captured in this analysis.

A comparison of pioglitazone and rosiglitazone for hospitalization for acute myocardial infarction in type 2 diabetes

BACKGROUND

Recent studies have raised concerns about potential increased cardiovascular (CV) risk in type 2 diabetes patients treated with some peroxisome proliferator-activated receptor gamma (PPAR-gamma) agonists.

OBJECTIVE

To ascertain the risk of hospitalization for acute myocardial infarction (AMI) in type 2 diabetes patients treated with pioglitazone relative to rosiglitazone.

METHODOLOGY

Using data covering 2003-2006 from a large health care insurer in the US, a retrospective cohort study was conducted in patients who initiated treatment with pioglitazone or rosiglitazone. The hazard ratio (HR) of incident hospitalization for AMI after initiation of treatment with these drugs was estimated from multivariate Cox's proportional hazards survival analysis; similarly, the HR was ascertained for hospitalization for the composite endpoint of AMI or coronary revascularization (CR).

RESULTS

A total of 29 911 eligible patients were identified in the database; 14 807 in the pioglitazone and 15 104 in the rosiglitazone group. Baseline demographics, medical history, and dispensed medications were generally well balanced between groups. The unadjusted HR for hospitalization for AMI was 0.82, 95%CI: 0.67-1.01. After adjustment for baseline covariates the HR was 0.78, 95%CI: 0.63-0.96. The adjusted HR for the composite of AMI or CR was 0.85, 95%CI: 0.75-0.98.

CONCLUSION

This retrospective cohort study showed that pioglitazone, in comparison with rosiglitazone, is associated with a 22% relative risk reduction of hospitalization for AMI in patients with type 2 diabetes.