Pharmacoeconomic analysis of HBV liver transplant therapies

The outcome of liver transplantation for patients infected with the hepatitis B virus (HBV) has greatly improved over the last several years. The rate of allograft infection has decreased from 85 to 25%, while the post-transplant mortality rate due to HBV has decreased from 50% at 18 months to nearly nonexistent. For the most part, this result has been due to the increased dose and extended use of hepatitis B immunoglobulin (HBIg). Current lack of knowledge of the amount of HBIg monotherapy that is necessary to suppress residual virus has led to an expensive therapy. In our early experience, no alternative existed at the time of transplant for this group of recipients. Administration of HBIg was directed toward patient safety and optimal outcome rather than cost containment. The significance of the economic impact of this decision is discussed in this article. Analysis of institutional expenses revealed that the cost of HBIg to establish viral control was fairly consistent over time, despite the increased purchase price of the drug. Individualized dosing of HBIg was more expensive in the first year after transplantation compared to typical monthly administration protocols, but was substantially less expensive after 12 months due to decreased dosage needs. In addition to HBIg acquisition price, factors that affect expenditure for HBIg maintenance include time intervals between doses, purchase contracts, overhead of drug administration, and methods employed in determining charge structures. Combination therapies with nucleoside analogues may have a beneficial effect on future costs. Controlled trials to identify the optimum and most cost-effective therapy need to be performed.