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Optimal timing for hepatitis C therapy in US patients eligible for liver transplantation: a cost-effectiveness
B Njei1,2, T R McCarty3, B E Fortune1
1Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.
Insights
Treating hepatitis C virus (HCV) before liver transplantation (LT) is most cost-effective for patients with lower MELD scores. For those with higher MELD scores or decompensated cirrhosis, preemptive post-LT treatment is preferred.
Area of Science:
- Hepatology
- Transplantation Medicine
- Health Economics
Background:
- Hepatitis C virus (HCV) recurrence post-liver transplantation (LT) is common and linked to worse outcomes.
- Optimal timing for HCV treatment in LT candidates is not well-defined.
Purpose of the Study:
- To compare the cost-effectiveness of treating HCV before versus after LT.
- To evaluate preemptive post-LT treatment versus treatment after HCV recurrence.
Main Methods:
- A Markov model simulated HCV patients (genotype 1 or 4) from transplant listing to death.
- Cost-effectiveness of ledipasvir-sofosbuvir (LDV/SOF) with ribavirin was analyzed for three strategies: pre-LT, preemptive post-LT, and post-LT after recurrence.
Main Results:
- For patients with Model for End-Stage Liver Disease (MELD) <25, pre-LT HCV treatment yielded more quality-adjusted life-years (QALYs) at lower cost.
- Pre-LT treatment was also most cost-effective for living donor LT recipients.
- For MELD ≥25, decompensated cirrhosis (Child-Pugh B/C), or hepatocellular carcinoma, preemptive post-LT treatment was more cost-effective.
Conclusions:
- HCV treatment before LT is the most cost-effective strategy for patients with MELD <25.
- For patients with MELD ≥25 or decompensated cirrhosis, preemptive post-LT treatment before recurrence offers the best cost-effectiveness.
Background:
Recurrence of hepatitis C virus (HCV) following liver transplantation (LT) is universal for those with ongoing viraemia and is associated with higher rates of allograft failure and death. However, the optimal timing of HCV treatment for patients awaiting transplant remains unclear.
Aim:
To evaluate the comparative cost-effectiveness of treating HCV pre-LT vs. post-LT (pre-emptive or after HCV recurrence).
Methods:
A Markov state-transition model was created to simulate the progression of a cohort of HCV-genotype 1 or 4 cirrhotic patients from the time of transplant listing until death. We then used this model to study the cost-effectiveness of ledipasvir-sofosbuvir (LDV/SOF) with ribavirin for 12 weeks, administered for three separate treatment strategies: (i) pre-LT; (ii) post-LT preemptively prior to HCV recurrence; or (iii) post-LT after HCV recurrence.
Results:
In the base-case analysis using a median model for end-stage liver disease (MELD) score <25 at the time of transplant, we found that pre-LT treatment of HCV led to more QALYs for fewer dollars compared to other strategies. Analysis limited to living donor LT recipients revealed that pre-LT treatment was also the most cost-effective strategy. When the analysis was repeated for MELD ≥25, decompensated disease (Child-Pugh class B or C), and hepatocellular carcinoma cases, preemptive post-LT strategy was more cost-effective.
Conclusions:
Treatment of HCV prior to liver transplantation appears to be the most cost-effective strategy for patients with a MELD score <25. For patients with a MELD ≥25 or decompensated cirrhosis, preemptive post-liver transplantation treatment before HCV recurrence is the most cost-effective strategy.
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