An analysis of the costs and benefits of new triple-therapy regimens for hepatitis C finds that they can be cost-effective when used universally for patients with advanced liver fibrosis and when guided by genotyping for patients with mild fibrosis. The study, led by Jeremy Goldhaber-Fiebert, PhD, assistant professor of medicine at the Stanford University School of Medicine, was published in the February 21, 2012, issue of Annals of Internal Medicine
The standard treatment for hepatitis C, pegylated interferon and ribavirin, is effective at producing sustained virologic response in around 40% to 60% of patients with hepatitis C virus (HCV) genotype 1. (Of the 2.7 million to 3.9 million people in the United States with hepatitis C, approximately 75% have HCV genotype 1.) The 2 protease inhibitors approved last year to treat hepatitis C, boceprevir (Victrelis) and telaprevir (Incivek), are administered as part of a triple-therapy regimen along with pegylated interferon and ribavirin. Triple therapy has brought the promise of higher cure rates and shorter treatment courses, but it has also brought new side effects and hefty price tags. Boceprevir costs $1100 per week and telaprevir costs $4100 per week.
To measure cost-effectiveness, the researchers looked at 3 treatment strategies for the disease—giving all patients standard treatment, giving all patients triple therapy, and giving triple therapy only to those whose Interleukin (IL)-28B genotype indicated they would be less responsive to standard therapy. The IL-28B gene codes for an immune response regulator and comes in three genotypes: CC, CT, and TT. Patients with the non-CC type have a 30% success rate on standard therapy and a 70% success rate on triple therapy; patients with the CC type have a 70% success rate on standard therapy and a 90% success rate on triple therapy.
Using the $1100-per-week cost of boceprevir for their cost estimates, the researchers determined that giving triple therapy to all hepatitis C patients with advanced fibrosis would be cost-effective and that giving IL-28B–guided triple therapy to hepatitis C patients with mild fibrosis would be cost-effective. The latter costs approximately $62,900 per quality-adjusted life-year (QALY) compared with standard treatment, and the former costs approximately $50,000 per QALY compared with IL-28B–guided triple therapy for patients with advanced fibrosis. (A treatment is generally considered cost-effective if it costs less than $100,000 per QALY.)
The researchers note that, depending on treatment duration, a complete course of telaprevir can cost 140% to 190% of a course of boceprevir. They point out that telaprevir appears to be more effective than boceprevir, although the 2 drugs have not been compared head to head. In addition, they note that levels of adherence to triple therapy are not yet known and that if they turn out to be lower than for standard treatment, then IL-28B–guided triple therapy could be the best option for all hepatitis C patients.
The researchers also suggest that the cost-effectiveness of re-treating patients whose initial treatment has failed will require further exploration. Their analysis found that re-treatment using IL-28B–guided triple therapy after the failure of initial standard treatment is cost-effective, although there is not enough evidence to analyze re-treatment with triple therapy after initial failure with triple therapy.
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