Cost Effectiveness of Treatment Options for Hepatitis B Patients with Cirrhosis

Individuals with chronic hepatitis B virus (HBV) infection are at risk for developing advanced liver disease, including cirrhosis and hepatocellular carcinoma.

Treatment with lamivudine (Epivir; 3TC) is effective, but limited by the development of drug-resistant virus when used as monotherapy. Two newer agents, adefovir (Hepsera) and entecavir (Baraclude), are associated with less viral resistance, but are more expensive.

As reported in the September 2006 American Journal of Gastroenterology, researchers in Los Angeles evaluated the cost-effectiveness of 6 treatment strategies in patients with HBV-related liver cirrhosis:

No treatment (the "do nothing" approach);

Lamivudine monotherapy;

Adefovir monotherapy;

Entecavir monotherapy;

Lamivudine with crossover to adefovir after resistance develops ("adefovir salvage")

Lamivudine with crossover to entecavir ("entecavir salvage").

The primary outcome was the incremental cost of therapy per quality-adjusted life-year (QALY) gained.

Results

Not surprisingly, the "do nothing" strategy was least effective and least expensive.

Compared with the "do nothing" approach, use of adefovir cost an incremental $19,731 per QALY gained.

Entecavir was more effective yet more expensive than adefovir, costing an incremental $25,626 per QALY gained.

Selecting between adefovir and entecavir was highly dependent on third-party payers' "willingess to pay."

45% of patients would qualify if payers are willing to pay $10,000 per QALY, and 60% would qualify if willing to pay $50K per QALY gained.

Neither lamivudine monotherapy nor the two "salvage" strategies were cost-effective.

However, between the 2 salvage strategies, adefovir salvage was more effective (leading to less drug resistance) and less expensive than entecavir salvage.

Conclusion

"Both entecavir and adefovir [monotherapy] are cost-effective" in patients with HBV-related cirrhosis, the authors concluded. "Selecting between adefovir and entecavir is highly dependent on budgetary restraints and willingness to pay."

In their discussion, the authors noted that for first-line therapy, the newer antiviral therapies adefovir and entecavir are both more effective overall and cost-effective in patients with HBV cirrhosis, and "should be preferred over lamivudine monotherapy." In this setting, adefovir was less effective and less expensive than entecavir.

In cirrhotic patients with previous lamivudine resistance, however, adefovir salvage therapy appeared both more effective and less expensive than entecavir salvage therapy.

"Although antiviral resistance is never a goal of therapy," the authors wrote, "the development of resistance has less severe health economic consequences in non-cirrhotics than cirrhotics, because patients with cirrhosis can ill afford the emergence of viral resistance and subsequent viral flares."

The researchers did not include another possible alternative strategy: starting treatment with combination antiviral therapy, which would be more expensive but less likely to produce drug resistance.

09/26/06

Reference
F Kanwal, M Farid, P Martin, and others. Treatment alternatives for hepatitis B cirrhosis: a cost-effectiveness analysis. American Journal of Gastroenterology 101(9): 2076-2089. September 2006.