The optimal timing of hepatitis C therapy in transplant eligible patients with Child B and C Cirrhosis: A Cost-Effectiveness Analysis.

Tapper, Elliot B; Hughes, Michael S; Buti, Maria; Dufour, Jean-François; Flamm, Steve; Firdoos, Saima; Curry, Michael P; Afdhal, Nezam H (2017). The optimal timing of hepatitis C therapy in transplant eligible patients with Child B and C Cirrhosis: A Cost-Effectiveness Analysis. Transplantation, 101(5), pp. 987-995. Lippincott Williams & Wilkins 10.1097/TP.0000000000001400

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BACKGROUND

Ledipasvir/sofosbuvir (LDV/SOF) has demonstrated high efficacy, safety and tolerability in HCV-infected patients. There is limited data, however, regarding the optimal timing of therapy in the context of possible liver transplantation (LT).

METHODS

We compared the cost-effectiveness of 12 weeks of HCV therapy before or after LT or nontreatment using a decision analytical microsimulation state-transition model for a simulated cohort of 10 000 patients with HCV Genotype 1 or 4 with Child B or C cirrhosis. All model parameters regarding the efficacy of therapy, adverse events and the effect of therapy on changes in model for endstage liver disease (MELD) scores were derived from the SOLAR-1 and 2 trials. The simulations were repeated with 10 000 samples from the parameter distributions. The primary outcome was cost (2014 US dollars) per quality adjusted life year (QALY).

RESULTS

Treatment before LT yielded more QALY for less money than treatment after LT or nontreatment. Treatment before LT was cost-effective in 100% of samples at a willingness-to-pay threshold of $100 000 in the base-case and when the analysis was restricted to Child B alone, Child C, or MELD > 15. Treatment before transplant was not cost-effective when MELD was 6-10. In sensitivity analyses, the MELD after which treatment before transplant was cost-effective was 13 and the maximum cost of LDV/SOF therapy at which treatment before LT is cost-effective is $177,381.

CONCLUSION

From a societal perspective, HCV therapy using LDV/SOF with ribavirin prior to LT is the most cost-effective strategy for patients with decompensated cirrhosis and MELD > 13.

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