Exceptions are patients without rapid viral response to boceprevir or the IL28B genotype, for whom dual therapy is still best.
The new triple therapy regimens with peginterferon alfa, ribavirin, and boceprevir or telaprevir lead to high rates of sustained virologic response (SVR) in patients with hepatitis C virus (HCV) infection (JW Gastroenterol Mar 30 2011 and JW Gastroenterol Sep 16 2011). But, given their adverse effects, drug interactions, potential viral mutations, and expense, it is unclear whether these regimens are more cost-effective than dual therapy.
Now, European investigators have created a Markov decision model — using data from untreated patients with genotype 1 HCV infection and stage 2 liver fibrosis — to evaluate the cost-effectiveness of the following five strategies over a 20-year horizon:
- Boceprevir response-guided therapy (RGT)
- Boceprevir IL28B genotype-guided therapy (IL28B)
- Boceprevir rapid virologic response–guided therapy (RVRT)
- Telaprevir RGT
- Telaprevir IL28B
In the IL28B strategies, if the IL28B CC genotype was identified, patients underwent dual therapy. In the boceprevir RVRT strategy, if rapid viral response was achieved during boceprevir lead-in, patients received dual therapy. Outcomes included costs (in 2011 euros), years of life gained, and incremental cost-effectiveness ratio (ICER).
The telaprevir IL28B and boceprevir RVRT strategies were the most clinically effective (survival improvement, 4.42 years and 4.04 years, respectively) and the most cost-effective. For both of these strategies, the quality-adjusted life year (QALY) estimate was improved by about 7 years, thanks to a 25% improvement in SVR rate, compared with dual therapy. This gain in SVR came at a relatively low cost of ICER per QALY of <10,000.
Comment: These results show that HCV triple therapy regimens are more cost-effective than previous dual therapy, especially if RVRT and IL28B data are used. Furthermore, the ICER per QALY was lower than the accepted societal threshold for willingness to pay. As with many modeling studies, the results are highly sensitive to certain assumptions and variables, including the cost of the regimens.
Source: Journal Watch Gastroenterology