Economic

Hybrid salvage strategy cost-effective for chronic hepatitis B treatment

Last Updated: 2005-05-17 15:47:14 -0400 (Reuters Health)

By Will Boggs, MD

NEW YORK (Reuters Health) - A hybrid salvage strategy that reserves adefovir treatment for lamivudine-resistant chronic hepatitis B appears cost-effective for most patients, according to a new report.

"Despite the effectiveness of adefovir in hepatitis B, it is simply not cost-effective to use it routinely as first-line therapy in all comers with hepatitis B," Dr. Brennan M.R. Spiegel from the David Geffen School of Medicine at UCLA, told Reuters Health. "Instead, it appears more prudent from a health economics perspective to save adefovir for when it's most useful -- namely, when lamivudine resistance has already occurred."

Dr. Spiegel and colleagues performed an economic analysis to estimate the cost-effectiveness of several strategies for managing chronic hepatitis B virus infection in patients with elevated liver enzyme levels and no evidence of cirrhosis.

Interferon monotherapy was associated with an incremental $6337 per quality adjusted life-year (QALY) gained, compared with doing nothing, the authors report. Adefovir salvage therapy (crossing over from lamivudine to adefovir when lamivudine resistance appears) was associated with an additional $8446 per QALY, compared with interferon monotherapy.

Lamivudine and adefovir monotherapy were more expensive and less effective than the other strategies, the researchers report in the in the May 17th Annals of Internal Medicine.

Similar results were obtained when only HBeAg-negative patients were considered, the researchers note, although all the strategies became more expensive and less effective.

In contrast, adefovir salvage strategy became the most effective and least expensive approach for patients who are HBeAg positive, the report indicates.

Three Monte Carlo analyses supported these findings, revealing that adefovir salvage strategy is most cost-effective in HBeAg-positive patients and that interferon monotherapy is most cost-effective in health care systems with tight budgetary constraints and a high prevalence of HBeAg-negative patients.

"Don't write-off interferon," Dr. Spiegel said. "It still has a role, especially in HBeAg negative patients and in health care settings that simply cannot afford other types of therapy."

"The conclusion that adefovir salvage is a dominant (HBeAg-positive patients) or cost-effective (HBeAg-negative patients) strategy may change if newer drugs, or combinations of current drugs, are more effective, cheaper, or both," write Dr. Douglas K. Owens from VA Palo Alto Health Care System in California and Dr. Martin Black from Temple University School of Medicine, Philadelphia, in a related editorial.

"It's important to understand that hepatitis B is a significant health problem, despite being nearly eclipsed by hepatitis C in terms of publicity," Dr. Spiegel added. "From a global standpoint, hepatitis B carries a much larger burden of illness."

Ann Intern Med 2005;142:821-831,863-864.