Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy.
Department of Hepatology and Gastroenterology, Niguarda Hospital, Milan, Italy.
International Center for Disease Health (ICDH), University of Milan-Bicocca, Monza, Italy.
Department of Hepatology and Liver Transplant Unit, Henri Mondor Hospital, Paris-Est University, Creteil, France.
Liver Center, Department of Internal Medicine, Yale University, New haven, CT, USA.
Different strategies of DAAs treatment are currently possible both pre and post liver-transplantation (LT). Clinical and economic consequences of these strategies still need to be adequately investigated; this study aims at assessing their cost-effectiveness. A decision-analytical model was created to simulate the progression of HCV-infected patients listed for decompensated cirrhosis (DCC) or for Hepatocellular carcinoma (HCC). Three DAAs treatment strategies were compared: (i) a 12-week course of DAAs prior to transplantation (PRE-LT), (ii) a 4-week course of DAAs starting at the time of transplantation (PERI-LT), and (iii) a 12-week course of DAAs administered at disease recurrence (POST-LT). The population was sub-stratified according to HCC presence and, in those without HCC, according to the MELD score at listing. Data on DAAs effectiveness was estimated using a cohort of patients still followed by 11 transplant centres of the European Liver and Intestine Transplant Association and by data available in the literature. In this study, PRE-LT treatment strategy was dominant for DCC patients with MELD<16 and cost-effective for those with MELD16-20, while POST-LT strategy emerged as cost-effective for DCC patients with MELD>20 and for those with HCC. Sensitivity analyses confirmed PRE-LT as the cost-effective strategy for patients with MELD≤20. In conclusion, PRE-LT treatment is cost-effective for patients with MELD≤20 without HCC, while treatments after LT are cost-effective in cirrhotic patients with MELD>20 and in those with HCC. It is worth reminding, though, that the final choice of a specific regimen at the patient level will have to be personalized based on clinical, social and transplant-related factors.