Original Contribution
The American Journal of Gastroenterology (2006) 101, 2076–2089; doi:10.1111/j.1572-0241.2006.00769.x
Treatment Alternatives for Hepatitis B Cirrhosis: A Cost-Effectiveness Analysis
Fasiha Kanwal MD, MSHS1,2,3,4, Mary Farid DO1,3, Paul Martin MD6, Gary Chen MD6, Ian M Gralnek MD, MSHS2,3, Gareth S Dulai MD, MSHS2,3 and Brennan M R Spiegel MD, MSHS1,2,3,4
- 1Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California
- 2Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
- 3UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, California
- 4CURE Digestive Diseases Research Center, Los Angeles, California
- 5Mount Sinai School of Medicine, New York, New York
- 6Cedars Sinai Medical Center, Los Angeles, California
Correspondence: Brennan M R Spiegel, MD, MSHS, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, UCLA/VA Center for outcomes Research and Education (CORE), 11301 Wilshire Boulevard, Building 115, Room 215E, Los Angeles, CA 90073.
Received 14 July 2005; Accepted 25 April 2006.
Abstract
BACKGROUND:
Hepatitis B virus (HBV) patients with cirrhosis are at risk for developing costly, morbid, or mortal events, and therefore need highly effective therapies. Lamivudine is effective but is limited by viral resistance. In contrast, adefovir and entecavir have lower viral resistance, but are more expensive. The most cost-effective approach is uncertain.
METHODS:
We evaluated the cost-effectiveness of six strategies in HBV cirrhosis: (1) No HBV treatment ("do nothing"), (2) lamivudine monotherapy, (3) adefovir monotherapy, (4) lamivudine with crossover to adefovir on resistance ("adefovir salvage"), (5) entecavir monotherapy, or (6) lamivudine with crossover to entecavir on resistance ("entecavir salvage"). The primary outcome was the incremental cost per quality-adjusted life-year (QALY) gained.
RESULTS:
The "do nothing" strategy was least effective yet least expensive. Compared with "do nothing," using adefovir cost an incremental $19,731. Entecavir was more effective yet more expensive than adefovir, and cost an incremental $25,626 per QALY gained versus adefovir. Selecting between entecavir versus adefovir was highly dependent on the third-party payer's "willingess-to-pay" (e.g., 45% and 60% of patients fall within budget if willing-to-pay $10K and $50K per QALY gained for entecavir, respectively). Both lamivudine monotherapy and the "salvage" strategies were not cost-effective. However, between the two salvage strategies, "adefovir salvage" was more effective and less expensive than "entecavir salvage."
CONCLUSION:
Both entecavir and adefovir are cost-effective in patients with HBV cirrhosis. Choosing between adefovir and entecavir is highly dependent on available budgets. In patients with HBV cirrhosis with previous lamivudine resistance, "adefovir salvage" appears more effective and less expensive than "entecavir salvage."
