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Abstract
BackgroundSeveral rescue therapies have been used in patients with lamivudine (LAM)-resistant chronic hepatitis B (CHB); however, the economic outcome of these therapies is unclear. The object of the current analysis was to evaluate the lifetime cost-effectiveness of rescue therapies among patients with LAM-resistant CHB.MethodsA Markov model was developed to simulate the clinical course of patients with LAM-resistant CHB. From the perspective of Chinese health care, a lifetime cost-utility analysis was performedfor 4 rescue strategies: adefovir (ADV), entecavir (ETV) or tenofovir (TDF) monotherapy and combination therapy using LAM and ADV. A hypothetical cohort of 45-year-old patients with genotypic or clinical LAM-resistant CHB entered the model, and the beginning health state was LAM-resistant CHB without other complications. The transition probabilities, efficacy and resistance data for each rescue therapy as well as the costs and utility data were estimated from the literature. The discount rate (3%) utilized for costs and benefits. Sensitivity analyses were used to explore the impact of uncertainty on the results.ResultsIn LAM-resistant HBeAg-positive and HBeAg-negative CHB cohorts, TDF monotherapy and combination therapy were on the efficiency frontier for both positive and negative populations. Compared with no treatment, the use of combination therapy cost an additional $6,531.7 to gain 1 additional quality-adjusted life year (QALY) for HBeAg-positive patients and $4,571.7 to gain 1 additional QALY for HBeAg-negative patients. TDF monotherapy for HBeAg-positive patients, shows greater increase in QALYs but higher incremental cost-effectiveness ratio (ICER) in comparison with combination therapy. In probabilistic sensitivity analyses, combination therapy was the preferred option for health care systems with limited health resources, such as Chinese health care system.ConclusionIn Chinese patients with LAM-resistant CHB, combination therapy is a more cost-effective option than the competing rescue therapies.
Highlights
Several rescue therapies have been used in patients with lamivudine (LAM)-resistant chronic hepatitis B (CHB); the economic outcome of these therapies is unclear
The comparison among the treatment alternatives was measured by the incremental cost-effectiveness ratio (ICER)
Base-case analysis In the LAM-resistant HBeAg-positive cohort, treatment with TDF monotherapy resulted in 11.17 quality-adjusted life year (QALY), and the lifetime cumulative incidence of compensated cirrhosis, decompensated cirrhosis, HCC and death was 30.7%, 11.7%, 13.1% and 25.5%, respectively
Summary
Several rescue therapies have been used in patients with lamivudine (LAM)-resistant chronic hepatitis B (CHB); the economic outcome of these therapies is unclear. Several oral nucleoside antiviral agents, such as lamivudine (LAM), adefovir (ADV), telbivudine (TBV), entecavir (ETV) and tenofovir (TDF), have been approved for the treatment of CHB Because of their superior efficacy and markedly low resistance, ETV and TDF have been recommended as first-line options for treatment of naïve CHB patients.[4] the high daily cost of ETV and TDF limits their widespread use in areas with limited health resources, such as in China [5]. Because the rate of virological breakthrough is approximately 40% in LAM-resistant patients after 4 years of ETV therapy,[23] recent guidelines for managing CHB recommend that ETV be used as a strategy for dealing with LAM resistance only when the addition of ADV is not appropriate [3,24] These rescue strategies have been introduced into clinical practice and have shown some health benefits for LAMresistant CHB patients, many problems remain. There are no report comparing the costeffectiveness of different rescue strategies for patients with LAM-resistant CHB
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