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A pragmatic and cost-effective strategy of a combination therapy of interferon alpha-2b and ribavirin for the treatment of chronic hepatitis c
A pragmatic and cost-effective strategy of a combination
therapy of interferon alpha-2b and ribavirin for the treatment
Markus Sagmeistera,b, John B. Wongb, Beat Mullhauptc and
Background Combination of interferon (IFN) alpha and
combination therapy dominates all other strategies. In
ribavirin is considered the standard treatment for patients
genotype 1 infection, 48 weeks of combination therapy for
with chronic hepatitis C. While combination therapy is
week-24 responders only prolongs life expectancy at a
more effective than IFN alone, the optimal management of
favourable cost-effectiveness ratio (CE) of 7135 euros per
combination treatment remains uncertain.
quality-adjusted life year (QALY). Taking response factorsother than genotype into account does not add to the
Objective To assess a pragmatic and cost-effective
effectiveness or cost effectiveness.
strategy for the therapy of treatment-naive patients withchronic hepatitis C.
Conclusion Treating non-cirrhotic patients with chronic
hepatitis C according to genotype only is most cost
Design Markov model on original data of two randomized
effective independent of the number of other known
response factors. Eur J Gastroenterol Hepatol 13:483±488& 2001 Lippincott Williams & Wilkins
Methods A validated computer simulation model was
applied to non-cirrhotic hepatitis C virus (HCV)-infected
European Journal of Gastroenterology & Hepatology 2001, 13:483±488
patients. Patient characteristics and ef®cacy of treatment
Keywords: cost-effectiveness, costs, hepatitis C, interferon, ribavirin
were extracted from two randomized trials reporting on
1445 non-cirrhotic patients. Different strategies were
Division of Gastroenterology and Hepatology, University Hospital, Zurich,
Switzerland; bDivision of Clinical Decision Making, Informatics and Telemedicine,
compared separately for genotype 1 and genotype non-1
New England Medical Center, Tufts University School of Medicine, Boston, USA;
(mostly genotype 2/3) infections: (1) no treatment; (2) IFN
and cDivision of Gastroenterology and Hepatology, Department of Medicine,
for 48 weeks (if at 12 weeks HCV RNA undetectable); (3)IFN and ribavirin for 24 weeks; (4) IFN and ribavirin for
Correspondence to M. Sagmeister MD, Division of Gastroenterology and
Hepatology, University Hospital, RaÈmistrasse 100, 8091 Zurich, Switzerland
48 weeks; (5) IFN and ribavirin for 48 weeks (if at 24 weeks
Tel: 41 255 11 11; e-mail: email@example.com
HCV RNA undetectable). All strategies were tested for
Supported, in part, by unrestricted grants from Essex Chemie AG Lucerne,
different combinations of known response factors.
Switzerland, and Roche Pharma (Schweiz) AG, Reinach, Switzerland.
Received 1 August 2000 Revised 8 September 2000
Results In genotype non-1 infection, 24 weeks of
tion of interferon alpha-2b with ribavirin (IFN-R; IFN
People infected with hepatitis C virus (HCV) will
3 MIU sc TIW and ribavirin 1000/1200 mg orally once
develop chronic hepatitis in 80% of cases Most
studies report a risk of 10±20% of developing cirrhosis
over a period of 20±30 years With established
Although combination therapy is more costly than
cirrhosis, the annual risk of developing hepatocellular
therapy with IFN alone, Younossi et al. have
carcinoma (HCC) rises considerably to 1±5%
shown a favourable CE of IFN-R compared with IFN.
The most favourable strategy was to perform viral
Until recently, 48 weeks of interferon (IFN; 3 million
genotyping to determine the duration of IFN-R with
units subcutaneously three times a week) was the only
genotype 1 patients receiving 48 weeks of IFN-R and
effective strategy for the treatment of chronic hepatitis
all others receiving 24 weeks of therapy. Wong et al.
C, with sustained response rates (SR) reaching only
also demonstrated a favourable CE of IFN-R.
15±20% Although IFN is costly, the cost-effective-
ness ratio (CE) for IFN falls within the limit of other
Poynard et al. con®rmed IFN-R as the ®rst-line
well accepted therapies Recent randomized
treatment of chronic hepatitis C, and introduced ®ve
trials have shown a higher effectiveness of a combina-
favourable independent response factors that are asso-
0954±691X & 2001 Lippincott Williams & Wilkins
484 European Journal of Gastroenterology & Hepatology 2001, Vol 13 No 5
ciated with a sustained response: genotype 2 or 3,
ribavirin 1000/1200 mg orally once daily for
baseline viral load less than 3.5 million copies/ml, no or
portal ®brosis only, female gender, and age less than
3. Combination therapy II (Comb II): after 24 weeks of
40 years. Those patients who are HCV-negative at
combination therapy, viral response is determined
week 24 and have less than four favourable response
and only responders continue treatment for an
factors should be treated for an additional 24 weeks.
additional 24 weeks (IFN 3 MIU sc TIW and
Poynard et al. argued that an approach that considered
ribavirin 1000/1200 mg orally once daily for 48
only virological characteristics (as suggested by Younos-
weeks, if at 24 weeks HCV RNA [PCR] undetect-
si et al. might be an oversimpli®cation and may
lead to wrong treatment decisions in certain patient
4. Combination therapy III (Comb III): patients are
treated for 48 weeks (IFN 3 MIU sc TIW and
ribavirin 1000/1200 mg orally once daily for
The aim of our study was to assess and optimize the
CE of different schemes of combination therapy with
5. No treatment: natural history without antiviral treat-
IFN-R. This evaluation, re¯ecting actual treatment
patterns and costs, was aimed at ®nding a pragmatic,
cost-effective strategy for treatment of patients with
The patient characteristics and the effectiveness of
treatment strategies were extracted from a data set of
1445 patients with mild or moderate hepatitis from two
Using standard decision analysis software (Decision
randomized trials comparing IFN with IFN-R
Maker 7.0 we applied an already established and
The mean patient age was 42.2 years (G1, 43.2 years; G
validated computer simulation model The mod-
non-1, 41.3 years); 34.9% were female; 66.3% had
el is based on a Markov simulation of the natural
moderate hepatitis; 64.6% of the patients were infected
history of hepatitis C. Cohorts of patients move through
with G1 and 32.0% were infected with genotype G2 or
prede®ned health states over time until all patients
have entered the dead state. Patients may progress over
time by given transition probabilities to more advanced
We de®ned an SR as viral negativity (HCV RNA
disease states or death. Morbidity and mortality from
negative by PCR, i.e. < 100 copies/ml) 24 weeks after
hepatitis C, and mortality from other causes as occur in
treatment. For our calculations, the SRs shown in
the general Swiss population, were considered. The
original model was extended to include therapeutic
options for HCC (orthotopic liver transplantation and
partial hepatectomy), re¯ecting current treatment mod-
The study included total direct costs for the year 1998
from a societal perspective, but excluded indirect costs,
such as lost productivity. To calculate the present value
Because viral genotype is the most important indepen-
of future costs, we used a 3% annual discount rate. The
dent response factor and is usually determined
cost evaluation followed actual treatment patterns for
before any antiviral treatment we examined
Switzerland. The costs of complications from HCV (the
®ve different strategies in two patient groups: those
annual frequency and type of medical care for each
with genotype 1 (G1) and those with genotype non-1
disease state) were estimated by a panel of Swiss
(G non-1, mostly genotype 2/3). We considered only
physicians (two gastroenterologists and three hepatolo-
those patients with mild to moderate hepatitis (includ-
gists). Costs for GP surgery visits and laboratory tests
ing bridging ®brosis) but not cirrhosis, because the
were based on reimbursement tariffs and the costs
optimal antiviral treatment of cirrhotic patients is still
for drugs were based on current retail prices.
1. IFN monotherapy (IFN): re¯ecting current recom-
Probability of sustained viral response (%)Ã
mendations the viral response is determined
after 12 weeks of IFN treatment. Only responders
continue antiviral treatment for an additional
weeks, if at 12 weeks HCV RNA [PCR] undetect-
ÃData extracted from 1445 patients with mild or moderate hepatitis C treated in
2. Combination therapy I (Comb I): patients are
IFN, interferon; tion therapy I; Comb II, combination therapy II;
treated for 24 weeks (IFN 3 MIU sc TIW and
Combination therapy for chronic hepatitis C Sagmeister et al. 485
Costs of monitoring and antiviral treatment
discounted with a rate of 3%. Strategies that are
The costs of treatment re¯ected current recommenda-
dominated (lower costs and higher effectiveness versus
tions for Switzerland and included a liver biopsy,
other strategies) were excluded from further evalua-
HCV RNA testing, genotyping and GP surgery visits
tions. Similarly, strategies were excluded by extended
dominance (a mix of other strategies has lower costs
The average length of stay per complication was based
A panel of Swiss physicians (two gastroenterologists
on the database of the Swiss Hospital Association
and three hepatologists) estimated the quality of life of
(VESKA) and on separate evaluations based on a
the health states using a time trade-off technique
consecutive series of liver transplantations (1995±1997)
Using these estimates, we assigned a utility weight (0
at the University Hospital, Berne (E.L. Renner, unpub-
death, 1 perfect health) to each health state, and used
lished data). Information on individual cost elements
was obtained mainly from VESKA and separate calcula-
tions of two large hospitals. The cost of a liver trans-
plantation was based on an analysis of the Swiss
We tested the sensitivity of our results to the in¯uence
hospital institute (SKI) We updated these data to
of Poynard's favourable response factors varied
re¯ect the current shorter average length of stay
discount rates, progression rate of cirrhosis and costs
and the increased costs of hospital care
and data are comparable to those reported in
the USA All costs are calculated in euros
(mean 1999 exchange rate euro/USD: 1.067).
G1 patients had a lower likelihood of sustained re-
The marginal CE is expressed as the additional costs
sponse than G non-1 patients, resulting in a lower life
per additional quality-adjusted life year (QALY) gained,
expectancy. The lower SR of G1 patients and longer
IFN, interferon; IFN-R, interferon alpha-2b with ribavirin.
Hepatocellular carcinoma (no OP), following years
Hepatocellular carcinoma (PH), following years
Hepatocellular carcinoma (OLT), following years
OP, operation; PH, partial hepatectomy; OLT, orthotopic liver transplantation.
486 European Journal of Gastroenterology & Hepatology 2001, Vol 13 No 5
Quality-of-life adjustments (utility weights)
G1 virus, Comb II is the most favourable strategy: it
should prolong life and be cost effective.
Comb I dominates all other strategies by reducing costs
and extending quality-adjusted life expectancy. Again,
compared with 24 weeks of combination treatment, the
quality-of-life decrements of treating all patients for
48 weeks (Comb III) exceeded the additional long-term
quality-of-life bene®ts. Compared with a strategy of no
antiviral therapy (natural history) or treating only 24-
week responders for 48 weeks (Comb II), Comb I
prolonged life and reduced costs. Thus for G non-1
OLT, orthotopic liver transplantation; PH, partial hepatectomy; IFN, interferon;
patients, Comb I is the optimal strategy, lengthening
IFN-R, interferon alpha-2b with ribavirin.
duration of antiviral treatment resulted in higher life-
To assess the sensitivity of our results to Poynard's
time costs compared with G non-1 patients
approach of favourable response factors we tested
each strategy (separately for G1 and G non-1 patients)
for the effect of the number of favourable response
factors present (c.f. Regardless of the number
The IFN strategy showed a favourable marginal CE
of favourable response factors (except genotype) pre-
(discounted) of 4886 euros (additional costs per QALY
sent, our results remained stable, with Comb II being
gained). Nevertheless, compared with IFN, Comb II
the most cost-effective strategy for patients with G1
should prolong life expectancy by 1.8 years on average
and Comb I being most cost effective for G non-1
at a still favourable CE ratio (discounted) of 7135 euros
patients. Therefore, consideration of known response
(additional costs per QALY gained). Treating all G1
factors, other than genotype, does not increase effec-
patients for 48 weeks (Comb III) rather than stopping
tiveness (QALY) or CE of the treatment strategies
treatment in 24-week non-responders (Comb II), how-
ever, led to a loss of quality-adjusted life expectancy, as
the quality-of-life decrements associated with treatment
We varied the discount rate from 0% to 5%, reduced
of all patients for 48 weeks outweighed the long-term
the histological progression rates to cirrhosis by 33%,
quality-of-life bene®ts obtained in the additional re-
and changed long-term disease costs by Æ 25%. In all
sponders Thus, for patients infected with
cases, our strategies remained below 24 960 euros per
ÃStrategies are in order of the rising lifetime costs.
QALY, quality-adjusted life year; CE, marginal cost-effectiveness ratio; IFN, interferon; Comb I, combination therapy I; DOM, dominated by other strategies; Comb II,
combination therapy II; Comb III, combination therapy III.
Combination therapy for chronic hepatitis C Sagmeister et al. 487
Sensitivity analysis of favourable response factors
most cost-effective strategy. G1 patients should be
(a) Genotype 1 with one or two favourable response factors
treated for 48 weeks only if a virological response has
occurred after 24 weeks of treatment. For G non-1
patients, IFN-R for 24 weeks dominated all other
strategies, including no antiviral therapy.
Our results con®rm and extend the study by Younossi
et al. We showed that for G1 patients the CE is
improved substantially by continuing combination ther-
(b) Genotype 1 with three or four favourable response factors
apy for a further 24 weeks in those patients who are
virological responders at week 24. Moreover, taking
response factors other than genotype into account, as
suggested by Poynard et al. did not improve the
CE Thus, deciding on the length of combi-
nation therapy in non-cirrhotic patients based solely on
the presence of genotypes non-1 and 1 and, in the case
of the latter, stopping treatment if HCV RNA in serum
is still detectable after 24 weeks of treatment, seems
(c) Genotype non-1 with two or three favourable response factors
simple, effective and cost effective.
Effectiveness of therapy was expressed as QALY
gained. When quality adjustments were made, quality-
of-life decrements associated with 48 weeks of combi-
nation therapy for all patients (Comb III) outweighed
the long-term quality-of-life bene®ts in the additional
responders. Thus, 24 weeks of combination therapy in
(d) Genotype non-1 with four or ®ve favourable response factors
G non-1 patients, and 48 weeks of combination therapy
in 24-week responders in G1 patients, maximized
As with any modelling approach, our analysis is limited
by the scarce availability of data on the natural history
of hepatitis C. Our conclusions, however, remain stable
even when varying assumptions over a wide range.
Thus, decreasing yearly progression rate to cirrhosis by
as much as 33%, increasing/decreasing long-term dis-
IFN, interferon; DOM: dominated by other strategies; Comb I, combination
therapy I; Comb II, combination therapy II; Comb III, combination therapy III.
ease-related costs by as much as 25%, or varying
discount rates between 0% and 5% did not affect our
conclusion that Comb I for G non-1 and Comb II for
G1 are the most favourable treatment strategies.
QALY gained and thus within accepted CE limits (e.g.
Collectively, our data demonstrate that IFN-R therapy
31 577 euros per QALY gained for coronary stenting
for non-cirrhotic patients with chronic hepatitis C is
with single-vessel disease 2371±17 097 euros per
most cost effective when genotype (1 versus non-1)
life year gained for cholesterol-lowering therapy with a
and, in G1, virological response at treatment week 24,
are taken into account for determining duration of
Our study is based on the original data of the two large
randomized trials comparing the ef®cacy of IFN
and IFN-R for treatment-naive patients. This allows for
The authors thank the International Hepatitis Interven-
a more detailed CE analysis than previous studies
tional Therapy Group for providing their data for this
We analysed ®ve different strategies separately
for both G1 and G non-1. Cirrhotic patients were not
included, as the antiviral treatment of cirrhotic patients
is still under clinical evaluation. Our data suggest that a
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