Dynamic decision analysis to determine optimal treatment duration in chronic hepatitis C.
BACKGROUND
Current guidelines for stopping treatment of chronic hepatitis C are based on hepatitis C ribonucleic acid measurements at 12 and 24 weeks.


OBJECTIVE
To explore an alternative approach for making individualized recommendations about treatment duration, based on simple alanine aminotransferase tests and on cost-per-cure.


METHODS
We analysed individual patient data from 13 randomized, controlled trials with interferon alone or combined with ribavirin. Using multiple logistic regression, we built a model that estimated the probability of sustained virological response for treatment durations of 24 and 48 weeks. Decisions to prolong treatment were based on an increase in probability of sustained virological response. If the increase was 10%, the cost-per-cure became decisive with a limit of 50,000.


RESULTS
Noncirrhotics with genotype 2 or 3 did not benefit when treatment was continued beyond 24 weeks. Sustained virological response rates in cirrhotic patients increased by 14-47% if treatment was continued up to 48 weeks. In noncirrhotic genotype 1 or 4 patients who had elevated alanine aminotransferase levels at week 4, the probability of sustained virological response increased by <10% if treatment was continued up to 48 weeks; the cost-per-cure for these patients would exceed 50,000.


CONCLUSIONS
The dynamics of alanine aminotransferase levels and cost-per-cure provides a useful alternative to determine the duration of therapy in chronic hepatitis C.
Veldt
B J
BJ
Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.
Hansen
B E
BE
Eijkemans
M J C
MJ
de Knegt
R J
RJ
Stijnen
T
T
Habbema
J D F
JD
Schalm
S W
SW
D000328:Adult; D000367:Age Factors; D000368:Aged; D000410:Alanine Transaminase / Q000097:blood*; D000998:Antiviral Agents / Q000191:economics / Q000627:therapeutic use; D004796:Clinical Enzyme Tests / Q000191:economics; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D019698:Hepatitis C, Chronic / Q000188:drug therapy* / Q000191:economics / Q000201:enzymology; D006801:Humans; D016898:Interferon-alpha / Q000191:economics / Q000627:therapeutic use; D008103:Liver Cirrhosis / Q000097:blood / Q000188:drug therapy / Q000191:economics; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012254:Ribavirin / Q000191:economics / Q000627:therapeutic use; D012737:Sex Factors
D000998:Antiviral Agents; D016898:Interferon-alpha; D012254:Ribavirin; D000410:Alanine Transaminase