Treatment alternatives for hepatitis B cirrhosis: a cost-effectiveness analysis.
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 US dollars 19,731. Entecavir was more effective yet more expensive than adefovir, and cost an incremental US dollars 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 US dollars 10K and US dollars 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."


CONCLUSIONS
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."
Kanwal
Fasiha
F
Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California 90073, USA.
Farid
Mary
M
Martin
Paul
P
Chen
Gary
G
Gralnek
Ian M
IM
Dulai
Gareth S
GS
Spiegel
Brennan M R
BM
D000998:Antiviral Agents / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D019694:Hepatitis B, Chronic / Q000150:complications* / Q000188:drug therapy; D006801:Humans; D007166:Immunosuppressive Agents / Q000191:economics* / Q000627:therapeutic use; D008103:Liver Cirrhosis / Q000188:drug therapy* / Q000191:economics* / Q000209:etiology; D011788:Quality of Life; D018894:Reverse Transcriptase Inhibitors / Q000191:economics* / Q000627:therapeutic use; D016896:Treatment Outcome
D000998:Antiviral Agents; D007166:Immunosuppressive Agents; D018894:Reverse Transcriptase Inhibitors