The cost-effectiveness and budget impact of competing therapies in hepatic encephalopathy - a decision analysis.
BACKGROUND
Treatment options for hepatic encephalopathy have disparate risks and benefits. Non-absorbable disaccharides and neomycin are limited by uncertain efficacy and common dose-limiting side effects. In contrast, rifaximin is safe and effective in hepatic encephalopathy, but is more expensive.


METHODS
We conducted a decision analysis to calculate the cost-effectiveness of six strategies in hepatic encephalopathy: (i) no hepatic encephalopathy treatment, (ii) lactulose monotherapy, (iii) lactitol monotherapy, (iv) neomycin monotherapy, (v) rifaximin monotherapy and (vi) up-front lactulose with crossover to rifaximin if poor response or intolerance of lactulose ('rifaximin salvage'). The primary outcome was cost per quality-adjusted life-year gained.


RESULTS
Under base-case conditions, 'do nothing' was least effective and rifaximin salvage was most effective. Lactulose monotherapy was least expensive, and rifaximin monotherapy was most expensive. When balancing cost and effectiveness, lactulose monotherapy and rifaximin salvage dominated alternative strategies. Compared to lactulose monotherapy, rifaximin salvage cost an incremental US$2315 per quality-adjusted life-year-gained. The cost of rifaximin had to fall below US$1.03/tab in order for rifaximin monotherapy to dominate lactulose monotherapy.


CONCLUSIONS
Rifaximin monotherapy is not cost-effective in the treatment of chronic hepatic encephalopathy at current average wholesale prices. However, a hybrid salvage strategy, reserving rifaximin for lactulose-refractory patients, may be highly cost-effective.
Huang
E
E
David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
Esrailian
E
E
Spiegel
B M R
BM
D003362:Cost-Benefit Analysis; D005260:Female; D005765:Gastrointestinal Agents / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use*; D006501:Hepatic Encephalopathy / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007792:Lactulose / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use*; D017093:Liver Failure / Q000150:complications* / Q000191:economics; D016031:Liver Transplantation; D015141:Los Angeles; D008297:Male; D008875:Middle Aged; D012294:Rifamycins / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use*; D000078262:Rifaximin
D005765:Gastrointestinal Agents; D012294:Rifamycins; D007792:Lactulose; D000078262:Rifaximin