title: The Optimal Timing of Hepatitis C Therapy in Transplant Eligible Patients With Child B and C Cirrhosis: A Cost-Effectiveness Analysis.
abstract: Ledipasvir (LDV)/sofosbuvir (SOF) has demonstrated high efficacy, safety, and tolerability in hepatitis C virus (HCV)-infected patients. There is limited data, however, regarding the optimal timing of therapy in the context of possible liver transplantation (LT).
  
  
  
  We compared the cost-effectiveness of 12 weeks of HCV therapy before or after LT or nontreatment using a decision analytical microsimulation state-transition model for a simulated cohort of 10 000 patients with HCV Genotype 1 or 4 with Child B or C cirrhosis. All model parameters regarding the efficacy of therapy, adverse events and the effect of therapy on changes in model for end-stage liver disease (MELD) scores were derived from the SOLAR-1 and 2 trials. The simulations were repeated with 10 000 samples from the parameter distributions. The primary outcome was cost (2014 US dollars) per quality adjusted life year.
  
  
  
  Treatment before LT yielded more quality-adjusted life year for less money than treatment after LT or nontreatment. Treatment before LT was cost-effective in 100% of samples at a willingness-to-pay threshold of US $100 000 in the base-case and when the analysis was restricted to Child B alone, Child C, or MELD > 15. Treatment before transplant was not cost-effective when MELD was 6-10. In sensitivity analyses, the MELD after which treatment before transplant was cost-effective was 13 and the maximum cost of LDV/SOF therapy at which treatment before LT is cost-effective is US $177 381.
  
  
  
  From a societal perspective, HCV therapy using LDV/SOF with ribavirin before LT is the most cost-effective strategy for patients with decompensated cirrhosis and MELD score greater than 13.
authors: 1 Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. 2 Harvard Medical School, Boston, MA. 3 Liver Unit, Department of Internal Medicine, Hospital Valle Hebron and Ciberehd del Institut Carlos III, Barcelona, Spain. 4 Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Berne, Switzerland. 5 Division of Gastroenterology/Hepatology, Northwestern University, Chicago, IL.
authors: Elliot B
authors: EB
authors: Tapper
authors: Michael S
authors: MS
authors: Hughes
authors: Maria
authors: M
authors: Buti
authors: Jean-Francois
authors: JF
authors: Dufour
authors: Steve
authors: S
authors: Flamm
authors: Saima
authors: S
authors: Firdoos
authors: Michael P
authors: MP
authors: Curry
authors: Nezam H
authors: NH
authors: Afdhal
mesh_terms: D000998:Antiviral Agents / Q000008:administration & dosage* / Q000191:economics* / Q000627:therapeutic use; D001562:Benzimidazoles / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004334:Drug Administration Schedule; D005449:Fluorenes / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D019698:Hepatitis C, Chronic / Q000150:complications / Q000188:drug therapy* / Q000191:economics / Q000601:surgery; D006801:Humans; D008103:Liver Cirrhosis / Q000601:surgery / Q000821:virology*; D016031:Liver Transplantation; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D012254:Ribavirin / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use; D000069474:Sofosbuvir; D016896:Treatment Outcome; D014481:United States; D014542:Uridine Monophosphate / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000191:economics / Q000627:therapeutic use
chemical_list: D000998:Antiviral Agents; D001562:Benzimidazoles; D005449:Fluorenes; C000595958:ledipasvir, sofosbuvir drug combination; D012254:Ribavirin; D014542:Uridine Monophosphate; D000069474:Sofosbuvir