1
|
Omer S, Iftime A, Constantinescu I, Dina I. Low-Cost Predictors for Liver Function and Clinical Outcomes after Sustained Virological Response in Patients with HCV-Related Cirrhosis and Thrombocytopenia. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010146. [PMID: 36676770 PMCID: PMC9865508 DOI: 10.3390/medicina59010146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 01/14/2023]
Abstract
Background and Objectives: To find low-cost markers that can identify the hepatitis C virus cirrhotic patients that are at risk for long-term severe adverse liver effects (ascites, ascites or upper gastrointestinal bleeding, hepatocellular carcinoma), after treatment. There is established evidence for the benefits of treating hepatitis C virus cirrhotic patients, but there is still some need for clarification concerning the real impact on the long-term evolution after achieving sustained virological response; there is no general consensus in the literature about identifying the patients that do not improve post-treatment. Materials and Methods: Our retrospective analysis investigated the long-term (2 years) evolution of 46 patients with cirrhosis with thrombocytopenia, previously infected with VHC, treated and who obtained an SVR after DAA treatment. Results: Despite the overall improvement, 8.7% patients developed hepatocellular carcinoma and 6.5% patients ascites/upper GI bleeding. We found that FIB-4, MELD and AFP changes at 1 year were the most significant predictors for these outcomes. Additionally, a drop in leukocyte count after 1 year seemed to indicate a risk for hepatocellular carcinoma, but this was not consistent. Conclusions: It might be beneficial to intensify the surveillance for post-treatment adverse liver effects for the patients with these marker changes at 1 year.
Collapse
Affiliation(s)
- Secil Omer
- Department of Medical Semiology, Saint Joan Hospital Bucharest, Carol Davila University of Medicine, 042122 Bucharest, Romania
| | - Adrian Iftime
- Department of Biophysics, Carol Davila University of Medicine, 050474 Bucharest, Romania
- Correspondence:
| | - Ileana Constantinescu
- Department of Immunology and Transplant Immunology, Fundeni Clinical Institute Bucharest, Carol Davila University of Medicine, 022328 Bucharest, Romania
| | - Ion Dina
- Department of Medical Semiology, Saint Joan Hospital Bucharest, Carol Davila University of Medicine, 042122 Bucharest, Romania
| |
Collapse
|
2
|
Huang P, Wang Y, Yue M, Ge Z, Xia X, Jeyarajan AJ, Holmes JA, Yu R, Zhu C, Yang S, Lin W, Chung RT. The risk of hepatitis C virus recurrence in hepatitis C virus-infected patients treated with direct-acting antivirals after achieving a sustained virological response: A comprehensive analysis. Liver Int 2021; 41:2341-2357. [PMID: 34051040 PMCID: PMC8455436 DOI: 10.1111/liv.14976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 01/03/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The risk for hepatitis C virus (HCV) recurrence persists after HCV eradication with direct-acting antivirals (DAAs), particularly in patients with ongoing high-risk behaviours. Our aim was to assess the risk of HCV recurrence (late relapse and/or reinfection) post-sustained virological response (SVR). METHODS We searched the literature for studies reporting HCV recurrence rates post-SVR in PubMed, Web of Science and the Cochrane Library. Identified publications were divided into groups based on patient risk for HCV reinfection: low-risk HCV mono-infection, high-risk HCV mono-infection and a human immunodeficiency virus (HIV)/HCV coinfection. The HCV recurrence rate for each study was calculated by using events divided by the person-years of follow-up (PYFU). HCV recurrence was defined as confirmed, detectable HCV RNA post-SVR. RESULTS In the 16 studies of low-risk patients, the pooled recurrence rate was 0.89/1000 PYFU (95% confidence interval [CI], 0.16-2.03). For the 19 studies of high-risk patients, the pooled recurrence rate was 29.37/1000 PYFU (95% CI, 15.54-46.91). For the eight studies of HIV/HCV-coinfected patients, the pooled recurrence rate was 23.25/1000 PYFU (95% CI, 4.24-53.39). The higher pooled estimates of recurrence in the high-risk and HIV/HCV-coinfected populations were predominantly driven by an increase in reinfection rather than late relapse. CONCLUSIONS The HCV recurrence risk after achieving SVR with all-oral DAAs therapy is low, and the risk of HCV recurrence in high-risk and HIV/HCV-coinfected populations was driven by an increase in reinfection rather than late relapse.
Collapse
Affiliation(s)
- Peng Huang
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Yan Wang
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Ming Yue
- Department of Infectious Diseases, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhijun Ge
- Department of Critical Care Medicine, The Affiliated Yixing Hospital of Jiangsu University, Yixing, China
| | - Xueshan Xia
- Faculty of Life Science and Technology, Kunming University of Science and Technology of Science and Technology, Yunnan, China
| | - Andre J. Jeyarajan
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Jacinta A. Holmes
- Department of Gastroenterology, St Vincent’s Hospital, Fitzroy, Australia
| | - Rongbin Yu
- Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Chuanwu Zhu
- Department of Hepatology, The Fifth People’s Hospital of Suzhou, Suzhou, China
| | - Sheng Yang
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Wenyu Lin
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
3
|
Heo M, Pericot-Valverde I, Rennert L, Akiyama MJ, Norton BL, Gormley M, Agyemang L, Arnsten JH, Litwin AH. Hepatitis C virus DAA treatment adherence patterns and SVR among people who inject drugs treated in opioid agonist therapy programs. Clin Infect Dis 2021; 73:2093-2100. [PMID: 33876230 DOI: 10.1093/cid/ciab334] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Adequate medication adherence is critical for achieving sustained viral response (SVR) of hepatitis C virus (HCV) among people who inject drugs (PWID). However, it is less known which patterns of direct-acting antiviral (DAA) treatment adherence are associated with SVR in this population or what factors are associated with each pattern. METHODS The randomized three-arm PREVAIL study utilized electronic blister packs to obtain daily time frame adherence data in opiate agonist therapy program settings. Exact logistic regressions were applied to test the associations between SVR and six types of treatment adherence patterns. RESULTS Of the 113 participants treated with combination DAAs, 109 (96.5%) achieved SVR. SVR was significantly associated with all pattern parameters except for number of switches between adherent and missed days: total adherent daily doses (exact AOR=1.12; 95%CI=1.04-1.22), percent total doses (1.09; 1.03-1.16), days on treatment (1.16; 1.05-1.32), maximum consecutive adherent days (1.34; 1.06-2.04), maximum consecutive non-adherent days (.85; .74-.95=.003). SVR was significantly associated with total adherent doses in the first two months of treatment, it was not in the last month. Compared to White participants (30.7±11.8(se)), Black (18.4±7.8) and Hispanic participants (19.2±6.1) had significantly shorter maximum consecutive adherent days. While alcohol intoxication was significantly associated with frequent switches, drug use was not associated with any adherence pattern. CONCLUSION Consistent maintenance of adequate total dose adherence over the entire course of HCV treatment is important in achieving SVR among PWID. Additional integrative addiction and medical care may be warranted for treating PWID experiencing alcohol intoxication.
Collapse
Affiliation(s)
- Moonseong Heo
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | | | - Lior Rennert
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Matthew J Akiyama
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Brianna L Norton
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mirinda Gormley
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Linda Agyemang
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Julia H Arnsten
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alain H Litwin
- Clemson University School of Health Research, Clemson University, Clemson, SC, USA.,Department of Medicine, University of South Carolina School of Medicine, Greenville, SC, USA Department of Internal Medicine, Prisma Health, Greenville, SC, USA
| |
Collapse
|
4
|
Norton BL, Akiyama MJ, Arnsten JH, Agyemang L, Heo M, Litwin AH. High HCV cure rates among people who inject drugs and have suboptimal adherence: A patient-centered approach to HCV models of care. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 93:103135. [PMID: 33667826 DOI: 10.1016/j.drugpo.2021.103135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/23/2020] [Accepted: 01/20/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Though people who inject drugs (PWID) make up the majority of the hepatitis C virus (HCV) epidemic, concerns about adherence often exclude PWID from receiving direct-acting antiviral (DAA) medication. The most effective models of HCV care to promote sustained virologic response (SVR) and high adherence need to be evaluated. METHODS We conducted a prospective cohort study in three opioid treatment programs (OTPs) in the Bronx, NY. Participants, in collaboration with providers, chose one of three models of onsite care: directly observed therapy (mDOT), group treatment (GT), or self-administered individual treatment (SIT). SVR12, daily adherence, and participant characteristics were compared between groups. RESULTS Of 61 participants, the majority were male (62%) and Latino (67%), with a mean age of 53 (SD 9). Participants received DAAs via one of three models of care: mDOT (21%), GT (25%), or SIT (54%). The majority (59%) used illicit drugs during treatment. Overall, SVR12 was 98% with no differences between models of care: mDOT (100%), GT (100%), and SIT (97%) (p = 1.0). Overall, daily adherence was 73% (SD 16); 86% among those who chose mDOT compared to 71% among those who chose GT (p<0.01) and 73% among those who chose SIT (p<0.01). CONCLUSION Despite ongoing illicit drug use and suboptimal adherence, SVR12 was high among PWID treated onsite at an OTP using any one of three models of care. Shared decision making in real world settings may be key to choosing the appropriate model of care for PWID.
Collapse
Affiliation(s)
- Brianna L Norton
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States.
| | - Matthew J Akiyama
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Julia H Arnsten
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Linda Agyemang
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Moonseong Heo
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States; School of Mathematical Science, Clemson University, Clemson, SC, United States
| | - Alain H Litwin
- Department of Medicine, University of South Carolina School of Medicine - Greenville, Greenville, SC, United States; Department of Medicine, Prisma Health-Upstate, Greenville, SC, United States; Clemson University School of Health Research, Clemson, SC, United States
| |
Collapse
|
5
|
Lin CP, Liang PC, Huang CI, Yeh ML, Hsu PY, Hsu CT, Wei YJ, Liu TW, Hsieh MY, Hou NJ, Jang TY, Lin YH, Wang CW, Lin ZY, Chen SC, Huang CF, Huang JF, Dai CY, Chuang WL, Yu ML. Concordance of SVR12, SVR24 and SVR durability in Taiwanese chronic hepatitis C patients with direct-acting antivirals. PLoS One 2021; 16:e0245479. [PMID: 33539408 PMCID: PMC7861540 DOI: 10.1371/journal.pone.0245479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/03/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS Undetectable HCV RNA 12 weeks after the end of treatment (SVR12) has been the valid efficacy endpoint in the era of direct-acting antivirals (DAAs). Its concordance with SVR4 and SVR24 and long-term durability is unknown in Taiwanese chronic hepatitis C (CHC) patients. METHODS A total of 1080 CHC patients who received all-oral DAAs and an achieved end-of-treatment virological response (EOTVR), defined as undetectable HCV RNA at the end of therapy, were consecutively enrolled. HCV RNA was monitored 4, 12, and 24 weeks after EOT. Patients who achieved SVR24, defined as undetectable HCV RNA 24 weeks after EOT, were followed annually for assessing SVR durability. RESULTS Eleven (1.02%) patients experienced HCV RNA reappearance after EOT. The most frequent timing of RNA reappearance was observed at SVR4 (n = 7), followed by SVR12 (n = 3) and SVR 24 (n = 1). The positive predictive value (PPV) and negative predictive value (NPV) of SVR4 in predicting SVR12 were 99.7% and 100%, respectively, whereas the PPV and NPV of SVR12 in predicting SVR24 were 99.9% and 100%, respectively. Pyrosequencing confirmed delayed relapse rather than reinfection for the patient who had detectable HCV RNA at SVR24. Among 978 patients who achieved SVR24, after a median follow-up period of 17.3±8.2 months, the SVR durability is 100% up to a 4-year follow-up. CONCLUSION Achievement of SVR12 provides excellent durability of HCV seroclearance after DAA therapy. On-demand HCV RNA beyond SVR12 should be recommended for patients with unexplainable abnormal liver function or high-risk behaviors.
Collapse
Affiliation(s)
- Chuan-Pin Lin
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Cheng Liang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-I Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lun Yeh
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Yao Hsu
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Ting Hsu
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Ju Wei
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Ta-Wei Liu
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Ming-Yen Hsieh
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Nai-Jen Hou
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Tyng-Yuang Jang
- Department of Internal Medicine, Pingtung Hospital, Ministry of Health and Welfare, Ping-Tung, Taiwan
| | - Yi-Hung Lin
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Chih-Wen Wang
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Zu-Yau Lin
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shinn-Cherng Chen
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Feng Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Occupational Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Yen Dai
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
- Insitute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Center For Intelligent Drug Systems and Smart Bio-devices (IDSB) and Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsin-Chu, Taiwan
- Center for Lipid Science and Aging Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
6
|
Chou R, Dana T, Fu R, Zakher B, Wagner J, Ramirez S, Grusing S, Jou JH. Screening for Hepatitis C Virus Infection in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2020; 323:2762185. [PMID: 32119034 DOI: 10.1001/jama.2019.20788] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE A 2013 review for the US Preventive Services Task Force (USPSTF) of hepatitis C virus (HCV) screening found interferon-based antiviral therapy associated with increased likelihood of sustained virologic response (SVR) and an association between achieving an SVR and improved clinical outcomes. New direct-acting antiviral (DAA) regimens are available. OBJECTIVE To update the 2013 review on HCV screening to inform the USPSTF. DATA SOURCES Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews through February 2019, with surveillance through September 2019. STUDY SELECTION Randomized clinical trials (RCTs) and nonrandomized treatment studies of HCV screening and DAA therapy; cohort studies on screening, antiviral therapy, and the association between an SVR after antiviral therapy and clinical outcomes. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. MAIN OUTCOMES AND MEASURES Mortality, morbidity, quality of life, screening and treatment harms, and screening diagnostic yield. RESULTS Eight RCTs of DAA therapy vs placebo or an outdated antiviral regimen, 48 other treatment studies, and 33 cohort studies, with a total of 179 230 participants, were included. No study evaluated effects of HCV screening vs no screening. One new study since the 2013 review (n = 5917) found similar diagnostic yield of risk-based screening (sensitivity, 82%; number needed to screen to identify 1 HCV case, 15) and birth cohort screening (sensitivity, 76%; number needed to screen, 29), assuming perfect implementation. Ten open-label studies (n = 3292) reported small improvements in some quality-of-life and functional outcomes (eg, less than 3 points on the 0 to 100 36-Item Short Form Health Survey physical and mental component summary scales) after DAA treatment compared with before treatment. Two cohort studies (n = 24 686) found inconsistent associations of antiviral therapy vs no therapy with risk of hepatocellular carcinoma. Forty-nine treatment studies (n = 10 181) found DAA regimens associated with pooled SVR rates greater than 95% across genotypes, and low short-term rates of serious adverse events (1.9%) and withdrawal due to adverse events (0.4%). An SVR after antiviral therapy was associated with decreased adjusted risk of all-cause mortality (13 studies, n = 36 986; pooled hazard ratio [HR], 0.40 [95% CI, 0.28-0.56) and hepatocellular carcinoma (20 studies, n = 84 491; pooled HR, 0.29 [95% CI, 0.23 to 0.38]) vs no SVR. CONCLUSIONS AND RELEVANCE Direct evidence on the effects of HCV screening on clinical outcomes remains unavailable, but DAA regimens were associated with SVR rates greater than 5% and few short-term harms relative to older antiviral therapies. An SVR after antiviral therapy was associated with improved clinical outcomes compared with no SVR.
Collapse
Affiliation(s)
- Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University-Portland State University, Portland
| | - Bernadette Zakher
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Jesse Wagner
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Shaun Ramirez
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Janice H Jou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland
| |
Collapse
|
7
|
Sahakyan Y, Wong WW, Yi Q, Thein HH, Tomlinson GA, Krahn MD. Long-term morbidity and mortality in a Canadian post-transfusion hepatitis C cohort: Over 15 years of follow-up. J Viral Hepat 2020; 27:235-242. [PMID: 31654536 DOI: 10.1111/jvh.13226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 01/27/2023]
Abstract
The Federal Government of Canada established a $1.1 billion compensation programme in 1999 to support individuals who acquired hepatitis C virus (HCV) through blood products between January 1986 and July 1990. We aimed to describe the morbidity and mortality of this unique post-transfusion cohort (n = 4550) followed for over 15 years from 2000 to 2016. The age-standardized mortality rates were compared with that of the Canadian general population and HCV cohorts from other countries. We evaluated all-cause mortality using Kaplan-Meier survival curves and HCV-related and unrelated mortality using competing risk models. The age-standardized all-cause and HCV-related mortality rates per 10 000 person-years were 127 (95% CI: 117-138) and 76 (95% CI: 69-85) for males, and 77 (95% CI: 69-87) and 43 (95% CI: 37-51) for females, respectively. The risk of death of the post-transfusion cohort was almost twice as high as the Canadian general population (rate ratio = 1.8; 95% CI: 1.7-1.9). All-cause, HCV-related and HCV-unrelated mortality were 20%, 12% and 8%, respectively at 15 years of follow-up. By comparison, HCV-related mortality rates per 10 000 person-years for population-based HCV cohorts varied from 18 and 11 in Australia to 65 and 43 in Scotland for males and females, respectively. We reported long-term follow-up data for the largest post-transfusion cohort in the literature. The all-cause mortality rates were markedly higher than that of the Canadian general population. We also showed that HCV-related mortality were greater compared to other HCV cohorts. This suggests that continued efforts to identify and treat post-transfusion HCV are warranted.
Collapse
Affiliation(s)
- Yeva Sahakyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - William Wl Wong
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada.,School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Qilong Yi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Hla-Hla Thein
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - George A Tomlinson
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Ontario, Canada.,Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Murray D Krahn
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Ontario, Canada.,Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| |
Collapse
|
8
|
Norton BL, Bachhuber MA, Singh R, Agyemang L, Arnsten JH, Cunningham CO, Litwin AH. Evaluation of contingency management as a strategy to improve HCV linkage to care and treatment in persons attending needle and syringe programs: A pilot study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 69:1-7. [PMID: 31003171 PMCID: PMC6704472 DOI: 10.1016/j.drugpo.2019.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/13/2019] [Accepted: 02/15/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND A greater proportion of HCV-infected people who inject drugs (PWID) need to be linked to care for HCV antiviral treatment. This study sets out to evaluate the efficacy of contingency management (CM) for improving HCV linkage to care, treatment initiation, adherence, and cure for PWID recruited from a needle and syringe program. METHODS Between March 2015 and April 2016, 20 participants were enrolled into the CM arm, and then subsequently enrolled 20 participants in the enhanced standard of care (eSOC) arm. Participants in the eSOC arm received an expedited appointment and a round-trip transit card. Participants enrolled in the CM arm received eSOC plus $25 for up to ten HCV clinical visits and $10 for each returned weekly medication blister pack. Adherence was measured via electronic blister packs. RESULTS Overall the median age was 47 years; most were men (67%) and Hispanic (69%). There were no significant differences in demographic characteristics between participants in the study arms. In the CM arm 74% were linked to HCV care, compared to 30% in the eSOC arm (p = 0.01). In the CM arm, 75% (9/12) of treatment eligible participants initiated treatment, compared to 100%(4/4) in the eSOC arm (p = 0.53). All patients (9/9) achieved cure in the CM arm, as compared to 75% (3/4) of patients in the eSOC arm. There were no differences in adherence between study arms. CONCLUSIONS In this pilot study, contingency management led to higher rates of HCV linkage to care for PWID, as compared to standard of care. CM should be considered as a possible intervention to improve the HCV treatment cascade for PWID.
Collapse
Affiliation(s)
- B L Norton
- Division of General Internal Medicine, Montefiore Medical Center, United States.
| | - M A Bachhuber
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - R Singh
- New York University, United States
| | - L Agyemang
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - J H Arnsten
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - C O Cunningham
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - A H Litwin
- Division of General Internal Medicine, Montefiore Medical Center, United States.
| |
Collapse
|
9
|
Chu CY, Cheng CH, Chen HL, Lin IT, Wu CH, Lee YK, Bair MJ. Long-term histological change in chronic hepatitis C patients who had received peginterferon plus ribavirin therapy with sustained virological response. J Formos Med Assoc 2018; 118:1129-1137. [PMID: 30472042 DOI: 10.1016/j.jfma.2018.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/10/2018] [Accepted: 11/07/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The improvement in liver histology is an important aim in the management of hepatitis C virus (HCV) infection. Previous studies suggest that antiviral treatment could reduce the progression of hepatic fibrosis, especially in patients with sustained virological response (SVR). However, most studies were limited by short-term evaluations and the liver stiffness was assessed by non-invasive methods. In our study, we performed a paired liver biopsy study aimed at analyzing the long-term histological changes in patients with SVR. METHODS We included 31 patients who had been previously treated with peginterferon plus ribavirin. All patients achieved SVR and had received pre- and post-treatment liver biopsies. The histological appearance of fibrosis and inflammation were assessed with METAVIR scoring system and Histological Activity Index (HAI) criteria. We analyzed several factors associated with the histological response. RESULTS The median interval between two biopsies was 93.0 months. The percentage of patients with fibrosis regression, stable, and progression were 19%, 45%, and 36%. A total of 71% of patients achieved inflammation improvement, whereas 6% and 23% of patients had stable disease and disease-progression, respectively. We showed that the patients without baseline advanced fibrosis and those having a lower baseline HAI score had higher risk of fibrosis worsening. Baseline fibrosis and necroinflammation status did not influence HAI change significantly. CONCLUSION The progression of hepatic fibrosis and inflammation can be reversed in some patients who had long-term virological suppression. Patients with advanced baseline fibrosis and higher inflammatory stages seemed to receive more histologic benefit from successful antiviral treatments.
Collapse
Affiliation(s)
- Chia-Ying Chu
- Department of Pathology, Taitung Mackay Memorial Hospital, Taiwan
| | - Chun-Han Cheng
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taiwan; Mackay Medical College, New Taipei, Taiwan
| | - Huan-Lin Chen
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taiwan; Mackay Medical College, New Taipei, Taiwan
| | - I-Tsung Lin
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taiwan; Mackay Medical College, New Taipei, Taiwan
| | - Chia-Hsien Wu
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taiwan; Mackay Medical College, New Taipei, Taiwan
| | - Yuan-Kai Lee
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taiwan; Mackay Medical College, New Taipei, Taiwan
| | - Ming-Jong Bair
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taiwan; Mackay Medical College, New Taipei, Taiwan.
| |
Collapse
|
10
|
Rice DP, Ordoveza MA, Palmer AM, Wu GY, Chirch LM. Timing of treatment initiation of direct-acting antivirals for HIV/HCV coinfected and HCV monoinfected patients. AIDS Care 2018; 30:1507-1511. [PMID: 30021452 DOI: 10.1080/09540121.2018.1499857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Direct-acting antiviral therapy is safe and cost-effective for the treatment of hepatitis C virus (HCV) infection. However, variability in drug payment rules represents a barrier to treatment that may disproportionately affect certain populations. We conducted a retrospective cohort study among HIV/HCV coinfected and HCV monoinfected patients using Kaplan-Meier and Fisher's exact test to analyze the time from the prescription of a direct-acting antiviral agent to delivery to the patient. Variables with significance p < .20 in univariate analysis were included in a Cox regression model. Factors associated with faster treatment were Infectious Diseases office setting (p = .01), public insurance payer (p = .01), and initial approval of requested regimen (p = .01). The presence of other liver disease was associated with delay in treatment (p = .05). Unrestrictive Medicare and Medicaid regulations resulted in more rapid delivery of medication compared to private payers. Fibrosis level, Child-Pugh class and HIV status did not significantly change time to treatment.
Collapse
Affiliation(s)
- Donald P Rice
- a University of Connecticut School of Medicine , Farmington , CT , USA
| | | | - Ann M Palmer
- a University of Connecticut School of Medicine , Farmington , CT , USA
| | - George Y Wu
- b University of Connecticut Health Center , Farmington , CT , USA
| | - Lisa M Chirch
- b University of Connecticut Health Center , Farmington , CT , USA
| |
Collapse
|
11
|
Kim RS, Weinberger AH, Chander G, Sulkowski MS, Norton B, Shuter J. Cigarette Smoking in Persons Living with Hepatitis C: The National Health and Nutrition Examination Survey (NHANES), 1999-2014. Am J Med 2018; 131:669-675. [PMID: 29408018 PMCID: PMC5963992 DOI: 10.1016/j.amjmed.2018.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/01/2018] [Accepted: 01/04/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cigarette smoking is common in persons living with hepatitis C (hepatitis C+), but national statistics on this harmful practice are lacking. A better understanding of smoking behaviors in hepatitis C+ individuals may help in the development of targeted treatment strategies. METHODS We extracted data from the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2014. Hepatitis C+ were compared with hepatitis C- adults in the entire sample and in the subset of current smokers. Measures included demographics, current smoking, cigarettes/day, nicotine dependence, other tobacco use, substance use, and medical and psychiatric comorbidities. RESULTS Complete smoking and hepatitis C virus (HCV) data were available for 39,472 (90.1%) of 43,793 adult participants in NHANES during the study years. Hepatitis C+ smoked at almost triple the rate of hepatitis C- adults (62.4% vs 22.9%), with no significant difference between hepatitis C+ men and women (64.5% vs 58.2%). Hepatitis C+ smokers were more likely to smoke daily than hepatitis C- smokers (87.5% vs 80.0%), but had similar levels of nicotine dependence. Hepatitis C+ smokers were more likely to be older (mean age: 47.1 vs 41.5 years), male (69.4% vs 54.4%), Black (21.2% vs 12.1%), less educated (any college: 31.8% vs 42.9%), poor (mean family monthly poverty index: 1.80 vs 2.47), uninsured (43.9% vs 30.4%), use drugs (cocaine: 11.1% vs 3.2%; heroin: 4.0% vs 0.6%), and be depressed (33.2% vs 13.5%). Multivariate analyses revealed significant associations of both hepatitis C infection and cigarette smoking with current depression and hypertension. CONCLUSIONS There is a cigarette smoking epidemic embedded within the hepatitis C epidemic in the United States. The sociodemographic profile of hepatitis C+ smokers suggests that the implementation of effective tobacco treatment will be challenging. Thoughtful treatment strategies that are mindful of the unique characteristics of this group are needed.
Collapse
Affiliation(s)
- Ryung S Kim
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY; Department of Applied Statistics, Yonsei University, Seoul, South Korea
| | - Andrea H Weinberger
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY; Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | | | - Mark S Sulkowski
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Brianna Norton
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Jonathan Shuter
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY; Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.
| |
Collapse
|
12
|
El Kassas M, Funk AL, Abd El Latif Y, Vasiliu A, Sherief A, Shimakawa Y, Youssef N, El Tahan A, Elbadry M, Farid AM, El Shazly Y, Doss W, Esmat G, Fontanet A. Letter: concordance of SVR4 and SVR12 following direct-acting anti-viral treatment in Egypt. Aliment Pharmacol Ther 2018; 47:1564-1566. [PMID: 29878419 DOI: 10.1111/apt.14628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- M El Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - A L Funk
- Emerging Disease Epidemiology Unit, Institut Pasteur, Paris, France
| | - Y Abd El Latif
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - A Vasiliu
- Emerging Disease Epidemiology Unit, Institut Pasteur, Paris, France
| | - A Sherief
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Y Shimakawa
- Emerging Disease Epidemiology Unit, Institut Pasteur, Paris, France
| | - N Youssef
- Medical Surgical Nursing Department, Faculty of Nursing, Cairo University, Cairo, Egypt
| | - A El Tahan
- New Cairo Viral Hepatitis Treatment Unit, Cairo, Egypt
| | - M Elbadry
- Tropical Medicine and Gastroenterology Department, Faculty of Medicine, Aswan University, Sahary City, Egypt
| | - A M Farid
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Y El Shazly
- Egyptian National Committee for Control of Viral Hepatitis, Cairo, Egypt
| | - W Doss
- Egyptian National Committee for Control of Viral Hepatitis, Cairo, Egypt
| | - G Esmat
- Egyptian National Committee for Control of Viral Hepatitis, Cairo, Egypt
| | - A Fontanet
- Emerging Disease Epidemiology Unit, Institut Pasteur, Paris, France.,Institut Pasteur, Conservatoire National des Arts et Métiers, Unité PACRI, Paris, France
| |
Collapse
|
13
|
Shuter J, Litwin AH, Sulkowski MS, Feinstein A, Bursky-Tammam A, Maslak S, Weinberger AH, Esan H, Segal KS, Norton B. Cigarette Smoking Behaviors and Beliefs in Persons Living With Hepatitis C. Nicotine Tob Res 2018; 19:836-844. [PMID: 27613890 DOI: 10.1093/ntr/ntw212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 08/11/2016] [Indexed: 02/07/2023]
Abstract
Background and Rationale Tobacco use is common among persons living with hepatitis C (PLHC), yet little is known about their smoking behaviors and beliefs. Modern hepatitis C treatment offers a unique opportunity to intensively engage this population about other health risks, including smoking. Main Results Seventy-seven tobacco users (40 hepatitis C virus [HCV] seropositive and 37 HCV seronegative) enrolled in an interview study in a New York City clinic. The mean age was 51.6, 57.1% were male, 40.3% Latino, and 49.4% black. 67.5% were single and 18.2% were employed. HCV+ smokers differed from HCV- smokers in having a higher prevalence of illicit substance use, depression, and hypertension. PLHC smokers were highly motivated to quit, with 52.5% stating an intention to quit within 30 days. Most of the PLHC smokers had used cessation-directed pharmacotherapy, but almost none had tried a quitline or a quit smoking website. PLHC smokers scored higher on the intrapersonal locus of control subscale. Almost a quarter (22.5%) believed that smoking "helped fight the HCV." Conclusions PLHC smokers have a high burden of psychiatric and substance use comorbidity. They exhibit characteristics that distinguish them from uninfected smokers, and many harbor false beliefs about imagined benefits of smoking. They are highly motivated to quit but underutilize cessation aids. Without aggressive intervention, smoking-related morbidity will likely mute the health benefits and longevity gains associated with hepatitis C treatment. Research such as this may prove useful in guiding the development of future tobacco treatment strategies. Implications This is the first paper to examine, in detail, sociobehavioral correlates of tobacco use in PLHC. PLHC are recognized by the Department of Health and Human Services as a high-priority health disparities population. We are not aware of any tobacco treatment services designed specifically for PLHC. The first step in designing an intervention is defining the characteristics of the target group. Our findings will begin to address this need, and may prove useful in optimizing tobacco treatment strategies for smokers living with hepatitis C.
Collapse
Affiliation(s)
- Jonathan Shuter
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY
| | - Alain H Litwin
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY
| | - Mark S Sulkowski
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Addi Feinstein
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY
| | | | - Stephen Maslak
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY
| | - Andrea H Weinberger
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Hannah Esan
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Kate S Segal
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Brianna Norton
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY
| |
Collapse
|
14
|
Buti M, Domínguez-Hernández R, Oyagüez I, Casado MA, Esteban R. Cost-effectiveness analysis of ledipasvir/sofosbuvir in patients with chronic hepatitis C: Treatment of patients with absence or mild fibrosis compared to patients with advanced fibrosis. J Viral Hepat 2017; 24:750-758. [PMID: 28273410 DOI: 10.1111/jvh.12704] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 01/30/2017] [Indexed: 01/16/2023]
Abstract
To evaluate the cost-effectiveness of ledipasvir/sofosbuvir (LDV/SOF) in treatment-naïve patients with chronic hepatitis C (CHC) genotype 1 (GT1) in the absence or mild fibrosis (F0-F1) versus advanced fibrosis (F2-F4), from the perspective of the Spanish Health System. A Markov model was developed to simulate disease progression, estimating costs and outcomes [life years gained (LYG) and quality-adjusted life years (QALY)] derived from starting with LDV/SOF in patients with F0-F1 compared with F2-F4. Therapy duration was 8 weeks in noncirrhotic patients with viral load <6 million IU/mL and 12 weeks in the remaining patients. Sustained virologic response rates were obtained from real-world cohort studies. Transition probabilities, utilities and direct costs were obtained from the literature. A 3% annual discount rate was applied to costs and outcomes. Sensitivity analyses were performed. LDV/SOF in F0-F1 patients was a dominant strategy, being more effective (19.85 LYG and 19.80 QALY) than beginning treatment in F2-F4 patients (18.63 LYG and 16.25 QALY), generating savings of €9228 per patient (€3661 due to disease management and monitoring). In a cohort of 1000 patients, LDV/SOF in F0-F1 patients decreased the number of cases of decompensated cirrhosis (93%), hepatocellular carcinoma (97%) and liver-related deaths (95%) and prevented 6 liver transplants compared to initiating LDV/SOF in F2-F4 patients. In CHC treatment-naïve GT1 patients, starting treatment with LDV/SOF in patients with F0-F1 compared to those with F2-F4 increases effectiveness by 1.22 LYG and 3.55 QALY gained and reduces disease burden and it is associated with cost savings.
Collapse
Affiliation(s)
- M Buti
- Liver Unit, University Hospital Vall d'Hebron and CIBERehd, Barcelona, Spain
| | | | - I Oyagüez
- Pharmacoeconomics & Outcomes Research Iberia (PORIB), Madrid, Spain
| | - M A Casado
- Pharmacoeconomics & Outcomes Research Iberia (PORIB), Madrid, Spain
| | - R Esteban
- Liver Unit, University Hospital Vall d'Hebron and CIBERehd, Barcelona, Spain
| |
Collapse
|
15
|
Zeng QL, Li B, Zhang XX, Chen Y, Fu YL, Lv J, Liu YM, Yu ZJ. Clinical Model for Predicting Hepatocellular Carcinomas in Patients with Post-Sustained Virologic Responses of Chronic Hepatitis C: A Case Control Study. Gut Liver 2017; 10:955-961. [PMID: 27257023 PMCID: PMC5087936 DOI: 10.5009/gnl15321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 08/24/2015] [Accepted: 09/22/2015] [Indexed: 12/30/2022] Open
Abstract
Background/Aims No clinical model exists to predict the occurrence of hepatocellular carcinoma in sustained virologic response-achieving (HCC after SVR) patients with chronic hepatitis C (CHC). Methods We performed a case-control study using a clinical database to research the risk factors for HCC after SVR. A predictive model based on risk factors was established, and the area under the receiver operating characteristic curve (AUC) was calculated. Results In the multivariate model, an initial diagnosis of compensated cirrhosis and post-SVR albumin reductions of 1 g/L were associated with 21.7-fold (95% CI, 4.2 to 112.3; p<0.001) and 1.3-fold (95% CI, 1.1 to 1.7; p=0.004) increases in the risk of HCC after SVR, respectively. A predictive model based on an initial diagnosis of compensated cirrhosis (yes, +1; no, 0) and post-SVR albumin ≤36.0 g/L (yes, +1; not, 0) predicted the occurrence of HCC after SVR with a cutoff value of >0, an AUC of 0.880, a sensitivity of 0.833, a specificity of 0.896, and a negative predictive value of 0.956. Conclusions An initial diagnosis of compensated cirrhosis combined with a post-SVR albumin value of ≤36.0 g/L predicts the occurrence of HCC after SVR in patients with CHC.
Collapse
Affiliation(s)
- Qing-Lei Zeng
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bing Li
- Treatment and Research Center for Liver Fibrosis, Beijing 302 Hospital, Beijing, China
| | - Xue-Xiu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Chen
- Center of Therapeutic Research for Hepatocellular Carcinoma, Beijing 302 Hospital, Beijing, China
| | - Yan-Ling Fu
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jun Lv
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan-Min Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zu-Jiang Yu
- Department of Infectious Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
16
|
Emmanuel B, Shardell MD, Tracy L, Kottilil S, El-Kamary SS. Racial disparity in all-cause mortality among hepatitis C virus-infected individuals in a general US population, NHANES III. J Viral Hepat 2017; 24:380-388. [PMID: 27905175 PMCID: PMC5739320 DOI: 10.1111/jvh.12656] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/01/2016] [Indexed: 12/25/2022]
Abstract
There are few long-term nationally representative studies of all-cause mortality among those infected with hepatitis C virus (HCV). When an additional 5 years of data were made publicly available in 2015, the Third National Health and Nutrition Examination Survey Linked Mortality File became the longest nationally representative study in the United States. Our objective was to update the estimated HCV-associated all-cause mortality in the general US population and determine any differences by sex, age and race/ethnicity. HCV status was assessed in 9117 nationally representative adults aged 18-59 years from 1988 to 1994, and mortality follow-up of the same individuals was completed through 2011 and made publicly available in 2015. There were 930 deaths over a median follow-up of 19.8 years. After adjusting for all covariate risk factors, chronic HCV had 2.63 times (95% CI: 1.59-4.37; P=.0002) higher all-cause mortality rate ratio (MRR) compared with being HCV negative. All-cause MRR was stratified by sex, age and race/ethnicity. Only race/ethnicity was a significant effect modifier of MRR (P<.0001) as the highest MRR of chronic HCV compared to HCV negative was 7.48 (95% CI: 2.15-26.10, P=.001) among Mexican Americans, 2.67 (95% CI: 2.67-5.56, P=.009) among non-Hispanic Whites and 2.02 (95% CI: 1.20-3.40, P=.007) among non-Hispanic Blacks. Racial disparity was seen in the all-cause mortality as Mexican Americans with chronic HCV had approximately seven times higher mortality rate than HCV-negative individuals. This suggests that these at-risk individuals should be targeted for HCV screening and treatment, given the availability of new highly effective HCV therapies.
Collapse
Affiliation(s)
- B Emmanuel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - M D Shardell
- National Institute of Aging, National Institutes of Health, Bethesda, MD, USA
| | - L Tracy
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Office of Biostatistics, Center for Drug Evaluation and Research Food and Drug Administration, Silver Spring, MD, USA
| | - S Kottilil
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S S El-Kamary
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
17
|
Bang CS, Song IH. Impact of antiviral therapy on hepatocellular carcinoma and mortality in patients with chronic hepatitis C: systematic review and meta-analysis. BMC Gastroenterol 2017; 17:46. [PMID: 28376711 PMCID: PMC5379714 DOI: 10.1186/s12876-017-0606-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 03/28/2017] [Indexed: 12/17/2022] Open
Abstract
Background The long-term clinical outcomes of antiviral therapy for patients with chronic hepatitis C are uncertain in terms of hepatitis C virus (HCV)-related morbidity and mortality according to the response to antiviral therapy. This study aimed to assess the impact of antiviral treatment on the development of HCC and mortality in patients with chronic HCV infection. Methods A systematic review was conducted for studies that evaluated the antiviral efficacy for patients with chronic hepatitis C or assessed the development of HCC or mortality between SVR (sustained virologic response) and non-SVR patients. The methodological quality of the enrolled publications was evaluated using Risk of Bias table or Newcastle-Ottawa scale. Random-effect model meta-analyses and meta-regression were performed. Publication bias was assessed. Results In total, 59 studies (4 RCTs, 15 prospective and 40 retrospective cohort studies) were included. Antiviral treatment was associated with reduced development of HCC (vs. no treatment; OR 0.392, 95% CI 0.275–0.557), and this effect was intensified when SVR was achieved (vs. no SVR, OR: 0.203, 95% CI 0.164–0.251). Antiviral treatment was associated with lower all-cause mortality (vs. no treatment; OR 0.380, 95% CI 0.295–0.489) and liver-specific mortality (OR 0.363, 95% CI 0.260–0.508). This rate was also intensified when SVR was achieved [all-cause mortality (vs. no SVR, OR 0.255, 95% CI 0.199–0.326), liver-specific mortality (OR 0.126, 95% CI 0.094–0.169)]. Sensitivity analyses revealed robust results, and a small study effect was minimal. Conclusions In patients with chronic hepatitis C, antiviral therapy can reduce the development of HCC and mortality, especially when SVR is achieved. Electronic supplementary material The online version of this article (doi:10.1186/s12876-017-0606-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Il Han Song
- Division of Hepatology, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea, Republic of Korea.
| |
Collapse
|
18
|
Leidner AJ, Chesson HW, Spradling PR, Holmberg SD. Assessing the Effect of Potential Reductions in Non-Hepatic Mortality on the Estimated Cost-Effectiveness of Hepatitis C Treatment in Early Stages of Liver Disease. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:65-74. [PMID: 27480538 PMCID: PMC5802335 DOI: 10.1007/s40258-016-0261-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Most cost-effectiveness analyses of hepatitis C (HCV) therapy focus on the benefits of reducing liver-related morbidity and mortality. OBJECTIVES Our objective was to assess how cost-effectiveness estimates of HCV therapy can vary depending on assumptions regarding the potential impact of HCV therapy on non-hepatic mortality. METHODS We adapted a state-transition model to include potential effects of HCV therapy on non-hepatic mortality. We assumed successful treatment could reduce non-hepatic mortality by as little as 0 % to as much as 100 %. Incremental cost-effectiveness ratios were computed comparing immediate treatment versus delayed treatment and comparing immediate treatment versus non-treatment. RESULTS Comparing immediate treatment versus delayed treatment, when we included a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per quality-adjusted life year (QALY) gained by HCV treatment fell by 76 % (from US$314,100 to US$76,900) for patients with no fibrosis and by 43 % (from US$62,500 to US$35,800) for patients with moderate fibrosis. Comparing immediate treatment versus non-treatment, assuming a 44 % reduction in non-hepatic mortality following successful HCV treatment, the incremental cost per QALY gained by HCV treatment fell by 64 % (from US$186,700 to US$67,300) for patients with no fibrosis and by 27 % (from US$35,000 to US$25,500) for patients with moderate fibrosis. CONCLUSION Including reductions in non-hepatic mortality from HCV treatment can have substantial effects on the estimated cost-effectiveness of treatment.
Collapse
Affiliation(s)
- Andrew J Leidner
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA.
| | - Harrell W Chesson
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - Scott D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| |
Collapse
|
19
|
Abstract
Treatment with direct-acting antiviral agents has revolutionized the approach to hepatitis C. We are now able to obtain high sustained virological response (SVR) rates, even in the historically difficult-to-treat patient populations. SVR translates into improved clinical outcomes, particularly overall and liver-related mortality, and benefits are more striking in patients with cirrhosis. A 2.5- to 5-fold risk reduction in the incidence of hepatocellular carcinoma and improvement in complications derived from portal hypertension have been reported as well. It is hypothesized that the benefits from SVR occur largely due to regression of fibrosis, which arises from the halt on the fibrogenic stimuli and activation of extracellular matrix reabsorption signals. Non-invasive markers of fibrosis are being utilized to assess regression, but it is still unclear how accurate they are in this clinical scenario. Interventions aiming to improve liver wellness and screening for cirrhosis-related complications should continue to be the norm after SVR.
Collapse
|
20
|
Scavone C, Sportiello L, Rafaniello C, Mascolo A, Sessa M, Rossi F, Capuano A. New era in treatment options of chronic hepatitis C: focus on safety of new direct-acting antivirals (DAAs). Expert Opin Drug Saf 2016; 15:85-100. [DOI: 10.1080/14740338.2016.1221396] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Cristina Scavone
- Department of Experimental Medicine, Section of Pharmacology, Second University of Naples, Naples, Italy
| | - Liberata Sportiello
- Department of Experimental Medicine, Section of Pharmacology, Second University of Naples, Naples, Italy
| | - Concetta Rafaniello
- Department of Experimental Medicine, Section of Pharmacology, Second University of Naples, Naples, Italy
| | - Annamaria Mascolo
- Department of Experimental Medicine, Section of Pharmacology, Second University of Naples, Naples, Italy
| | - Maurizio Sessa
- Department of Experimental Medicine, Section of Pharmacology, Second University of Naples, Naples, Italy
| | - Francesco Rossi
- Department of Experimental Medicine, Section of Pharmacology, Second University of Naples, Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology, Second University of Naples, Naples, Italy
| |
Collapse
|
21
|
Terrault NA, Hassanein TI. Management of the patient with SVR. J Hepatol 2016; 65:S120-S129. [PMID: 27641982 DOI: 10.1016/j.jhep.2016.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 02/07/2023]
Abstract
In the current era of therapy with direct-acting antiviral (DAAs) drugs, achievement of a sustained virological response (SVR) is achievable in ⩾90% of hepatitis C-infected patients. SVR benefits are well-recognized with reductions in rates of liver complications, hepatocellular carcinoma and mortality. Additional benefits include reduced morbidity related to extrahepatic and systemic manifestations of hepatitis C such as renal, dermatologic, and metabolic complications. However, not all patients will derive all of these benefits and monitoring for progression is necessary, especially in those with more advanced fibrosis. To maximize the health benefits of SVR, counseling patients on best means to maintain good liver health and prevent reinfection are also important.
Collapse
Affiliation(s)
| | - Tarek I Hassanein
- University of California San Diego and Southern California GI and Liver Centers, USA.
| |
Collapse
|
22
|
Ho SB, Dollarhide A, Thorisdottir H, Michelsen J, Perry C, Kravetz D, Herrin A, Carlson L, Hadley S, Montoya D, Robinson S, Sanchez C, Enrique E, Groessl E. A Primary Care-based Collaborative Hepatitis C Clinic: Clinical Structure and Virologic Outcomes with Direct Acting Antiviral Therapy. ACTA ACUST UNITED AC 2016. [DOI: 10.2174/1874220301603010070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background:
Currently 4 million persons in the US have active hepatitis C virus (HCV) infection and most have never successfully completed antiviral treatment. Newer therapies herald potential for wider uptake and acceptance of treatment, but the number of hepatology specialists is limited and newer models are needed to increase access to care. The aim of this study is to describe a collaborative primary care-based clinic for HCV treatment.
Methods:
Retrospective analysis of a collaborative primary care clinic developed for the evaluation and treatment of patients with chronic hepatitis C at one VA medical center. A half-day clinic was organized with 4 primary care MDs, 2 hepatologists, 2 nurse practitioners, and a co-located psychiatrist, pharmacist and nurse case manager. Clinic productivity and outcomes related to the number of patients who initiated and completed treatment with direct acting antivirals (DAA) and pegylated interferon and ribavirin were evaluated.
Results:
In this 18 month period, the clinic had 1890 confirmed HCV registry patients and 1690 clinic visits. 74 HCV genotype 1 patients initiated DAA therapy. Primary care providers treated 47 patients (32% cirrhotic) and hepatologists treated 27 patients (48% cirrhotic). Final SVR rate was 54.6% (39.2% cirrhotics vs. 65.2% noncirrhotics). SVR rates were higher in patients with primary care providers (61.7%) vs. hepatologists (44.4%). Despite numerous adverse events, early treatment termination for adverse events occurred in 5.3% vs. 21.3% for virologic non-response. Multivariate analysis revealed no significant differences between primary care and hepatology for SVR and treatment discontinuations.
Conclusion:
This clinic demonstrated effectiveness and safety with DAA therapy. This illustrates potential for a primary care based collaborative clinic, which will be crucial for expanding access to effective HCV care.
Collapse
|
23
|
Chidi AP, Bryce CL, Donohue JM, Fine MJ, Landsittel DP, Myaskovsky L, Rogal SS, Switzer GE, Tsung A, Smith KJ. Economic and Public Health Impacts of Policies Restricting Access to Hepatitis C Treatment for Medicaid Patients. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:326-34. [PMID: 27325324 PMCID: PMC4916393 DOI: 10.1016/j.jval.2016.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 01/24/2016] [Accepted: 01/27/2016] [Indexed: 05/27/2023]
Abstract
BACKGROUND Interferon-free hepatitis C treatment regimens are effective but very costly. The cost-effectiveness, budget, and public health impacts of current Medicaid treatment policies restricting treatment to patients with advanced disease remain unknown. OBJECTIVES To evaluate the cost-effectiveness of current Medicaid policies restricting hepatitis C treatment to patients with advanced disease compared with a strategy providing unrestricted access to hepatitis C treatment, assess the budget and public health impact of each strategy, and estimate the feasibility and long-term effects of increased access to treatment for patients with hepatitis C. METHODS Using a Markov model, we compared two strategies for 45- to 55-year-old Medicaid beneficiaries: 1) Current Practice-only advanced disease is treated before Medicare eligibility and 2) Full Access-both early-stage and advanced disease are treated before Medicare eligibility. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die each year. Morbidity was reduced after successful treatment. We calculated the incremental cost-effectiveness ratio and compared the costs and public health effects of each strategy from the perspective of Medicare alone as well as the Centers for Medicare & Medicaid Services perspective. We varied model inputs in one-way and probabilistic sensitivity analyses. RESULTS Full Access was less costly and more effective than Current Practice for all cohorts and perspectives, with differences in cost ranging from $5,369 to $11,960 and in effectiveness from 0.82 to 3.01 quality-adjusted life-years. In a probabilistic sensitivity analysis, Full Access was cost saving in 93% of model iterations. Compared with Current Practice, Full Access averted 5,994 hepatocellular carcinoma cases and 121 liver transplants per 100,000 patients. CONCLUSIONS Current Medicaid policies restricting hepatitis C treatment to patients with advanced disease are more costly and less effective than unrestricted, full-access strategies. Collaboration between state and federal payers may be needed to realize the full public health impact of recent innovations in hepatitis C treatment.
Collapse
Affiliation(s)
- Alexis P Chidi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA.
| | - Cindy L Bryce
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Julie M Donohue
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Michael J Fine
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | | | - Larissa Myaskovsky
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Shari S Rogal
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Galen E Switzer
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Allan Tsung
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System Pittsburgh, PA, USA
| | - Kenneth J Smith
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
24
|
Stubbs A, Naylor P, Ravindran K, Benjaram S, Reddy N, Mutchnick S, May E, Ehrinpreis M, Mutchnick M. Racial diversity in mortality and morbidity in urban patients with hepatitis C. J Viral Hepat 2016; 23:439-46. [PMID: 26818494 DOI: 10.1111/jvh.12504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/24/2015] [Indexed: 12/24/2022]
Abstract
Defining mortality for Caucasians and African American patients with chronic hepatitis C with respect to racial diversity is critical for counselling patients on therapy options. The objective of this study was to define racial diversity influence on mortality and morbidity of 3724 consecutive hepatitis C virus (HCV)-infected patients seen in an urban clinic between 1995 and 2008. Mortality, as of 2011, was defined using the SSA National Death Index and correlated with early visit medical information. The HCV chronically infected patient population consisted of 2879 African Americans (AA), 758 Caucasians and 87 other, and the majority were not treated for their infection prior to 2011. The average time to death from first visit was 5 years, the average age at death was 55 years, and despite racial diversity, AA were just as likely to be reported dead as Caucasians (23% AA vs 22% Caucasians). Cirrhosis and fibrosis (liver biopsy, AST Platelet Ratio Index or Fibrosis-4) at first visit as well as low albumin, diabetes, renal impairment and cardiac symptoms were associated with increased mortality. Treated patients who cleared the virus (sustained viral response (SVR); AA = 59; Caucasians = 40) had lower mortality than patients who were not treated (AA: 5% vs 27%; Caucasians 5% vs 26%). Hence, we find that race is not a factor in the early mortality of patients with chronic HCV infection and achieving a SVR reduced mortality. Unexpectedly, nonresponding AA also benefited by a lower mortality. African American patients with kidney disease and low albumin were at highest risk and should be treated as soon as identified.
Collapse
Affiliation(s)
- A Stubbs
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - P Naylor
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - K Ravindran
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - S Benjaram
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - N Reddy
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - S Mutchnick
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - E May
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - M Ehrinpreis
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - M Mutchnick
- Division of Gastroenterology, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
25
|
Avegno J, Carlisle M. Evaluating the Patient with Right Upper Quadrant Abdominal Pain. Emerg Med Clin North Am 2016; 34:211-28. [DOI: 10.1016/j.emc.2015.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
26
|
Buti M, Domínguez-Hernández R, Oyagüez I, Casado MÁ. [Cost-effectiveness analysis of sofosbuvir, peginterferon and ribavirin in patients with chronic hepatitis C: Early treatment in the initial stage of fibrosis vs. delayed treatment in advanced fibrosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:449-57. [PMID: 27084669 DOI: 10.1016/j.gastrohep.2016.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/26/2016] [Accepted: 03/07/2016] [Indexed: 01/16/2023]
Abstract
AIMS Cost-effectiveness analysis of sofosbuvir combined with peginterferon alpha-2a and ribavirin (SOF/Peg-IFN/RBV) in early versus advanced fibrosis in previously untreated patients with chronic hepatitis C genotype 1 (CHC-GT1), from the perspective of the Spanish National Health System (NHS). METHODS A Markov model was developed to compare lifetime costs and outcomes (life years gained [LYGs] and quality-adjusted life years [QALYs]) of 2 treatment strategies: SOF/Peg-IFN/RBV administered during early fibrosis (mild-moderate fibrosis; F2-F3) or advanced fibrosis (cirrhosis; F4). Efficacy (sustained virologic response), annual transition probabilities, disease management costs and utilities were obtained from the literature. Costs and outcomes were discounted annually at 3%. Direct costs were considered, expressed in Euros (€, 2014). Probabilistic sensitivity analysis (PSA) was also performed. RESULTS SOF/Peg-IFN/RBV therapy at F2-F3 was more effective (19.12 LYGs and 14.14 QALYs) compared to F4. In a cohort of 1,000 patients, SOF/Peg-IFN/RBV prevented 66 cases of decompensated cirrhosis, 60 hepatocellular carcinomas and 4 liver transplantations compared with therapy in advanced fibrosis. The total lifetime cost of early therapy (€43,263) was less than the cost of treatment in the advanced stage (€49,018). Early therapy was a dominant strategy, more effective and less costly in all simulations. In the PSA analysis, administration of SOF/PEG-IFN/RBV at F2-F3 was dominant in all simulations. CONCLUSIONS Starting SOF/Peg-IFN/RBV therapy at F2-F3, compared with therapy at F4, reduced the incidence of liver disease complications and was associated with cost savings for the Spanish NHS in CHC-GT1 patients.
Collapse
Affiliation(s)
- María Buti
- Unidad de Hepatología, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), España
| | | | - Itziar Oyagüez
- Pharmacoeconomics & Outcomes Research Iberia, Madrid, España
| | | |
Collapse
|
27
|
Chidi AP, Rogal S, Bryce CL, Fine MJ, Good CB, Myaskovsky L, Rustgi VK, Tsung A, Smith KJ. Cost-effectiveness of new antiviral regimens for treatment-naïve U.S. veterans with hepatitis C. Hepatology 2016; 63:428-36. [PMID: 26524695 PMCID: PMC4718749 DOI: 10.1002/hep.28327] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/30/2015] [Indexed: 12/17/2022]
Abstract
UNLABELLED Recently approved, interferon-free medication regimens for treating hepatitis C are highly effective, but extremely costly. We aimed to identify cost-effective strategies for managing treatment-naïve U.S. veterans with new hepatitis C medication regimens. We developed a Markov model with 1-year cycle length for a cohort of 60-year-old veterans with untreated genotype 1 hepatitis C seeking treatment in a typical year. We compared using sofosbuvir/ledipasvir or ombitasvir/ritonavir/paritaprevir/dasabuvir to treat: (1) any patient seeking treatment; (2) only patients with advanced fibrosis or cirrhosis; or (3) patients with advanced disease first and healthier patients 1 year later. The previous standard of care, sofosbuvir/simeprevir or sofosbuvir/pegylated interferon/ribavirin, was included for comparison. Patients could develop progressive fibrosis, cirrhosis, or hepatocellular carcinoma, undergo transplantation, or die. Complications were less likely after sustained virological response. We calculated the incremental cost per quality-adjusted life year (QALY) and varied model inputs in one-way and probabilistic sensitivity analyses. We used the Veterans Health Administration perspective with a lifetime time horizon and 3% annual discounting. Treating any patient with ombitasvir-based therapy was the preferred strategy ($35,560; 14.0 QALYs). All other strategies were dominated (greater costs/QALY gained than more effective strategies). Varying treatment efficacy, price, and/or duration changed the preferred strategy. In probabilistic sensitivity analysis, treating any patient with ombitasvir-based therapy was cost-effective in 70% of iterations at a $50,000/QALY threshold and 65% of iterations at a $100,000/QALY threshold. CONCLUSION Managing any treatment-naïve genotype 1 hepatitis C patient with ombitasvir-based therapy is the most economically efficient strategy, although price and efficacy can impact cost-effectiveness. It is economically unfavorable to restrict treatment to patients with advanced disease or use a staged treatment strategy. (Hepatology 2016;63:428-436).
Collapse
Affiliation(s)
- Alexis P. Chidi
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Shari Rogal
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Cindy L. Bryce
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Hines, IL
| | - Michael J. Fine
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Chester B. Good
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL,VA Center for Medication Safety, Department of Veterans Affairs, Hines, IL
| | - Larissa Myaskovsky
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| | - Vinod K. Rustgi
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth J. Smith
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Hines, IL,VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Hines, IL
| |
Collapse
|
28
|
Maier MM, Ross DB, Chartier M, Belperio PS, Backus LI. Cascade of Care for Hepatitis C Virus Infection Within the US Veterans Health Administration. Am J Public Health 2015; 106:353-8. [PMID: 26562129 DOI: 10.2105/ajph.2015.302927] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We measured the quality of HCV care using a cascade of HCV care model. METHODS We estimated the number of patients diagnosed with chronic HCV, linked to HCV care, treated with HCV antivirals, and having achieved a sustained virologic response (SVR) in the electronic medical record data from the Veterans Health Administration's Corporate Data Warehouse and the HCV Clinical Case Registry in 2013. RESULTS Of the estimated 233,898 patients with chronic HCV, 77% (181,168) were diagnosed, 69% (160,794) were linked to HCV care, 17% (39,388) were treated with HCV antivirals, and 7% (15,983) had achieved SVR. CONCLUSIONS This Cascade of HCV Care provides a clinically relevant model to measure the quality of HCV care within a health care system and to compare HCV care across health systems.
Collapse
Affiliation(s)
- Marissa M Maier
- Marissa M. Maier is with the VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. David B. Ross is with the VA Washington DC Health Care System, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Maggie Chartier is with the VA San Francisco Health Care System, VHA, San Francisco, CA, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Pamela S. Belperio is with the VA Greater Los Angeles Health Care System, VHA, Los Angeles, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Lisa I. Backus is with the VA Palo Alto Health Care System, VHA, Palo Alto, CA, and the Office of Public Health/Population Health, VHA, Washington, DC
| | - David B Ross
- Marissa M. Maier is with the VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. David B. Ross is with the VA Washington DC Health Care System, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Maggie Chartier is with the VA San Francisco Health Care System, VHA, San Francisco, CA, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Pamela S. Belperio is with the VA Greater Los Angeles Health Care System, VHA, Los Angeles, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Lisa I. Backus is with the VA Palo Alto Health Care System, VHA, Palo Alto, CA, and the Office of Public Health/Population Health, VHA, Washington, DC
| | - Maggie Chartier
- Marissa M. Maier is with the VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. David B. Ross is with the VA Washington DC Health Care System, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Maggie Chartier is with the VA San Francisco Health Care System, VHA, San Francisco, CA, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Pamela S. Belperio is with the VA Greater Los Angeles Health Care System, VHA, Los Angeles, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Lisa I. Backus is with the VA Palo Alto Health Care System, VHA, Palo Alto, CA, and the Office of Public Health/Population Health, VHA, Washington, DC
| | - Pamela S Belperio
- Marissa M. Maier is with the VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. David B. Ross is with the VA Washington DC Health Care System, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Maggie Chartier is with the VA San Francisco Health Care System, VHA, San Francisco, CA, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Pamela S. Belperio is with the VA Greater Los Angeles Health Care System, VHA, Los Angeles, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Lisa I. Backus is with the VA Palo Alto Health Care System, VHA, Palo Alto, CA, and the Office of Public Health/Population Health, VHA, Washington, DC
| | - Lisa I Backus
- Marissa M. Maier is with the VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. David B. Ross is with the VA Washington DC Health Care System, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Maggie Chartier is with the VA San Francisco Health Care System, VHA, San Francisco, CA, and the Office of Public Health/HIV, Hepatitis, and Public Health Pathogens Programs, VHA, Washington, DC. Pamela S. Belperio is with the VA Greater Los Angeles Health Care System, VHA, Los Angeles, CA, and the Office of Public Health/Population Health, VHA, Washington, DC. Lisa I. Backus is with the VA Palo Alto Health Care System, VHA, Palo Alto, CA, and the Office of Public Health/Population Health, VHA, Washington, DC
| |
Collapse
|
29
|
Ho SB, Bräu N, Cheung R, Liu L, Sanchez C, Sklar M, Phelps TE, Marcus SG, Wasil MM, Tisi A, Huynh L, Robinson SK, Gifford AL, Asch SM, Groessl EJ. Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse. Clin Gastroenterol Hepatol 2015; 13:2005-14.e1-3. [PMID: 25724704 DOI: 10.1016/j.cgh.2015.02.022] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/22/2014] [Accepted: 02/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR). METHODS We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR. RESULTS Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups. CONCLUSIONS Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.
Collapse
Affiliation(s)
- Samuel B Ho
- Gastroenterology Section, Medicine Service, VA San Diego Healthcare System, San Diego, California; Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego, California.
| | - Norbert Bräu
- Infectious Disease Section, James J. Peters VA Medical Center, Bronx, New York; Divisions of Infectious Disease and Liver Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ramsey Cheung
- Gastroenterology Section, Medicine Service, VA Palo Alto Healthcare System, Palo Alto, California; Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| | - Lin Liu
- Division of Biostatistics, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Courtney Sanchez
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Marisa Sklar
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Tyler E Phelps
- Gastroenterology Section, Medicine Service, VA Palo Alto Healthcare System, Palo Alto, California
| | - Sonja G Marcus
- Research Service, James J. Peters VA Medical Center, Bronx, New York
| | - Michelene M Wasil
- Research Service, VA San Diego Healthcare System, San Diego, California
| | - Amelia Tisi
- Research Service, James J. Peters VA Medical Center, Bronx, New York
| | - Lia Huynh
- Research Service, VA Palo Alto Healthcare System, Palo Alto, California
| | - Shannon K Robinson
- Department of Psychiatry, VA San Diego Healthcare System, San Diego, California; Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Allen L Gifford
- Infectious Disease Section, Medicine Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts; Departments of Health Policy and Management and Medicine, Boston University, Boston, Massachusetts
| | - Steven M Asch
- Research Service, VA Palo Alto Healthcare System, Palo Alto, California; Division of General Medical Disciplines, Department of Medicine, Stanford University, Stanford, California
| | - Erik J Groessl
- Division of Health Services Research & Development, Research Service, VA San Diego Healthcare System, San Diego, California; Division of Behavioral Medicine, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| |
Collapse
|
30
|
Achieving Sustained Virological Response in Hepatitis C Reduces the Long-Term Risk of Hepatocellular Carcinoma: An Updated Meta-Analysis Employing Relative and Absolute Outcome Measures. Clin Drug Investig 2015; 35:843-50. [DOI: 10.1007/s40261-015-0338-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
31
|
Reddy N, Naylor P, Hakim Z, Asbahi R, Ravindran K, May E, Ehrinpreis M, Mutchnick M. Effect of Treatment for CHC on Liver Disease Progression and Hepatocellular Carcinoma Development in African Americans. J Clin Transl Hepatol 2015; 3:163-8. [PMID: 26623262 PMCID: PMC4663197 DOI: 10.14218/jcth.2015.00013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/14/2015] [Accepted: 05/18/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIMS African Americans (AA) historically have a low response rate to hepatitis C therapies, and there is limited information available for this patient population regarding the development and treatment of chronic hepatitis C (CHC). The aim of this study was to evaluate liver disease progression and hepatocellular carcinoma (HCC) development in AA with CHC. METHODS Between 1995 and 2008, 246 AA patients with CHC were identified from a database of patients and followed until 2012-2013 (average 8 years) or the development of HCC after 2008. RESULTS Viral clearance (intent to treat; sustained virus response (SVR)) was achieved in 15% of patients with interferon based therapies with or without ribavirin. AA patients who achieved an SVR (n=22) did not develop HCC or new onset cirrhosis, whereas the HCC incidence in untreated AA patients was 23% (51/203). Patients who achieved an SVR also had improved fibrosis, as defined by the AST Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4) score, relative to nonresponders and untreated patients. CONCLUSIONS The severity of liver disease at the first visit (except for cirrhosis) correlated with the development of HCC, but because of the overlap in values between patients, these measurements were not useful for predicting individual risk. Since cirrhosis at the first visit was not a predictive factor, treatment with newer antiviral therapies is the best option for reducing the incidence of advanced liver disease and its harmful outcomes in the AA population.
Collapse
Affiliation(s)
- Naveen Reddy
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| | - Paul Naylor
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| | - Zaher Hakim
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| | - Redwan Asbahi
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| | - Karthik Ravindran
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| | - Elizabeth May
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| | - Murray Ehrinpreis
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| | - Milton Mutchnick
- Department of Internal Medicine/Division of Gastroenterology, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI, USA
| |
Collapse
|
32
|
Younossi ZM, Stepanova M, Marcellin P, Afdhal N, Kowdley KV, Zeuzem S, Hunt SL. Treatment with ledipasvir and sofosbuvir improves patient-reported outcomes: Results from the ION-1, -2, and -3 clinical trials. Hepatology 2015; 61:1798-808. [PMID: 25627448 DOI: 10.1002/hep.27724] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/22/2015] [Indexed: 12/15/2022]
Abstract
UNLABELLED Treatment with interferon (IFN) and ribavirin (RBV) significantly impairs quality of life and other patient-reported outcomes (PROs). Patient experience with IFN- and RBV-free anti-HCV (hepatitis C virus) regimens has not been reported. We assessed PROs in patients treated with ledipasvir and sofosbuvir (LDV/SOF) with and without RBV. Four different PRO questionnaires were administered at baseline, during, and post-treatment in HCV genotype 1 patients treated with LDV/SOF±RBV (ION-1, -2, and -3). A total of 1,952 patients were enrolled to be treated for 8 (N = 431), 12 (N = 867), or 24 weeks (N = 654) with LDV/SOF (N = 1,080) or LDV/SOF+RBV (N = 872). Baseline demographics and psychiatric disorders were similar between treatment groups (all P > 0.05). Patients receiving LDV/SOF regimens showed significant improvement of PRO scores during treatment (up to +7.4%, +7.0%, and +6.7% on a normalized 0%-100% scale in the 8-, 12-, and 24-week-long treatment groups, respectively (all P < 0.0001). These PRO improvements coincided with early viral suppression after 2 weeks of treatment and maximized by the end of treatment. On the other hand, during treatment with LDV/SOF+RBV, PRO scores declined (up to -5.5% regardless of treatment duration; P < 0.0001). Receiving RBV was an independent predictor of PRO impairment in multivariate analysis (beta up to -5.9%; P < 0.0001). Patients who achieved sustained virological response at 12 weeks showed significant improvement of their PROs post-treatment (up to +8.3%; P < 0.0001). CONCLUSION IFN- and RBV-free regimens with LDV/SOF result in early HCV suppression with simultaneous improvement in PROs that continued throughout the duration of treatment and post-treatment.
Collapse
Affiliation(s)
- Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA
| | - Maria Stepanova
- CLDQ LLC, Washington, DC
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA
| | | | - Nezam Afdhal
- Hepatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, WA
| | - Stefan Zeuzem
- Department of Medicine, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Sharon L Hunt
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA
| |
Collapse
|
33
|
Simmons B, Saleem J, Heath K, Cooke GS, Hill A. Long-Term Treatment Outcomes of Patients Infected With Hepatitis C Virus: A Systematic Review and Meta-analysis of the Survival Benefit of Achieving a Sustained Virological Response. Clin Infect Dis 2015; 61:730-40. [PMID: 25987643 PMCID: PMC4530725 DOI: 10.1093/cid/civ396] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/09/2015] [Indexed: 02/06/2023] Open
Abstract
The results of this meta-analysis suggest that there is a significant survival benefit of achieving an sustained virologic response compared with unsuccessful treatment in the general hepatitis C virus-infected population. This benefit is held in patients with cirrhosis and those coinfected with human immunodeficiency virus. Background. Achievement of a sustained virologic response (SVR) after treatment for Hepatitis C infection is associated with improved outcomes. This meta-analysis aimed to determine the impact of SVR on long-term mortality risk compared with nonresponders in a range of populations. Methods. An electronic search identified all studies assessing all-cause mortality in SVR and non-SVR patients. Eligible articles were stratified into general, cirrhotic, and populations coinfected with human immunodeficiency virus. The adjusted hazard ratio (95% confidence interval [CI]) for mortality in patients achieving SVR vs non-SVR, and pooled estimates for the 5-year mortality in each group were calculated. Results. 31 studies (n = 33 360) were identified as suitable for inclusion. Median follow-up time was 5.4 years (interquartile range, 4.9–7.5) across all studies. The adjusted hazard ratio of mortality for patients achieving SVR vs non-SVR was 0.50 (95% CI, .37–.67) in the general population, 0.26 (95% CI, .18–.74) in the cirrhotic group, and 0.21 (.10–.45) in the coinfected group. The pooled 5-year mortality rates were significantly lower for patients achieving SVR compared with non-SVR in all 3 populations. Conclusions. The results suggest that there is a significant survival benefit of achieving an SVR compared with unsuccessful treatment in a range of populations infected with hepatitis C virus.
Collapse
Affiliation(s)
| | | | | | | | - Andrew Hill
- Pharmacology and Therapeutics, Liverpool University, United Kingdom
| |
Collapse
|
34
|
Bichoupan K, Dieterich DT, Martel-Laferrière V. HIV-hepatitis C virus co-infection in the era of direct-acting antivirals. Curr HIV/AIDS Rep 2015; 11:241-9. [PMID: 24996617 DOI: 10.1007/s11904-014-0217-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Approximately one-third of patients infected with human immunodeficiency virus (HIV) are concomitantly infected with hepatitis C virus (HCV). As a result, liver disease remains a major source of morbidity and mortality in HIV patients. Prior to 2011, treatments of HCV lacked efficacy in clinical trials in HIV/HCV co-infected patients. Fortunately, several direct-acting antivirals (DAAs) have now entered clinical practice and others have reached advanced stages of clinical development. These therapies offer significant benefits such as improved rates of sustained virologic response (SVR), shortened durations of treatment, and compatibility with HIV antiretroviral therapies. Treatments such as sofosbuvir (SOF) have received approval for HIV/HCV co-infected patients. Moreover, interferon-free options exist for HIV/HCV co-infected patients who may be ineligible or intolerant of interferon. Despite these improvements, physicians must be aware of the differences between these DAAs, the patient characteristics that play a role on the effectiveness of these medications, and the drug-drug interactions these DAAs may have with existing HIV antiretroviral therapies. The aim of this review is to discuss the prevalence and incidence of HIV/HCV co-infection, critical factors related to patient evaluation, current treatment options, and new developments in the management of HIV/HCV co-infected patients.
Collapse
Affiliation(s)
- Kian Bichoupan
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY, USA,
| | | | | |
Collapse
|
35
|
Smith-Palmer J, Cerri K, Valentine W. Achieving sustained virologic response in hepatitis C: a systematic review of the clinical, economic and quality of life benefits. BMC Infect Dis 2015; 15:19. [PMID: 25596623 PMCID: PMC4299677 DOI: 10.1186/s12879-015-0748-8] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/07/2015] [Indexed: 02/08/2023] Open
Abstract
Background The goal of chronic hepatitis C treatment is to remove the virus to avoid progression of HCV-related disease. Sustained virologic response (SVR) is the most widely used efficacy endpoint in clinical studies of hepatitis C, and represents the eradication of HCV from the body. The aim of the current review was to examine the long-term clinical, economic and quality of life benefits associated with achieving SVR. Methods A systematic literature review was performed using the PubMed, EMBASE and Cochrane library databases to identify articles examining the clinical, economic and quality of life benefits associated with SVR, published in English language from 2002–2013. For inclusion studies were required to enroll ≥100 patients and to report clinical endpoints including hepatocellular carcinoma, overall- or liver-related mortality, or progression of disease/complications (e.g. portal hypertension, esophageal varices). Review of economic studies on cost/cost-effectiveness of achieving SVR were focused on studies assessing boceprevir/telaprevir plus pegIFN and ribavirin as this represents the current standard of care in several jurisdictions worldwide. Quality of life evidence was required to use validated quality of life instruments and provide a quantitative analysis of the impact of SVR versus no treatment or treatment failure. Results SVR is durable with late relapse rates over 4–5 year periods being in the range of 1–2%. Patients who achieve SVR frequently demonstrate some regression of fibrosis/cirrhosis and have a substantially reduced risk for hepatocellular carcinoma (relative risk [RR] 0.1–0.25), liver-related mortality (RR 0.03–0.2) and overall mortality (RR 0.1–0.3) in comparison with no treatment or treatment failure. In the 5 years post-treatment, medical costs for patients achieving SVR are 13-fold lower than patients not achieving SVR. Patients who achieve SVR also have health state utility values that are 0.05 to 0.31 higher than non-responders to treatment. Conclusions SVR represents the fundamental goal of antiviral treatment for patients infected with chronic HCV, so as to reduce risk of liver disease progression. Achievement of SVR has implications beyond those of clearing viral infection; it is associated with improved long-term clinical outcomes, economic benefits and improved health-related quality of life. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-0748-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jayne Smith-Palmer
- Ossian Health Economics and Communications, Ossian Health Economics and Communications GmbH, Bäumleingasse 20, 4051, Basel, Switzerland.
| | | | - William Valentine
- Ossian Health Economics and Communications, Ossian Health Economics and Communications GmbH, Bäumleingasse 20, 4051, Basel, Switzerland.
| |
Collapse
|
36
|
Yoshida EM, Sulkowski MS, Gane EJ, Herring RW, Ratziu V, Ding X, Wang J, Chuang SM, Ma J, McNally J, Stamm LM, Brainard DM, Symonds WT, McHutchison JG, Beavers KL, Jacobson IM, Reddy KR, Lawitz E. Concordance of sustained virological response 4, 12, and 24 weeks post-treatment with sofosbuvir-containing regimens for hepatitis C virus. Hepatology 2015; 61:41-5. [PMID: 25314116 DOI: 10.1002/hep.27366] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/12/2014] [Indexed: 12/12/2022]
Abstract
UNLABELLED Historically, clinical trials of regimens to treat chronic infection with hepatitis C virus (HCV) have used, as their primary efficacy endpoint, a sustained virological response (SVR)—defined as HCV RNA levels below a designated threshold of quantification—24 weeks after the end of treatment (SVR24). More recently, regulatory authorities have begun to accept SVR at 12 weeks post-treatment (SVR12) as a valid efficacy endpoint because of its high rate of concordance with SVR24. However, the concordance between SVR12 and SVR24 has not been systematically assessed with new regimens of recently approved direct-acting antiviral agents. The aim of this study was to assess the concordance between SVR at various post-treatment time points in phase III clinical trials of sofosbuvir (SOF)-containing regimens. We conducted a retrospective analysis of five trials enrolling 863 patients infected with HCV genotypes 1-6. The concordance between SVR at 4 weeks post-treatment (SVR4) and SVR12, and between SVR12 and SVR24, were determined, as well as positive predictive values (PPVs) and negative predictive values (NPVs). Overall, 779 of 796 patients (98.0%) with an SVR4 also achieved an SVR12, making the PPV of SVR4 for SVR12 98% and the NPV 100%. Of the 779 patients with an SVR12, 777 (99.7%) also achieved an SVR24, making the PPV of SVR12 for SVR24 >99% and the NPV 100%. Of patients who relapsed post-therapy, 77.6% did so within 4 weeks of completing therapy. CONCLUSION Data from phase III studies demonstrate that with SOF-based regimens, with or without interferon, SVR12 and SVR24 correlate closely. Thus, SVR12 can be used effectively to determine "cure" rates in trials and in clinical practice.
Collapse
|
37
|
Kielland KB, Amundsen EJ, Dalgard O. HCV treatment uptake in people who have injected drugs - observations in a large cohort that received addiction treatment 1970-1984. Scand J Gastroenterol 2014; 49:1465-72. [PMID: 25310139 DOI: 10.3109/00365521.2014.968860] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aim of this study was to document antiviral treatment uptake among former or current people who inject drugs (PWID) with chronic hepatitis C and to explore a possible association between treatment and mortality. MATERIAL AND METHODS This is a longitudinal cohort study of PWID admitted for drug abuse treatment 1970-1984. The 245 hepatitis C virus (HCV) RNA-positive patients alive by the end of 1996 were followed 1997-2012 through linkage to several health registers. Treatment uptake was mainly documented by information on prescription of antiviral medication registered in the Norwegian Prescription Database from 2004. Cox regression, with a time-dependent covariate measuring end-of-treatment, was employed to evaluate mortality after treatment. RESULTS At the end of the follow-up, median time since HCV exposure was 36 years, and 19.2% (47/245) had been prescribed antiviral treatment for chronic HCV infection. No gender difference was observed. Among those alive at the end of the study period, 27.8% (44/158) had been treated. Relative hazard of death was 0.21 (95% confidence interval [CI] 0.07-0.68), comparing periods for patients after versus before or without treatment. Mortality rate after treatment was 0.8 per 100 person years (95% CI 0.3-2.4) compared to 2.8 (95% CI 2.2-3.5) in untreated patients and before treatment. The most important causes of death among the untreated were drug-related. CONCLUSIONS Among PWID infected with HCV, approximately one-fourth of those still alive at a median of 36 years after exposure had received HCV treatment. Treatment was associated with increased survival, probably mainly due to selection bias.
Collapse
Affiliation(s)
- Knut Boe Kielland
- National Centre for Dual Diagnosis, Innlandet Hospital Trust , Brumunddal , Norway
| | | | | |
Collapse
|