Assessment of Alternative Treatment Strategies for Chronic Genotype 1 Hepatitis C

There is great potential to improve health outcomes for Veterans and other patients with chronic genotype 1 (GT1) Hepatitis C (HCV) infections through the use of newly-available triple combination therapies that include directly acting antivirals (DAA) along with recently developed patient genotyping (IL-28B) which is predictive of HCV treatment response. Chronic GT1 HCV infections have been historically difficult to treat, with low cure rates on standard two drug therapy (Pegylated...
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There is great potential to improve health outcomes for Veterans and other patients with chronic genotype 1 (GT1) Hepatitis C (HCV) infections through the use of newly-available triple combination therapies that include directly acting antivirals (DAA) along with recently developed patient genotyping (IL-28B) which is predictive of HCV treatment response. Chronic GT1 HCV infections have been historically difficult to treat, with low cure rates on standard two drug therapy (Pegylated Interferon + Ribavirin), high rates of side-effects and treatment discontinuation, and low rates of uptake. Recently, FDA approved two DAAs (boceprevir and telaprevir). Used in combination with standard two drug therapy as triple therapy, these DAAs show higher rates of sustained viral response, though they are also more costly and have more severe side-effect profiles. IL-28B genotyping can help to identify patients least likely to respond to standard therapy and hence who stand to benefit the most from triple therapy and for whom, therefore, the increased risks of side-effects may be most justified. We addressed four related questions: Key Question #1: What are the current usage patterns of directly acting antivirals and of IL-28B patient genotyping in the VA health system? And how do these patterns differ by VISN? Key Question #2: What will be the health impacts of using either of two available directly acting antivirals combined with pegylated interferon and ribavirin (triple therapy)? Key Question #3: How will be the magnitudes of the health impacts measured in Key Question #2 change if IL-28B patient genotyping is used to offer triple therapy to those less likely to benefit from two-drug pegylated interferon + ribavirin? Key Question #4: What will be the cost and resource use patterns when using either triple therapy or IL-28B-guided triple therapy? We used analysis of observational data and decision analysis to answer these questions over a 5 year time horizon, all in comparison to health outcomes and costs if standard two-drug treatment were continued without adoption of either of the new technologies. Importantly, these results are appropriate for short-term budgeting and planning considerations but are not appropriate for formal cost-effectiveness analyses as they do not represent the full costs and benefits experienced over a life time.