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MELD score determines DAAs’ cost-effectiveness pre- or post-transplant

Direct-acting antiviral treatment in patients with hepatitis C and cirrhosis was most cost-effective and cost-saving pre-liver transplant among those with a MELD score of 21 or less, but post-liver transplant among those with a MELD score over 21, according to a recent study.

“The decision to treat HCV pre-LT versus post-LT, needs to balance the benefits and potential harms of HCV treatment in patients on the LT waiting list. In addition, such trade-offs need to factor-in the cost-effectiveness and value of pre-LT versus post-LT HCV treatment,” the researchers wrote.

Using the simulation of liver transplant candidates (SIM-LT) model, the researchers simulated a virtual trial of 1 million patients with HCV and decompensated cirrhosis without HCC receiving DAAs pre-LT versus post-LT.

The simulation included data from the United Network for Organ Sharing, results of the two SOLAR studies and other previously published studies. Mean age of patients was 50 years and MELD scores ranged from 10 to 40. Researchers simulated for each patient both the scenario of DAA treatment pre-LT and the scenario of treatment post-LT.

Patients with lower MELD scores, particularly 27 or lower, had higher quality-adjusted life-years if they were treated for HCV before liver transplant, whereas those with higher MELD scores had higher quality-adjusted life-years with treatment post-LT.

Patients with MELD scores of 15 or lower who underwent DAA treatment pre-LT had increased quality-adjusted life-years and decreased cost, while patients with MELD scores of 16 to 21 had increased quality-adjusted life-years and cost, up to the commonly accepted willingness to pay threshold of $100,000 per quality-adjusted life-year.

Pre-LT DAA treatment was not cost-effective among patients with MELD scores of 22 to 27, despite higher quality-adjusted live years. The researchers found, however, that pre-LT DAA treatment would become cost-effective if it decreased below $51,000 for patients with MELD scores of 22 to 23 or below $16,000 for those with MELD scores of 24 to 25. They did not find o a price reduction to make pre-LT DAA treatment cost-effective for patients with MELD scores of 26 to 27. However, post-LT DAA treatment became cost-effective above a score of 27.

Following an analysis of the UNOS database regions, the researchers found that Region 3, 10 and 11 had relatively shorter wait-list times for LT. In those Regions, pre-LT DAA treatment was cost-effective and cost-saving in patients with MELD scores of 19 or lower.

“Prior studies have provided conflicting evidence about the cost-effectiveness of timing of HCV treatment. We believe the reason for these conflicting findings is that these studies aggregated all patients with MELD scores [15 or higher] into one category and thus failed to identify a threshold above which post-LT HCV treatment could be cost-effective,” the researchers wrote. “Our study, because it considered MELD as a continuum, provides more granular results by MELD scores and thus aids patient-level decision making.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures. Please see the full study for the other researchers’ relevant financial disclosures.