Cost Effectiveness of Pre- vs Post-Liver Transplant Hepatitis C Treatment With Direct-Acting Antivirals

BACKGROUND & AIMS: Oral direct-acting antivirals (DAAs) for hepatitis C virus (HCV) treatment offer new hope to both pre- and post-liver transplant (LT) patients. However, whether to treat HCV patients before vs after LT is not clear because treatment can improve liver function but could reduce the chance of receiving an LT while on the waiting list. Our objective was to evaluate the cost effectiveness of pre-LT vs post-LT HCV treatment with oral DAAs in decompensated cirrhotic patients on the LT waiting list. METHODS: We used a validated mathematical model that simulated a virtual trial comparing long-term clinical and cost outcomes of pre-LT vs post-LT HCV treatment with oral DAAs. Model parameters were estimated from United Network for Organ Sharing data, SOLAR-1 and 2 trials, and published studies. For each strategy, we estimated the quality-adjusted life-year, life expectancy, cost, and the incremental cost-effectiveness ratio. RESULTS: For lower MELD scores, quality-adjusted life-years were higher with pre-LT HCV treatment compared with post-LT treatment. Pre-LT HCV treatment was cost saving in patients with MELD scores of 15 or less, and cost effective in patients with MELD scores of 16 to 21. In contrast, post-LT HCV treatment was cost effective in patients with MELD scores of 22 to 29 and cost saving if MELD scores were 30 or higher. Results varied by drug prices and by United Network for Organ Sharing regions. CONCLUSIONS: For cirrhotic patients awaiting LT, pre-LT HCV treatment with DAAs is cost effective/saving in patients with MELD scores of 21 or lower, whereas post-LT HCV treatment is cost effective/saving in patients with MELD scores of 22 or higher.