People with hepatitis C who develop anemia as a side effect of treatment may consider taking an additional therapy for the side effect rather than halting HCV treatment altogether. That's because this option may be more cost-effective in the long run, according to a group of doctors from UCLA and the California VA, who published a study on the topic earlier this month.1
Brennan M.R. Spiegel, MD, who heads the UCLA/VA Center for Outcomes Research and Education (CORE), led the research. "We sought to determine the cost effectiveness of [additional] treatment with an erythropoietic growth factor versus standard care in the treatment of hepatitis C," wrote Spiegel and his colleagues.
Ribavirin Side Effect
In people diagnosed with hepatitis C, a commonly prescribed treatment combination is interferon-alfa and ribavirin, an antiviral drug taken orally. This combination is designed to halt the liver inflammation associated with the disease.2 However, one side effect of ribavirin is anemia, a condition characterized by low amounts of red blood cells. This results in an insufficient supply of oxygen to the tissues fed by the blood supply. Symptoms can vary; people with mild forms of anemia may be asymptomatic, but those with more severe forms can experience the following symptoms:
• Fatigue
• Dizziness
• Increased thirst
• Sweating
• Weak and rapid pulse
• Rapid breathing
• Low leg cramps during exercise
• Shortness of breath
• Chest pain
The latter symptoms occur more often in severe anemia.3
Anemia Affects Compliance
Yet, compliance with the interferon/ribavirin treatment combination "is significantly undermined" due to this side effect of ribavirin, Spiegel and his colleagues wrote. According to the researchers, up to one-third of patients receiving combination therapy develop ribavirin-linked anemia. Additionally, quality of life suffers when this side effect develops, they wrote. "These data present a marked disconnect between the goal of achieving SVR [sustained virologic response] through optimal adherence and the clinical reality of nonprevalent noncompliance."
(Sustained virologic response is a measurement of treatment outcome that describes undetected levels of HCV for a minimum of six months after therapy has ended).4
While medications like epoetin alfa or darbepoetin alfa help increase hemoglobin levels in the blood, thus successfully treating anemia, no prospective studies have been performed to evaluate whether these medications optimize adherence or are more cost-effective than reducing the dose of ribavirin, or stopping it altogether, Spiegel and his team wrote.
Comparative Cost Analysis
To answer that question, the investigators developed a cost-effectiveness analysis using a hypothetical model of two varying strategies to treat ribavirin-induced anemia.
In one scenario, patients who developed progressive anemia had their hepatitis medications halted. In the second scenario, patients who developed progressive anemia also began erythropoietic growth factor treatment, but maintained their ribavirin dose. This analysis took typical characteristics of hepatitis patients into account, based on data from primary treatment trials.
After comparing costs between the two treatment strategies, the team determined that treatment using erythropoietic growth factors was more cost effective as compared to the standard approach—discontinuing hepatitis treatment. Using these adjunctive medications is also more likely to increase patient compliance, the research team wrote. Cost effectiveness was based on standards that they say are accepted by society and many insurers for treating a chronic condition like hepatitis C.
"The cost-effectiveness of erythropoietic growth factor therapy is not only achieved by improving post-treatment HRQOL [health-related quality of life], but also by improving HRQOL during treatment compared with standard care," wrote Spiegel and his colleagues.
The researchers acknowledge that their findings may not necessarily apply to the entire population of hepatitis patients, but "we attempted to guard against inaccurate base-case results by systemically reviewing the [medical] literature, and by performing a probabilistic sensitivity analysis to acknowledge that each estimate is likely to vary in clinical practice," they wrote.
1. Spiegel BMR, Chen K, Chiou CF, Robbins S, Younossi ZM. Erythropoietic growth factors for treatment-induced anemia in hepatitis C: a cost-effectiveness analysis. Clin Gastroenterol Hepatol 2005 Oct;3(10):1034-42.
2. The Merck Manual. Chronic Hepatitis. Available at: http://www.merck.com/mmhe/sec10/ch137/ch137c.html?qt=hepatitis%20ribavirin&alt=sh.
3. The Merck Manual. Blood Disorders. Anemia. Available at: http://www.merck.com/mmhe/sec14/ch172/ch172a.html?qt=anemia&alt=sh. Accessed October 17, 2005.
4. Fried MW, Shiffman ML, Reddy KR et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med 2002 Sep 26;347(13):975-82.
John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include overseeing health news coverage for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
