Dan Yock Young, Wai Chun Tao, Yeoh Khay Guan, Lim Seng Gee
Department of Gastroenterology, National University Hospital, Singapore.
Liver Transpl. 2006 May;12(5):736-46. doi: 10.1002/lt.20685.
Hepatitis B immunoglobulin with lamivudine prophylaxis (LAM/HBIG) is effective in preventing Hepatitis B (HBV) recurrence posttransplant but is expensive and inconvenient. Lamivudine-resistant HBV, which has limited the usefulness of lamivudine monoprophylaxis in transplant, can now be effectively controlled with adefovir dipivoxil. We performed a cost-effectiveness analysis on the strategies of lamivudine prophylaxis with adefovir rescue(LAM/ADV) compared to combination LAM/intravenous fixed high-dose HBIG prophylaxis(LAM/ivHBIG) or LAM/intramuscular HBIG prophylaxis(LAM/imHBIG). Markov modeling was performed with analysis from societal perspective. Probability rates were derived from systematic review of the literature and cost taken from MEDICARE database. Outcome measures were incremental cost-effectiveness ratio(ICER) and cost to prevent each HBV recurrence and death. Analysis was performed at 5 years posttransplant as well as at end of life expectancy (15 years). Combination LAM/ivHBIG cost an additional USD562,000 at 15 years, while LAM/imHBIG cost an additional USD139,000 per patient compared to LAM/ADV. Although there is an estimated increase in recurrence of 53% with LAM/ADV and 7.6% increased mortality at the end of life expectancy (15 years), the ICER of LAM/ivHBIG over LAM/ADV treatment is USD760,000 per quality-adjusted life-years and for LAM/imHBIG, USD 188,000. Cost-effectiveness is most sensitive to cost of HBIG. Lamivudine prophylaxis with adefovir dipivoxil salvage offers the more cost-effective option for HBV patients undergoing liver transplant but with higher recurrence and death rate using a model that favors LAM/HBIG. Lowering the cost of HBIG maintenance will improve cost-effectiveness of LAM/HBIG strategy. In conclusion, a tailored approach based on individual risks will optimize the cost-benefit of HBV transplant prophylaxis.
拉米夫定联合乙肝免疫球蛋白预防（LAM/HBIG）对预防肝移植后乙肝（HBV）复发有效，但费用高昂且使用不便。拉米夫定耐药的HBV限制了拉米夫定单药预防在肝移植中的应用，而阿德福韦酯现在可以有效控制这种情况。我们对拉米夫定预防联合阿德福韦挽救（LAM/ADV）策略与拉米夫定联合静脉注射固定高剂量乙肝免疫球蛋白预防（LAM/ivHBIG）或拉米夫定联合肌肉注射乙肝免疫球蛋白预防（LAM/imHBIG）策略进行了成本效益分析。采用马尔可夫模型从社会角度进行分析。概率率来自对文献的系统综述，成本取自医疗保险数据库。结果指标为增量成本效益比（ICER）以及预防每次HBV复发和死亡的成本。在移植后5年以及预期寿命结束时（15年）进行分析。与LAM/ADV相比，LAM/ivHBIG在15年时每位患者额外花费56.2万美元，而LAM/imHBIG每位患者额外花费13.9万美元。尽管预计LAM/ADV组复发率增加53%，预期寿命结束时（15年）死亡率增加7.6%，但LAM/ivHBIG相对于LAM/ADV治疗的ICER为每质量调整生命年76万美元，LAM/imHBIG为18.8万美元。成本效益对乙肝免疫球蛋白的成本最为敏感。拉米夫定预防联合阿德福韦酯挽救对于接受肝移植的HBV患者是更具成本效益的选择，但在倾向于LAM/HBIG的模型中复发率和死亡率更高。降低乙肝免疫球蛋白维持治疗的成本将提高LAM/HBIG策略的成本效益。总之，基于个体风险的定制方法将优化HBV移植预防的成本效益。
