Huang E, Esrailian E, Spiegel B M R
David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
Aliment Pharmacol Ther. 2007 Oct 15;26(8):1147-61. doi: 10.1111/j.1365-2036.2007.03464.x.
Treatment options for hepatic encephalopathy have disparate risks and benefits. Non-absorbable disaccharides and neomycin are limited by uncertain efficacy and common dose-limiting side effects. In contrast, rifaximin is safe and effective in hepatic encephalopathy, but is more expensive.
We conducted a decision analysis to calculate the cost-effectiveness of six strategies in hepatic encephalopathy: (i) no hepatic encephalopathy treatment, (ii) lactulose monotherapy, (iii) lactitol monotherapy, (iv) neomycin monotherapy, (v) rifaximin monotherapy and (vi) up-front lactulose with crossover to rifaximin if poor response or intolerance of lactulose ('rifaximin salvage'). The primary outcome was cost per quality-adjusted life-year gained.
Under base-case conditions, 'do nothing' was least effective and rifaximin salvage was most effective. Lactulose monotherapy was least expensive, and rifaximin monotherapy was most expensive. When balancing cost and effectiveness, lactulose monotherapy and rifaximin salvage dominated alternative strategies. Compared to lactulose monotherapy, rifaximin salvage cost an incremental US$2315 per quality-adjusted life-year-gained. The cost of rifaximin had to fall below US$1.03/tab in order for rifaximin monotherapy to dominate lactulose monotherapy.
Rifaximin monotherapy is not cost-effective in the treatment of chronic hepatic encephalopathy at current average wholesale prices. However, a hybrid salvage strategy, reserving rifaximin for lactulose-refractory patients, may be highly cost-effective.
肝性脑病的治疗方案有着不同的风险和益处。不可吸收双糖和新霉素因疗效不确定和常见的剂量限制性副作用而受到限制。相比之下，利福昔明在肝性脑病治疗中安全有效，但价格更高。
我们进行了一项决策分析，以计算肝性脑病六种治疗策略的成本效益：（i）不进行肝性脑病治疗，（ii）乳果糖单药治疗，（iii）拉克替醇单药治疗，（iv）新霉素单药治疗，（v）利福昔明单药治疗，以及（vi）初始使用乳果糖，若对乳果糖反应不佳或不耐受则改用利福昔明（“利福昔明挽救疗法”）。主要结局指标是每获得一个质量调整生命年的成本。
在基础病例条件下，“不采取任何措施”效果最差，利福昔明挽救疗法效果最佳。乳果糖单药治疗最便宜，利福昔明单药治疗最昂贵。在权衡成本和效果时，乳果糖单药治疗和利福昔明挽救疗法优于其他替代策略。与乳果糖单药治疗相比，利福昔明挽救疗法每获得一个质量调整生命年的增量成本为2315美元。为使利福昔明单药治疗优于乳果糖单药治疗，利福昔明的成本必须降至每片1.03美元以下。
按照当前的平均批发价格，利福昔明单药治疗慢性肝性脑病不具有成本效益。然而，一种混合挽救策略，即仅将利福昔明用于对乳果糖难治的患者，可能具有很高的成本效益。
