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Whom to Treat in Hepatitis C?

Many clinicians are justifiably confused about the optimal management of patients with hepatitis C virus (HCV), especially what tests to order to best target interferon treatment. This computer model examined the usefulness and cost-effectiveness of pretreatment determinations of HCV genotype, quantitative plasma HCV RNA, and liver histology in predicting the likelihood of a sustained response to interferon.

Eleven management strategies were evaluated, including empiric treatment of all infected patients, treating only on the basis of viral load or genotype, and using two or three tests sequentially. All selective strategies raised the probability of achieving a sustained response, from an estimated 8 percent for treating all comers to 23 percent for several highly selective strategies, but they also increased the likelihood of missing some patients who would have responded to treatment. For instance, treating only patients with mild hepatitis on biopsy would raise the likelihood of response to 9.3 percent but would miss an estimated 82 percent of sustained responders. Given this tradeoff, the authors preferred the strategy of treating all patients with interferon without pretreatment testing.

Comment: These authors have long argued that interferon treatment is cost-effective for most patients with hepatitis C (see JW Jan 1 1998, p. 1, accession number 971212001, and Ann Intern Med 1997; 127:855). Now that ribavirin raises both the efficacy and the toxicity of treatment, their calculations bear repeating.

— A Zuger

Published in Journal Watch General Medicine January 19, 1999

Citation(s):

Wong JB et al. Pretreatment evaluation of chronic hepatitis C: Risks, benefits, and costs. JAMA 1998 Dec 23 280 2088-2093.

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