Antiviral combination therapy with interferon/peginterferon plus ribavirin for patients with chronic hepatitis C in Germany: a health technology assessment commissioned by the German Agency for Health Technology Assessment

Objective: The purpose of this health technology assessment (HTA), commissioned by the German Agency for HTA at the German Federal Ministry of Health and Social Security, was to systematically review the evidence on effectiveness and cost-effectiveness of antiviral treatment (AVT) for initial chronic hepatitis C (CHC) and to apply these data in the context of the German health care system. Methods: A systematic literature search was conducted to identify randomised controlled trials (RCTs), meta-analyses, and HTAs that evaluated initial AVT for CHC. A modified version of the German Hepatitis C Model (GEHMO) -- a decision-analytic Markov model -- was used to determine long-term morbidity, life expectancy, quality of life, costs and cost-effectiveness of different treatment strategies. Model parameters were derived from German databases, international RCTs, and a Cochrane Review. Results: Overall, 9 RCTs, 2 HTA reports, 1 Cochrane review, and 2 meta-analyses examining medical effectiveness of antiviral combination therapy, as well as 7 economic evaluations, met the inclusion criteria. These studies indicate that combination therapy with peginterferon plus ribavirin produced the highest sustained virological response rates (54-61%), followed by interferon plus ribavirin with 38-54%, and interferon monotherapy with 11-21%. Based on international cost-effectiveness studies, interferon plus ribavirin is cost-effective compared to interferon monotherapy. No published articles were available regarding cost-effectiveness of peginterferon plus ribavirin. In our decision analysis, these findings were confirmed and the discounted incremental cost-effectiveness ratio for peginterferon plus ribavirin was € 9,800 per quality-adjusted life-year gained compared to interferon monotherapy (as the next best non-dominated strategy). Sensitivity analyses showed robust results across a wide range of model parameters. Conclusions: This HTA suggests that initial combination therapy prolongs life, improves quality of life, and is cost-effective in patients with CHC. Combination of peginterferon and ribavirin is the most effective and efficient treatment strategy among the examined options.