21 Mar Off
Last month I gave an overview of Hepatitis C, and its natural history, and would like to follow up this month with a discussion of treatment. As you know there are now a dozen new drugs called Directly Acting Anti-viral Agents (DAA’s) on the market. Studies show that treatment with a DAA alone or in combination with others produces sustained virologic responses (SVR) 95% of the time and higher. SVR’s have been associated with lower all-cause mortality, liver related mortality & transplantation, hepatocellular carcinoma (HCC) and end stage liver disease (ESLD) in people with hepatitis C and even in the presence of advanced liver fibrosis. Furthermore, there was a recent study in NEJM showing nearly 95% SVR’s in patients with decompensated cirrhosis using combination DAA therapy. Moreover, even if the word “curable” is avoided, SVR’s are durable 99% of the time five years out from treatment! This is pretty heady stuff!
The point is this: just because you have a participant with hepatitis C doesn’t mean that they should be treated. It must be remembered that the average PACE participant is 78 years of age, with average life expectancy of 2.5 years, possesses 9 co-morbidities, is on 11 medications, has functional impairment in 3 ADL’s and has been certified to be nursing home eligible. This was not the type of patient seen in the clinical trials and therefore, we have no information about the response rates in our participant population to these medications.
But as always in PACE, the question is, what are the goals of care expressed by the participant and or their caregivers? Is the treatment being offered consistent with their goals of care? What is the impact of the burden of treatment on their lives especially in light of the fact that many of our participants aren’t viewing their life in terms of life prolongation? What is the chance, given the indolent course discussed last month, that treatment is going to impact their life span anyway, and is that in any way important to the participant? For the majority of our participants, I would argue that the answer is no.
That said, there is an increasing number of participants joining PACE who are between 55-65 years of age. This cohort has a higher incidence of mental health disorders, substance use disorder (drug/alcohol abuse, dependence), and developmental disabilities. It is certainly possible that there may be, in that cohort, a participant who would, upon review of life expectancy, functional status and their goals of care, benefit from treatment. Next month, will conclude with a discussion of the cost of treating hepatitis C and how your PACE program may be reimbursed for these most expensive drug treatments.