Cost-Effectiveness of Rifaximin Treatment in Patients with Hepatic Encephalopathy

Abstract

BACKGROUND: Hepatic encephalopathy (HE) is a complication of cirrhosis of the liver causing neuropsychiatric abnormalities. Clinical manifestations of overt HE result in increased health care resource utilization and effects on patient quality of life. While lactulose has historically been the mainstay of treatment for acute HE and maintenance of remission, there is an unmet need for additional therapeutic options with a favorable adverse event profile. Compared with lactulose alone, rifaximin has demonstrated proven efficacy in complete reversal of HE and reduction in the incidence of HE recurrence, mortality, and hospitalizations. Evidence suggests the benefit of long-term prophylactic therapy with rifaximin; however, there is a need to assess the economic impact of rifaximin treatment in patients with HE. OBJECTIVE: To assess the incremental cost-effectiveness of rifaximin ± lactulose versus lactulose monotherapy in patients with overt HE.METHODS: A Markov model was developed in Excel with 4 health states (remission, overt HE, liver transplantation, and death) to predict costs and outcomes of patients with HE after initiation of maintenance therapy with rifaximin ± lactulose to avoid recurrent HE episodes. Cost-effectiveness of rifaximin was evaluated through estimation of incremental cost per qualityadjusted life-year (QALY) or life-year (LY) gained. Analyses were conducted over a lifetime horizon. One-way deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty in results. RESULTS:The rifaximin ± lactulose regimen provided added health benefits despite an additional cost versus lactulose monotherapy. Model results showed an incremental benefit of $29,161 per QALY gained and $27,762 per LY gained with rifaximin ± lactulose versus lactulose monotherapy. Probabilistic sensitivity analyses demonstrated that the rifaximin ± lactulose regimen was cost-effective ~99% of the time at a threshold of $50,000 per QALY/LY gained, which falls within the commonly accepted threshold for incremental cost-effectiveness. CONCLUSIONS:The clinical benefit of rifaximin, combined with an acceptable economic profile, demonstrates the advantages of rifaximin maintenance therapy as an important option to consider for patients at risk of recurrent HE.

The Use of Rifaximin in Patients With Cirrhosis

“…Even in tertiary-care centers, 12.5% of patients who were admitted with HE, were subsequently discharged without HE-specific medications, which translated directly into readmissions (55) . Given the expense of hospitalizations, studies have shown that rifaximin is costeffective for prevention of recurrence, but greater education of providers, patients and caregivers is needed (56) .…”

“…( 55 ) Given the expense of hospitalizations, studies have shown that rifaximin is cost‐effective for prevention of recurrence, but greater education of providers, patients, and caregivers is needed. ( 56 )…”

Evaluation of the Long-term Administration of Rifaximin for More than Three Years in the Treatment of Repeated and Recurrent Overt Hepatic Encephalopathy

“…The cost-effectiveness of rifaximin treatment in patients with HE has been also shown by Jesudian et al, who suggested that rifaximin plus lactulose was advantageous in comparison to lactulose monotherapy with regard to costbenefit, and that rifaximin maintenance treatment is very important for patients with at risk for the development of recurrent HE (28).…”

Hepatic Encephalopathy-Related Hospitalizations in Cirrhosis: Transition of Care and Closing the Revolving Door

“…A cost-effectiveness analysis published in 2020 showed that rifaximin plus lactulose was cost-effective at a willingnessto-pay threshold of $50,000 per QALY/LY [47].…”