There are more and more directly effective antiviral drugs for the treatment of Hepatitis C. The only problem is the high cost. Many doctors are reluctant to prescribe the new therapies because they fear recourse claims from health insurance companies. By Armin Schafberger, medical consultant at Deutsche Aidshilfe.
The old is gone. Almost completely. That's a good thing
For years, the standard treatment of Hepatitis C of interferon and ribavirin. Depending on the genotype, it lasted six to 18 months; the chances of success varied between 30 and 90 per cent. The interferon used to date in particular has many side effects: Flu symptoms, anaemia, fatigue, weight loss, hair loss, irritability, concentration problems and depression.
The new hepatitis C drugs: good as hell and expensive as hell
In the course of last year, new drugs were authorised. Unlike interferon, they do not act on the infection via the immune system, but directly on the HCV replication cycle. (This is what HIV drugs also do.) According to the guidelines of the German Society for Gastroenterology, Digestive and Metabolic Diseases, which have been in force since February 2015, interferon treatment will no longer be available (apart from in exceptional cases). Only ribavirin - the best-tolerated drug of the old guard - is still needed.
Advantages of the new therapies
- The therapies are more effective. In most cases, success rates of 90 or 95 per cent are achieved or even exceeded!
- As far as is known, the medication is very well tolerated.
- Therapies no longer last as long, usually only twelve weeks, in some cases only eight weeks for (previously untreated) therapy-naïve patients, and 24 weeks for patients with cirrhosis or after (unsuccessful) previous therapy.
Disadvantages of the new therapies
- As with HIV medication, HCV can become resistant to the medication. For this reason, at least two, more likely three, sometimes even four drugs are combined to achieve a sufficient effect - this reduces the risk of resistance developing.
- The therapies are so expensive that there are problems with access to the new form of therapy in all countries.
Disease severity and genotype decisive for drug selection
Which medication the doctor suggests for treatment depends on which HCV genotype you are infected with, as the available medication does not work equally well for all genotypes.
What does the cure cost?
According to German guidelines, a chronic infection can be treated regardless of the degree of liver damage. But why are doctors in Germany so reluctant to prescribe the new substances? In recent months, there has been much public discussion about the high cost of the drugs.
For the most favourable treatment, the cost of the medication is around €45,000. A twelve-week therapy with the new substances costs between €54,000 and €95,000, depending on the combination. In extreme cases, a 24-week therapy can cost almost €200,000.
Many doctors fear that health insurance companies could demand their money back if they make a (small) mistake when prescribing. Doctors not only have to choose the best - scientifically sound - therapy, but also - if there are two or more options - the most cost-effective one.
It is therefore important in the guidelines at what point or with what strength a therapy is recommended. Until February 2015, the more cost-effective interferon therapies were still mentioned in the guidelines. These have now been cancelled. Doctors' fear of recourse claims should therefore subside somewhat.
Health insurance companies negotiate with industry and doctors
Negotiations are currently underway at all levels. On the one hand, the health insurance funds are trying to negotiate acceptable prices with the pharmaceutical industry. In the case of the drug Sofosbuvir, a moderate price reduction was agreed with the manufacturer at the beginning of this year. On the other hand, the health insurance funds, currently the AOK in particular, are concluding supply contracts with some doctors that set out the rules for prescribing the medication. Such contracts already exist in Berlin, the Rhineland and Hesse. These contracts stipulate that doctors must hold separate consultations or obtain a second medical opinion before prescribing the new substances. However, patients have to agree to special contracts with these doctors before treatment can take place. It remains exciting.
More about Hepatitis C on ICH WEISS WAS ICH TU.
