Like many urban centers in the Northeastern US, Philadelphia has a chronic shortage of donor livers. But the advent of new antivirals that eradicate hepatitis C infection is starting to change that picture. In a visit to Hahnemann University Hospital, MD Magazine spoke to specialists and patients who are seeing what a difference those drugs can make. Video interviews follow the article.
How can any pill that costs $1,000 daily possibly be considered cost effective?
Ask Carol Nyce, a retired nurse, mother, wife and grandmother who was cured of the hepatitis C infection that would likely have made her a candidate for a liver transplant. Those pills, the new antivirals that wipe out the disease, gave her back her health.
The Harleysville, PA resident contracted the virus through a blood transfusion when she had brain surgery decades ago. Interferon treatment made her miserable and did not work. Now, on the new antivirals, after years of being weak and worried, she is better.
“I am cured and I’m feeling good—I am feeling just wonderful,” Nyce said. How do you put a price on that?, she wondered.
Her story is typical of what physicians and patients see as one of modern medicine’s great success stories: the new antivirals that knock out hepatitis C.
At Hahnemann University Hospital, in Philadelphia, PA, the new drugs are putting a new face on the specter of hepatitis C, surgeons, hepatologists, and patients agreed.
Though the drugs are expensive, they are cheap compared to the cost of having advanced liver disease including liver cancer, and of liver transplantation.
A third of patients who are fortunate enough to get a donor liver still have to live with the threat of the infection returning, said David Reich, MD chief of multi-organ transplantation and hepato-pancreato-biliary surgery at Hahnemann University Hospital in Philadelphia.
Reich and his colleagues believe that not only will the new drugs cure patients, they will ultimately increase the supply of donor livers.
It’s really probably the greatest change in my field in over a decade, easily,” he said.
Hepatitis C patients whose liver disease puts them on a downward trajectory headed for transplant will start to reverse course. An estimated 40% of patients on liver transplant lists are there because of hepatitis C.
“The big picture is that some patients with hepatitis C will not progress to needing liver transplant because their livers will improve,” Reich said, “They may come off the transplant list.”
That has already happened to several of his patients.
Of course, hepatitis infection is not the only reason patients come to need transplants.
For Andrej Holowchak, a Levittown, PA resident, it was primary biliary cirrhosis that put him on a transplant list. He lived through many medical crises including hepatic encephalopathy, and a build-up of 1-liters of fluid in his abdomen that required repeated draining, until a successful transplant gave him back his life. Now he’s looking forward to returning to work managing an auto repair facility, and “a normal family lifestyle,” he said. His 8-year-old daughter has never known her father as a healthy man. “It’s been horrible,” he said, of his long bout with liver disease.
His hepatologist, Kenneth Rothstein, MD, chief of gastroenterology and hepatology at Drexel University and medical director of abdominal transplantation at Hahnemann said such stories as his patient’s do not always have such a happy ending.
“Patients are waiting longer and longer to get a liver,” Rothstein said, adding that Holowchak “should have had a liver one or two years ago but it just wasn’t going to be.”
Rothstein said his hope is that “as treatments for hepatitis C become more firmly established . . .we’ll see less of need for transplants,” but that should take a year or two to result in less demand for liver transplantation. Not that hepatologists are likely to run out of patients, he added. Obesity is behind a new epidemic of fatty liver disease, which can also progress to liver failure.
“It’s not all about obesity but obesity drives it, so with obesity you get diabetes, you get high cholesterol, high triglycerides, things like that,” he said. There are drugs in the pipeline that researchers hope will be effective, he said.
Santiago Munoz, MD, chief of hepatology at Hahnemann University Hospital agreed that the burgeoning fatty liver epidemic “will also eventually have a medical solution,” but that for now “we probably are in fatty liver where we were in hepatitis C about 10 or 15 years ago.”
Munoz, who treated hepatitis C patient Carol Nyce, said that while the new antivirals are miraculous, “The big challenge now is we have probably about 4 million people with the infection in the US, yet throughout the last 30 years we have been able to diagnoses less than a million.”
The new treatments “are so simple and incredibly effective” he said, but finding all the uncounted, undiagnosed people who need them will be a monumental task. And that’s just in the US. “Most of the hepatitis C is really outside the US in Asia and Africa,” he said.
As for the controversy over the drugs’ pricing, Munoz said, “It’s an issue. . . . the sticker upfront cost is very high, but from a society’s point of view, by saving persons the transplant treatment, from liver failure—believe it or not they are actually cost-effective across the board.”
To learn more about the doctors and patients and see their full interviews click here.