Adherence to Hepatitis C Therapies and
The Impact of Comorbid Conditions
Mary Cassler RPh, MBA, Lon Castle, M.D., Bill Dreitlein, Pharm.D.,
Mona Khalid, MBA, MPH, Helen Kourlas, Pharm D., and Jane Barlow, M.D., MBA,
MPH
April 11, 2011
International Conference on Viral Hepatitis 2011
Objective
• Analyze Hepatitis C patients’ adherence through a large
pharmacy database to identify:
o Patterns of adherence
o Opportunities to improve adherence amongst this
population
o Other comorbid conditions that affect adherence
o Predictors for early treatment discontinuation
o Opportunities to avoid side affects associated with HCV
therapies
Background
• Studies show that HCV patients should maintain adherence rates of
≥80-85% in order to receive optimal benefits from HCV therapies1,2
o
o
Suboptimum drug exposure has been shown to be associated with
physician-directed dose reductions due to side effects
Little evidence exists to show association of suboptimum drug exposure to
missed doses by patients
• Common side effects of HCV therapies makes it challenging for
patient’s to adhere to HCV regimen
o
o
Approximately 20-40% of interferon patients suffer from depression3
Greater than 50% of patients treated with ribavirin experience a decline in
Hb, necessitating a dose reduction4
Source: 1Lo Re, et al. Adherence to Hepatitis C Virus Therapy and Early Virologic Outcomes. CID 20009: 48:186–93
2McHutchinson, et al. Adherence to Combination Therapy Enhances Sustained
Response in Genotype-1–Infected Patients With Chronic Hepatitis C. Gastroenterology 2002;123:1061–1069
3 Lui, et al. Impact of Depressive Symptoms and Their Treatment on Completing Antiviral Treatment in Patients With Chronic HepatitisC J Clin Gastroenterol
Volume 44, Number 8, September 2010
4Krishnan, et al. Ribavirin-Induced Anemia in Hepatitis C Virus Patients Undergoing Combination Therapy. PLoS Comput Biol. 2011 Feb 3;7(2):e1001072
Methodology
• A national pharmacy benefit management (PBM) claims database
was used to identify patients new to interferon and ribavirin
therapies
• A one-year review period was used to monitor patients’ claims and
168 days follow-up period was used to calculate their medication
possession ratio (MPR)
• Adherence to therapy was defined as MPR ≥80%
• Comorbidities such as HIV and depression were evaluated to
determine their impact on patients’ adherence to HCV therapies
Results
• 3607 HCV Patients Identified:
o 1657 were being treated for depression
o 109 were coinfected with HIV
 66 of these patients were also being treated for depression
o
60.4% were adherent to their HCV medications
 Patients being treated for depression had the highest MPR
adherence rates
 61.5% depression only
 69.7% depression and HIV
Patient Counts by Comorbid Conditions
Source: Medco Data 2010
Definition of adherence
• Compliance
o
o
Is the patient taking their medication as prescribed?
Are they receiving sufficient daily doses of medication?
• Persistency
o
o
o
Is patient filling medication regularly?
Are there any gaps in therapy?
Has the patient dropped off therapy?
• Adherence
o
Compliance + Persistency
Percentage of Patients Compliant to Therapy
Source: Medco Data 2010
Persistency to Hep-C Therapy
Source: Medco Data 2010
MPR Impact by Comorbid Conditions
Source: Medco Data 2010
Interferon adherence by MPR Group
MPR Groups
• 68.5% of interferon
patients have MPR ≥80%
• ~11% of patients have
suboptimal adherence that
could be amendable by
interventions
o
Healthcare provider
interventions could
potentially push them into
optimal MPR
Source: Medco data, 2010.
Interferon MPR Groups
Ribavirin adherence by MPR Group
Ribavirin MPR Groups
MPR Groups
• 62.6% of ribavirin
patients have MPR
≥80%
o
Adherence can be
influenced by
physicians stopping
drug due to anemia
• ~14% of patients have
suboptimal adherence
that could be
amendable by
interventions
Source: Medco data, 2010.
Conclusions
• 40% of patients do not achieve ≥80% adherence rates and
therefore risk the development of medication resistance,
inadequate viral suppression and disease progression
• Patients concurrently receiving antidepressant medications
demonstrated higher adherence to HCV therapies
• There may be value in identifying and appropriately treating
patients with depression.
o
o
Proactive monitoring is particularly warranted in patients with HCV,
especially considering the established link between IFN therapy and
the onset of depressive symptoms.
Identification and treatment of depression may be more important for
those with comorbid HIV disease
• Effective depression screening by healthcare professionals may be
a valuable tool to improve treatment adherence in patients with
HCV.
Next Steps
• Additional studies are needed to validate these findings
• Develop a screening tool to identify and evaluate depression in
patients receiving HCV therapies and treat them appropriately
• Create an adherence program that will identify those patients <80%
adherent and incorporate targeted interventions to improve
adherence
• Design an adherence program that:
o
o
incorporates a comprehensive depression screening tool
shares the results of the program with physicians so that they can
proactively determine best depression treatment options.