Curing hepatitis C, but at what cost?

In the contest to get a creative name, few pathogens have done worse than hepatitis C. In the 1970s there were two known viruses that caused hepatitis: liver inflammation. You might have already guessed that these two viruses were called hepatitis A and hepatitis B. It was known at that time that people sometimes developed hepatitis after blood transfusions and that the majority of those patients tested negative for hepatitis A and B. A new pathogen was hypothesized and called non-A, non-B hepatitis. It wasn’t until 1989 until the virus was isolated and named (drum-roll, please) hepatitis C.

Hepatitis C is transmissible through contact with blood. Before the advent of routine testing of the blood supply it was transmitted through transfusions. It is still transmitted through the sharing of drug and tattoo needles and, in less developed countries, through the reuse of unsterilized medical equipment. Hepatitis C can cause liver failure and liver cancer. There are over 3 million people in the US who are infected with hepatitis C. It is the leading cause of liver transplantation and liver cancer in the US.

There are vaccines against hepatitis A and B, but none yet for hepatitis C.

For decades the standard therapy for hepatitis C has been a regimen including interferon and ribavirin. Interferon has to be given by injection and can have debilitating side effects. A course of treatment lasts 6 to 12 months, and many who begin a course are unable to tolerate it. Fewer than 50% of patients who are treated with this regimen have a meaningful benefit. Because of the length and difficulty of the treatment many hepatitis C patients are thought to be poor candidates and never are offered treatment.

This post is about a whole crop of studies published in the last two months in the New England Journal of Medicine about the safety and efficacy of novel treatments for hepatitis C. (For links to the individual studies, see the right sidebar of this related NEJM editorial.) Eight recent studies have examined several new medication regimens with truly remarkable results.

The new regimens involve oral medications, so injections are unnecessary. Rather than lasting 6 to 12 months they last 8 to 12 weeks. They are very well tolerated with fairly mild side effects. Best of all, over 90% of the patients appear to have complete clearance of the virus. These results suggest that these medications are no longer in the realm of treating hepatitis C. Instead, for most patients, these medications are a cure for hepatitis C.

Of course, there’s a catch. The medications are astronomically expensive. One of the medications (sofosbuvir) costs $84,000 for a 12-week course. This has caused much consternation and bloviating about pharmaceutical corporate greed. (I’m fascinated by articles that rhapsodically praise the extraordinary medical and scientific breakthrough that these medications represent and a few sentences later vilify the companies that made those breakthroughs possible.)

If we keep our cool and do absolutely nothing, the prices will eventually drop. Competition from newer medications, expiration of patents, and negotiations with insurers will all drive prices down over the next several years. Remember, cell phones and cars were wildly unaffordable when they were new. If we all get angry and insist on making these medicines affordable by legislating that insurers cover them, we could make sure that their prices stay astronomic forever.

The exciting news is that within a decade or two we might be able to eradicate hepatitis C. Then maybe we can concentrate our resources on viruses with cooler names, like MERS and Ebola.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • John C. Key MD

    I hate to villify Big Pharma, but when you produce a product that is too expensive for the average patient to purchase, I don’t think you have accomplished much…whether it is an atypical antipsychotic, or sofosbuvir. It you don’t get it to the masses you are just blowing smoke.

  • NewMexicoRam

    Sounds like the old supply and demand mantra.
    But it does have it’s limits. Most governments regulate the gas and electric utilities. And don’t forget one more–primary care physicians.

  • Ronald Hirsch, MD

    So where is the outrage at the price of Avastin or Provenge that do almost nothing for cancer? This drug CURES the other terrible “C” disease-hepatitis C-in 90% of patients. Can anyone name one other drug equally effective? The payoff may not come for years when these patients do not need liver transplants or develop cirrhosis so we need to broaden your view to understand that this drug is a great bargain. We all need to get past the stigma placed on patients with hep C and realize they deserve this medication just as patients with the appropriate type of cancer believe they deserve access to Avastin.

  • eqvet2015

    If hepatitis C were bacterial, its name would have changed 4 times by now. Poor viruses don’t get any love…

  • http://cognovant.com/ W Joseph Ketcherside, MD

    So the exciting news is that in a decade or two, after the patents expire and competitors force realistic pricing, we will be able to cure Hepatitis C. A disease we actually know how to cure now, but gouging by pharma makes impossible. Wow. I had to re-read several of the author’s sentences to be sure he really did say that out loud.

    For all the folks who scream about the rationing they think would occur in a single-payer or other universal system of care, what do you call this? This is unconscionable.