The use of all-oral direct-acting antivirals in hepatitis C virus-infected patients with substance use disorders.
The use of all-oral direct-acting antivirals in hepatitis C virus-infected patients with substance use disorders.
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DOI：
10.18553/jmcp.2021.27.7.873
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发表时间：
2021-07
影响因子：
2.1
通讯作者：
Park H
中科院分区：
文献类型：
--
作者：
Jiang X;Song HJ;Wang W;Henry L;Childs-Kean LM;Re VL 3rd;Park H
有证据表明，对于患有药物使用障碍（SUD）的人来说，开始针对丙型肝炎病毒（HCV）的直接作用抗病毒（DAA）治疗存在障碍。然而，缺乏SUD和HCV患者在接受处方后开始DAA治疗并继续治疗的真实的临床证据。目的：（1）比较DAA时代伴和不伴SUD的HCV感染患者的HCV治疗开始（处方填写）率和提前终止率，（2）确定与SUD患者的HCV治疗开始和提前终止相关的患者水平因素。对MarketScan数据库（2012年1月至2018年12月）中新诊断的初治HCV感染患者（年龄≥ 18岁）（伴和不伴SUD）进行了回顾性队列分析。我们使用多变量考克斯回归来估计有SUD的患者与无SUD的患者在开始治疗和提前终止治疗的95%置信区间内的校正风险比（aHR）。我们共确定了29，228例新诊断的HCV感染患者（6，385例SUD和22，843例无SUD）。总体而言，SUD患者开始DAA治疗的比例显著低于无SUD患者（24% vs 34%; P < 0.01）。在调整人口统计学和临床特征后，SUD患者开始DAA治疗的可能性低于无SUD患者（aHR，0.87 [0.82-0.92]）。有和无SUD的患者之间DAA治疗中止率无差异（4% vs 3%：aHR，1.13 [0.81-1.60]）。在SUD患者（n = 6，385）中，启动DAA治疗的发生率较低与年龄较小和合并症相关，包括酒精性肝病（ALD; aHR，0.44 [0.33-0.57]）、慢性肾病（CKD）（aHR，0.52 [0.36-0.75]）和B型肝炎病毒（HBV; aHR，0.64 [0.44-0.92]）。DAA治疗中止与年轻、利巴韦林（RBV）治疗（aHR，3.78 [2.21-6.47]）和肝硬化诊断（aHR，2.42 [1.21-4.84]）相关，但与SUD治疗（aHR，0.68 [0.34-1.34]）无关。HCV感染的SUD患者的治疗开始率显著较低，尤其是年轻女性和ALD、CKD和HBV患者。DAA停药无差异。然而，接受RBV治疗和/或肝硬化的年轻患者更有可能停止治疗。针对这些群体的干预措施是必要的，以提高DAA启动和治疗维持在HCV感染的SUD患者。
There is evidence that barriers exist for the initiation of direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) for those with substance use disorders (SUDs). However, real world clinical evidence of DAA treatment initiation following receipt of a prescription and continuation among those with SUDs and HCV is lacking. To (1) compare HCV treatment initiation (prescription fill) rates and early discontinuation rates between HCV-infected patients with and without SUDs in the DAA era, and (2) identify patient-level factors associated with HCV treatment initiation and early discontinuation in patients with SUDs. A retrospective cohort analysis of the MarketScan databases (January 2012-December 2018) was conducted for newly diagnosed treatment naïve HCV-infected patients (age ≥ 18) with and without SUDs. We used multivariable Cox regression to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals of treatment initiation and early discontinuation in those with SUDs versus those without. We identified a total of 29,228 newly diagnosed HCV-infected patients (6,385 with SUDs and 22,843 without SUDs). Overall, DAA treatment initiation for patients with SUDs was significantly lower than that for those without SUDs (24% vs 34%; P < 0.01). After adjusting for demographics and clinical characteristics, patients with SUDs were less likely to initiate DAA treatments than those without SUDs (aHR, 0.87 [0.82-0.92]). There was no difference in discontinuation of DAA treatment between those with and without SUDs (4% vs 3%: aHR, 1.13 [0.81-1.60]). Among patients with SUDs (n = 6,385), lower rates of initiating DAA treatment was associated with younger age, and comorbidities including alcoholic liver disease (ALD; aHR, 0.44 [0.33-0.57), chronic kidney disease (CKD) (aHR, 0.52 [0.36-0.75]), and hepatitis B virus (HBV; aHR, 0.64 [0.44-0.92]). DAA treatment discontinuation was associated with younger age, ribavirin (RBV) therapy (aHR, 3.78 [2.21-6.47]), and cirrhosis diagnosis (aHR, 2.42 [1.21-4.84]) but not SUD treatment (aHR, 0.68 [0.34-1.34]). HCV-infected patients with SUDs had significantly lower treatment initiation rates, especially in young females and those with ALD, CKD, and HBV. No difference was found in DAA discontinuation. However, younger patients with RBV treatment and/or cirrhosis were more likely to stop treatment. Interventions directed towards these groups are needed to enhance DAA initiation and treatment maintenance among HCV-infected patients with SUDs.
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