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It is better to treat with new drugs than to spend money on retreatment
The drugs for hepatitis C, which appeared several years ago, have transferred this disease from the category of fatal to completely curable. In Russia, drugs are registered that quickly deal with this infection, but the regions in which modern treatment is available to patients can be counted on one hand. But where innovative therapy is applied, it literally works wonders.
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The drugs for hepatitis C, which appeared several years ago, have transferred this disease from the category of fatal to completely curable. In Russia, drugs are registered that quickly deal with this infection, but the regions in which modern treatment is available to patients can be counted on one hand. About what miracles the innovative therapy of hepatitis C works, and how it saves not only people's lives, but also budgetary funds, Mednovosti talk with the head of the hepatological center of the Buzovskoy health care institution of the Oryol region “GB im. SP Botkin”, the chief freelance infectious disease specialist of the region Victoria Adonyeva.
Miser pays twice
- The situation with chronic viral hepatitis in our country is the same as in the rest of the world, it is a major medical and social problem. The hepatological center in the Oryol region was established seven years ago, and from the very beginning we have developed such a tariff for outpatient care in the compulsory health insurance system so that all patients in the Oryol region can undergo a diagnosis of the disease at the level of Russian and European standards and absolutely free. When our regional program was being created, there was still no opportunity to treat hepatitis in the compulsory medical insurance system, but the Oryol region found the necessary funds. And today 100% of patients with hepatitis B are treated at the expense of the regional budget. As for hepatitis C, we are trying to get closer to this indicator.
The Oryol region is not the richest region, but he was able to find the necessary funds. How did you manage it?
The issues of providing medical care to patients with chronic viral hepatitis were repeatedly considered at meetings of the regional duma, the government of the Oryol region, and over the past 10 years funds for the treatment and prevention of viral hepatitis in the region have been allocated regularly.
The money is allocated by economists, and it is necessary to negotiate with them in their language. We have collected clear statistics on how many patients who are admitted to an oncological dispensary with lymphomas (malignant blood diseases), hepatocellular cancer, are infected with hepatitis viruses, what mortality we have in hospitals from complications of liver cirrhosis, and how many children become infected during childbirth. And these statistics clearly showed what medical costs are spent on these patients, what social and economic losses society bears, how many people of working age die.
That is, they confirmed the simple truth that a miser pays twice
- Yes, the miser pays twice. When my colleagues and I defended the need to introduce all new treatment regimens in the region, we calculated the entire pharmacoeconomics and showed that it is cost-effective to treat with new drugs. Indeed, such patients require considerable investment. But these funds are required once, and they leave us as healthy people and live on happily ever after. And in the end, it turns out to be more profitable than spending money on their retreatment, with cheap, but less effective drugs.
Disease of the young
The largest number of cases of chronic hepatitis is detected for the first time in the age group of 30-39 years, and a greater number of our patients are in the most working age. In second place are people 20-29 years old who want to have children, but are afraid of this due to the fact that they are infected. We try to support and treat them in every possible way, first of all, because healthy children in our virtually dying out region (in the Oryol region, the death rate exceeds the birth rate - ed.) Is a great value. We are fighting for every child.
Today, a perinatal protection program is working in the region, hepatologists must control the birth of all infected women. There is a drug that can reduce your viral load to zero and can be taken during pregnancy. And I can proudly say that thanks to these prevention measures, since 2008, we have not had a single child infected with hepatitis B during childbirth. Although in other regions this remains a problem.
For treatment - to the neighbors
So is the treatment?
- Unfortunately yes. According to inter-territorial calculations, within the framework of the compulsory medical insurance program, patients from Belgorod, Smolensk, Lipetsk are treated in our small town (300 thousand people). The fact is that many of our neighbors do not treat infectious diseases under the compulsory medical insurance scheme. The infectious diseases hospitals are on regional funding and, apparently, these funds are not enough. Some of our patients are treated within the framework of the regional program, and the other part - within the framework of the compulsory medical insurance program. The second source of funding appeared three years ago, when the Federal Compulsory Medical Insurance Fund developed a program for the treatment of hepatitis in a day hospital, and we immediately picked up this idea.
As a result, about 8 thousand people are now observed in our center. That is, we carry out about 10-12 thousand visits per year. This is a very big burden, as for a good university hospital. But we do not refuse anyone, we solve these issues with our territorial CHI fund, where they always find a way to support us and provide our patients with treatment, as well as patients from other regions of the Central Federal District according to inter-territorial calculations.
Life saving therapy
Now it is possible to treat very difficult categories of patients with cirrhosis, even at the stage of hepatocellular cancer. We work very closely with oncologists and in the treatment of lymphomas, which are also caused by hepatitis viruses. It is often necessary to carry out antiviral treatment in parallel with chemotherapy. And this gives very good results.
Is the availability of innovative drugs limited by their high cost or are there still problems with registration?
Everything depends on the means. Most effective therapeutic regimens are registered in Russia. And, as soon as a new scheme is registered, we immediately purchase it. They are very expensive, but in the end they pay off handsomely
- This year we prepared for transplantation a patient with a very rare congenital kidney disease, infected with hepatitis C. A 19-year-old girl turned into a disabled person receiving renal replacement therapy in a year (dialysis procedures were performed every other day), and she was put on a waiting list for kidney transplantation … At the time when she was diagnosed with hepatitis C in November 2017, we could not help her in any way - the necessary drug was not yet available in Russia. But in October 2018, this drug appeared at auctions, we immediately bought it out and in November we were already able to start therapy.
It was such a powerful scheme that the virus went away instantly and the improvement in kidney function began immediately. A month after treatment, her creatinine and blood urea levels dropped by half. And if before treatment it was stage 5 chronic kidney disease, now it is assessed as stage 3, that is, we were able to significantly improve the quality of life of our patient and, possibly, the prognosis of the disease.
Another case involves a hepatitis C-infected donor kidney. For half a year we tried with all our might to compensate the boy, and as soon as the drug he needed was registered in Russia, we immediately bought it. And in this diagram, the glomerular filtration rate (there is such a term for nephrologists) has increased almost one and a half times, that is, the graft has cleared. A little more than a year has passed since the treatment, and now the boy feels great, all blood counts are normal.
Total screening against the "affectionate killer"
What other diseases are provoked by the hepatitis virus?
- This is a systemic, generalized infection. The virus replicates in many organs and tissues of the body, even in the brain. Diabetes of the second type is often associated with hepatitis - according to statistics, up to 40% of cases. There are a lot of infected among patients with kidney disease, blood diseases. Therefore, we try to involve all related specialists in the work on early detection of hepatitis in target groups. Infection is also quite high among those people who underwent surgery or blood transfusion in the 90s. We sometimes first detect hepatitis C already at the stage of cirrhosis or liver cancer.
Last year, we lost a 43-year-old man whose hepatitis was first diagnosed at the stage of hepatocellular cancer. We reacted very quickly, but he already had metastases to the adrenal glands, and it was not possible to save him. And he was infected, presumably, back in the late 90s.
Hepatitis is therefore called "affectionate killer" because a person lives to the terminal stage of liver damage without any symptoms. And very often we receive patients in whom the virus was detected by accident - for example, during a mandatory examination before a planned operation. Therefore, total screening is so important - it allows detecting liver cancer at the first stage and successfully treating it. In the Oryol region, a screening program has been running for a year, thanks to which there were twice as many cases of hepatitis C detected than a year earlier. Our deputies even turned to the State Duma with a proposal to introduce hepatitis testing into the medical examination plan, but so far they have not received support - after all, it is very expensive.
How do you deal with hepatitis B, for which there is no cure yet?
- There is no radical treatment, but thanks to the regional program, all patients who require long-term therapy receive it free of charge at the expense of the region. Thanks to this, their viral load is suppressed to zero, and they cease to pose a danger to others. In addition, lowering viral load prevents the development of cirrhosis and liver cancer. That is, these people live a full life, have families, give birth to children.
Unfortunately, so far there are few regions that could boast of such results. Do you share your experiences with your neighbors?
- Sure. In May we will host the eighth interregional conference, which will bring together the entire Central Federal District. This year we also invited oncologists. We will do a large master class on the early detection and timely treatment of hepatocellular cancer, on the routing of these patients, the interaction of related specialists (hepatologists, infectious disease specialists, gastroenterologists, therapists, oncologists). Unfortunately, the average lifespan from the moment liver cancer is diagnosed is six months. And in order for such patients to have a chance for life, it is necessary to identify them as quickly as possible and begin treatment.