Cost-effectiveness of Aflibercept, Bevacizumab, and Ranibizumab for Diabetic Macular Edema Treatment

Abstract

Importance: Anti-vascular endothelial growth factor (anti-VEGF) medicines have revolutionized diabetic macular edema (DME) treatment. A recent randomized clinical trial comparing anti-VEGF agents for patients with decreased vision from DME found that at one year aflibercept (2.0-mg) achieved better visual outcomes than repackaged (compounded) bevacizumab (1.25-mg) or ranibizumab (0.3-mg); the worse the starting vision, the greater the treatment benefit with aflibercept. However, aflibercept and ranibizumab, respectively, are approximately 31 and 20 times more expensive than bevacizumab. Objective: To determine the incremental cost-effectiveness ratios (ICERs) of each of these agents for DME. Design, Setting, Participants: Post-hoc analysis of efficacy, safety, and resource utilization data at 1 one year follow-up from a Diabetic Retinopathy Clinical Research Network randomized clinical trial. Main Outcomes and Measures: ICERs for all trial participants and subgroups with baseline vision of approximate Snellen equivalent 20/32 to 20/40 (“better vision”) and baseline vision of approximate Snellen equivalent 20/50 or worse (“worse vision”). One-year trial data were used to calculate cost-effectiveness over one year for the 3 anti-VEGF agents; mathematical modeling then was used to project 10-year cost-effectiveness results. Results: For all participants, over one year, the ICERs of aflibercept and ranibizumab compared with bevacizumab were $1,110,000 per quality-adjusted life-year (QALY) and $1,730,000/QALY. Over 10 years, they were $349,000/QALY and $603,000/QALY, respectively. Compared with ranibizumab, aflibercept’s ICER was $648,000/QALY at one year and $203,000/QALY at ten years. For the subgroup with worse baseline vision, the 10-year ICERs of aflibercept and ranibizumab compared with bevacizumab were $287,000/QALY and $817,000/QALY, respectively. In eyes with decreased vision from DME, treatment costs of aflibercept and ranibizumab would need to decline by 69% and 80%, respectively, to reach a cost-effectiveness threshold of $100,000/QALY compared with bevacizumab over a 10-year horizon; for the subgroup with worse baseline vision, the costs would need to decline by 62% and 84%, respectively. Conclusions and Relevance: Aflibercept 2.0-mg and ranibizumab 0.3-mg are not cost-effective relative to bevacizumab for treatment of DME unless their prices decline substantially. These results highlight the challenges that clinicians, patients, and policy-makers face when safety and efficacy results are at odds with cost-effectiveness results.

Anti–Vascular Endothelial Growth Factor Comparative Effectiveness Trial for Diabetic Macular Edema

“…Regarding cost, based on incremental cost-effectiveness ratios aflibercept and ranibizumab are not considered cost-effective by standard benchmarks (e.g., greater than $150,000 quality adjusted life years). 3 Although post-hoc analyses should be viewed with caution given the potential for bias, these results explore clinically relevant questions that give further information potentially helpful for interpreting DRCR.net Protocol T results through 2 years.…”

Effectiveness and Safety of Intravitreal Dexamethasone Implant (Ozurdex) in Patients with Diabetic Macular Edema: A Real-World Experience

“…Typically, patients with retinal diseases such as DME require multiple doses of anti-VEGF agents. As the burden of injections is high in many of these retinal disorders, there are still some relevant questions about treatment, such as (1) the choice of agent and (2) the economic burden of therapy [28, 30]. In this regard, the use of corticosteroid implants may offer advantages, given the less frequent need for injections [14].…”

Comparisons of Efficacy of Intravitreal Aflibercept and Ranibizumab in Eyes with Diabetic Macular Edema

“…However, a recent study reported that the cost-effectiveness of aflibercept and ranibizumab for DME is poorer than that of bevacizumab [15]. In cases of refractory DME, frequent anti-VEGF antibodies injection may be required.…”