Early-switch versus late-switch in patients with diabetic macular edema: a cost-effectiveness study

Abstract

Background To evaluate the cost-effectiveness of early- versus late-switch to the intravitreal-dexamethasone implant (DEX-i) in patients with diabetic macular edema (DME) who did not adequately respond to vascular endothelial growth factor inhibitors (anti-VEGF). Methods Retrospective analysis of a multicenter Clinical Data Registry. The registry included DME eyes who received 3 intravitreal anti-VEGF injections (early-switch) or > 3 intravitreal anti-VEGF injections (late-switch) before switching to DEX-i injections. The primary outcome was to estimate the incremental cost needed to obtain a best-corrected visual acuity (BCVA) improvement ≥ 0.1 or a central-retinal thickness CRT ≤ 250 μm. Results The analysis included 108 eyes, 32 (29.6%) and 76 (70.4%) in the early- and late-switch groups, respectively. Early-switch strategy was associated with a cost saving of €3,057.8; 95% CI: €2,406.4–3,928.4, p < 0.0001). Regarding incremental-cost-effectiveness ratio, late-switch group was associated with an incremental cost of €25,735.2 and €13,533.2 for achieving a BCVA improvement ≥ 0.1 at month 12 and at any of the time-point measured, respectively. At month 12, 38 (35.2%) eyes achieved a BCVA improvement ≥ 0.1. At month 12, 52 (48.1) eyes had achieved a CRT ≤ 250 micron. As compared to baseline, the mean (95% CI) CRT reduction was − 163.1 (− 212.5 to − 113.7) µm and − 161.6 (− 183.8 to − 139.3) µm in the early-switch and late-switch groups, respectively, p = 0.9463. Conclusions In DME eyes, who did not adequately respond to anti-VEGF, switching to DEX-i at early stages (after the first 3-monthly injections) was found to be more cost-effective than extending the treatment to 6-monthly injections of anti-VEGF.

Predictive factors for treatment outcomes with intravitreal anti-vascular endothelial growth factor injections in diabetic macular edema in clinical practice

“…In this study, eyes switched to early steroid (after three anti-VEGF) obtained better functional and anatomical outcomes than those who underwent later switch (after six injections) [68]. Additionally, early switch was associated with a cost saving of € 3057.8 as reported by Ruiz-Moreno et al [70]. Ultimately it remains unknown at this time, whether alternative therapies would benefit eyes with limited initial response, hence the need for future studies and metaanalyses to explore this further.…”

Switching to an Intravitreal Dexamethasone Implant after Intravitreal Anti-VEGF Therapy for Diabetic Macular Edema: A Review

“…Nevertheless, the DEX implant is preferred in cost–benefit analyses [ 79 , 84 , 85 , 86 ]. According to international guidelines, the best DME treatment for a diabetic patient will therefore depend on numerous factors, including the patient’s baseline status, the identification of predictive biomarkers, and the patient’s responsiveness to individual treatment [ 78 ].…”

The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When

“…Switching from anti-VEGF therapy to Ozurdex in cases of persistent and unresponsive DME has shown to be helpful [ 116 , 131 ], providing better functional and anatomical results and higher cost-effectiveness in cases of “early switch”, i.e., after non-adequate response to 3-monthly anti-VEGF injections [ 116 , 132 ].…”