Bevacizumab substantially cost effective compared with aflibercept monotherapy for diabetic macular edema: JAMA
Intravitreous anti-vascular endothelial growth factor (VEGF) injections are the standard treatment for eyes with vision loss from diabetic macular edema (DME). The most widely used anti-VEGF agents for DME are aflibercept (Regeneron); ranibizumab (Genentech/Roche); and bevacizumab (Genentech/Roche), which is used off label. The DRCR Retina Network Protocol T demonstrated that all 3 medications are highly effective in improving visual acuity for DME. However, in eyes with visual acuity of 20/50 or worse, the aflibercept group had better visual acuity through 2 years than the bevacizumab group, despite many eyes in the bevacizumab group achieving good visual outcomes.
Based on 2022 Centers for Medicare & Medicaid Services reimbursement rates for dose and injection procedures, bevacizumab costs $182.06 per injection ($67.86 for the drug and $114.20 for the procedure), and aflibercept costs $1945.69 per injection ($1831.49 for the drug and $114.20 for the procedure). As a result of the cost difference, some insurance companies may require a patient to initiate DME treatment with bevacizumab and switch to another anti-VEGF agent if the clinical response is not adequate.
Given the respective costs of the treatments and the results of Protocol AC, it is important to evaluate the relative cost-effectiveness of these different management strategies for treating DME.
To evaluate the cost and cost-effectiveness of aflibercept monotherapy vs bevacizumab-first strategies for DME treatment David W. Hutton conducted a study.
The DRCR Retina Network Protocol AC included 312 study eyes of 270 participants at 54 clinical sites in the US. Participants were enrolled between December 2017 and November 2019. This economic evaluation was a preplanned secondary analysis of a US randomized clinical trial of participants aged 18 years or older with center-involved DME and best-corrected visual acuity of 20/50 to 20/320 enrolled from December 15, 2017, through November 25, 2019. Intervention included Aflibercept monotherapy or bevacizumab first, switching to aflibercept in eyes with protocol-defined suboptimal response. Between February and July 2022, the incremental cost-effectiveness ratio (ICER) in cost per quality-adjusted life-year (QALY) over 2 years was assessed. Efficacy and resource utilization data from the randomized clinical trial were used with health utility mapping from the literature and Medicare unit costs.
This study included 228 participants with 1 study eye. The aflibercept monotherapy group included 116 participants, and the bevacizumab-first group included 112, of whom 62.5% were eventually switched to aflibercept. Over 2 years, the cost of aflibercept monotherapy was $26 504 vs $13 929 for the bevacizumab-first group, a difference of $12 575. The aflibercept monotherapy group gained 0.015 QALYs using the better-seeing eye and had an ICER of $837 077 per QALY gained compared with the bevacizumab-first group. Aflibercept could be cost-effective with an ICER of $100 000 per QALY if the price per dose were $305 or less or the price of bevacizumab was $1307 per dose or more.
Variability in individual needs will influence clinician and patient decisions about how to treat specific eyes with center involved DME. Although the bevacizumab-first group costs still averaged approximately $14 000 over 2 years, this approach, as used in this economic evaluation in which 62.5% of this group eventually switched to aflibercept, may confer substantial cost savings on a societal level without sacrificing visual acuity gains over 2 years compared with aflibercept monotherapy for treatment of center-involved DME.
Source: David W. Hutton, Adam R. Glassman, Danni Liu; JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2022.6142
