Intravitreous ranibizumab cost-effective for some patients with proliferative diabetic retinopathy

By Will Boggs MD

NEW YORK (Reuters Health) - Intravitreous ranibizumab appears to be cost-effective in patients with proliferative diabetic retinopathy (PDR) who have vision-impairing diabetic macular edema (DME), according to data from the Diabetic Retinopathy Clinical Research Network (DRCR.net).

Panretinal photocoagulation (PRP) has long been the standard of care for treating most eyes with PDR, but it can cause peripheral vision loss and exacerbate DME. Intravitreous ranibizumab is also effective, but much more expensive than PRP, at around $2,000 per treatment versus around $345 for PRP.

Adam R. Glassman from Jaeb Center for Health Research in Tampa, Florida, and colleagues used data from DRCR.net Protocol S to assess the incremental cost-effectiveness of 0.5 mg ranibizumab versus PRP for the treatment of PDR.

Among patients with vision-impairing DME at baseline, ranibizumab treatment costs averaged $29,574, and PRP plus ranibizumab treatment costs averaged $24,520, a nonsignificant difference.

For those without vision-impairing DME at baseline, ranibizumab costs averaged $22,576, compared with $7,445 for PRP, also a non-significant difference, the researchers report in JAMA Ophthalmology, online May 8.

Ranibizumab provided slight improvements in health utilities versus PRP over two years.

During this two-year horizon, the incremental cost-effectiveness ratio of ranibizumab was $55,568 per quality-adjusted life-year (QALY) for patients with vision-impairing DME at baseline and $662,978 per QALY for those without vision-impairing DME at baseline.

In sensitivity analyses, ranibizumab without PRP would become cost-saving for patients with vision-impairing DME if the cost of ranibizumab dropped to $900 per dose.

For the incremental cost-effectiveness of ranibizumab to fall to around $100,000 per QALY for patients without vision-impairing DME, the cost of ranibizumab would need to decrease to $400 per dose while the cost of PRP would need to increase to $600 per laser session.

“Additional data beyond 2 years would be valuable to determine whether the cost-effectiveness results obtained at 2 years persist with longer follow-up,” the researchers conclude. “Until then, considerations of visual acuity and other ocular outcomes (such as visual field loss, need for vitrectomy, and need for anti-VEGF therapy for DME among eyes without DME at the time of initiating treatment for PDR), ocular and systemic safety, adherence to and frequency of follow-up of each regimen, and patient preferences should be weighed by patients with physician guidance when deciding whether to consider initiating anti-VEGF or PRP for PDR.”

Dr. Jonathan S. Chang from Harkness Eye Institute at Columbia University, New York, who recently compared the costs of these two treatments in patients with PDR, told Reuters Health by email, "We did not have access to the same full dataset that the DRCR authors had, but in our model we also found that use of panretinal photocoagulation, a standard of treatment for proliferative diabetic retinopathy, has better cost-utility than that of intravitreal ranibizumab for diabetic retinopathy.”

“It was notable that for patients with diabetic macular edema and proliferative diabetic retinopathy the intravitreal ranibizumab was within the cost-effective threshold of $50,000-$150,000 per QALY,” he said. “Our findings did not seem to differ greatly, as we found intravitreal ranibizumab for any patients with proliferative diabetic retinopathy ranged between $138,000-164,000 per QALY.”

“It is nice to see that as retina specialists we have multiple cost-effective options for treatment of diabetic retinopathy, a potentially blinding disease,” Dr. Chang said. “For patients with diabetic macular edema and proliferative diabetic retinopathy, it is good to know that anti-VEGF therapy can assist with treating both diseases, and may be a good way to start vision improvement and retinopathy reduction before deciding to initiate laser treatment.”

Dr. Marco A. Zarbin from Rutgers New Jersey Medical School's Institute of Ophthalmology and Visual Science, in Newark, recently reviewed the use of anti-VEGF injections in this setting. He told Reuters Health by email, "I was not surprised that when DME is present, ranibizumab is a better approach, because the main cause of visual loss among diabetic patients is DME. PRP can exacerbate DME, whereas ranibizumab not only induces regression of PDR, but it also is highly effective treatment for DME, as shown in the pivotal RIDE and RISE trials, as well as in other studies.”

In a related research letter, Glassman and colleagues report a trend toward increased Antiplatelet Trialists’ Collaboration events associated with ranibizumab treatment compared with PRP in Protocol S. Such events include nonfatal myocardial infarction, nonfatal stroke and death attributed to cardiac, cerebral, hemorrhagic, embolic or other vascular disorders or of unknown cause.

The team notes that there was no control group without ranibizumab exposure.

“Because Diabetic Retinopathy Clinical Research Network is informing Protocol S participants about the trend toward increased cardiovascular events within the ranibizumab arm, the network believes it is important to make this information publically available,” they write. “However, network investigators remain uncertain about a possible association between increased cardiovascular events and the treatment of proliferative diabetic retinopathy with ranibizumab. A full report is planned on the completion of the 5-year follow-up in 2018.”

Genentech provided ranibizumab for the study and funds to the DRCR.net.

Glassman did not respond to a request for comments.

SOURCE: http://bit.ly/2pC5WB6 and http://bit.ly/2qvIZTY

JAMA Ophthalmol 2017.

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