Comparing Cost-Effectiveness of Diabetic Macular Edema Drugs

Expensive drugs that treat vision loss in patients with diabetic macular edema (DME) are not cost effective, a recent study published in JAMA Ophthalmology found.

Anti-vascular endothelial growth factor (VEGF) medications, such as aflibercept, compounded bevacizumab, and ranibizumab, have had success improving vision in DME patients. However, aflibercept and ranibizumab carry a high price tag compared with compounded bevacizumab.

In 2013, Medicare Part B expenditures totaled $2.5 billion for aflibercept and ranibizumab alone.

Analyzing the safety, efficacy, and resource utilization data at the 1-year follow-up from the Diabetic Retinopathy Clinical Researcher (DRCR) Network Comparative Effectiveness Trial, researchers examined the incremental cost-effectiveness rations (ICERs) of aflibercept, bevacizumab, and ranibizumab in DME patients.

Baseline vision of approximate Snellen (eye chart) that was equivalent of 20/32 to 20/40 and a baseline vision of approximate Snellen equivalent 20/50 or worse was used to determine ICERs for participants and subgroups. The 1-year trial data was used to calculate the cost-effectiveness at 1 year for the 3 medications.

Researchers then used mathematical modeling to project 10-year cost-effectiveness results. There was a total of 634 participants in the study, 209 were in the aflibercept arm, 207 in the bevacizumab arm, and 208 in the ranibizumab group.

The results of the study showed that patients with visual acuities (VAs) of 20/50 or worse had a greater average VA increase with aflibercept, compared with ranibizumab or bevacizumab. The findings suggest that VA benefits from aflibercept had modest quality-of-life improvements at a higher cost than bevacizumab.

The ICERs were significantly higher than thresholders per quality-adjusted life-year (QALY). Authors noted that any realistic differences in VA achieved with the 3 agents between 2 and 10 years that would alter relative cost-effectiveness were unlikely.

Compared with bevacizumab, aflibercept and ranibizumab would need to decrease by 69% and 80%, respectively, in order to achieve a cost-effectiveness threshold of $100,000 per QALY.

“From a societal perspective, bevacizumab as first-line therapy for DME would confer the greatest value, along with substantial cost savings vs the other agents,” the authors wrote. “These results highlight the challenges that physicians, patients, and policymakers face when safety and efficacy results are at odds with cost-effectiveness results.”