Early IVA Conversion Linked to Reduced Vision Loss But At What Cost?

David J. Ramsey, MD, PhD, MPH

Injections such as ranibizumab, aflibercept, and bevacizumab target vascular endothelial growth factor (VEGF) often improve vision. These anti-VEGF agents are used to treat patients with diabetic macular edema.

Despite the fact that the injections all target the vascular endothelial growth factor, these agents vary substantially in the average wholesale cost.

According to a poster presented by David J. Ramsey, MD, PhD, MPH, of the department of ophthalmology at Lahey Hospital and Medical Center, the average wholesale cost for 2.0mg of aflibercept is $1,850, 0.3mg of ranibizumab is $1,170 and 1.25 mg (including compounding) of bevacizumab is $60.

In the past, clinical trials have explored the efficacy between the 3 agents as monotherapies for treating DME, but there have been relatively few studies with a focus on the impact of changing from 1 agent to a different agent if the event of an incomplete or delayed response.

In this study, conducted by Dr. Ramsey and investigators from Lahey Hospital and Medical Center, Tufts University School of Medicine, and Yale University, the investigators set out to evaluate the timing of the switch to intravitreal aflibercept (IVA) on “short-term functional and anatomic outcomes” in addition to the cost-effectiveness of the treatments.

The study consisted of a retrospective case series of 30 eyes (25 patients with DME) treated with >3 consecutive injections of ranibizumab and/or bevacizumab prior to conversion to aflibercept.

Patients were divided into 2 groups: The early switch group included 18 patients that switched to aflibercept after receiving <6 injections of bevacizumab and/or ranibizumab. The late switch group included 12 patients that switched to aflibercept after receiving >7 injections of bevacizumab and/or ranibizumab.

At each injection visit the investigators assessed Snellen visual acuity (VA), converted to logMAR and central macular thickness (CMT) measured with optical coherence tomography (OCT).

The authors also note that “quality adjusted life years (QALYs) gained and total cost of treatment were used to calculate the net monetary benefit of treatment at a willingness to pay threshold of $100,000/QALY.”

Early and late switch patients both had improved VA at the first visit following conversion to aflibercept (p<0,01, p<0.05) but only the early switch group continued to maintain VA gains through the end of follow up (p<0.05).

Further, early and late switch patients had decreased CMT after switching to aflibercept, which was maintained through the end of follow up (p<0.01).

When considering the cost-effectiveness portion of the study, the investigators calculated that early switch patients saved $22,885 per eye over the course of treatment, compared to late switch patients while producing an additional 0.027 QALYs/eye, yielding an NMB >25,000/eye.

The “decreased overall expenditures were related to cost prior to switch to aflibercept. Both early and late groups had a similar number of total aflibercept injections (6.4+4.8 versus 6.4+3.7 injections, ns).”

Furthermore, the investigators determined that QALYs were maximized with 6 or fewer pre-switch injections, whereas cost savings and NMB accrue the longer that the switch is delayed (up to 12 pre-switch injections).

The authors conclude that early conversion to aflibercept in patients with persistent DME following therapy with bevacizumab and/or ranibizumab maximizes the functional outcomes and results in improved quality of life. Therefore, while it is critical to recognize patients with delayed treatment response to reduce the progression of vision loss, improve quality of life, this comes at a cost to the institution.

This study was presented in a poster presentation titled: “Early Conversion to Aflibercept for Persistent DME After Prior Treatment with Bevacizumab and/or Ranibizumab Results in Better Visual Outcomes,” at the American Academy of Ophthalmology Annual Meeting 2018 in Chicago, Illinois.

Disclosures: David J Ramsey, MD: None