JAMA Ophthalmology, June 2017
Hutton et al. conducted a preplanned cost analysis of data from a randomized clinical trial in which ranibizumab had noninferior visual acuity (VA) outcomes at 2 years when compared to panretinal photocoagulation (PRP) for treating proliferative diabetic retinopathy (PDR). The authors noted that ranibizumab appears more cost-effective than PRP if the PDR is accompanied by vision-impairing diabetic macular edema (DME) for which anti-VEGF treatment would be given for the DME. That is, ranibizumab given for both the PDR and DME appears more cost-effective than giving ranibizumab for the DME and PRP for the PDR.
In a secondary analysis of the Diabetic Retinopathy Clinical Research Network (DRCR.net) Protocol S trial, data were evaluated for 213 adults with PDR who had undergone unilateral therapy in the initial study. Study participants had been randomly assigned to receive intravitreal ranibizumab (administered monthly or less frequently) or PRP (performed at baseline and, if needed, at follow-up). Any participant with concomitant vision-impairing DME received ranibizumab, regardless of initial treatment assignment.
In the original study, ranibizumab was deemed noninferior to PRP for the primary outcome of mean change in VA from baseline to 2 years. Furthermore, there were advantages to the anti-VEGF arm, including better VA over 2 years, fewer vitrectomies, less peripheral field loss, and decreased chance of developing DME with vision loss among eyes without vision-impairing DME at baseline. However, 1 injection of ranibizumab costs nearly 6 times more than a session of PRP. In the cost analysis, 2-year data of costs of treatment and complications (in dollars) and effectiveness (in quality-adjusted life-year, or QALY, based on VA outcomes) for ranibizumab and PRP were compared for the patients with (n = 46) and without (n = 167) vision-impairing DME at baseline.
The results, expressed as incremental cost-effectiveness ratios of ranibizumab versus PRP during the 2-year period, were $55,568 per QALY for patients with DME and $662,978 per QALY for those without DME. (In the United States, $50,000 to $150,000 per QALY typically is considered cost-effective.)
The authors cautioned that cost-effectiveness beyond 2 years of follow-up is not known, nor is the effectiveness of other anti-VEGF agents, such as aflibercept or compounded bevacizumab. The authors recommended weighing the pros and cons of ranibizumab and PRP on a case-by-case basis. (Also see related commentary by Steven M. Kymes, PhD, in the same issue.)
The original article can be found here.