Damian McNamara

May 23, 2013

SEATTLE, Washington — Bevacizumab (Avastin, Genentech) is more cost effective than ranibizumab (Lucentis, Genentech) for neovascular age-related macular degeneration, according to new research from the United Kingdom.

Given their similarities in efficacy, cost difference may become the most relevant clinical decision-making factor.

"My message is based on cost effectiveness," Chris Rogers, PhD, from the Clinical Trials and Evaluation Unit at the University of Bristol, UK, told Medscape Medical News. "On the basis of the 1-year interim analysis, the data suggest that as-needed Avastin is the most cost effective."

She presented the data to a standing-room-only crowd here at the Association for Research in Vision Ophthalmology (ARVO) 2013 Annual Meeting.

Dr. Rogers cautioned, however, that the Inhibit Vascular Endothelial Growth Factor in Age-Related Choroidal Neovascularisation (IVAN) study is ongoing, and the relative cost effectiveness of these agents and treatment strategies could change over time.

Two-year safety and efficacy IVAN study outcomes were also announced here in a separate presentation reported by Medscape Medical News.

Dr. Rogers and colleagues sought to determine whether monthly bevacizumab, monthly ranibizumab, as-needed bevacizumab, or as-needed ranibizumab represented "the best value for the money."

The researchers calculated drug unit costs on the basis of data from the British National Formulary and the UK Department of Health. They tracked medication costs associated with changes due to expected adverse events, as well as charges for hospitalizations, consultations, and total number of injections.

They analyzed the costs of administering and monitoring the intravitreal injections in 610 patients randomly assigned on the basis of detailed questionnaires from IVAN study sites. All of the patients had untreated age-related macular degeneration and were older than 50 years.

Lucentis costs more than $1 million more per quality-adjusted life year than Avastin. Dr. Chris Rogers

Translating the data to US dollars, Dr. Rogers calculated "monthly Lucentis costs to be about $12,000 more than Avastin on an as-needed basis." This means, she projected, that "Lucentis costs more than $1 million more per quality-adjusted life year than Avastin."

Differences in quality-adjusted life years across the 4 treatment arms were not statistically significant (P ≥ .11).

Ranibizumab More Expensive

"What is very apparent is the majority of the costs are driven by the drugs," Dr. Rogers said. For example, costs associated with administration of drugs and adverse events are minimal.

"Lucentis represents poor value for the money. The cost of the drug is not offset by decreasing dosing frequency or adverse events," Dr. Rogers concluded. "There is little or no quality-of-life improvement to justify the cost."

In the big picture, "The UK National Health Service could save $130 million per year by switching from Lucentis to Avastin," Dr. Rogers estimated.

John Wittenborn, from the National Opinion Research Center at the University of Chicago, in Illinois, told Medscape Medical News, "Assessing the cost effectiveness of 1 therapy relative to another involves dividing the increase in costs by the presumed gain in outcomes — in this case, quality-adjusted life years. If the current finding of no significant difference in quality-adjusted life years between ranibizumab and bevacizumab holds true, then from a cost-effectiveness perspective, there is no justification for using the costlier drug."

Wittenborn is the primary investigator in a study assessing the economic burden of vision loss and eye disorders among people younger than 40 years in the United States.

"In the UK, cost effectiveness can heavily influence treatment recommendations and coverage by the National Health Service," Wittenborn explained. "However, in the United States, language in the Affordable Care Act expressly prohibits the consideration of cost in coverage determinations by government-sponsored programs, instead recommending 'comparative effectiveness analysis,' where only outcomes are considered."

The stark cost-effectiveness results of this study, he said, "may be of little consequence in the United States, where a comparative effectiveness analysis would state they are equal."

Allison Neves, a spokesperson for Genentech, Inc, said that she does not agree with all of Dr. Rogers claims. "The analysis did not consider the negative impact adverse events can have on patients," she told Medscape Medical News. "For example, if a patient had a heart attack, that was assumed to have no effect on the patient's quality of life. Their estimates for adverse event costs were narrowly defined and did not adequately capture the lifetime of increased healthcare costs these adverse events can inflict on patients, their families, and society as a whole."

Neves also professed that the "generic 5-question survey used to evaluate the relative effectiveness of the 2 therapies contains no questions about vision or visual functioning and has been shown to be an inadequate measure of effectiveness for this treatment population."

Dr. Rogers says that his team will update the cost and cost-effectiveness findings as the IVAN study continues.

The IVAN trial is funded by the National Institute for Health Research Health Technology Assessment program in the UK. Dr. Rogers receives gifts in kind, honoraria, or travel reimbursement from Novartis, the European manufacturer of ranibizumab. Several of the other coauthors also have financial relationships with Novartis and Pfizer. Allison Neves is an employee of Genentech, the US manufacturer of both ranibizumab and bevacizumab. John Wittenbom has disclosed no relevant financial relationships.

Association for Research in Vision Ophthalmology (ARVO) 2013 Annual Meeting. Abstract 373. Presented May 5, 2013.


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