Intravitreous Ranibizumab Cost-Effective for Some With Proliferative Diabetic Retinopathy

By Will Boggs MD

November 05, 2019

NEW YORK (Reuters Health) - At five years, intravitreous ranibizumab therapy for proliferative diabetic retinopathy (PDR) appears to be cost-effective relative to panretinal photocoagulation (PRP), but only in eyes with vision-impairing center-involved diabetic macular edema (CI-DME), according to new findings.

"These cost-effectiveness analyses may be relevant to decisions made on a broader, public-health level," Adam R. Glassman of Jaeb Center for Health Research, in Tampa, Florida told Reuters Health by email.

The study is a secondary analysis of the Protocol S randomized clinical trial. Five-year visual acuity outcomes were similar in the PRP and intravitreous ranibizumab groups in Protocol S, but the high loss to follow-up in both groups raised the question whether the groups remained comparable.

The two-year cost-effectiveness analysis of Protocol S showed that ranibizumab was unlikely to be cost-effective for patients with PDR without CI-DME, but possibly cost-effective for patients with PDR with CI-DME.

In the current study, online October 24 in JAMA Ophthalmology, Glassman and colleagues in the DRCR Retina Network estimated the five-year and 10-year cost-effectiveness of intravitreous ranibizumab versus PRP.

Among patients with PDR without CI-DME causing visual loss at baseline, treatment with ranibizumab versus PRP had an incremental cost-effectiveness ratio (ICER) of $582,268 per quality-adjusted life-year (QALY) at five years and $742,202 per QALY at 10 years.

In contrast, among patients with PDR with vision-impairing CI-DME at baseline, ranibizumab treatment appeared cost-effective compared with PRP, with ICERs of $65,576 per QALY at five years and $63,930 per QALY at 10 years.

According to sensitivity analyses, ranibizumab may be more cost-effective for combinations of patients with worse utility associated with moderate vision loss, lower ranibizumab prices, or better long-term vision outcomes with ranibizumab therapy.

"This cost-effectiveness analysis could be considered by a clinician when choosing treatments for an individual patient with PDR, but it is important to realize there are many additional factors that go into making a treatment decision for an individual patient, including treatment efficacy, anticipated visit compliance, visit frequency, and cost to the patient," Glassman said.

"The take-home message of the DRCR team is simple," write Dr. Steven M. Kymes of Lundbeck, in Deerfield, Illinois, and Dr. David Vollman of Washington University School of Medicine, in St. Louis, Missouri, in a linked editorial. "In patients with proliferative diabetic retinopathy but without diabetic macular edema in the center of the macula with loss of visual acuity, the first-line use of panretinal photocoagulation rather than anti-vascular endothelial growth factor for the proliferative diabetic retinopathy is the best use of society’s resources."

Dr. Rishi P. Singh from Cleveland Clinic and Case Western Reserve University, in Cleveland, Ohio, who recently reviewed the role of anti-vascular endothelial growth factor (anti-VEGF) in the management of PDR, told Reuters Health by email, "Clearly we realize that anti-VEGF therapy for proliferative diabetic retinopathy is not the most cost-effective approach, especially in those patients without diabetic macular edema and proliferative disease."

"PDR treatment has evolved, and while monthly treatment approaches might not be the best option, newer anti-VEGFs and long-acting delivery systems are coming which could make the treatment of PDR a more cost-effective option," he said.

"I think at this point it is safe to say that while offering anti-VEGF as a treatment option for PDR, it is more likely to be used as an adjunct to laser treatment rather than primary therapy," said Dr. Singh, who was not involved in the new analysis. "The studies at least help to better triage patients by treating their PDR on the first date seen expeditiously and then scheduling their PRP when it is convenient for both the patient and the provider."


JAMA Ophthalmol 2019.