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Samacá-Samacá D, Hernández-Castillo C, Prieto-Pinto L, Rodríguez F, Sardi C, Ocampo H, Kock J, Hernández F. Efficacy and safety of faricimab for neovascular age-related macular degeneration: a systematic review and network meta-analysis. BMJ Open Ophthalmol 2024; 9:e001702. [PMID: 39043575 PMCID: PMC11268043 DOI: 10.1136/bmjophth-2024-001702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/06/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of faricimab compared with other anti-vascular endothelial growth factor (anti-VEGF) agents in treating neovascular age-related macular degeneration (nAMD) patients. METHODS AND ANALYSIS A systematic review (SR) was conducted up to January 2023. Network meta-analyses (NMA) were performed, including sensitivity and subgroup analyses for naïve population. Outcomes included changes in visual acuity (Early Treatment of Diabetic Retinopathy Study [ETDRS] letters), anatomical changes, frequency of injections and adverse events. The Cochrane Collaboration guidelines and the Confidence in Network Meta-Analysis framework were used for the SR and the certainty of evidence, respectively. RESULTS From 4128 identified records through electronic databases and complementary searches, 63 randomised controlled trials (RCTs) met the eligibility criteria, with 42 included in the NMA. Faricimab showed a significant reduction in the number of annual injections compared with most fixed and flexible anti-VEGF treatment regimens, while showing no statistically significant differences in visual acuity through ETDRS letter gain, demonstrating a comparable efficacy. Retinal thickness results showed comparable efficacy to other anti-VEGF agents, and inferior only to brolucizumab. Results also showed that more patients treated with faricimab were free from post-treatment retinal fluid compared with aflibercept every 8 weeks, and both ranibizumab and bevacizumab, in the fixed and pro re nata (PRN) assessed schedules. Faricimab showed a comparable safety profile regarding the risk of ocular adverse events and serious ocular adverse events (SOAE), except for the comparison with brolucizumab quarterly, in which faricimab showed a significant reduction for SOAE risk. CONCLUSION Faricimab showed a comparable clinical benefit in efficacy and safety outcomes, with a reduction in annual injections compared with fixed and flexible anti-VEGF drug regimens, representing a valuable treatment option for nAMD patients. PROSPERO REGISTRATION NUMBER CRD42023394226.
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Affiliation(s)
| | | | | | - Francisco Rodríguez
- FUNDONAL, Bogota, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá D.C, Colombia
| | - Carolina Sardi
- Instituto Nacional de Investigación en Oftalmología, Medellín, Colombia
| | | | - Joshua Kock
- Evidence Generation, Roche Colombia, Bogotá D.C, Colombia
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Fang HS, Bai CH, Cheng CK. STRICT PRO RE NATA VERSUS TREAT-AND-EXTEND REGIMENS IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: A SYSTEMATIC REVIEW AND META-ANALYSIS. Retina 2023; 43:420-432. [PMID: 36669130 DOI: 10.1097/iae.0000000000003690] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 11/22/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE To compare the visual and anatomical outcomes between strict pro re nata (strict PRN) and treat-and-extend (T&E) anti-vascular endothelial growth factor (anti-VEGF) regimens for neovascular age-related macular degeneration (nAMD). METHODS A meta-analysis of 1-year and 2-year changes between strict PRN and T&E anti-VEGF regimens were conducted in both randomized controlled trials (RCTs) and real-world studies (RWSs). The best-corrected visual acuity (BCVA), central retinal thickness (CRT), and weighted mean numbers of visits and injections were evaluated. RESULTS A total of 19 RCTs and 23 RWSs (2,530 eyes in strict PRN and 4,399 eyes in T&E) were included. Mean BCVA change in strict PRN group in both 1-year and 2-year (5.95 and 5.78, respectively) was noninferior to the T&E group (7.85 and 5.96, respectively). Mean CRT changes were also similar in both strict PRN and T&E groups. Mean number of visits were significantly more in the strict PRN group, whereas mean number of injections was significantly more in the T&E group. CONCLUSION The strict PRN regimen demonstrates a noninferior BCVA improvement to the T&E regimen, achieving fewer injections, and may be both economically and medically beneficial. Both selections should be provided to patients with an overall consideration.
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Affiliation(s)
- Hwa-Shin Fang
- Department of Ophthalmology, Shin-Kong Wu Ho-Su Memorial Hospital
| | - Chyi-Huey Bai
- Department of Public Health, College of Medicine, Taipei Medical University
- School of Public Health, College of Public Health, Taipei Medical University
| | - Cheng-Kuo Cheng
- Department of Ophthalmology, Shin-Kong Wu Ho-Su Memorial Hospital
- School of Medicine, National Taiwan University; and
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
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Karimaghaei C, Ali A, Safdar N, Tanwani A, Schmitz-Brown M, Banaee T, El-Annan J, Gupta PK. The Injection Practice Patterns of Retina Specialists in Managing Exudative Age-Related Macular Degeneration: A Retrospective Study. Clin Ophthalmol 2023; 17:375-383. [PMID: 36721668 PMCID: PMC9884458 DOI: 10.2147/opth.s391282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/28/2022] [Indexed: 01/27/2023] Open
Abstract
Purpose To compare the PRN anti-VEGF injection patterns of four retina specialists with respect to the visual and anatomic outcomes in the management of wet age-related macular degeneration (AMD). Methods Medical records of patients who received bevacizumab, ranibizumab, and aflibercept anti-VEGF injections (years 2010-2020) by four retina specialists were reviewed for frequency, injection intervals, best corrected visual acuity (BCVA), and central macular thickness, center involved (CMT) for statistical analysis. Outcomes measured were change in logMAR BCVA and CMT from the first to last injection visit. Results Out of 137 AMD patients, 172 eyes were injected by four retina specialists in PRN fashion. Although all four specialists started the injection at similar baseline BCVA and CMT (p > 0.1), significant differences in mean injection number (9.0, p = 0.0001), injection intervals (5.06 weeks, p = 0.001), and total length of treatments (53.3 weeks, p = 0.0001) were observed. The mean change in logMAR BCVA between the first and last injection was -0.05, -0.22, 0.07, and 0.06 for the four specialists, respectively (p = 0.031), and the mean change in CMT was -53.3, -41.4, -72.7, and -21.9 µm (p = 0.41), respectively. Conclusion Despite similar baseline criteria for injections by the retina specialists, different anti-VEGF injection regimens were practiced resulting in variations in BCVA and CMT outcomes. This suggests a need in establishing a universally adoptable injection regimen with possible integration of the confounding factors to reduce burden on both patients and retina specialists.
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Affiliation(s)
- Cina Karimaghaei
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA,Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Amir Ali
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Nida Safdar
- Department of Ophthalmology, Nazareth Hospital, Trinity Health Mid-Atlantic, Philadelphia, PA, USA,IC Laser Eye Care, Bensalem, PA, USA
| | - Anika Tanwani
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mary Schmitz-Brown
- Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Touka Banaee
- Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Jaafar El-Annan
- Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, TX, USA
| | - Praveena K Gupta
- Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, TX, USA,Correspondence: Praveena K Gupta Professor, Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA, Tel +1 409-747-5823, Fax +1 409 747-5824, Email
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Matonti F, Korobelnik JF, Dot C, Gualino V, Soler V, Mrejen S, Delyfer MN, Baillif S, Streho M, Gascon P, Creuzot-Garcher C, Kodjikian L. Comparative Effectiveness of Intravitreal Anti-Vascular Endothelial Growth Factor Therapies for Managing Neovascular Age-Related Macular Degeneration: A Meta-Analysis. J Clin Med 2022; 11:1834. [PMID: 35407439 PMCID: PMC8999505 DOI: 10.3390/jcm11071834] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 12/11/2022] Open
Abstract
Intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) have become the standard of care for age-related macular degeneration (AMD). Although most pivotal trials have used monthly injections, alternative strategies that enable the injections to be administered on a more flexible schedule, including pro re nata (PRN) and treat-and-extend (T&E) regimens, are being applied more frequently. This review sought to provide further scientific evidence about the visual outcomes and treatment burden among the currently available anti-VEGF agents and regimens, including aflibercept, ranibizumab, abicipar and brolucizumab. To this end, a systematic review of published randomized studies was conducted from the MEDLINE and EMBASE databases and the Cochrane library, and a meta-analysis was applied to the obtained data using single-means modeling to compare the efficacy and maintenance among the different available treatments and regimens at Years 1 and 2. Quality analysis identified the best-informed data for modeling purposes. Overall, 47 relevant publications were retrieved for the analysis. Superior efficacy, meaning that there were observed improvements in visual acuity (VA) and central retinal thickness (CRT), occurred with monthly versus PRN regimens, yet a higher IVI number was also observed. Conversely, the T&E regimens displayed similar efficacy to the monthly regimens, but with a reduced IVI number. Aflibercept T&E exhibited similar efficacy to ranibizumab T&E, but with significantly lower IVI numbers at both Year 1 (p < 0.0001) and Year 2 (p = 0.0011). Though all of the regimens resulted in maintained efficacy between Years 1 and 2, the required IVI number varied. The retrieved data did not enable other regimens or newer anti-VEGF agents such as brolucizumab to be compared. In conclusion, the T&E regimens were shown to be the most efficient, optimizing durable effectiveness whilst minimizing the IVI number in newly diagnosed exudative AMD, with aflibercept requiring the lowest IVI number.
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Affiliation(s)
- Frédéric Matonti
- Centre Monticelli Paradis, 433 Bis Rue Paradis, 13008 Marseille, France;
- National Center for Scientific Research (CNRS), Timone Neuroscience Institue (INT), Aix Marseille University, 13008 Marseille, France
- Groupe Almaviva Santé, Clinique Juge, 13008 Marseille, France
| | - Jean-François Korobelnik
- Department of Ophthalmology, Bordeaux University Hospital, 33000 Bordeaux, France; (J.-F.K.); (M.-N.D.)
- INSERM, BPH, UMR1219, Bordeaux University, 33000 Bordeaux, France
| | - Corinne Dot
- Department of Ophthalmology, Desgenettes Military Hospital, 69003 Lyon, France;
| | - Vincent Gualino
- Clinique Honoré Cave, Department of Ophthalmology, 82000 Montauban, France;
- Unité de Rétine, Ophthalmology Department, Hôpital Pierre-Paul Riquet, Toulouse University Hospital, 31300 Toulouse, France;
- Place Baylac, TSA 40031, CEDEX 9, 31059 Toulouse, France
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université de Paris, 75014 Paris, France
| | - Vincent Soler
- Unité de Rétine, Ophthalmology Department, Hôpital Pierre-Paul Riquet, Toulouse University Hospital, 31300 Toulouse, France;
- University Toulouse III, 31000 Toulouse, France
- CERCO UMR 5549, Centre National de la Recherche Scientifique, 31000 Toulouse, France
| | - Sarah Mrejen
- Centre d’Imagerie et de Laser, 75015 Paris, France;
- Centre Hospitalier National Ophtalmologique des 1520, 75012 Paris, France
| | - Marie-Noëlle Delyfer
- Department of Ophthalmology, Bordeaux University Hospital, 33000 Bordeaux, France; (J.-F.K.); (M.-N.D.)
- INSERM, BPH, UMR1219, Bordeaux University, 33000 Bordeaux, France
| | - Stéphanie Baillif
- Department of Ophthalmology, Pasteur 2 University Hospital, Côte d’Azur University, 06108 Nice, France;
| | - Maté Streho
- Explore Vision Centre, 75001 Paris, France;
- Department of Ophthalmology, Lariboisière Hospital, 75010 Paris, France
| | - Pierre Gascon
- Centre Monticelli Paradis, 433 Bis Rue Paradis, 13008 Marseille, France;
- Department of Ophthalmology, Aix-Marseille University, Hôpital Nord, Chemin des Bourrely, 13008 Marseille, France
| | | | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, 69002 Lyon, France;
- UMR-CNRS 5510 Matéis, University of Lyon, 69622 Villeurbanne, France
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Zhang Y, Gao S, Li X, Huang X, Zhang Y, Chang T, Cai Z, Zhang M. Efficacy and Safety of Anti-Vascular Endothelial Growth Factor Monotherapies for Neovascular Age-Related Macular Degeneration: A Mixed Treatment Comparison. Front Pharmacol 2022; 12:797108. [PMID: 34992542 PMCID: PMC8724554 DOI: 10.3389/fphar.2021.797108] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/29/2021] [Indexed: 02/05/2023] Open
Abstract
Background: We aimed to evaluate the comparative efficacy and safety of anti-vascular endothelial growth factor (anti-VEGF) monotherapy to identify its utilization and prioritization in patients with neovascular age-related macular degeneration (nAMD). Methods: Eligible studies included randomized controlled trials comparing the recommended anti-VEGF agents (ranibizumab, bevacizumab, aflibercept, brolucizumab, and conbercept) under various therapeutic regimens. Outcomes of interest included the mean change in best-corrected visual acuity (BCVA), serious adverse events, the proportion of patients who gained ≥15 letters or lost <15 letters in BCVA, the mean change in central retinal thickness, and the number of injections within 12 months. Results: Twenty-seven trials including 10,484 participants and eighteen treatments were identified in the network meta-analysis. The aflibercept 2 mg bimonthly, ranibizumab 0.5 mg T&E, and brolucizumab 6 mg q12w/q8w regimens had better visual efficacy. Brolucizumab had absolute superiority in anatomical outcomes and a relative advantage of safety, as well as good performance of aflibercept 2 mg T&E. The proactive regimens had slightly better efficacy but a slightly increased number of injections versus the reactive regimen. Bevacizumab had a statistically non-significant trend toward a lower degree of efficacy and safety. Conclusion: The visual efficacy of four individual anti-VEGF drugs is comparable. Several statistically significant differences were observed considering special anti-VEGF regimens, suggesting that brolucizumab 6 mg q12w/q8w, aflibercept 2 mg bimonthly or T&E, and ranibizumab 0.5 mg T&E are the ideal anti-VEGF regimens for nAMD patients. In the current landscape, based on the premise of equivalent efficacy and safety, the optimal choice of anti-VEGF monotherapies seems mandatory to obtain maximal benefit.
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Affiliation(s)
- Yun Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Sheng Gao
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Xun Li
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Xi Huang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Tiancong Chang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Zhaolun Cai
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Meixia Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.,Research Laboratory of Macular Disease, West China Hospital, Sichuan University, Chengdu, China
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Saenz‐de‐Viteri M, Recalde S, Fernandez‐Robredo P, López Gálvez MI, Arias Barquet L, Figueroa MS, García‐Arumí J, García‐Layana A, Figueroa MS, Rodríguez MF, Arumí JG, Amat P, Alicante V, García‐Layana A, Barquet LA, Moreno JMR, Puyuelo JA, Maresca FA, Taulet EC, Gálvez MIL, Imaz RT, Sánchez EG, Dorta LMC, González EE, Osés SV, Hernández SA, Miguel MR, Rementería EB, Castilla RC, Castillo JV, Guajardo LL, Pinazo RG, Iribarren JJA, García LR, López FC, Garrido JAL, López‐Herrera ML, Castiella MSA, Moreno ÓR, Alday NM, Sanz ÁF, Campos JG, Hernandez M, Llorente S, Sayar O, Iriarte EO. Role of intraretinal and subretinal fluid on clinical and anatomical outcomes in patients with neovascular age-related macular degeneration treated with bimonthly, treat-and-extend and as-needed ranibizumab in the In-Eye study. Acta Ophthalmol 2021; 99:861-870. [PMID: 33720541 DOI: 10.1111/aos.14786] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/18/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE To assess the effect of fluid status at baseline (BL) and at the end of the loading phase (LP) of three different ranibizumab regimens: treat-and-extend (T&E), fixed bimonthly (FBM) injections and pro re nata (PRN), in patients with neovascular age-related macular degeneration (nAMD). DESIGN Post hoc analysis of the In-Eye study (phase IV clinical trial). METHODS Patients were randomized 1:1:1 to the three study arms and were treated accordingly. The presence and type of fluid, intraretinal fluid (IRF) or subretinal fluid (SRF) and the anatomical and visual outcomes were analysed. MAIN OUTCOME MEASURES Best-corrected visual acuity (BCVA), the mean change from baseline BCVA (BL BCVA), and the proportion of eyes gaining more than 15 letters or losing more than five letters were analysed. Morphological characteristics including the subtype of choroidal neovascular membrane and the development of atrophy and fibrosis were also evaluated. RESULTS Patients with SRF at LP had better visual outcomes than patients with IRF. The persistence of SRF did not affect the mean change from BL BCVA among the three treatment regimens. However, in patients with IRF mean change from BL BCVA was significantly lower in the FBM group. The presence of IRF at BL and at the end of the loading phase was associated with the development of fibrosis at the end of the study; this result was contrary to that observed for patients with SRF. CONCLUSIONS While SRF is compatible with good visual and anatomical outcomes, IRF leads to worse results in patients with nAMD; our results suggest that patients with IRF have better outcomes when individualized treatment regimens are used (PRN or T&E) in contrast with a FBM regimen.
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Affiliation(s)
- Manuel Saenz‐de‐Viteri
- Department of Ophthalmology Clínica Universidad de Navarra Pamplona Spain
- Experimental Ophthalmology Laboratory Universidad de Navarra Pamplona Spain
- Red Temática de Investigación Cooperativa en Salud: ‘Prevention, Early Detection, and Treatment of the Prevalent Degenerative and Chronic Ocular Pathology’ from (RD16/0008/0021) Ministerio de Ciencia, Innovación y Universidades Instituto de Salud Carlos III Madrid Spain
| | - Sergio Recalde
- Experimental Ophthalmology Laboratory Universidad de Navarra Pamplona Spain
- Red Temática de Investigación Cooperativa en Salud: ‘Prevention, Early Detection, and Treatment of the Prevalent Degenerative and Chronic Ocular Pathology’ from (RD16/0008/0021) Ministerio de Ciencia, Innovación y Universidades Instituto de Salud Carlos III Madrid Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA) Pamplona Spain
| | - Patricia Fernandez‐Robredo
- Experimental Ophthalmology Laboratory Universidad de Navarra Pamplona Spain
- Red Temática de Investigación Cooperativa en Salud: ‘Prevention, Early Detection, and Treatment of the Prevalent Degenerative and Chronic Ocular Pathology’ from (RD16/0008/0021) Ministerio de Ciencia, Innovación y Universidades Instituto de Salud Carlos III Madrid Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA) Pamplona Spain
| | | | - Lluís Arias Barquet
- Red Temática de Investigación Cooperativa en Salud: ‘Prevention, Early Detection, and Treatment of the Prevalent Degenerative and Chronic Ocular Pathology’ from (RD16/0008/0021) Ministerio de Ciencia, Innovación y Universidades Instituto de Salud Carlos III Madrid Spain
- Department of Ophthalmology Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat Barcelona Spain
| | - Marta S. Figueroa
- Department of Ophthalmology Hospital Universitario Ramón y Cajal Madrid Spain
| | - José García‐Arumí
- Department of Ophthalmology Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Alfredo García‐Layana
- Department of Ophthalmology Clínica Universidad de Navarra Pamplona Spain
- Experimental Ophthalmology Laboratory Universidad de Navarra Pamplona Spain
- Red Temática de Investigación Cooperativa en Salud: ‘Prevention, Early Detection, and Treatment of the Prevalent Degenerative and Chronic Ocular Pathology’ from (RD16/0008/0021) Ministerio de Ciencia, Innovación y Universidades Instituto de Salud Carlos III Madrid Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA) Pamplona Spain
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Yu JS, Carlton R, Agashivala N, Hassan T, Wykoff CC. Brolucizumab vs aflibercept and ranibizumab for neovascular age-related macular degeneration: a cost-effectiveness analysis. J Manag Care Spec Pharm 2021; 27:743-752. [PMID: 34057392 PMCID: PMC10390922 DOI: 10.18553/jmcp.2021.27.6.743] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Age-related macular degeneration (AMD) is a leading cause of blindness worldwide and is the most common cause of blindness in developed countries. Despite antivascular endothelial growth factor (anti-VEGF) therapy demonstrating improvements in visual and anatomical outcomes, unmet needs remain. Brolucizumab-dbll (ie, brolucizumab), a VEGF inhibitor for treatment of neovascular (wet) AMD and recently approved by the FDA for its treatment of wet AMD, attempts to mitigate treatment burden through less frequent injections. OBJECTIVE: To assess the incremental cost-effectiveness of brolucizumab compared with aflibercept and ranibizumab, given similar costs per injection and the potential for longer dosing intervals based on phase 3 clinical trial data. METHODS: A Markov model was developed to model the treatment of wet AMD patients with brolucizumab vs aflibercept and vs ranibizumab over a lifetime time horizon (base case) and 5-year time horizon (scenario analysis). The Markov model consisted of 3 primary health states: on treatment, off treatment, and death. Markov substates (5 total) described visual acuity (VA) ranging from no vision impairment to blindness. These VA-based substates were defined by best-corrected visual acuity (BCVA) values measured using Early Treatment Diabetic Retinopathy Study letters. Fixed-dosing regimens for each therapy were included in the model: dosing every 4 weeks (q4w) for the first 3 months followed by dosing q8w/q12w for brolucizumab, dosing q4w for the first 3 months followed by dosing q8w for aflibercept, and q4w for ranibizumab. RESULTS: In the base case, brolucizumab was less costly than aflibercept ($63,614 vs $72,189), and brolucizumab generated 0.0079 more quality-adjusted life-years (QALYs) than aflibercept (4.580 vs 4.572). Lower total costs with brolucizumab were driven by reduced drug costs ($56,432 vs $64,057), reduced administration costs ($6,013 vs $6,825), and reduced monitoring costs ($1,168 vs $1,306). When evaluating the cost-effectiveness of brolucizumab over a 5-year time horizon, brolucizumab was less costly than aflibercept ($44,644 vs $50,772) and generated an additional 0.0049 QALYs (2.953 vs 2.948). Additionally, brolucizumab was less costly than ranibizumab ($63,614 vs $128,163) and generated 0.0078 more QALYs than ranibizumab (4.580 vs 4.572) in the base case. Lower total costs with brolucizumab were driven by reduced drug costs ($56,432 vs $114,516), reduced administration costs ($6,013 vs $11,541), and reduced monitoring costs ($1,168 vs $2,107). When evaluating the cost-effectiveness of brolucizumab over a 5-year time horizon, brolucizumab was less costly than ranibizumab ($44,644 vs $89,665), and brolucizumab generated an additional 0.0046 QALYs (2.953 vs 2.948). CONCLUSIONS: Brolucizumab can be cost saving and cost-effective compared with aflibercept and ranibizumab in the treatment of wet AMD. DISCLOSURES: Novartis Pharmaceuticals Corporation provided funding to Xcenda for the cost-effectiveness analysis and preparation of this manuscript. Carlton is an employee of Xcenda. Agashivala is employed by Novartis Pharmaceuticals Corporation; Yu was an employee of Novartis Pharmaceutical Corporation at the time of this study. Hassan reports personal fees from iOPEN, BVI/Visitrec, ArcticDx, Bayer, F. Hoffmann-La Roche Ltd, Broadspot, BMC, Katalyst Surgical, Alcon, Vitreq, Surgicube, personal Ocugenix, Regeneron, Allergan, Oculus Surgical, Novartis, Genentech, and Eyepoint, unrelated to this work. Wykoff reports personal fees from Corcept Therapeutics, DORC, EyePoint, Gyroscope, IVERIC Bio, Merck, Notal Vision, ONL Therapeutics, Oxurion, Palatin, PolyPhotonix, Takeda, Thea Open Innovation; grants from Aerie Pharmaceuticals, Aldeyra, Gemini Therapeutics, Graybug Vision, IONIS Pharmaceutical, LMRI, Mylan, Neurotech Pharmaceuticals, Outlook Pharmaceuticals, Samsung Bioepis, Senju, Taiwan Liposome Company, Xbrane BioPharma, Santen; and grants and personal fees from Adverum, Allergan, Apellis, Chengdu Kanghong Biotechnologies (KHB), Clearside Biomedical, Genentech, Kodiak Sciences, NGM Biopharmaceuticals, Novartis, Opthea, Recens Medical, Regenxbio, Roche, and Regeneron, unrelated to this work. This research was presented as a virtual poster at the AMCP 2020 Annual Meeting, April 2020.
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Affiliation(s)
- Justin S Yu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | | | | | - Tarek Hassan
- Oakland University William Beaumont School of Medicine and Associated Retinal Consultants, Royal Oak, MI
| | - Charles C Wykoff
- Retina Consultants of Houston, Retina Consultants of America, and Blanton Eye Institute and Houston Methodist Hospital, Houston, TX
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López Gálvez MI, Arias Barquet L, S. Figueroa M, García‐Layana A, Ruiz Moreno JM, Fernandez Rodríguez M, García Arumí J, Amat Peral P, Ascaso Puyuelo J, Armada Maresca F, Cervera Taulet E, Torres Imaz R, Gutierrez Sánchez E, Cordovés Dorta LM, Esteban González E, Velilla Osés S, Abengoechea Hernández S, Ruiz Miguel M, Basauri Rementería E, Caballos Castilla R, Villavilla Castillo J, López Guajardo L, Gallego Pinazo R, Araiz Iribarren JJ, Rodriguez García L, Cabrera López F, López Garrido JA, López‐Herrera ML, Alforja Castiella MS, Ruiz Moreno Ó, Martinez Alday N, Fernández‐Vega Sanz Á, Garcia Campos J. Bimonthly, treat-and-extend and as-needed ranibizumab in naïve neovascular age-related macular degeneration patients: 12-month outcomes of a randomized study. Acta Ophthalmol 2020; 98:e820-e829. [PMID: 32190990 DOI: 10.1111/aos.14399] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 02/20/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE To assess the noninferiority of the treat-and-extend (T&E) and fixed bimonthly regimens of 0.5 mg intravitreal ranibizumab as compared with the pro re nata (PRN) in naïve patients with neovascular age-related macular degeneration (nAMD). METHODS Phase IV, randomized, 12-month, multicentre trial. Patients aged ≥50 years with nAMD and visual impairment [best-corrected visual acuity (BCVA) between 23 and 78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters] were eligible. Patients (one eye per patient) were randomized to bimonthly, n = 103, T&E, n = 99 or PRN, n = 104. Noninferiority was established at five letters ETDRS. RESULTS The mean (95% CI) difference in BCVA at 12 months was 7.2 (4.2-10.2), 6.4 (2.9-9.8), and 8.0 (51.1-11.0) in the bimonthly, T&E and PRN, respectively. The bimonthly or T&E regimens were not inferior to the PRN scheme. All regimens were associated with a significant reduction of central subfield thickness and volume. The mean (95% CI) number of injections in the bimonthly regimen (7.6, 7.5-7.7) was similar as compared with the PRN regimen (7.4, 6.7-8.0) (p = 0.159) but lower than in the T&E regimen (9.3, 8.9-9.7) (p < 0.001). CONCLUSION At 12 months, bimonthly and T&E ranibizumab were noninferior to PRN in naïve nAMD.
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Affiliation(s)
| | - Lluís Arias Barquet
- Department of Ophthalmology Hospital Universitari de Bellvitge L’Hospitalet de Llobregat Barcelona Spain
| | - Marta. S. Figueroa
- Department of Ophthalmology Hospital Universitario Ramón y Cajal Madrid Spain
| | | | - José M. Ruiz Moreno
- Department of Ophthalmology Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
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Li E, Donati S, Lindsley KB, Krzystolik MG, Virgili G. Treatment regimens for administration of anti-vascular endothelial growth factor agents for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2020; 5:CD012208. [PMID: 32374423 PMCID: PMC7202375 DOI: 10.1002/14651858.cd012208.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is one of the leading causes of permanent blindness worldwide. The current mainstay of treatment for neovascular AMD (nAMD) is intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents: aflibercept, ranibizumab, and off-label bevacizumab. Injections can be given monthly, every two or three months ('extended-fixed'), or as needed (pro re nata (PRN)). A variant of PRN is 'treat-and-extend' whereby injections are resumed if recurrence is detected and then delivered with increasing intervals. Currently, injection frequency varies among practitioners, which underscores the need to characterize an optimized approach to nAMD management. OBJECTIVES To investigate the effects of monthly versus non-monthly intravitreous injection of an anti-VEGF agent in people with newly diagnosed nAMD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, and three trials registers from 2004 to October 2019; checked references; handsearched conference abstracts; and contacted pharmaceutical companies to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared different treatment regimens for anti-VEGF agents in people with newly diagnosed nAMD. We considered standard doses only (ranibizumab 0.5 mg, bevacizumab 1.25 mg, aflibercept 2.0 mg, or a combination of these). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for trial selection, data extraction, and analysis. MAIN RESULTS We included 15 RCTs. The total number of participants was 7732, ranging from 37 to 2457 in each trial. The trials were conducted worldwide. Of these, six trials exclusively took place in the US, and three included centers from more than one country. Eight trials were at high risk of bias for at least one domain and all trials had at least one domain at unclear risk of bias. Seven trials (3525 participants) compared a PRN regimen with a monthly injection regimen, of which five trials delivered four to eight injections using standard PRN and three delivered nine or 10 injections using a treat-and-extend regimen in the first year. The overall mean change in best-corrected visual acuity (BCVA) at one year was +8.8 letters in the monthly injection group. Compared to the monthly injection, there was moderate-certainty evidence that the mean difference (MD) in BCVA change at one year for the standard PRN subgroup was -1.7 letters (95% confidence interval (CI) -2.8 to -0.6; 4 trials, 2299 participants), favoring monthly injections. There was low-certainty evidence of a similar BCVA change with the treat-and-extend subgroup (0.5 letters, 95% CI -3.1 to 4.2; 3 trials, 1226 participants). Compared to monthly injection, there was low-certainty evidence that fewer participants gained 15 or more lines of vision with standard PRN treatment at one year (risk ratio (RR) 0.87, 95% CI 0.76 to 0.99; 4 trials, 2299 participants) and low-certainty evidence of a similar gain with treat-and-extend versus monthly regimens (RR 1.11, 95% CI 0.91 to 1.36; 3 trials, 1169 participants). The mean change in central retinal thickness was a decrease of -166 μm in the monthly injection group; the MD compared with standard PRN was 21 μm (95% CI 6 to 32; 4 trials, 2215 participants; moderate-certainty evidence) and with treat-and extend was 22 μm (95% CI 37 to -81 μm; 2 trials, 635 participants; low-certainty evidence), in favor of monthly injection. Only one trial (498 participants) measured quality of life and reported no evidence of a difference between regimens, but data could not be extracted (low-certainty evidence). Both PRN regimens (standard and 'treat-and-extend') used fewer injections than monthly regimens (standard PRN: MD -4.6 injections, 95% CI -5.4 to -3.8; 4 trials, 2336 participants; treat-and-extend: -2.4 injections, 95% CI -2.7 to -2.1 injections; moderate-certainty evidence for both comparisons). Two trials provided cost data (1105 participants, trials conducted in the US and the UK). They found that cost differences between regimens were reduced if bevacizumab rather than aflibercept or ranibizumab were used, since bevacizumab was less costly (low-certainty evidence). PRN regimens were associated with a reduced risk of endophthalmitis compared with monthly injections (Peto odds ratio (OR) 0.13, 95% CI 0.04 to 0.46; 6 RCTs, 3175 participants; moderate-certainty evidence). Using data from all trials included in this review, we estimated the risk of endophthalmitis with monthly injections to be 8 in every 1000 people per year. The corresponding risk for people receiving PRN regimens was 1 in every 1000 people per year (95% CI 0 to 4). Three trials (1439 participants) compared an extended-fixed regimen (number of injections reported in only one large trial: 7.5 in one year) with monthly injections. There was moderate-certainty evidence that BCVA at one year was similar for extended-fixed and monthly injections (MD in BCVA change compared to extended-fixed group: -1.3 letters, 95% CI -3.9 to 1.3; RR of gaining 15 letters or more: 0.94, 95% CI 0.80 to 1.10). The change in central retinal thickness was a decrease of 137 μm in the monthly group; the MD with the extended-fixed group was 8 μm (95% CI -11 to 27; low-certainty evidence). The frequency of endophthalmitis was lower in the extended-fixed regimen compared to the monthly group, but this estimate was imprecise (RR 0.19, 95% CI 0.03 to 1.11; low-certainty evidence). If we assumed a risk of 8 cases of endophthalmitis in 1000 people receiving monthly injections over one year, then the corresponding risk with extended-fixed regimen was 2 in 1000 people (95% CI 0 to 9). Other evidence comparing different extended-fixed or PRN regimens yielded inconclusive results. AUTHORS' CONCLUSIONS We found that, at one year, monthly regimens are probably more effective than PRN regimens using seven or eight injections in the first year, but the difference is small and clinically insignificant. Endophthalmitis is probably more common with monthly injections and differences in costs between regimens are higher if aflibercept or ranibizumab are used compared to bevacizumab. This evidence only applies to settings in which regimens are implemented as described in the trials, whereas undertreatment is likely to be common in real-world settings. There are no data from RCTs on long-term effects of different treatment regimens.
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Affiliation(s)
- Emily Li
- Transitional Year Residency Program, Signature Healthcare Brockton Hospital, Brockton, MA, USA
| | - Simone Donati
- Department of Surgical and Morphological Sciences, Section of Ophthalmology, University of Insubria, Varese-Como, Varese, Italy
| | - Kristina B Lindsley
- Life Sciences, Oncology, & Genomics, IBM Watson Health, Baltimore, Maryland, USA
| | - Magdalena G Krzystolik
- Department of Ophthalmology, Retina Service, Mass Eye and Ear Infirmary, Providence, RI, USA
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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