Value-based medicine and interventions for macular degeneration

Direct Treatment Costs of Neovascular Age-related Macular Degeneration and Comparison of Gained and/or Preserved Vision with Expenditure

Objectives:

The aim was to quantify the direct medical cost of neovascular age-related macular degeneration (AMD) versus gained or preserved vision.

Materials and Methods:

Data of patients treated for neovascular AMD between January 2009 to January 2014 were reviewed. Patients with complete follow-up for two years, treated with only intravitreal ranibizumab injections and with no intraocular surgery were included. Demographics, diagnostic investigations, the number of visits and injections, changes in visual acuity (VA) at one year and two years from baseline were noted. Total cost was calculated for the first and second years, and the cost of improving or preserving initial vision level was determined with subgroup analysis.

Results:

Two-hundred eyes of 175 patients (86 male and 89 female) with a mean age of 72.3±7.8 years were included. Mean VA was 0.67 logMAR at baseline, 0.60 logMAR at the end of the first year, and 0.67 logMAR at the end of the second year. At the end of the 2 years, VA increased in 82 eyes (41%), remained the same in 42 eyes (21%), and decreased in 76 eyes (38%). The mean number of visits in the first and second years were 6.56 (3-12) and 5.74 (3-10), respectively. An average of 4.42 (1-8) injections were performed in the first year and 2.25 (0-7) in the second. The total direct medical cost for AMD was 9,628 TL (Turkish Lira) per patient for 2 years, which consisted of 529 TL in visit costs, 115 TL in fluorescein and indocyanine angiography costs, 611 TL in injection procedure costs, and 8,371 TL in drug costs. The cost of one line of VA gain was 11,911 TL in the first year.

Conclusion:

This study showed that treatment increased or stabilized vision in a reasonable proportion of patients, that cost of management decreases in the second year, and that drug expenses are the leading item in reimbursement.

Treatment of age-related macular degeneration: focus on ranibizumab

Ranibizumab, a humanized antigen-binding fragment (Fab) that binds all isoforms of VEGF-A, significantly slows down loss of vision and causes significant visual improvement in many patients with choroidal neovascularization (CNV) due to exudative age-related macular degeneration (AMD). These benefits of intravitreal ranibizumab apply to all angiographic subtypes of neovascular AMD and across all lesion sizes when the drug is injected at monthly intervals as shown in two pivotal phase III trials (ANCHOR and MARINA). The results from the PrONTO study suggest that less frequent treatment with ranibizumab through a variable dosing regimen dependent on optical coherence tomography (OCT) findings is a treatment option that results in comparably favorable visual outcomes. Currently, it is unclear whether combination therapy of ranibizumab with photodynamic therapy (PDT) provides any significant advantage over ranibizumab monotherapy (FOCUS trial); however, the combination of PDT and ranibizumab may decrease the need for frequent retreatment. This question will be addressed in the SUMMIT trial. Therapy with ranibizumab is generally very well tolerated with a low rate of seriously adverse ocular events or systemic side-effects. The advent of vascular endothelial growth factor (VEGF) inhibitors has revolutionized the therapy of neovascular AMD. Ranibizumab at the moment appears to be the most effective approved treatment for neovascular AMD.

Anti-VEGF agents for age-related macular degeneration

Age-related macular degeneration (AMD) is a leading cause of legal blindness in the elderly in the industrialized world and the third major cause of blindness around the globe. Although neovascular AMD is less prevalent than atrophic AMD, it accounts for most cases with severe visual loss from AMD. VEGF seems to be a key contributary factor in the pathophysiology underlying neovascular AMD. Until recently, treatment options for neovascular AMD were limited. With the recent development of anti-VEGF therapies that have demonstrated efficacy in studies with broad eligibility criteria, the repertoire of treatments for neovascular AMD has been significantly expanded to now include the various recognized angiographic lesion subtypes. To discuss recent anti-VEGF agents in the management of AMD. Although therapy with anti-VEGF agents is the gold standard with promising results, many intravitreal injections are often required, and they do not cure all cases of wet AMD. With the recent advances in the medical therapy of exudative AMD, there is reason to be optimistic about future management of AMD as well.

The future implications and indications of anti-vascular endothelial growth factor therapy in ophthalmic practice

In the last few years anti-vascular endothelial growth factor (VEGF) therapy has changed the paradigm in the treatment of neovascular age-related macular degeneration (ARMD). Besides, its potential use in the treatment of diabetic retinopathy and other possible proliferative vascular disorders has also shown promise. Clinical trial results have shown tremendous beneficial effect of ranibizumab in ARMD. Off-label use of bevacizumab has also shown similar benefit but long-term and clinical trial results do not exist. Some of the potential questions in the use of anti-VEGF are recurring cost, possible long-term effect on physiological function of VEGF and determination of endpoint of treatment. Overall, the use of anti-VEGF therapy in ocular angiogenesis has proven to be beneficial at least now.