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Veritti D, Sarao V, Soppelsa V, Danese C, Chhablani J, Lanzetta P. Managing Neovascular Age-Related Macular Degeneration in Clinical Practice: Systematic Review, Meta-Analysis, and Meta-Regression. J Clin Med 2022; 11:jcm11020325. [PMID: 35054021 PMCID: PMC8781865 DOI: 10.3390/jcm11020325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/03/2022] [Accepted: 01/07/2022] [Indexed: 12/23/2022] Open
Abstract
The use of anti-vascular endothelial growth factor (VEGF) agents has profoundly changed the prognosis of neovascular age-related macular degeneration (nAMD). As clinical experiences have accumulated, it has become mandatory to summarize data to give information that can be useful in everyday practice. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies that reported 12-month changes in best-corrected visual acuity (BCVA) in patients with nAMD on anti-VEGF monotherapy. Data were analyzed in a random-effects meta-analysis with BCVA change as the primary outcome. Meta-regression was conducted to evaluate the impact of multiple covariates. Four hundred and twelve heterogeneous study populations (109,666 eyes) were included. Anti-VEGFs induced an overall improvement of +5.37 ETDRS letters at 12 months. Meta-regression showed that mean BCVA change was statistically greater for RCTs (p = 0.0032) in comparison with observational studies. Populations following a proactive regimen had better outcomes than those following a reactive treatment regimen. Mean BCVA change was greater in younger populations, with lower baseline BCVA and treated with a higher number of injections (p < 0.001). Our results confirm that anti-VEGFs may produce a significant functional improvement at 12 months in patients with nAMD.
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Affiliation(s)
- Daniele Veritti
- Department of Medicine-Ophthalmology, University of Udine, 33100 Udine, Italy; (D.V.); (V.S.); (V.S.); (C.D.)
| | - Valentina Sarao
- Department of Medicine-Ophthalmology, University of Udine, 33100 Udine, Italy; (D.V.); (V.S.); (V.S.); (C.D.)
- Istituto Europeo di Microchirurgia Oculare (IEMO), 33100 Udine, Italy
| | - Valentina Soppelsa
- Department of Medicine-Ophthalmology, University of Udine, 33100 Udine, Italy; (D.V.); (V.S.); (V.S.); (C.D.)
| | - Carla Danese
- Department of Medicine-Ophthalmology, University of Udine, 33100 Udine, Italy; (D.V.); (V.S.); (V.S.); (C.D.)
| | - Jay Chhablani
- Medical Retina and Vitreoretinal Surgery, University of Pittsburgh School of Medicine, Pittsburg, PA 15261, USA;
| | - Paolo Lanzetta
- Department of Medicine-Ophthalmology, University of Udine, 33100 Udine, Italy; (D.V.); (V.S.); (V.S.); (C.D.)
- Istituto Europeo di Microchirurgia Oculare (IEMO), 33100 Udine, Italy
- Correspondence: ; Tel.: +39-04-3255-9907
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Quist SW, de Jong LA, van Asten F, Knoester P, Postma MJ, Freriks RD. Cost-minimisation analysis of a treat-and-extend regimen with anti-VEGFs in patients with neovascular age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 2021; 260:1083-1095. [PMID: 34643793 PMCID: PMC8511619 DOI: 10.1007/s00417-021-05359-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/16/2021] [Accepted: 07/27/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Although intraocular anti-vascular endothelial growth factors (anti-VEGFs) are effective as treatment of neovascular age-related macular degeneration (nAMD), the (economic) burden on the healthcare system is considerable. A treat-and-extend (T&E) regimen is associated with a lower number of injections without compromising the effectiveness and can therefore help optimise nAMD treatment. This study investigates the per-patient costs associated with nAMD treatment, when using aflibercept, bevacizumab, or ranibizumab with a T&E regimen. Methods In this cost-minimisation model, the per-patient costs in the Netherlands were modelled using a healthcare payers’ perspective over a 3-year time horizon with the assumption that efficacy of treatments is similar. Additionally, the break-even price of the different anti-VEGFs was calculated relative to the cheapest option and injection frequency. Results The injection frequency varied from 14.2 for aflibercept to 27.4 for bevacizumab in 3 years. Nonetheless, bevacizumab remains the cheapest treatment option (€14,215), followed by aflibercept (€18,202) and ranibizumab (€31,048). The medication covers the majority of the per-patient costs for aflibercept and ranibizumab, while administration covers the majority of the per-patient costs for bevacizumab. The break-even prices of aflibercept and ranibizumab are respectively €507 and €60.58 per injection. Brolucizumab was included in the scenario analysis and was more expensive than aflibercept (€20,446). Brolucizumab should reduce to 13.8 injections over 3 years to be as costly as aflibercept. Conclusion Bevacizumab is the cheapest anti-VEGF treatment. The list prices of all anti-VEGFs should reduce to be as costly as bevacizumab. Aflibercept is the second-choice treatment and so far brolucizumab is not.
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Affiliation(s)
- S W Quist
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands. .,Asc Academics, Professor Enno Dirk Wiersmastraat 5, Groningen, The Netherlands.
| | - L A de Jong
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands.,Asc Academics, Professor Enno Dirk Wiersmastraat 5, Groningen, The Netherlands
| | - F van Asten
- Department of Ophthalmology, Radboud University Medical Center, Philips Van Leydenlaan 15, Nijmegen, The Netherlands
| | - P Knoester
- Department of Pharmacy, Alrijne Hospital, Simon Smitweg 1, Leiderdorp, The Netherlands
| | - M J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands.,Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Nettelbosje 2, Groningen, The Netherlands
| | - R D Freriks
- Asc Academics, Professor Enno Dirk Wiersmastraat 5, Groningen, The Netherlands.,Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Nettelbosje 2, Groningen, The Netherlands
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Phan LT, Broadhead GK, Hong TH, Chang AA. Predictors of Visual Acuity After Treatment of Neovascular Age-Related Macular Degeneration - Current Perspectives. Clin Ophthalmol 2021; 15:3351-3367. [PMID: 34408393 PMCID: PMC8364912 DOI: 10.2147/opth.s205147] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/30/2022] Open
Abstract
Visual acuity is a key outcome measure in the treatment of neovascular age-related macular degeneration (nAMD) using anti-vascular endothelial growth factor agents. Large variations in visual responses between individuals within clinical trials and real-world studies may relate to underlying differences in patient and treatment factors. Most notably, a better baseline visual acuity, younger age and smaller choroidal neovascularization lesion size have been strongly associated with achieving better visual outcomes. In addition, there is emerging evidence for other roles including genetic factors and anatomical variables such as fluid status. Apart from patient-related factors, treatments that favor a higher number of injections tend to provide better visual outcomes. Overall, the identification of predictive factors does not currently play an essential role in the clinical management of patients with nAMD. However, they have allowed for the understanding that early detection, timely management and close monitoring of the disease are required to achieve optimal visual outcomes. Further investigation into predictive factors alongside the development of novel therapeutic agents may one day provide a means to accurately predict patient outcomes. Treatment regimens that offer flexible dosing patterns such as the treat-and-extend strategy currently provide a degree of personalization during treatment.
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Affiliation(s)
- Long T Phan
- Sydney Retina, Sydney, New South Wales, Australia.,Discipline of Orthoptics, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Geoffrey K Broadhead
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew A Chang
- Sydney Retina, Sydney, New South Wales, Australia.,Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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Kodjikian L, Parravano M, Clemens A, Dolz-Marco R, Holz FG, Munk MR, Nicolò M, Ricci F, Silva R, Talks SJ, Verma RK, Zarranz-Ventura J, Zweifel SA. Fluid as a critical biomarker in neovascular age-related macular degeneration management: literature review and consensus recommendations. Eye (Lond) 2021; 35:2119-2135. [PMID: 33795837 PMCID: PMC8302650 DOI: 10.1038/s41433-021-01487-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 12/23/2022] Open
Abstract
Current guidelines on the management of patients with neovascular age-related macular degeneration (nAMD) lack clear recommendations on the interpretation of fluid as seen on optical coherence tomography (OCT) imaging and the incorporation of this information into an ongoing disease treatment strategy. Our objective was to review current guidelines and scientific evidence on the role of fluid as a biomarker in the management of nAMD, and develop a clinically oriented, practical algorithm for diagnosis and management based on a consensus of expert European retinal specialists. PubMed was searched for articles published since 2006 relating to the role of fluid in nAMD. A total of 654 publications were screened for relevance and 66 publications were included for review. Of these, 14 were treatment guidelines, consensus statements and systematic reviews or meta-analyses, in which OCT was consistently recommended as an important tool in the initial diagnosis and ongoing management of nAMD. However, few guidelines distinguished between types of fluid when providing recommendations. A total of 52 publications reported primary evidence from clinical trials, studies, and chart reviews. Observations from these were sometimes inconsistent, but trends were observed with regard to features reported as being predictive of visual outcomes. Based on these findings, diagnostic recommendations and a treatment algorithm based on a treat-and-extend (T&E) regimen were developed. These provide guidance on the diagnosis of nAMD as well as a simple treatment pathway based on the T&E regimen, with treatment decisions made according to the observations of fluid as a critical biomarker for disease activity.
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Affiliation(s)
- Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France.,UMR-CNRS 5510 Matéis, Villeurbanne, INSA de Lyon, Université Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | | | - Andreas Clemens
- Novartis Pharma AG, Basel, Switzerland.,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Marion R Munk
- Department of Ophthalmology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Massimo Nicolò
- University Eye Clinic of Genoa DINOGMI, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Federico Ricci
- Department of Experimental Medicine, University Tor Vergata, Rome, Italy
| | - Rufino Silva
- Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra (ICBR-FMUC), Coimbra, Portugal.,Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal.,Association of Innovation and Biomedical Research in Light and Image (AIBILI), Coimbra, Portugal
| | - S James Talks
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Javier Zarranz-Ventura
- Hospital Clínic de Barcelona, Barcelona, Spain.,Institut de Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sandrine A Zweifel
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland. .,University of Zurich, Zurich, Switzerland.
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Optical coherence tomography angiography for identifying choroidal neovascular membranes: a masked study in clinical practice. Eye (Lond) 2020; 35:134-141. [PMID: 33235335 DOI: 10.1038/s41433-020-01285-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND/OBJECTIVES Optical coherence tomography angiography (OCT-A) allows non-invasive imaging of chorio-retinal vasculature, and is a potential alternative to fluorescein angiography (FA). Sensitivity and specificity of OCT-A for detecting choroidal neovascularisation (CNV) in treatment-naïve neovascular age-related macular degeneration (nAMD) patients is examined, using the Heidelberg Spectralis in a 'real world' setting. SUBJECT/METHODS Overall, 43 eyes from 26 patients were included in the study. Spectral domain OCT (SD-OCT), OCT-A and FA images were obtained at baseline. Each of the three retinal image modalities was systematically assessed by three masked clinicians. Decisions about the presence/absence of CNV were recorded using an automated segmentation for OCT-A, a manual method, and using both OCT-A and SD-OCT in conjunction. Additional information about the presence of sub-retinal hyper-reflective material (SHRM) and the 'double layer sign' (DLS) were recorded. RESULTS The average sensitivity and specificity of the OCT-A for the detection of CNV in treatment naïve AMD was 89% and 87% for the combined SD-OCT and OCT-A, 76% and 91% for the automated segmentation and 84% and 85% for the manual segmentation, respectively. Inter-clinician agreement was 0.59-65 kappa. In patients without CNV, SHRM was present in only 6% while DLS was present in 28%. Sensitivity and specificity was >78% for both SHRM and DLS. CONCLUSIONS OCT-A provides a reliable tool for detecting CNV in treatment naïve nAMD patients, with high sensitivity and specificity. Combined use of SD-OCT images and SHRM as an additional bio-marker, OCT-A could become an alternative to FA in routine clinical practice.
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Mehta H, Kim LN, Mathis T, Zalmay P, Ghanchi F, Amoaku WM, Kodjikian L. Trends in Real-World Neovascular AMD Treatment Outcomes in the UK. Clin Ophthalmol 2020; 14:3331-3342. [PMID: 33116384 PMCID: PMC7569079 DOI: 10.2147/opth.s275977] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/17/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose To report trends in real-world outcomes of anti-vascular endothelial growth factor (anti-VEGF) therapy for neovascular age-related macular degeneration (nAMD) in the United Kingdom (UK) over the last decade. Design Systematic review. Methods Medline, PubMed, and Embase databases were searched from 9 April 2010 to 8 April 2020 for publications that met the inclusion criteria: treatment-naïve eyes, UK-only data and ≥1 year of follow-up. ICHOM (International Consortium for Health Outcome Measures) outcomes and study quality were assessed. Visual acuity (VA) trends were assessed in studies with ≥100 eyes at baseline. Results Twenty-six studies (n=25,761 eyes) were included, meeting 14–17 out of 20 Institute of Health Economics Quality Appraisal of Case Series checklist domains. Only ranibizumab and aflibercept outcome data were available. The mean injection number in the first year of treatment was 5.9 in publications from 2010 to 2015 and 7.1 from 2015 to 2020. Average baseline VA and mean one-year, two-year and three-year VA gains gradually improved over the last decade. Longer-term studies reported that the visual gains achieved in the first year of treatment were rarely maintained, with under-treatment a likely contributing factor. Conclusion UK real-world outcomes have improved over the last decade with improved service delivery and the adoption of more proactive treatment regimens but are still not always as impressive as registration clinical trial results. Access to longer-acting anti-VEGF therapies would reduce the treatment burden for patients, carers, and the healthcare system, potentially making replication of clinical trial results possible in the NHS.
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Affiliation(s)
- Hemal Mehta
- Ophthalmology, Royal Free London NHS Foundation Trust, London, UK.,Macular Research Group, Save Sight Institute, Sydney University, Sydney, Australia
| | - Leah N Kim
- Macular Research Group, Save Sight Institute, Sydney University, Sydney, Australia
| | - Thibaud Mathis
- Service d'ophtalmologie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Lyon, France.,Laboratoire UMR-CNRS 5510 Matéis, Université Lyon 1, Villeurbanne, Lyon, France
| | - Pardis Zalmay
- Ophthalmology, Royal Free London NHS Foundation Trust, London, UK
| | - Faruque Ghanchi
- Ophthalmology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Winfried M Amoaku
- Academic Ophthalmology and Vision Sciences, Division of Clinical Neurosciences, Eye and ENT Centre, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Laurent Kodjikian
- Service d'ophtalmologie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Lyon, France.,Laboratoire UMR-CNRS 5510 Matéis, Université Lyon 1, Villeurbanne, Lyon, France
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