Cost-effectiveness of ranibizumab and bevacizumab for age-related macular degeneration: 2-year findings from the IVAN randomised trial

Abstract

Objective: To assess the incremental cost and cost-effectiveness of continuous and discontinuous regimens of bevacizumab (Avastin) and ranibizumab (Lucentis) for neovascular age-related macular degeneration (nAMD) from a UK National Health Service (NHS) perspective.

Design: A within-trial cost-utility analysis with a 2-year time horizon, based on a multicentre factorial, non-inferiority randomised controlled trial.

Setting: 23 hospital ophthalmology clinics.

Participants: 610 patients aged ?50?years with untreated nAMD in the study eye.

Interventions: 0.5?mg ranibizumab or 1.25?mg bevacizumab given continuously (monthly) or discontinuously (as-needed) for 2?years.

Main Outcome Measures: Quality-adjusted life-years (QALYs).

Results: Total 2-year costs ranged from £3002/patient ($4700; 95% CI £2601 to £3403) for discontinuous bevacizumab to £18?590/patient ($29?106; 95% CI £18?258 to £18?922) for continuous ranibizumab. Ranibizumab was significantly more costly than bevacizumab for both continuous (+£14?989/patient ($23?468); 95% CI £14?522 to £15?456; p<0.001) and discontinuous treatment (+£8498 ($13?305); 95% CI £7700 to £9295; p<0.001), with negligible difference in QALYs. Continuous ranibizumab would only be cost-effective compared with continuous bevacizumab if the NHS were willing to pay £3.5 million ($5.5 million) per additional QALY gained. Patients receiving continuous bevacizumab accrued higher total costs (+£599 ($938); 95% CI £91 to £1107; p=0.021) than those receiving discontinuous bevacizumab, but also accrued non-significantly more QALYs (+0.020; 95% CI -0.032 to 0.071; p=0.452). Continuous bevacizumab therefore cost £30?220 ($47?316) per QALY gained versus discontinuous bevacizumab. However, bootstrapping demonstrated that if the NHS is willing to pay £20?000/QALY gained, there is a 37% chance that continuous bevacizumab is cost-effective versus discontinuous bevacizumab.

Conclustions: Ranibizumab is not cost-effective compared with bevacizumab, being substantially more costly and producing little or no QALY gain. Discontinuous bevacizumab is likely to be the most cost-effective of the four treatment strategies evaluated in this UK trial, although there is a 37% chance that continuous bevacizumab is cost-effective.

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Identifiers

ORCID for A.J. Lotery: orcid.org/0000-0001-5541-4305

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