The University of Southampton
University of Southampton Institutional Repository

Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT

Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT
Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT

Background: licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period. 

Objective: the objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion. 

Design: this was a three-arm, double-masked, randomised controlled non-inferiority trial. Setting: The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018. 

Participants: a total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial. Interventions: The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154). 

Main outcome measures: the primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of –5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years. 

Results: the adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows – ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval –2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference –1.73 letters, 95% confidence interval –6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was –3.96 letters, 95% confidence interval –8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means –1.8, 95% confidence interval –2.9 to –0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model-and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000–30,000 per quality-adjusted life-year. Limitations: The comparison of aflibercept and bevacizumab was a post hoc analysis. 

Conclusion: the study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered. Future work: To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use. 

Trial registration: Current Controlled Trials ISRCTN13623634.

1366-5278
Hykin, Philip
668bf80b-3b95-4522-9ff0-8303a692b77b
Prevost, A. Toby
5fd7066c-e170-46f6-8d3e-501532dc7810
Sivaprasad, Sobha
f2d2ba7d-03f8-48e2-9f2b-2bbe6ffd5213
Vasconcelos, Joana C.
09229be4-0952-4ec6-a6df-32712ebf229a
Murphy, Caroline
6f95b133-c7a6-4852-96a8-52fe28fbc075
Kelly, Joanna
bc3e1b74-8080-478f-b7d5-87ae2819a325
Ramu, Jayashree
e7eb6048-1992-45f2-ba04-3704b0687648
Alshreef, Abualbishr
5c8c2ac4-feb0-4940-9623-05ed2995853d
Flight, Laura
e05aaef5-71ca-48fa-b8af-877cb85eed01
Pennington, Rebekah
d07c4179-2e55-4a8d-8ff6-633250005083
Hounsome, Barry
efa277a8-897e-4b41-abca-53702f91b36c
Lever, Ellen
dd05a231-ab3c-4edf-8459-6e524ad14223
Metry, Andrew
e2cbf70b-f969-47d9-982b-86a2250dd21b
Poku, Edith
a032a5e6-1e6e-43d1-ad64-2d785c4ab8f1
Yang, Yit
fa4a4f63-34cb-4fb4-8c19-622dc0e4a765
Harding, Simon P.
f7a586c8-02fb-4274-992d-eb2cabf1286d
Lotery, Andrew
5ecc2d2d-d0b4-468f-ad2c-df7156f8e514
Chakravarthy, Usha
2c06cdaf-94c0-409a-8eff-2f624c120a5e
Brazier, John
9e2c7436-1494-4043-ba1d-6024b81124ed
Hykin, Philip
668bf80b-3b95-4522-9ff0-8303a692b77b
Prevost, A. Toby
5fd7066c-e170-46f6-8d3e-501532dc7810
Sivaprasad, Sobha
f2d2ba7d-03f8-48e2-9f2b-2bbe6ffd5213
Vasconcelos, Joana C.
09229be4-0952-4ec6-a6df-32712ebf229a
Murphy, Caroline
6f95b133-c7a6-4852-96a8-52fe28fbc075
Kelly, Joanna
bc3e1b74-8080-478f-b7d5-87ae2819a325
Ramu, Jayashree
e7eb6048-1992-45f2-ba04-3704b0687648
Alshreef, Abualbishr
5c8c2ac4-feb0-4940-9623-05ed2995853d
Flight, Laura
e05aaef5-71ca-48fa-b8af-877cb85eed01
Pennington, Rebekah
d07c4179-2e55-4a8d-8ff6-633250005083
Hounsome, Barry
efa277a8-897e-4b41-abca-53702f91b36c
Lever, Ellen
dd05a231-ab3c-4edf-8459-6e524ad14223
Metry, Andrew
e2cbf70b-f969-47d9-982b-86a2250dd21b
Poku, Edith
a032a5e6-1e6e-43d1-ad64-2d785c4ab8f1
Yang, Yit
fa4a4f63-34cb-4fb4-8c19-622dc0e4a765
Harding, Simon P.
f7a586c8-02fb-4274-992d-eb2cabf1286d
Lotery, Andrew
5ecc2d2d-d0b4-468f-ad2c-df7156f8e514
Chakravarthy, Usha
2c06cdaf-94c0-409a-8eff-2f624c120a5e
Brazier, John
9e2c7436-1494-4043-ba1d-6024b81124ed

Hykin, Philip, Prevost, A. Toby, Sivaprasad, Sobha, Vasconcelos, Joana C., Murphy, Caroline, Kelly, Joanna, Ramu, Jayashree, Alshreef, Abualbishr, Flight, Laura, Pennington, Rebekah, Hounsome, Barry, Lever, Ellen, Metry, Andrew, Poku, Edith, Yang, Yit, Harding, Simon P., Lotery, Andrew, Chakravarthy, Usha and Brazier, John (2021) Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT. Health Technology Assessment, 25 (38). (doi:10.3310/HTA25380).

Record type: Article

Abstract

Background: licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period. 

Objective: the objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion. 

Design: this was a three-arm, double-masked, randomised controlled non-inferiority trial. Setting: The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018. 

Participants: a total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial. Interventions: The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154). 

Main outcome measures: the primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of –5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years. 

Results: the adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows – ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval –2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference –1.73 letters, 95% confidence interval –6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was –3.96 letters, 95% confidence interval –8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means –1.8, 95% confidence interval –2.9 to –0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model-and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000–30,000 per quality-adjusted life-year. Limitations: The comparison of aflibercept and bevacizumab was a post hoc analysis. 

Conclusion: the study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered. Future work: To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use. 

Trial registration: Current Controlled Trials ISRCTN13623634.

This record has no associated files available for download.

More information

Published date: 16 June 2021
Additional Information: Funding Information: Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information. Funding Information: Declared competing interests of authors: Philip Hykin has received grants, personal fees and nonfinancial support from Bayer AG (Leverkusen, Germany), Novartis International AG (Basel, Switzerland) and Allergan plc (Dublin, Ireland). A Toby Prevost was a member of the National Institute for Health Research (NIHR) Public Health Research Committee (June 2014–June 2020) and is a member of the NIHR COVID Call (Recovery and Learning) Committee (June 2020–present); he has received a lecture fee from Bayer AG and a grant from Boehringer Ingelheim (Ingelheim, Germany). Sobha Sivaprasad is part of the NIHR Health Technology Assessment (HTA) Commissioning Board (31 July 2017–present) and has received personal fees and grants from Novartis International AG, Bayer AG, Allergan plc and Boehringer Ingelheim, personal fees from F. Hoffmann-La Roche AG (Basel, Switzerland), personal fees and non-financial support from Optos plc (Marlborough, MA, USA) and personal fees from Heidelberg Engineering Inc. (Franklin, MA, USA). Laura Flight has received grants from NIHR for her NIHR Doctoral Fellowship, Adaptive Design Clinical Trials and their Impact on the Economic Evaluation of Health Care Technologies (DRF-2015-08-013), and another NIHR project, Value-based Adaptive Clinical Trial Designs for Efficient Delivery of NIHR Research (NIHR130354). Rebekah Pennington has received research grants from F. Hoffmann-La Roche AG. Yit Yang has received personal fees and non-financial support from Novartis International AG, Bayer AG and personal fees from Allergan plc and F. Hoffmann-La Roche AG. Simon P Harding has received grants to his employer from the NIHR HTA Clinical Evaluation and Trials UK and F. Hoffmann-La Roche AG. Andrew Lotery has received travel support from Bayer AG, and personal fees from Novartis International AG and Allergan plc. Usha Chakravarthy has received grants from NIHR [for the Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) trial, 07/36/01], was part of the HTA Prioritisation Committee (2010–14) and has received personal fees from Allergan plc and Novartis International AG. Funding Information: Declared competing interests of authors: Philip Hykin has received grants, personal fees and non-financial support from Bayer AG (Leverkusen, Germany), Novartis International AG (Basel, Switzerland) and Allergan plc (Dublin, Ireland). A Toby Prevost was a member of the National Institute for Health Research (NIHR) Public Health Research Committee (June 2014?June 2020) and is a member of the NIHR COVID Call (Recovery and Learning) Committee (June 2020?present); he has received a lecture fee from Bayer AG and a grant from Boehringer Ingelheim (Ingelheim, Germany). Sobha Sivaprasad is part of the NIHR Health Technology Assessment (HTA) Commissioning Board (31 July 2017?present) and has received personal fees and grants from Novartis International AG, Bayer AG, Allergan plc and Boehringer Ingelheim, personal fees from F. Hoffmann-La Roche AG (Basel, Switzerland), personal fees and non-financial support from Optos plc (Marlborough, MA, USA) and personal fees from Heidelberg Engineering Inc. (Franklin, MA, USA). Laura Flight has received grants from NIHR for her NIHR Doctoral Fellowship, Adaptive Design Clinical Trials and their Impact on the Economic Evaluation of Health Care Technologies (DRF-2015-08-013), and another NIHR project, Value-based Adaptive Clinical Trial Designs for Efficient Delivery of NIHR Research (NIHR130354). Rebekah Pennington has received research grants from F. Hoffmann-La Roche AG. Yit Yang has received personal fees and non-financial support from Novartis International AG, Bayer AG and personal fees from Allergan plc and F. Hoffmann-La Roche AG. Simon P Harding has received grants to his employer from the NIHR HTA Clinical Evaluation and Trials UK and F. Hoffmann-La Roche AG. Andrew Lotery has received travel support from Bayer AG, and personal fees from Novartis International AG and Allergan plc. Usha Chakravarthy has received grants from NIHR [for the Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) trial, 07/36/01], was part of the HTA Prioritisation Committee (2010?14) and has received personal fees from Allergan plc and Novartis International AG.Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information. Funding Information: This project was funded by the NIHR HTA Clinical Evaluation and Trials programme (number 11/92/03). The trial was sponsored by the NIHR Moorfields Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust. The research was supported by the NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the University College London Institute of Ophthalmology, the UK Clinical Research Collaboration-registered KCTU at King’s Health Partners, which is part-funded by the NIHR Maudsley Biomedical Research Centre, at South London and Maudsley NHS Foundation Trust, and King’s College London. Funding Information: The research reported in this issue of the journal was funded by the HTA programme as project number 11/92/03. The contractual start date was in June 2014. The draft report began editorial review in August 2019 and was accepted for publication in June 2020. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report. Publisher Copyright: © Queen’s Printer and Controller of HMSO 2021. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

Identifiers

Local EPrints ID: 453451
URI: http://eprints.soton.ac.uk/id/eprint/453451
ISSN: 1366-5278
PURE UUID: b415f61d-f42d-4578-8d2e-31ecb256106d
ORCID for Andrew Lotery: ORCID iD orcid.org/0000-0001-5541-4305

Catalogue record

Date deposited: 17 Jan 2022 17:47
Last modified: 18 Mar 2024 02:57

Export record

Altmetrics

Contributors

Author: Philip Hykin
Author: A. Toby Prevost
Author: Sobha Sivaprasad
Author: Joana C. Vasconcelos
Author: Caroline Murphy
Author: Joanna Kelly
Author: Jayashree Ramu
Author: Abualbishr Alshreef
Author: Laura Flight
Author: Rebekah Pennington
Author: Barry Hounsome
Author: Ellen Lever
Author: Andrew Metry
Author: Edith Poku
Author: Yit Yang
Author: Simon P. Harding
Author: Andrew Lotery ORCID iD
Author: Usha Chakravarthy
Author: John Brazier

Download statistics

Downloads from ePrints over the past year. Other digital versions may also be available to download e.g. from the publisher's website.

View more statistics

Atom RSS 1.0 RSS 2.0

Contact ePrints Soton: eprints@soton.ac.uk

ePrints Soton supports OAI 2.0 with a base URL of http://eprints.soton.ac.uk/cgi/oai2

This repository has been built using EPrints software, developed at the University of Southampton, but available to everyone to use.

We use cookies to ensure that we give you the best experience on our website. If you continue without changing your settings, we will assume that you are happy to receive cookies on the University of Southampton website.

×