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Abstract
Background
Ranibizumab and aflibercept are alternative anti-vascular endothelial growth factor agents approved for the treatment of visual impairment (VI) due to diabetic macular edema (DME).
Objective
To estimate, from a UK healthcare perspective, the cost-effectiveness of ranibizumab 0.5 mg pro re nata (PRN) and ranibizumab 0.5 mg treat and extend (T&E) compared with aflibercept 2 mg every 8 weeks after five initial monthly doses (2q8) in the treatment of VI due to DME.
Methods
A Markov model previously reviewed by the National Institute for Health and Care Excellence was used to simulate the long-term outcomes and costs of treating DME. Health states were defined by increments of ten letters in best-corrected visual acuity (BCVA), with a 3-month cycle length. Patients could gain (or lose) a maximum of two health states between cycles. A 3-year treatment time frame and a lifetime horizon were used. Future costs and health outcomes were discounted at 3.5% per annum. Patient baseline characteristics and the efficacy of ranibizumab PRN were derived using data from the RESTORE study. The relative efficacies of ranibizumab PRN, ranibizumab T&E, and aflibercept were assessed with a network meta-analysis. Different utilities were assigned based on BCVA and whether the treated eye was the better- or the worse-seeing eye. Sensitivity analyses tested the robustness of the model.
Results
Lifetime costs per patient of treating DME were £20,019 for ranibizumab PRN, £22,930 for ranibizumab T&E, and £25,859 for aflibercept 2q8. Ranibizumab was dominant over aflibercept, with an incremental gain of 0.05 quality-adjusted life-years (QALYs) and cost savings of £5,841 (PRN) and £2,930 (T&E) compared with aflibercept. Ranibizumab PRN and ranibizumab T&E had 79% and 67% probability, respectively, of being cost-effective relative to aflibercept at a willingness-to-pay threshold of £20,000/QALY. When assuming the higher end of PRN injection frequency (15.9 over 3 years), the cost savings associated with ranibizumab were £3,969.
Conclusion
From a UK healthcare perspective, ranibizumab provides greater health gains with lower overall costs than aflibercept in patients with VI due to DME.
Supplementary materials
Table S1 Calculation of aflibercept transition probabilities
Table S2 Costs of visual impairment
Table S3 Key variables with varying value in the probability sensitivity analysis
Acknowledgments
The authors would like to thank Fernando Gibson, PhD, from PharmaGenesis™, London, UK, for editorial support in developing the manuscript. This project was funded by Novartis Pharma AG, Basel, Switzerland.
Disclosure
Stephane Régnier is an employee of Novartis Pharma AG and William Malcolm is an employee of Novartis Pharmaceuticals UK Ltd; Jennifer Haig and Weiguang Xue are employees of Optum and received payment from Novartis Pharma AG for this work. The abstract of this paper was presented at the 2014 ISPOR conference in Amsterdam, the Netherlands, as a poster presentation with interim findings. The poster’s abstract was published in “Poster Abstracts” in the November 2014 issue of Value in Health. (http://www.valueinhealthjournal.com/article/S1098-3015(14)04062-5/pdf). The actual paper, however, has never been published.