PUBLICATION EXCLUSIVE: From the outside looking in at anti-VEGF therapy

As an anterior segment surgeon, I am a little out of my comfort zone commenting on the details of the many studies evaluating the indications and outcomes after the use of anti-VEGF therapy. I do not perform intravitreal injections of anti-VEGF, nor do any of the 26 doctors at Minnesota Eye Consultants. We do, however, have many patients in our practice who are being treated by retina specialist colleagues.

My first impression is that intravitreal anti-VEGF therapy for wet age-related macular degeneration, diabetic retinopathy and macular edema from a host of causes has been an extraordinary advance — as important to ophthalmology as the development of phacoemulsification and IOLs.

My second impression is that anti-VEGF therapy is very expensive for both the individual patient and society as a whole if the so-called branded FDA-approved drugs are utilized. The Medicare allowable for Avastin (bevacizumab, Genentech) is $69, for Lucentis (ranibizumab, Genentech) is $1,189 and for Eylea (aflibercept, Regeneron) is $1,961. The expenditure on these drugs by CMS is approaching 25% of the entire Part B Medicare drug expenditure. As indications expand, the population ages, and the number of Americans with diabetes and wet AMD grows, one has to be concerned that the cost of anti-VEGF therapy will break the bank. We have been challenged by our federal government to pursue the “triple aim” — generate good outcomes, achieve high patient satisfaction and reduce costs. While I strongly believe that a good return on investment for the pharmaceutical industry is required to catalyze investment and the innovation cycle, the cost of anti-VEGF drugs is stressing many countries’ health care budgets and may soon do the same in the U.S. I do not have the answer, but in the field of cataract surgery, innovation over time significantly reduced the cost per case as surgical volumes expanded. The same needs to occur for anti-VEGF therapy.

My third impression is that, for many indications, the outcomes achieved with the three drugs available are equivalent. This suggests to me that the lower-cost alternatives are reasonable for many patients. However, for some indications, such as diabetic macular edema presenting with a visual acuity of 20/50 or worse, the selection of Eylea seems indicated by the superior outcomes achieved in the Protocol T studies: 19 letters of improvement for Eylea vs. 14 for Lucentis and 12 for Avastin at 1 year. Eylea also generated a greater reduction in macular thickness, with 169 µm for Eylea, 147 µm for Lucentis and 101 µm for Avastin.

Fourth, it is important for the comprehensive ophthalmologist to be familiar with the side effects and adverse events associated with these injections. In most studies the most common complications were vitreous hemorrhage in about 3% of cases and elevated IOP in about 11%. Systemic side effects, including cardiovascular events, were rare and similar with all three drugs. Endophthalmitis is very rare, less than one per 2,000.

Click here to read the full publication exclusive, Lindstrom's Perspective, published in Ocular Surgery News U.S. Edition, February 25, 2017.