Protocol AC shows cost-effectiveness of using bevacizumab first in center-involved DME
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SEATTLE — In eyes with center-involved diabetic macular edema, using bevacizumab first and switching to aflibercept if needed is more cost-effective over 2 years as compared with aflibercept monotherapy, according to DRCR Protocol AC.
Protocol T showed benefit of aflibercept over bevacizumab at 1 and 2 years, but the 15-letter gain at 2 years was comparable between the two drugs. Given the cost difference of these findings, Protocol AC investigated the potential cost-effectiveness of using bevacizumab first with a switch to aflibercept if needed in eyes with moderate to severe vision loss from center-involved DME over 2 years.
“We performed Protocol AC in which 312 eyes with center-involved DME with central subfield thickness [above gender-specific thresholds and visual acuity of] 20/50 or worse were given either aflibercept monotherapy or bevacizumab first and then switched to aflibercept based on prespecified suboptimal response criteria for visual acuity and central subfield thickness,” Mathew W. MacCumber, MD, PhD, said at the American Society of Retina Specialists annual meeting.
Cost included clinic visits, OCT, injection and anti-VEGF costs. Quality-adjusted life years were used as a measure of health utility, and the incremental cost-effectiveness ratio was calculated as the difference in cost divided by the difference in outcomes.
Visits and number of injections were similar between the groups up to 2 years. In the bevacizumab-first group, about two-thirds of patients required a switch to aflibercept. Visual acuity gains were also similar in both groups.
The increased cost for aflibercept monotherapy was more than $12,500 per participant over 2 years.
“If we look at cost-effectiveness, for aflibercept the cost was substantial when using it as monotherapy, about $26,000 across 2 years. For bevacizumab first, the cost was about $14,000, with the incremental difference of $12,575. If we look at quality-adjusted life years over 2 years, there was a small benefit, 0.015, [in favor of aflibercept monotherapy], but if we do that division, we find that over $800,000 was the incremental cost-effectiveness ratio,” MacCumber said.
A limitation of the study was that the results were based on a single trial and 2-year outcomes.
“We didn’t look at longer-term potential impacts,” he said.
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MacCumber MW. Cost-effectiveness of aflibercept monotherapy versus bevacizumab-first for diabetic macular edema (Protocol AC). Presented at: American Society of Retina Specialists annual meeting; July 28-Aug. 1, 2023; Seattle.
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