Letter to the Editor
The diabetic retinopathy clinical research network analysis of the cost-effectiveness of aflibercept, bevacizumab and ranibizumab for the treatment of diabetic macular oedema and its application in Spain
Análisis del DRCR Network sobre coste-efectividad de aflibercept, bevacizumab y ranibizumab para el tratamiento de edema macular diabético y su aplicación en España
A. Navarro-Navarroa,
, D. Saloma, J.J. Martínez-Toldosb, P. Udaondoc, C. Fernández-Martínezb, L. Gutiérrez-Ariasa, A. Hervása, R. Rodrigod
Corresponding author
a Servicio de Oftalmología, Hospital de Manises, Manises, Valencia, Spain
b Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain
c Servicio de Oftalmología, Hospital Universitario La Fe, Valencia, Spain
d Grupo de Biomedicina Molecular, Celular y Genómica, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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"apellidos" => "Udaondo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "C." "apellidos" => "Fernández-Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "L." "apellidos" => "Gutiérrez-Arias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "A." "apellidos" => "Hervás" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "R." "apellidos" => "Rodrigo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital de Manises, Manises, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital General Universitario de Elche, Elche, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Grupo de Biomedicina Molecular, Celular y Genómica, Instituto de Investigación Sanitaria La Fe, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis del DRCR <span class="elsevierStyleItalic">Network</span> sobre coste-efectividad de aflibercept, bevacizumab y ranibizumab para el tratamiento de edema macular diabético y su aplicación en España" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Macular disease is one of the main causes of overburdened ophthalmology departments due to the appearance of new pharmacological therapies that, in addition, involve high costs and the need of adequately managing available resources.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A cost-effectiveness study was recently published comparing the 3 anti-VEGF medicaments used at present for intravitreal treatment of diabetic macular oedema (DME).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Said study analyzed the incremental cost-effectiveness ratios of aflibercept, bevacizumab and ranibizumab with a <span class="elsevierStyleItalic">post hoc</span> analysis of data obtained in a previous clinical trial of the same group in the United States about comparative effectiveness. The conclusion was that aflibercept and ranibizumab are not cost-effective when compared to bevacizumab for treating DME unless their price diminishes considerably.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Other studies carried out in Europe have analyzed the cost-effectiveness of said medicaments for age-related macular degeneration<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">2,3</span></a> and reached similar conclusions. As in the United States, these studies also utilized a vial of aflibercept and ranibizumab per patient. However, it must be noted that these calculations are based on the current costs in the respective countries and that, in contrast with many Spanish hospitals, the bevacizumab vial is divided, which is not done with aflibercept or ranibizumab.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain, as the vials of these 2 drugs have 0.28 and 0.23<span class="elsevierStyleHsp" style=""></span>ml, respectively, they are usually split in 3 doses having 0.07<span class="elsevierStyleHsp" style=""></span>ml, which is the required dose for each injection, in order to considerably diminish the cost of treating each patient. This practice has been carried out for years, in the case of the Community of Valencia with the agreement of the High Health and/or Economic Impact Medicaments Committee (MAISE), demonstrating effectiveness rates similar to those obtained without splitting vials in daily clinical practice. By splitting aflibercept vials in 3 doses, the cost of 612.31<span class="elsevierStyleHsp" style=""></span>€ per vial as per the agreement with the Social Security goes down to 204.1<span class="elsevierStyleHsp" style=""></span>€ for each injection. In the case of ranibizumab, the cost of each injection goes down from 644.54<span class="elsevierStyleHsp" style=""></span>€ to 214.85<span class="elsevierStyleHsp" style=""></span>€.</p><p id="par0025" class="elsevierStylePara elsevierViewall">According to the article published by Ross et al.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> the maximum price per injection to consider aflibercept as cost-effective against bevacizumab is of 240<span class="elsevierStyleHsp" style=""></span>$ (226.6<span class="elsevierStyleHsp" style=""></span>€) for the first year and 570<span class="elsevierStyleHsp" style=""></span>$ (538.1<span class="elsevierStyleHsp" style=""></span>€) for 10 years, while 4 ranibizumab the maximum price would be 100<span class="elsevierStyleHsp" style=""></span>$ (94.3<span class="elsevierStyleHsp" style=""></span>€) for the first year and 230<span class="elsevierStyleHsp" style=""></span>$ (217.1<span class="elsevierStyleHsp" style=""></span>€) for 10 years. Extrapolating the results of said study to the Spanish population, it can be concluded that aflibercept would be cost-effective in the context of the public health system of Spain for treating DME, even from the first year, and ranibizumab would also be cost-effective in a 10-year projection. Even though the overall costs in the United States are not comparable to those of Spain, which constitutes a limitation for drawing definitive conclusions, we do consider that the obtained results support the current management policy splitting aflibercept and ranibizumab vials.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Navarro-Navarro A, Salom D, Martínez-Toldos JJ, Udaondo P, Fernández-Martínez C, Gutiérrez-Arias L, et al. Análisis del DRCR <span class="elsevierStyleItalic">Network</span> sobre coste-efectividad de aflibercept, bevacizumab y ranibizumab para el tratamiento de edema macular diabético y su aplicación en España. Arch Soc Esp Oftalmol. 2017;92:245–246.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cost-effectiveness of aflibercept, bevacizumab, and ranibizumab for diabetic macular edema treatment: analysis from the diabetic retinopathy clinical research network comparative effectiveness trial" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Diabetic Retinopathy Clinical Research Network" "etal" => false "autores" => array:6 [ 0 => "E.L. Ross" 1 => "D.W. Hutton" 2 => "J.D. Stein" 3 => "N.M. Bressler" 4 => "L.M. Jampol" 5 => "A.R. Glassman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamaophthalmol.2016.1669" "Revista" => array:6 [ "tituloSerie" => "JAMA Ophthalmol" "fecha" => "2016" "volumen" => "134" "paginaInicial" => "888" "paginaFinal" => "896" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27280850" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cost-effectiveness of treating wet age-related macular degeneration at the Kuopio University Hospital in Finland based on a two-eye Markov transition model" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Vottonen" 1 => "E. Kankaanpää" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/aos.13185" "Revista" => array:6 [ "tituloSerie" => "Acta Ophthalmol" "fecha" => "2016" "volumen" => "94" "paginaInicial" => "652" "paginaFinal" => "656" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27481048" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cost-effectiveness of ranibizumab and bevacizumab for age-related macular degeneration: 2-year findings from the IVAN randomised trial" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "IVAN Study Investigators" "etal" => true "autores" => array:6 [ 0 => "H.A. Dakin" 1 => "S. Wordsworth" 2 => "C.A. Rogers" 3 => "G. Abangma" 4 => "J. Raftery" 5 => "S.P. Harding" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmjopen-2014-005094" "Revista" => array:5 [ "tituloSerie" => "BMJ Open" "fecha" => "2014" "volumen" => "4" "paginaInicial" => "e005094" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25079928" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000009200000005/v1_201704260025/S2173579417300634/v1_201704260025/en/main.assets" "Apartado" => array:4 [ "identificador" => "5813" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000009200000005/v1_201704260025/S2173579417300634/v1_201704260025/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579417300634?idApp=UINPBA00004N" ]
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