Off-label Use of Avastin in Diabetic Macular Edema More Cost-effective than Eylea

Treating patients with diabetic macular edema first with Avastin (bevacizumab) — and then switching to Eylea (aflibercept) if patients don’t have a response — can result in cost savings without sacrificing visual acuity gains, according to a new study recently published in JAMA Ophthalmology.

In terms of cost-effectiveness, investigators found that over two years, the average cost of Eylea monotherapy was about $26,500 compared with about $14,000 for the Avastin-first group. At 2022 prices, they estimated that for every 10,000 new patients starting therapy, $125 million can be saved using Avastin first.

Macular edema is swelling in part of the retina and can result in blurry vision. A common cause of this edema is diabetic retinopathy, an eye condition that causes vision loss in people with diabetes.

Both Genentech’s Avastin and Regeneron’s Eylea are anti-vascular endothelial growth factors (VEGFs). Anti-VEGFs block the protein that leads to abnormal growth of blood vessels in the eye, which can swell and leak fluid. This can lead to symptoms and retinal damage.

Avastin is a therapy that has been approved to treat patients with several cancers, but it is used off-label to treat eye diseases.

Eylea is approved by the FDA as a treatment treat several eye diseases, including age-related macular degeneration, diabetic retinopathy and diabetic macular edema. A comparative efficacy study of Eylea, Avastin and Genentech’s Lucentis (ranibizumab) showed that all three anti-VEGFs improved visual acuity.

Avastin, however, has a lower price. Based on 2022 Centers for Medicare & Medicaid Services reimbursement rates for dose and injection procedures, Avastin costs $182.06 per injection ($67.86 for the drug and $114.20 for the procedure), according the JAMA Ophthalmology study researchers. Meanwhile, Eylea costs $1,945.69 per injection ($1,831.49 for the drug and $114.20 for the procedure).

The researchers said that, because of this cost difference, some insurance companies may require a patient to start diabetic macular edematreatment with bevacizumab and switch to another anti-VEGF agent if the clinical response is not adequate. 

David W. Hutton, Ph.D.

In the JAMA Ophthalmology study, Investigators led by David W. Hutton, Ph.D., wanted to evaluate the cost and cost-effectiveness of Eylea monotherapy compared with Avastin-first strategies for diabetic macular edema treatment. Hutton is an associate professor at the University of Michigan School of Public Health in Ann Arbor.

They conducted an economic evaluation of 228 patients with diabetic macular degeneration over two years, from Dec. 15, 2017, and Nov. 25, 2019. The Eylea monotherapy group included 116 patients, and the Avastin-first group included 112, of whom 62.5% were eventually switched to Eylea.

Investigators found that the cost of Eylea monotherapy was $26,504 compared with $13,929 for the Avastin-first group, a difference of $12,575. The mean visual acuity letter score for the Eylea group was 58.8 at baseline and 72.4 at two years. For the Avastin-first group, the mean visual acuity letter score was 57.2 at baseline and 72.7 at two years.

“This economic evaluation using a cost-effectiveness analysis found that an aflibercept monotherapy treatment approach is not cost-effective compared with a bevacizumab-first approach for eyes with moderate to severe vision loss from center-involved DME,” investigators wrote. “The health-related quality-of-life gains that favored aflibercept monotherapy in the first year were small and not statistically significant.”

Investigators said that Eylea could be cost-effective with an incremental cost-effectiveness ratio of $100,000 per quality-adjusted life-year if the price per dose were $305 or less or the price of Avastin was $1,307 per dose or more.

Investigators indicated that there were limitations, including that this estimate of cost-effectiveness was just a single, two-year trial and costs were based on Medicare reimbursement values.