[The treatment of the exsudative age-related macular degeneration with choroidal neovascular membrane, its possibilities and economical indexes].
OBJECTIVE
To establish the probable prevalence and incidence of the exsudative (wet) age-related macular degeneration (AMD) in the Czech Republic and to compare possibilities and the expensiveness of the photodynamic therapy (PDT) and the treatment with substances blocking the vascular endothelial growth factor (anti-VEGF).


METHODS
The calculation of the probable prevalence and incidence of the exsudative AMD in the Czech Republic (CR) was based on the world epidemiological studies. The expenses of the PDT and the anti-VEGF treatment for the patient and for the health insurances were based on the calculation of the Visudyne and anti-VEGF substances' prices in CR and worldwide.


RESULTS
If the European prevalence of the exsudative AMD in patients over 65 years of age is 2.3% and the prevalence of the risk soft drusen is 15 %, so in the CR out of 1.44 millions of inhabitants older than 65 years have approximately 33 000 the AMD, and the drusen at risk 216.000 inhabitants. If the 5-years incidence of the exsudative AMD in patients with drusen at risk is 3.4%, it may be expected the turn of the soft drusen into the exsudative AMD during the 5-years period in 7340 patients, or 1460 patients a year. The PDT is indicated in approx. 20% of exsudative AMD with the classical or predominantly classical choroid neovascularization (CNV), i.e. approx. 300 patients a year. If, at the average, 5.6 PDT sessions during 2 years are needed and the price is 42.500 CZK (Czech Crowns; 1 USD = approx. 20-22 CZK; 1 Euro = approx. 27-29 CZK) for one injection of Visudyne, so the average cost per patient is 238,000 CZK and the costs for all of them 71.4 millions of CZK. If the patient's participation is 7395 CZK per one dose of Visudyne, then the average patient's expense for the PDT during the 2 years period is 41 412 CZK. Anti-VEFG drugs as intravitreal injections are effective in all forms of exsudative AMD. Macugen (pegaptanib), already registered in the CR, should be applied in six-weeks intervals, during the two-years treatment period altogether up to 17 injections. At the price of 1000 USD for one application, the average treatment cost is 17,000 USD (= approx. 350, 000 CZK). If the one-year incidence of exsudative AMD is 1460 patients,their treatment with Macugen would cost 511 mil. CZK, and the treatment of 1140 patients with occult CNV not suitable for PDT would cost 410 mil. CZK. Lucentis (ranibizumab), which is about to be registered in the CR, is applied in one-months intervals, during two years altogether up to 20 injections. At the price 1200 USD a dose, the treatment costs for one patient would be 24,000 USD (approx. 500 000 CZK), treatment of all patients with exsudative AMD 730 mil. CZK, and costs for patients not suitable-for PDT treatment would be 585 mil. CZK. The intravitreal application of Avastin (bevacizumab) is "off label"; in the first three months is applied monthly, and later on, in 1-3 months interval, until the disappearance of exsudative changes. The maximum of applications is 10 injections during 2 years. At the price 3000 CZK for 1 injection, the treatment costs for one patient would be 30,000 CZK; treatment costs for all patients would be 43.8 mil. CZK, and for patients not suitable for PDT would be 34.8 mil. CZK.


CONCLUSIONS
Nowadays, the PDT and anti-VEFG substances are the optimal treatment methods in exsudative AMD with CNV. PDT i s indicated in theclassical or predominantly classical choroid neovascularization (CNV), anti-VEFG drugs are effective in all forms of exsudative AMD. The high prices of Visudyne, Macugen, and Lucentis create barriers to their general use in all patients with exsudative AMD. Ten times lower price of "off label" applied Avastin supports its use in the competition with other anti-VEGF drugs. The combination of PDT with anti-VEGF drugs suggests the possible way, how to, not only, improve the effectiveness, but also to lower the number of applications, and by this means, also to reduce the economical expenses of the treatment dramatically.
Karel
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Ocní klinika JL, Praha 5, Nové Butovice.
D000368:Aged; D000911:Antibodies, Monoclonal / Q000191:economics / Q000627:therapeutic use; D020256:Choroidal Neovascularization / Q000150:complications*; D018153:Czech Republic / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008268:Macular Degeneration / Q000150:complications / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D010778:Photochemotherapy / Q000191:economics*; D015995:Prevalence; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors
D000911:Antibodies, Monoclonal; D042461:Vascular Endothelial Growth Factor A