title: Cost-effectiveness of ranibizumab and bevacizumab for age-related macular degeneration: 2-year findings from the IVAN randomised trial.
abstract: OBJECTIVE
  To assess the incremental cost and cost-effectiveness of continuous and discontinuous regimens of bevacizumab (Avastin) and ranibizumab (Lucentis) for neovascular age-related macular degeneration (nAMD) from a UK National Health Service (NHS) perspective.
  
  
  METHODS
  A within-trial cost-utility analysis with a 2-year time horizon, based on a multicentre factorial, non-inferiority randomised controlled trial.
  
  
  METHODS
  23 hospital ophthalmology clinics.
  
  
  METHODS
  610 patients aged ≥50 years with untreated nAMD in the study eye.
  
  
  METHODS
  0.5 mg ranibizumab or 1.25 mg bevacizumab given continuously (monthly) or discontinuously (as-needed) for 2 years.
  
  
  METHODS
  Quality-adjusted life-years (QALYs).
  
  
  RESULTS
  Total 2-year costs ranged from £3002/patient ($4700; 95% CI £2601 to £3403) for discontinuous bevacizumab to £18 590/patient ($29 106; 95% CI £18 258 to £18 922) for continuous ranibizumab. Ranibizumab was significantly more costly than bevacizumab for both continuous (+£14 989/patient ($23 468); 95% CI £14 522 to £15 456; p<0.001) and discontinuous treatment (+£8498 ($13 305); 95% CI £7700 to £9295; p<0.001), with negligible difference in QALYs. Continuous ranibizumab would only be cost-effective compared with continuous bevacizumab if the NHS were willing to pay £3.5 million ($5.5 million) per additional QALY gained. Patients receiving continuous bevacizumab accrued higher total costs (+£599 ($938); 95% CI £91 to £1107; p=0.021) than those receiving discontinuous bevacizumab, but also accrued non-significantly more QALYs (+0.020; 95% CI -0.032 to 0.071; p=0.452). Continuous bevacizumab therefore cost £30 220 ($47 316) per QALY gained versus discontinuous bevacizumab. However, bootstrapping demonstrated that if the NHS is willing to pay £20 000/QALY gained, there is a 37% chance that continuous bevacizumab is cost-effective versus discontinuous bevacizumab.
  
  
  CONCLUSIONS
  Ranibizumab is not cost-effective compared with bevacizumab, being substantially more costly and producing little or no QALY gain. Discontinuous bevacizumab is likely to be the most cost-effective of the four treatment strategies evaluated in this UK trial, although there is a 37% chance that continuous bevacizumab is cost-effective.
  
  
  BACKGROUND
  ISRCTN92166560.
authors: Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK.
authors: Helen A
authors: HA
authors: Dakin
authors: Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK.
authors: Sarah
authors: S
authors: Wordsworth
authors: Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
authors: Chris A
authors: CA
authors: Rogers
authors: Swiss Re Services Ltd, Research and Development, London, UK.
authors: Giselle
authors: G
authors: Abangma
authors: Primary Care & Population Sciences, University of Southampton, Southampton, UK.
authors: James
authors: J
authors: Raftery
authors: Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK.
authors: Simon P
authors: SP
authors: Harding
authors: Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
authors: Andrew J
authors: AJ
authors: Lotery
authors: Oxford Eye Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.
authors: Susan M
authors: SM
authors: Downes
authors: Centre for Experimental Medicine, The Queen's University of Belfast, Belfast, UK.
authors: Usha
authors: U
authors: Chakravarthy
authors: Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
authors: Barnaby C
authors: BC
authors: Reeves
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000191:economics* / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000191:economics* / Q000627:therapeutic use; D000068258:Bevacizumab; D003362:Cost-Benefit Analysis; D016527:Drug Costs / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008268:Macular Degeneration / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D000069579:Ranibizumab; D012044:Regression Analysis; D006113:United Kingdom; D014792:Visual Acuity
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; D000068258:Bevacizumab; D000069579:Ranibizumab
keywords: Neovascular age-related macular degeneration (AMD); cost-effectiveness; cost-minimisation analysis; cost-utility analysis; trial-based economic evaluation; vascular endothelial growth factor (VEGF) inhibitors