title: Triple combination therapy and zeaxanthin for the treatment of neovascular age-related macular degeneration: an interventional comparative study and cost-effectiveness analysis.
abstract: BACKGROUND
  Reports of triple combination therapy for neovascular age-related macular degeneration (AMD) suggest a benefit, as do reports for zeaxanthin. An interventional comparative study was thus undertaken to evaluate the efficacy of triple combination therapy with and without zeaxanthin, as well as the economic viability of the therapies.
  
  
  METHODS
  The cases of 543 consecutive eyes of 424 patients with subfoveal choroidal neovascularization (CNV) secondary to AMD were reviewed. All eyes were treated with triple combination therapy (triple therapy) consisting of: (1) reduced-fluence photodynamic therapy with verteporfin, (2) intravitreal bevacizumab and (3) intravitreal dexamethasone. Therapy was repeated as necessary. One cohort of patients was also given supplementation with 20 mg of oral zeaxanthin (Zx) daily.
  
  
  RESULTS
  The triple therapy group without Zx received a mean of 2.8 treatment cycles and 87 % of patients had stable or improved vision at 24 months. In the triple therapy group with Zx, the mean number of treatment cycles was 2.1, with 83 % of patients having stable or improved vision at 24 months. At 24 months, CNV developed in 12.5 % of fellow eyes treated with triple therapy alone; CNV developed in 6.25 % of eyes treated with triple therapy with Zx (p = 0.03). An average cost-utility analysis revealed that triple therapy was cost-effective with a cost-utility ratio of $26,574/QALY, while triple therapy with Zx was more cost-effective with an average cost-utility ratio of $19,962/QALY. The incremental cost-utility analysis assessing the addition of Zx to triple therapy disclosed Zx supplementation was very cost-effective at $5302/QALY. When it was assumed that triple therapy with Zx reduced fellow eye CNV development by 30.3 %, the incremental cost-utility dropped to (-$6332/QALY), indicating that adding Zx to triple therapy yielded greater patient value, and was also less expensive than using triple therapy alone.
  
  
  CONCLUSIONS
  Triple therapy is comparatively effective and cost-effective. Considerably less treatment is needed than reported in monotherapy studies. The addition of oral Zx appears to further reduce the treatment cycles required, and possibly reduce the risk of CNV development in the fellow eye.
authors.affiliation: The Center for Value-Based Medicine®, Box 335, Flourtown, PA 19031 USA.|The Retina Center of St. Louis County, St. Louis, MO USA.
authors.forename: R Joseph
authors.initials: RJ
authors.lastname: Olk
authors.affiliation: The Center for Value-Based Medicine®, Box 335, Flourtown, PA 19031 USA.|The Retina Center of St. Louis County, St. Louis, MO USA.
authors.forename: Enrique
authors.initials: E
authors.lastname: Peralta
authors.affiliation: The Center for Value-Based Medicine®, Box 335, Flourtown, PA 19031 USA.|ZeaVision, 680F Crown Industrial Court, Chesterfield, MO 63005 USA.
authors.forename: Dennis L
authors.initials: DL
authors.lastname: Gierhart
authors.affiliation: The Center for Value-Based Medicine®, Box 335, Flourtown, PA 19031 USA.|Retina Service, Wills Eye Hospital, Jefferson Medical College, philadelphia, PA USA.
authors.forename: Gary C
authors.initials: GC
authors.lastname: Brown
authors.affiliation: The Center for Value-Based Medicine®, Box 335, Flourtown, PA 19031 USA.|Research Department, Wills Eye Hospital, Jefferson Medical College, philadelphia, PA USA.
authors.forename: Melissa M
authors.initials: MM
authors.lastname: Brown
keywords: Combination therapy; Cost-effective; Macular pigment; Neovascular age-related macular neovascularization; Zeaxanthin