Real-world injection frequency and cost of ranibizumab and aflibercept for the treatment of neovascular age-related macular degeneration and diabetic macular edema

Abstract

BACKGROUND: Ranibizumab and aflibercept are FDA-approved treatments for patients with neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME). Although these agents differ in cost and labeled dosing, it is unclear whether these differences are reflected in clinical practice. OBJECTIVE: To compare the real-world frequency and cost of ranibizumab and aflibercept injections among treatment-naive and previously treated patients with nAMD and DME. METHODS: Claims data from MarketScan Research Databases were retrospectively reviewed to identify treatment-naive patients with nAMD who initiated intravitreal ranibizumab or aflibercept between January 1, 2014, and January 1, 2016, and treatment-naive patients with DME who initiated intravitreal ranibizumab or aflibercept between July 29, 2014, and July 1, 2016. Patients who switched to subsequent-line aflibercept or ranibizumab during the study period were eligible to enter previously treated subgroups. Multivariable regression models were derived to compare the per-patient frequency and cost of injections between ranibizumab- and aflibercept-treated patients with nAMD over 12 months (treatment-naive: n=1,087 and n=1,578; previously treated: n=221 and n=751) and 24 months (treatment-naive: n=454 and n=568; previously treated: n=93 and n=284) and in patients with DME over 6 months (treatment-naive: n=507 and n=681; previously treated: n=53 and n=223) and 12 months (treatment-naive: n=326 and n=382; previously treated: n=24 and n=122). RESULTS: After adjusting for patient demographics and clinical characteristics, per-patient injection frequency and cost were not significantly different between treatment-naive patients with nAMD who received ranibizumab versus aflibercept over 12 months (5.62 vs. 5.54; P=0.52, and $11,351 vs. $10,702; P=0.06, respectively) and 24 months (7.86 vs. 8.37; P=0.16, and $16,286 vs. $16,666; P=0.69, respectively). In previously treated patients with nAMD, injection frequency was significantly lower among ranibizumab- versus aflibercept-treated patients over 24 months (7.98 vs. 9.63; P=0.03), whereas treatment costs were comparable over 12 months ($11,512 vs. $12,050; P=0.44) and 24 months ($16,303 vs. $19,361; P=0.13). In treatment-naive patients with DME, ranibizumab was associated with significantly fewer injections and lower costs than aflibercept over 6 months (2.60 vs. 2.92 and $3,379 vs. $5,925, respectively; both P<0.001) and 12 months (3.33 vs. 3.87 and $4,136 vs. $7,656, respectively; both P<0.001). Similar cost savings were observed among previously treated patients with DME who received ranibizumab over 6 months ($3,834 vs. $6,775 for aflibercept; P=0.0001) and 12 months ($4,606 vs. $9,190; P=0.02), despite nonsignificant differences in injection frequency during follow-up. CONCLUSIONS: Although the frequency and cost of ranibizumab and aflibercept injections were generally comparable among patients treated for nAMD, ranibizumab was associated with estimated per-patient-per-year cost savings of $3,500-$4,500 in those treated for DME. Most patients received fewer injections than any FDA-indicated dosing schedule, suggesting potential undertreatment that may result in suboptimal vision outcomes.