Cost-effectiveness of ranibizumab and bevacizumab for age-related macular degeneration: 2-year findings from the IVAN randomised trial

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. Design: A within-trial cost-utility analysis with a 2-year time horizon, based on a multicentre factorial, non-inferiority randomised controlled trial. Setting: 23 hospital ophthalmology clinics. Participants: 610 patients aged >= 50 years with untreated nAMD in the study eye. Interventions: 0.5 mg ranibizumab or 1.25 mg bevacizumab given continuously (monthly) or discontinuously (as-needed) for 2 years. Main outcome measures: Quality-adjusted life-years (QALYs). Results: Total 2-year costs ranged from 3002 pound/patient ($4700; 95% CI 2601 pound to 3403) pound for discontinuous bevacizumab to 18 pound 590/patient ($29 106; 95% CI 18 pound 258 to 18 pound 922) for continuous ranibizumab. Ranibizumab was significantly more costly than bevacizumab for both continuous (+14 pound 989/patient ($23 468); 95% CI 14 pound 522 to 15 pound 456; p<0.001) and discontinuous treatment (+8498 pound ($13 305); 95% CI 7700 pound to 9295; pound 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 pound ($938); 95% CI 91 pound to 1107; pound 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 pound 220 ($47 316) per QALY gained versus discontinuous bevacizumab. However, bootstrapping demonstrated that if the NHS is willing to pay 20 pound 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.