Age-related macular degeneration: treatment at what cost?

Abstract

An estimated 8·4 million people worldwide have moderate to severe vision loss caused by age-related macular degeneration (AMD). A Seminar by Paul Mitchell and colleagues in today's Lancet describes the latest developments in this devastating condition. The first symptoms of visual distortion or scotoma in one eye might indicate early-phase disease. Later stage AMD is classed as either wet, characterised by choroidal neovascularisation, or dry, characterised by atrophy. Beyond slowing disease progression with micronutrient supplementation, atrophic AMD has no treatment. Wet AMD, however, can now be managed very successfully with repeated intravitreal injections of anti-VEGF drugs, two of which are now licensed in the UK, ranibizumab (Lucentis) and aflibercept (Eylea). The rate of blindness attributed to AMD has fallen by around 50% in some countries. The main drawback of this treatment is the cost. Each injection costs up to £800, and most patients require around eight injections per year. A third very similar drug, bevacizumab (Avastin), which costs only £28 per injection, had very similar efficacy to ranibizumab and aflibercep in several studies including the IVAN trial (funded by the UK Department of Health). Bevacizumab is widely used in other countries including the USA and Australia for AMD, and in the UK for other conditions that also cause neovascularisation (eg, diabetic retinopathy). But because it is not licensed for AMD in the UK, this cheaper alternative is not used widely in the NHS for this common condition. On Sept 21, the UK High Court found in favour of 12 clinical commissioning groups in the northeast of England who were taken to court by Novartis and Bayer, the manufacturers of ranibizumab and aflibercept, for offering the cheaper unlicensed alternative, bevacizumab, to NHS patients. Bayer and Novartis are considering appealing the decision. The decision to allow physicians to use bevacizumab on cost grounds was welcomed the Royal College of Opthalmologists who have campaigned on this issue since 2012, estimating that the adoption of bevacizumab would release £500 million per year back to the NHS. In the UK at least, this might be the beginning of a new era for AMD and could give doctors the freedom to prescribe the cheaper unlicensed alternative. Age-related macular degenerationAge-related macular degeneration is a leading cause of visual impairment and severe vision loss. Clinically, it is classified as early-stage (medium-sized drusen and retinal pigmentary changes) to late-stage (neovascular and atrophic). Age-related macular degeneration is a multifactorial disorder, with dysregulation in the complement, lipid, angiogenic, inflammatory, and extracellular matrix pathways implicated in its pathogenesis. More than 50 genetic susceptibility loci have been identified, of which the most important are in the CFH and ARMS2 genes. Full-Text PDF