Cost-effectiveness of ranibizumab compared with photodynamic treatment of neovascular age-related macular degeneration

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Objective: This study compared the cost-effectiveness of ranibizumab with that of photodynamic therapy (PDT) in the treatment of predominantly classic choroidal neovascularization secondary to age-related macular degeneration (AMD) from the perspective of a third-party payer in a Spanish setting. Methods: We constructed a Markov model with 5 states defined by visual acuity (VA) in the better-seeing eye (Snellen scale), as follows: VA >20/40, ≤20/40 to >20/80, ≤20/80 to >20/200, ≤20/200 to >20/400, and ≤20/400. A death state was also included. We took transition probabilities, number of ranibizumab injections, and number of PDT treatments from the ANCHOR (Anti—Vascular Endothelial Growth Factor Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in Age-Related Macular Degeneration) trial. Utilities were taken from a published study of patients' preferences. We used unit costs from our hospital and drug costs from a national database. Resource utilization was determined by an ophthalmologist according to current clinical practice. We performed univariate, threshold, and probabilistic sensitivity analyses. Incremental costs (2007 €) and quality-adjusted life-years (QALYs), both discounted at a 3% annual rate, and incremental cost-effectiveness ratios (ICERs; €/QALY) were determined for the 2-year and life-expectancy time horizons. Results: Treating patients with varying degrees of visual impairment with ranibizumab instead of PDT, with a 2-year time horizon, was found to be €18,328 more costly and to confer 0.140 additional QALY (€131,275/QALY). This ICER was reduced to €39,398/ QALY for the longer life-expectancy time horizon. According to the probabilistic sensitivity analysis, PDT is the therapy of choice in all cases below the threshold of €30,000/QALY for the 2-year time horizon. Ranibizumab was the optimal intervention in 26% of cases in the longer lifetime horizon. When the initial VA was ≤20/400, the ICER increased to €255,477 over 2 years. When ranibizumab was administered on an as-needed basis, as in the PrONTO (Prospective Optical coherence tomography imaging of patients with Neovascular AMD Treated with intra-Ocular ranibizumab) trial, the ICERs were reduced to €29,566/QALY and €11,469/QALY in the 2-year and life-expectancy horizons, respectively. Conclusions: Based on these results, ranibizumab was not cost-effective when administered on a monthly basis. When administered as needed, ranibizumab was cost-effective compared with PDT for the treatment of AMD.