A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN)
Background: Bevacizumab (Avastin®, Roche), which is used in cancer therapy, is the ‘parent’ molecule from which ranibizumab (Lucentis®, Novartis) was derived for the treatment of neovascular age-related macular degeneration (nAMD). There were reports in the literature on the effectiveness of bevaciz...
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NIHR Journals Library
2015-10-01
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Series: | Health Technology Assessment |
Online Access: | https://doi.org/10.3310/hta19780 |
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Article |
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DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Usha Chakravarthy Simon P Harding Chris A Rogers Susan Downes Andrew J Lotery Helen A Dakin Lucy Culliford Lauren J Scott Rachel L Nash Jodi Taylor Alyson Muldrew Jayashree Sahni Sarah Wordsworth James Raftery Tunde Peto Barnaby C Reeves |
spellingShingle |
Usha Chakravarthy Simon P Harding Chris A Rogers Susan Downes Andrew J Lotery Helen A Dakin Lucy Culliford Lauren J Scott Rachel L Nash Jodi Taylor Alyson Muldrew Jayashree Sahni Sarah Wordsworth James Raftery Tunde Peto Barnaby C Reeves A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) Health Technology Assessment |
author_facet |
Usha Chakravarthy Simon P Harding Chris A Rogers Susan Downes Andrew J Lotery Helen A Dakin Lucy Culliford Lauren J Scott Rachel L Nash Jodi Taylor Alyson Muldrew Jayashree Sahni Sarah Wordsworth James Raftery Tunde Peto Barnaby C Reeves |
author_sort |
Usha Chakravarthy |
title |
A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) |
title_short |
A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) |
title_full |
A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) |
title_fullStr |
A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) |
title_full_unstemmed |
A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN) |
title_sort |
randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to inhibit vegf in age-related choroidal neovascularisation (ivan) |
publisher |
NIHR Journals Library |
series |
Health Technology Assessment |
issn |
1366-5278 2046-4924 |
publishDate |
2015-10-01 |
description |
Background: Bevacizumab (Avastin®, Roche), which is used in cancer therapy, is the ‘parent’ molecule from which ranibizumab (Lucentis®, Novartis) was derived for the treatment of neovascular age-related macular degeneration (nAMD). There were reports in the literature on the effectiveness of bevacizumab in treating nAMD, but no trials. The cost per dose of bevacizumab is about 5–10% that of ranibizumab. This trial was a head-to-head comparison of these two drugs. Objective: To compare the clinical effectiveness and cost-effectiveness of ranibizumab and bevacizumab, and two treatment regimens, for nAMD. Design: Multicentre, factorial randomised controlled trial with within-trial cost–utility and cost-minimisation analyses from the perspective of the UK NHS. Participants, health professionals and researchers were masked to allocation of drug but not regimen. Computer-generated random allocations to combinations of ranibizumab or bevacizumab, and continuous or discontinuous regimen, were stratified by centre, blocked and concealed. Setting: Twenty-three ophthalmology departments in NHS hospitals. Participants: Patients ≥ 50 years old with active nAMD in the study eye with best corrected distance visual acuity (BCVA) ≥ 25 letters measured on a Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. Previous treatment for nAMD, long-standing disease, lesion diameter > 6000 µm, thick blood at the fovea and any other confounding ocular disease were exclusion criteria. One eye per participant was studied; the fellow eye was treated according to usual care, if required. Interventions: Ranibizumab and bevacizumab were procured commercially. Doses were ranibizumab 0.5 mg or bevacizumab 1.25 mg. The repackaged bevacizumab was quality assured. All participants were treated at visits 0, 1 and 2. Participants randomised to the continuous regimen were treated monthly thereafter. Participants randomised to the discontinuous regimen were not retreated after visit 2 unless pre-specified criteria for active disease were met. If retreatment was needed, monthly injections over 3 months were mandated. Main outcome measures: The primary outcome was BCVA. The non-inferiority margin was 3.5 letters. Secondary outcomes were contrast sensitivity; near visual acuity; reading index; neovascular lesion morphology; generic and disease-specific patient-reported outcomes, including macular disease-specific quality of life; survival free from treatment failure; resource use; quality-adjusted life-years (QALYs); and development of new geographic atrophy (GA) (outcome added during the trial). Results are reported for the study eye, except for patient-reported outcomes. Results: Between 27 March 2008 and 15 October 2010, 610 participants were allocated and treated (314 ranibizumab, 296 bevacizumab; at 3 months, 305 continuous, 300 discontinuous). After 2 years, bevacizumab was neither non-inferior nor inferior to ranibizumab [–1.37 letters, 95% confidence interval (CI) –3.75 to +1.01 letters] and discontinuous treatment was neither non-inferior nor inferior to continuous treatment (–1.63 letters, 95% CI –4.01 to +0.75 letters). Lesion thickness at the fovea was similar by drug [geometric mean ratio (GMR) 0.96, 95% CI 0.90 to 1.03; p = 0.24] but 9% less with continuous treatment (GMR 0.91, 95% CI 0.85 to 0.97; p = 0.004). Odds of developing new GA during the trial were similar by drug [odds ratio (OR) 0.87, 95% CI 0.61 to 1.25; p = 0.46] but significantly higher with continuous treatment (OR 1.47, 95% CI 1.03 to 2.11; p = 0.033). Safety outcomes did not differ by drug but mortality was lower with continuous treatment (OR 0.47, 95% CI 0.22 to 1.03; p = 0.05). Continuous ranibizumab cost £3.5M per QALY compared with continuous bevacizumab; continuous bevacizumab cost £30,220 per QALY compared with discontinuous bevacizumab. These results were robust in sensitivity analyses. Conclusions: Ranibizumab and bevacizumab have similar efficacy. Discontinuing treatment and restarting when required results in slightly worse efficacy. Safety was worse with discontinuous treatment, although new GA developed more often with continuous treatment. Ranibizumab is not cost-effective, although it remains uncertain whether or not continuous bevacizumab is cost-effective compared with discontinuous bevacizumab at £20,000 per QALY threshold. Future studies should focus on the ocular safety of the two drugs, further optimisation of treatment regimens and criteria for stopping treatment. Trial registration: Current Controlled Trials ISRCTN92166560. Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 78. See the NIHR Journals Library website for further project information. |
url |
https://doi.org/10.3310/hta19780 |
work_keys_str_mv |
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doaj-f812995b8dcc423880e3a1ac57b1b1ef2020-11-24T21:18:01ZengNIHR Journals LibraryHealth Technology Assessment1366-52782046-49242015-10-01197810.3310/hta1978007/36/01A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN)Usha Chakravarthy0Simon P Harding1Chris A Rogers2Susan Downes3Andrew J Lotery4Helen A Dakin5Lucy Culliford6Lauren J Scott7Rachel L Nash8Jodi Taylor9Alyson Muldrew10Jayashree Sahni11Sarah Wordsworth12James Raftery13Tunde Peto14Barnaby C Reeves15Centre for Experimental Medicine, Institute of Clinical Science, Queen’s University Belfast, Belfast, UKDepartment of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UKClinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UKOxford University Hospitals NHS Trust, Oxford, UKClinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UKHealth Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UKClinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UKClinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UKClinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UKClinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UKCentre for Experimental Medicine, Institute of Clinical Science, Queen’s University Belfast, Belfast, UKDepartment of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UKHealth Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UKWessex Institute, University of Southampton, Southampton, UKNational Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UKClinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UKBackground: Bevacizumab (Avastin®, Roche), which is used in cancer therapy, is the ‘parent’ molecule from which ranibizumab (Lucentis®, Novartis) was derived for the treatment of neovascular age-related macular degeneration (nAMD). There were reports in the literature on the effectiveness of bevacizumab in treating nAMD, but no trials. The cost per dose of bevacizumab is about 5–10% that of ranibizumab. This trial was a head-to-head comparison of these two drugs. Objective: To compare the clinical effectiveness and cost-effectiveness of ranibizumab and bevacizumab, and two treatment regimens, for nAMD. Design: Multicentre, factorial randomised controlled trial with within-trial cost–utility and cost-minimisation analyses from the perspective of the UK NHS. Participants, health professionals and researchers were masked to allocation of drug but not regimen. Computer-generated random allocations to combinations of ranibizumab or bevacizumab, and continuous or discontinuous regimen, were stratified by centre, blocked and concealed. Setting: Twenty-three ophthalmology departments in NHS hospitals. Participants: Patients ≥ 50 years old with active nAMD in the study eye with best corrected distance visual acuity (BCVA) ≥ 25 letters measured on a Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. Previous treatment for nAMD, long-standing disease, lesion diameter > 6000 µm, thick blood at the fovea and any other confounding ocular disease were exclusion criteria. One eye per participant was studied; the fellow eye was treated according to usual care, if required. Interventions: Ranibizumab and bevacizumab were procured commercially. Doses were ranibizumab 0.5 mg or bevacizumab 1.25 mg. The repackaged bevacizumab was quality assured. All participants were treated at visits 0, 1 and 2. Participants randomised to the continuous regimen were treated monthly thereafter. Participants randomised to the discontinuous regimen were not retreated after visit 2 unless pre-specified criteria for active disease were met. If retreatment was needed, monthly injections over 3 months were mandated. Main outcome measures: The primary outcome was BCVA. The non-inferiority margin was 3.5 letters. Secondary outcomes were contrast sensitivity; near visual acuity; reading index; neovascular lesion morphology; generic and disease-specific patient-reported outcomes, including macular disease-specific quality of life; survival free from treatment failure; resource use; quality-adjusted life-years (QALYs); and development of new geographic atrophy (GA) (outcome added during the trial). Results are reported for the study eye, except for patient-reported outcomes. Results: Between 27 March 2008 and 15 October 2010, 610 participants were allocated and treated (314 ranibizumab, 296 bevacizumab; at 3 months, 305 continuous, 300 discontinuous). After 2 years, bevacizumab was neither non-inferior nor inferior to ranibizumab [–1.37 letters, 95% confidence interval (CI) –3.75 to +1.01 letters] and discontinuous treatment was neither non-inferior nor inferior to continuous treatment (–1.63 letters, 95% CI –4.01 to +0.75 letters). Lesion thickness at the fovea was similar by drug [geometric mean ratio (GMR) 0.96, 95% CI 0.90 to 1.03; p = 0.24] but 9% less with continuous treatment (GMR 0.91, 95% CI 0.85 to 0.97; p = 0.004). Odds of developing new GA during the trial were similar by drug [odds ratio (OR) 0.87, 95% CI 0.61 to 1.25; p = 0.46] but significantly higher with continuous treatment (OR 1.47, 95% CI 1.03 to 2.11; p = 0.033). Safety outcomes did not differ by drug but mortality was lower with continuous treatment (OR 0.47, 95% CI 0.22 to 1.03; p = 0.05). Continuous ranibizumab cost £3.5M per QALY compared with continuous bevacizumab; continuous bevacizumab cost £30,220 per QALY compared with discontinuous bevacizumab. These results were robust in sensitivity analyses. Conclusions: Ranibizumab and bevacizumab have similar efficacy. Discontinuing treatment and restarting when required results in slightly worse efficacy. Safety was worse with discontinuous treatment, although new GA developed more often with continuous treatment. Ranibizumab is not cost-effective, although it remains uncertain whether or not continuous bevacizumab is cost-effective compared with discontinuous bevacizumab at £20,000 per QALY threshold. Future studies should focus on the ocular safety of the two drugs, further optimisation of treatment regimens and criteria for stopping treatment. Trial registration: Current Controlled Trials ISRCTN92166560. Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 78. See the NIHR Journals Library website for further project information.https://doi.org/10.3310/hta19780 |