Cost-effectiveness of anti-vascular endothelial growth factor and macular laser treatments for people with centre-involving diabetic macular oedema and central retinal thickness of at least 400 micrometres

BACKGROUND: Diabetic macular oedema (DMO) is a common cause of vision loss and blindness. To inform the 2024 UK NICE guideline for treating people with centre-involving DMO (CI-DMO) and central retinal thickness (CRT) of ≥400 µm, the cost-effectiveness of various anti-vascular endothelial growth factor (anti-VEGF) and macular laser treatments was evaluated.

METHODS: A de novo Markov model evaluated the lifetime costs and quality-adjusted life-years (QALYs) of various anti-VEGFs (aflibercept, bevacizumab, brolucizumab, faricimab, ranibizumab and ranibizumab biosimilar), macular lasers (standard threshold laser and subthreshold micropulse laser), and some treatment combinations from the perspective of the UK NHS. The model included eight health states defined by best-corrected visual acuity ranging between >85 and ≤25 letters. The model's inputs were derived from published literature, while an original network meta-analysis of several clinical trials informed visual outcomes.

RESULTS: All anti-VEGFs demonstrated greater clinical effectiveness and produced more QALYs (ranging from 9.211 to 9.271) than both types of macular lasers (8.928 and 8.944), but lasers were the most cost-effective due to their substantially lower costs. Using confidential price discounts, ranibizumab biosimilar (Ongavia) and brolucizumab had ICERs below £20,000 per QALY, while aflibercept, ranibizumab (Lucentis) and faricimab had ICERs below £25,000 per QALY, compared to no treatment. Bevacizumab was the most cost-effective anti-VEGF treatment due to its significantly lower cost.

CONCLUSIONS: Given their clinical and cost-effectiveness at confidential prices, NICE recommends offering a licensed cost-effective anti-VEGF as first-line treatment for people with CI-DMO and CRT ≥ 400 µm. The use of bevacizumab for this population is not licensed in the UK and would be considered off-label.