Pangaea Express: CADTH recommendations for the Treatment of Retinal Conditions

May 27, 2016

By Marla Weingarten

CADTH carried out a therapeutic review comparing the clinical effectiveness and relative cost of drugs used to treat retinal conditions of age-related macular degeneration (AMD), choroidal neovascularization (CNV), diabetic macular edema (DME), pathologic myopia (PM), and retinal vein occlusion (RVO). The review included aflibercept and ranibizumab, two commonly used anti-VEGF drugs, as well as bevacizumab, also an anti-VEGF agent but approved by Health Canada only for intravenous injection to treat certain types of metastatic cancer.

The review found that all three anti-VEGF drugs have similar clinical effects. Based on the fact that bevacizumab is about one-tenth the cost of the other drugs, the committee recommended the following:

Recommendation 1:

For the treatment of patients with wet AMD, DME, RVO, or CNV due to PM, bevacizumab is the preferred initial anti-VEGF therapy, based on similar clinical effectiveness and lower cost compared with other anti-VEGF treatments. Ranibizumab or aflibercept can be used as alternative treatment options in patients who do not respond to bevacizumab (see Note 1)* or in patients who experience thromboembolism following the initiation of bevacizumab treatment or who are at a high risk of cardiovascular adverse events (see Note 2)*.

Recommendation 2:

There are no specific recommendations for anti-VEGF therapy for any subgroups of patients within any of the conditions of interest.

Recommendation 3:

The frequency and dose of intravitreal injections of the anti-VEGF drugs should be determined by the treating ophthalmologist, but should not exceed that recommended for a particular retinal condition by the product monograph (if available) or that used in randomized clinical trials.

Regarding the safety of bevacizumab for retinal conditions which has been a concern for some patient groups, the review committee stated: “While the Committee concluded that there is no credible, consistent evidence to suggest that properly prepared and handled aliquoted bevacizumab presents a greater risk of harm than other antiVEGF drugs, it did include provisions in the recommendations to ensure that public payers that choose to reimburse bevacizumab for the treatment of retinal conditions have in place appropriate preparation, distribution, and storage procedures, as well as a system to monitor the safety of all anti-VEGF drugs, including bevacizumab.”

*Go here for explanation of notes and more

Bevacizumab is already being reimbursed by public payers for the treatment of retinal conditions in British Columbia, Nova Scotia, New Brunswick, and Manitoba and in Alberta, physicians are able to prescribe the drug for retinal condition that require anti-VEGF treatment. This recommendation by CADTH will surely open the door for other provinces to follow suit and to even list bevacizumab as the preferred drug for retinal conditions.

This recommendation begs the question “What does an NOC really mean"? In addition to bevacizumab, CADTH is also reviewing the use of inflectra (infliximab) for Crohn’s disease and Ulcerative Colitis, neither of which indications were granted NOC by Health Canada. Are economic considerations over-riding Health Canada’s efficacy and safety review process??

For more information contact Marla Weingarten, Consultant, The Pangaea Group