Bevacizumab diabetic macular odema guidance

Cornwall & Isles of Scilly
Devon, Plymouth and Torbay
Peninsula Health Technology Commissioning Group

Commissioning decision: Bevacizumab for diabetic macular
oedema

The Peninsula Health Technology Commissioning Group (PHTCG) has come
to a decision on the use of bevacizumab for the treatment of diabetic macular
oedema. This treatment will not be routinely commissioned.

Rationale for the decision

Laser therapy is the accepted standard treatment for most patients who experience clinically significant diabetic macular oedema. Laser cannot be used for oedema affecting the fovea and in such cases intravitreal triamcinolone may be offered. There is evidence from one relatively small randomised controlled trial that bevacizumab is significantly more effective than laser for the treatment of diabetic macular oedema both in terms of an improvement in visual acuity and stabilisation of visual acuity. Two year data from the same trial suggests that the effect of bevacizumab is maintained. No randomised controlled trials were identified comparing long term treatment with bevacizumab with intravitreal triamcinolone given alone as either a single dose or as multiple doses. There is insufficient evidence from randomised controlled trials to support the use of bevacizumab as an adjunct to laser therapy. Health economic evaluation indicates that bevacizumab is not a cost-effective treatment option for this indication compared with laser therapy or with intravitreal triamcinolone. Bevacizumab leads to improved outcomes as compared with laser therapy and intravitreal triamcinolone but there is a large difference in costs for bevacizumab compared with these treatments. Although bevacizumab is relatively inexpensive, the extra cost of regular intravitreal administration and monitoring of patients receiving bevacizumab far outweighs the costs associated with intravitreal triamcinolone or laser. The conclusion drawn from these data is that using bevacizumab in place of laser or intravitreal triamcinolone is poor value for money for the NHS. Guidance notes on exceptionality

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. In reaching its decision, the Peninsula Health Technology Commissioning Group considered efficacy data from the BOLT trial which compared bevacizumab with laser therapy in patients with persistent clinically significant macular oedema and best corrected visual acuity between 6/12 and 6/60. The Royal College of Ophthalmologists’ guidance on diabetic retinopathy (issued 2005) advises that laser therapy is recommended for diabetic macular oedema when vision is 6/9 or less.
Plain language summary

Diabetic macular oedema is a condition in which there is swelling of the retina leading to visual impairment. The standard treatment for this condition is laser therapy. A small clinical trial has shown that bevacizumab is more effective than laser therapy for the treatment of diabetic macular oedema. More patients receiving bevacizumab had an improvement in their vision and fewer patients’ vision worsened during the trial. Some patients who have oedema in the centre of the retina, known as foveal oedema, cannot be treated with laser therapy and are given a drug called triamcinolone by injection into the eye. There is no evidence from clinical trials comparing long term use of bevacizumab with triamcinolone alone. An economic analysis has shown that although bevacizumab is more effective than laser, the costs of administration and monitoring patients receiving bevacizumab outweigh the costs associated with laser therapy or triamcinolone. This is considered to make bevacizumab poor value for money compared to laser therapy or triamcinolone.

Date of decision: 27th June 2012

Source: http://www.kernowccg.nhs.uk/media/102214/bevacizumabdiabeticmacularodema.pdf