Neovascular age-related macular degeneration (nAMD) is a major cause of sight loss in older people and there are about 40,000 new cases in the UK each year. The condition is due to the growth of leaky new blood vessels in the eye, caused by a protein called vascular endothelial growth factor (VEGF). Without treatment, two thirds of people with the condition experience severe loss of sight within two years of being diagnosed.
The condition can be treated by drugs that reduce the effects of the VEGF protein. A number of drugs are available that work in the same way to stop the production of VEGF. Ranibizumab (Lucentis) is an expensive drug and currently licensed to treat nAMD. However some clinicians were using a similar but much cheaper anti-VEGF drug, Bevacizumab (Avastin). These clinicians believed it was just as effective at treating nAMD and that if this could be proved, its use by the wider NHS would lead to huge savings.
In 2007, a team of researchers led by Professor Usha Chakravarthy, of Queen’s University, Belfast set out to compare Lucentis with Avastin in a randomised controlled trial, to find out whether Avastin is as clinically and cost-effective as Lucentis in treating nAMD.
Researchers assessed 610 patients across 23 hospital ophthalmology clinics in England, Wales and Northern Ireland, with each participant being allocated one of the drugs and one of the dosing intensities.
The results showed that Avastin, currently licensed to treat cancer and costing £28 per injection, was just as good as (neither worse nor better) Lucentis, (£561 per injection) in terms of the patients’ best corrected visual acuity.
In the UK, if Avastin were used as the treatment of choice, the NHS would be able to save millions of pounds each year. As in many other countries, some NHS clinicians have used Avastin for many years for the effective treatment of nAMD rather than Lucentis.
The study findings have had an international impact, acting as the basis for recommendations made in the World Health Organisations (WHO) 2017 report ‘The selection and use of essential medicines’, and informed National Institute for Health and Care Excellence (NICE) clinical guidelines on the treatment of nAMD, concluding that Avastin was as safe and effective as Lucentis.
NHS Clinical Commissioners and the Royal College of Ophthalmologists welcomed the fact that NICE had acknowledged the similar safety and effectiveness of all the anti-VEGF drugs. They had been working with the GMC to clarify their position, and in a joint statement, said, “There is now the potential to make considerable cost savings whilst empowering ophthalmologists to make clinical judgements with individual patients on the most appropriate choice of treatment.”
In September 2018, the research helped win a landmark court ruling between two drug companies and 12 Northern Clinical Commissioning Groups (CCGs) which focused on their decision to offer the drug which is not currently licensed to treat wet AMD.
‘The drug is undeniably equally effective, and much less expensive, and will save in excess of £13.5m per year for the 12 CCGs involved in this litigation alone, and hundreds of millions of pounds across the country.-David Hambleton, the CCG chief officer in South Tyneside and former geriatrician
‘The team welcome the fact that the NHS will have the opportunity to extend the use of Avastin to routine clinical practice.-Lead researcher Professor Usha Chakravarthy, of Queen’s University, Belfast
The trials and triumphs of eye health research - a blog by Professor Barnaby Reeves, Co-investigator on the IVAN trial and co-director of the Clinical Trials and Evaluation Unit at Bristol Medical School; Professor Usha Chakravarthy, Chief investigator of the IVAN trial
Read the five year observational follow-up of the IVAN trial cohort: a study of function and morphology
Cohen.D, January 24th 2018. Doctors are cleared to prescribe cheaper drug for wet AMD. British Medical Journal. https://doi.org/10.1136/bmj.k344