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New VEGF Antagonists in AMD – New Quandaries Abound

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New VEGF Antagonists in AMD – New Quandaries Abound 4 By Nick Lane PhD New VEGF antagonists in AMD – new quandaries abound predominantly classic CNV most suitable But here is the rub. Ranibizumab is a Of course, in both advanced cancer and for treatment with verteporfin PDT. molecular cousin of a larger antibody, wet AMD, angiogenesis is an important Even so, despite the relatively slow known as bevacizumab (molecular weight factor in determining outcome. Genentech disease progression, patients treated with 148 kDa), marketed by Genentech as felt that bevacizumab was too big to ® ffective vascular-endothelial growth- ranibizumab experienced a mean increase Avastin . Engineered on the DNA level, penetrate the retina by intravitreal factor (VEGF) antagonists have been of seven letters VA at 12 months, while ranibizumab has several specific base injection; and while life-threatening adverse a long time coming, after first being patients in the control group had a mean changes that increase its affinity to VEGF. events (a higher risk of thromboembolic E decrease of 10.5 letters. Some 34% of the The FDA approved bevacizumab for events such as stroke and MI) might be proposed back in the 1970s; but now, like London buses, three have arrived at once 0.5 mg-treatment group experienced a treating advanced colorectal cancer in acceptable in treating advanced cancer, for the treatment of wet AMD. Far from better than15-letter gain in VA, compared February 2004, and it is still in trials for systemic treatment with bevacizumab for being just ‘me-too’ drugs in the same class, with 4.6% in the control group. other forms of cancer. AMD seemed to be using a sledgehammer the VEGF antagonists have called attention On behalf of the MARINA Study Group, to crack a nut.The risk of such adverse to difficult issues relating to cost, efficacy, Joan Miller MD (Massachusetts Eye and Ear quality of evidence, share value, and a Infirmary), told delegates at the ASRS potential split between industry, regulators meeting in Montreal,“These data are very and practicing clinicians.The issues have compelling because, for the first time, we repercussions throughout medicine. have a potential treatment which has been What is a cost-effective drug? The first VEGF antagonist to be shown to improve vision in a significant Many new medicines, such as pegaptanib The advantage of using an ICER, or cost approved for AMD was pegaptanib number of patients with wet AMD as (Macugen, Eyetech/Pfizer) or indeed per QALY, is that it is a standard measure (Macugen®, Pfizer/Eyetech), which received opposed to just slowing progression of FDA fast-track approval last December. vision loss.” verteporfin PDT (Visudyne, Novartis), that can give a comparison across Despite this good news, it’s fair to say that Another trial (FOCUS, phase I/II) seem prohibitively expensive, with prices different areas of medicine. Should a the results were disappointing, no doubt compared verteporfin PDT plus often in excess of $1000 per treatment. cash-strapped health system fork out for a for the co-developers.While ranibizumab with PDT alone in patients As probably the best treatment so far, new cancer drug, or ranibizumab, and unquestionably effective at slowing the with predominantly classic CNV.The ranibizumab (Lucentis, Genentech) seems when should it refuse to pay? While rarely progression of neovascular AMD, and the results were similarly encouraging (also certain to follow a similar path. But when stated in as many words, a presumed accompanying loss of visual acuity, hopes presented first directly to the press in does it become simply too expensive to ‘threshold’ cost-effectiveness of $50,000 for a treatment substantially better than May): 90% of patients receiving reimburse? per QALY is generally thought worth verteporfin PDT (Visudyne®, Novartis) combination therapy had stable or paying by reimbursement agencies; any were dashed. improved vision (<15 letters loss) Verteporfin PDT has been mired in cost- more may well not get reimbursed. Some 70% of patients receiving compared with 62% of patients receiving effectiveness issues for almost its whole pegaptanib lost fewer than 15 letters VA PDT alone. time on the market, but newer drugs Given a known efficacy and QALY, this compared with 55% of placebo-injected What may be hidden in the small print is rarely face the same problem. Their cost- means that a pharma company can hardly patients at one year; but only 6% or 7% of still unpublished. In September the FDA effectiveness is virtually guaranteed to be get it wrong now. Simply plug in the patients gained more than 15 letters notified Genentech that it would not grant close to the threshold accepted by number of QALYs gained and calculate compared with 2% in the control group. the company’s request for fast-track society. How so? By wielding the weapon the cost effectiveness threshold. A recent These results are similar to verteporfin review, which allows for a rolling BLA of ICERs per QALY backwards. paper by Sanjay Sharma et al (Can J (Biologics Licence Application). However, PDT, both in terms of efficacy and Ophthalmol, 2005), on anecortave acetate Genentech plans to file for approval this treatment cost, no snippet for pegaptanib The term ICER means incremental cost (Retaane, Alcon) shows how it is done. December, and still have the potential to at around $1000 per injection. effectiveness ratio. The most common They calculate that the threshold cost Higher hopes turned instead to obtain priority review status for definition is simply the ratio of cost to ranibizumab. effectiveness for anecortave works out at ranibizumab (Lucentis®), developed by outcome. Outcome is usually given as a $2986 per vial. The producers, Alcon, can Genentech in partnership with Novartis, QALY, or quality-adjusted life-year gained. Genentech in Competition with Itself argue that at that price it is just as cost- and still in phase III trials. In May 2005, QALYs range from 1, for a full additional effective as other products that have been Genentech announced good one-year data So far, so good.The only surprise, a year in perfect health, to zero, for death. reimbursed in the past. directly to the press, two months before positive one, is that ranibizumab looks It’s also possible to score negative giving ophthalmologists a chance to judge substantially better than pegaptanib. Is this QALYs, for fates considered worse than Of course there is still plenty of scope for for themselves at the American Society of a fluke or real? It might well be real.There death. A QALY of, say, 0.5, implies that dispute. One factor is the time span Retinal Specialists meeting in Montreal at are five or six different isoforms of VEGF, lifespan may not be extended, but quality considered. This is a problem that has the end of July. I call attention to this with differing molecular weights and of life is improved; or that lifespan is frustrated verteporfin PDT. In the UK, the properties.The heavier isoforms are deliberately: giving shareholders priority extended, but quality of life is poor. NHS Health Technology Assessment membrane-bound, whereas the lighter over clinicians is a trend that should not calculated an ICER of £150,000-180,000 isoforms diffuse through the vasculature. be encouraged. Because quality of life is subjective, per QALY, but this was based on a two- But the data do seem to be genuinely Ranibizumab is a humanised antibody that QALYs are also obviously somewhat year period (then the limit of RCT data), extremely encouraging. In the MARINA binds to all the isoforms of VEGF, whereas subjective. QALYs are often high in pegaptanib is a ribonucleic aptamer (a during which time the re-treatment costs trial, 95% of patients treated with ophthalmology, because people value molecule that binds with an affinity that are maximum and the benefits are limited ranibizumab maintained or improved their their sight so highly. For example, a depends on its shape), which binds only to to the two-year period. If the treatment vision (defined as <15 letters loss of VA on recent poll (www.costofblindness.org) the ETDRS charts), versus 62% of placebo- VEGF165.While this is thought to play an benefit persists beyond two years (which revealed that 69% of Canadians would injected patients. If the control group important role in AMD, it is nonetheless it does), but fewer treatments are needed rather lose the use of their legs, or their seems to have done particularly well, this just a single isoform. So differences in both (which they are), then the cost per QALY hearing, than their vision; and those is partly attributable to the patient mechanism of action and target could falls. population, who had minimally classic or account for the observed differences in already legally blind were willing to accept occult CNV lesions, which are generally efficacy. a 50% cut in their remaining years to less aggressive than the classic or recover sight. EuroTimes November 2005 5 events would be virtually eliminated by Ophthalmic Surgery, Lasers and Imaging, in brink of bankruptcy. In other countries, showed that only the smaller antibody intravitreal injection of a smaller antibody July 2005. including much of the EU, reimbursement fragments could penetrate the retina. On that could penetrate the retina, so In an accompanying editorial, Elias is a major issue. that basis, we developed ranibizumab for Genentech developed ranibizumab for Reichel MD, of the New England Eye Verteporfin PDT, for example, has been intravitreal injection.” intravitreal injection. Centre,Tufts University, concluded, stalled at the National Institute for Clinical She noted that in addition to retinal Then in June 2005, Drs Stephan Michels, “Bevacizumab is a readily available drug Excellence (NICE) in the UK for several penetration, the company considered a Philip Rosenfeld and their colleagues at the that costs a fraction of the proposed years, pending the resolution of number of other factors based on pre- Bascom Palmer Eye Institute, University of alternatives.The dramatic findings of interminable cost-effectiveness arguments.
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