Joseph Coney, MD, FASRS, FACS, discusses switching anti-VEGF agents in the treatment of wet AMD and what payers should consider when switching anti-VEGF therapies.
Jim Kenney, RPh, MBA: Dr Luo, what’s the value of these newer agents with a longer duration of action in wet AMD [age-related macular degeneration], or longer interval? Does that impact resource utilization and patient quality of life? What are your thoughts there?
Caesar Luo, MD, FASRS, FACS: Absolutely. I’m doing some of these data analyses now because I think when you talk about drugs that are all relatively the same cost, well, if we’re using one drug significantly less, it is going to cost the system less very quickly. That calculus changes very quickly. Right now the data we have, there’s a recent study done out here at UCSF [the University of California San Francisco] that looked at on-label dosing. They compared Lucentis [ranibizumab], aflibercept, and faricimab. They found that if you look at on-label dosing, faricimab over 3 years saves money over the other 2 treatments because of less frequent dosing, even with the higher cost. They looked at WAC, the wholesale acquisition cost, for each drug. For Lucentis, if you stay on label with Q4 [every 4 weeks] dosing, it’s $37,000, and I believe aflibercept was over $6000. They looked at it in a more nuanced fashion, they looked at it in folks who had to travel further to get to their appointments. The further you had to travel, the more that delta became because they had more cost savings with fewer treatments. Again, that’s on-label dosing, which is not what we do. Again, we treat and extend these folks, and I would say the majority of my patients taking aflibercept are not on 8-week dosing. Most of them, I would say are on less than that. If I can get 3, like we’ve seen 2, 4, 6 extra weeks on faricimab, that cost savings should be a conversation these payers have because ultimately it would save them money and be able to maintain quality of life for these patients.
Jim Kenney, RPh, MBA: Dr Coney, I have a question for you on switching. When would switching be appropriate for anti-VEGF agents? I think as we see more pressure coming from the health plans, biosimilars are coming out, they may be less expensive than some of the branded agents. That may be an attempt to force switching patients from one agent to another. Is that appropriate? What consideration should be taken into account if they’re thinking about trying to implement some type of switch therapy approach with the anti-VEGFs?
Joseph Coney, MD, FASRS, FACS: I think we danced around this earlier. I think these are our high flyers, or our more burdened patients, or the ones we say have an incomplete response to current therapy. Some of them may have worsening disease. Some of those individuals you simply can’t extend them. Maybe they did fairly well at maybe a Q4- or a Q6-week dosing, but you can’t get them to Q8. Maybe they have persistent or even fluctuating fluid. Sometimes we get really comfortable with persistent fluid. I think all of us treat till the OCTs [optical coherence tomography scans] are dry, and sometimes if the fluid doesn’t change, we extend them, and we get comfortable when that fluid maybe doesn’t change. We’ve gotten more comfortable with subretinal fluid vs intraretinal fluid, but I think in theory, we all try to treat until those OCTs are dry. I think the problem is when we have fluctuating fluid because we know fluctuating fluid may be a sign of active disease, so that may be another person we may try to switch to some type of different therapy.
Then you have those who require injections and they’re just getting tired. They’re doing well, maybe they’re Q6 to Q8, but can they really be at Q12 or Q16 dosing? These are all things you have to consider. Some of them may be just lifestyle, and some of them may be more fluctuating disease or actually worsening disease. These are things that I talk about with my patients. Some of my patients who I switched to the newer agents, they were doing great and they were at Q8, and some were Q10, but now with the newer medicines, they’re at Q16. That may not sound like a lot to you, but when you tell someone they’re getting 2 or 3 fewer injections a year, that’s a big difference. I know the numbers seem fairly small, but the quality of life they have is big. Truthfully, those patients don’t mind coming in and being rechecked. What they do mind is receiving an injection. But all these things we do take into account. I think part of it is looking at the patient as a whole and then looking at the disease as a whole to see how we can maximize their [therapy] while giving them the least amount of treatments.
Jim Kenney, RPh, MBA: What the payers have to look at is what’s the total number of treatments over a period of time. What’s the average number of doses per year or per 2 years, make those determinations, and figure out that it is less expensive. Even though a drug may be more expensive on a per unit basis, as you mentioned Dr Luo, it’s not as expensive over time because of that dosing interval. I think that’s important.
Joseph Coney, MD, FASRS, FACS: Jim, I think the most important thing is that we know once the retinas are dry, year 2, year 3, they’re getting fewer injections. The most important thing is getting the retina as dry as possible, and then over time, you’re finding that those injections get less and less over time. Particularly in diabetes, sometimes they may only need 1 or 2 injections by year 3, and that’s critical.
Jim Kenney, RPh, MBA: That’s great feedback because typically we would look at a couple of years, and I think that’s how most of the manufacturers have sort of promoted these products, take a look at the utilization over a couple of years. But if that third year is even less, you do get pushback that there is patient turnover, and the patient may not be at the plan 3 years out, but I think that’s an irrelevant argument. I think the bottom line is if over 3 years there’s a big difference, it’s worth noting, and looking at the utilization. So that may be a suggestion as well for the audience to pull your utilization and see what the claims look like.
Transcript edited for clarity.