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FROM THE CHIEF MEDICAL EDITOR

CATT's Cautionary Tale

Larry E. Patterson, MD

I'm not a retina specialist, but I've paid attention lately to the debate about Avastin vs. Lucentis. As you know, Lucentis was approved a while back as a revolutionary treatment for wet age-related macular degeneration. It worked far better than anything we'd had in the past. Instead of just reducing visual loss with AMD, we were actually gaining vision in many patients. The problem was that patients often needed monthly injections, each being very expensive.

Along came Avastin, ironically made by the same company and previously FDA-approved, but for stuff that had nothing to do with macular degeneration. Doctors way smarter than I noted that the chemical compound of these two drugs was quite similar, and in carefully selected cases started using it. It seemed to work about as well as the much more expensive Lucentis. Quickly, it caught on with retina specialists. By 2008, 35.6 percent of injections were done with Lucentis and 64.4 percent with Avastin. Medicare paid $536 million for the Lucentis. The off-label use of Avastin cost $20.8 million.¹

But were the two drugs really comparable? The CATT study (Comparison of AMD Treatments Trial) just concluded that, yes, patients treated with Avastin statistically had the same visual acuity improvement as those treated with Lucentis. There were very slight advantages to Lucentis in retinal thickness reduction, and there is still a debatable question as to whether the Avastin patients suffered a tiny increase in systemic side effects. Another study, funded by the manufacturer, showed a slightly increased risk of stroke with Avastin.

So what's the point? Depending on who you talk to, the cost of Lucentis is around $1950 per injection, while Avastin costs about $50. I'm sure some statistician can give a more precise analysis, but this country boy doesn't need it. Lucentis costs a boatload more than Avastin. As physicians working in a cost-cutting environment that is about to get even uglier, we had better get on the less expensive bandwagon when we have scientific studies showing this much comparable efficacy with this much economic disparity. The pie is only so big, and rumored to be getting smaller in the near future. Retina specialists have already voted with their prescription pads, favoring Avastin two-to-one over Lucentis. The rest of us need to look for similar cost savings out there in our areas of specialty. Remember: if we don't cut costs, insurers will do it for us.

One more thing. You'll notice that I've violated proper medical journalistic protocol by calling these drugs by their brand names. If I might speak on behalf of all of us who don't inject these drugs on a regular basis: sorry, we don't even know how to pronounce bevacizumab and ranibizumab, much less know which is which. Just now, even my spell-checker went on strike. I did figure out that Avastin starts with an “A”, which is really close to the “B” in bevacizumab. Maybe that will be of some help!

1. Brechner RJ, Rosenfeld PJ, et al. Pharmacotherapy for neovascular age-related macular degeneration: an analysis of the 100% 2008 Medicare fee for-service Part B claims file. Am J Ophthalmol. 2011;151:887-895.