OBJECTIVES: In treating center-involving diabetic macular edema (DME), there are patients that will require intensive treatment and still respond insufficiently to intravitreal anti-VEGF compounds. In such cases, therapeutic options include a switch to corticosteroid implants, which include the longer-acting fluocinolone acetonide (FAc) implant or the shorter-acting dexamethasone implant. Based on a cost-cost model and a systematic literature review (SLR) the effectiveness of treatments after initiation of anti-VEGF treatment and their associated costs was assessed.

METHODS: A short term cost-cost model was built in MS Excel with a 3 year time horizon to compare available DME treatments i.e., ranibizumab (Lucentis®), aflibercept (Eylea®), FAc implant (ILUVIEN®) and dexamethasone implant (OZURDEX®). Costs included drug costs –including estimated rebates-, procedure costs for injection and optical coherence tomography (OCT), as well as the cost of managing adverse events (cataract surgery, endophthalmitis, medical and surgical glaucoma treatment). Effectiveness was based on a systematic literature review (SLR) of randomised controlled trials (RCT).

RESULTS: In the 3-year period, total DME treatment costs for one average patient in Germany -considering second line only- were: €15.463, ranibizumab; €13.980, aflibercept; €10.562, FAc implant; and, €11.931, dexamethasone implant. For all treatment regimens drug costs were the clearly predominant costs, followed by injection costs (with variations dependent on the specific drug) and then OCT costs. Uni- and multivariate sensitivity analyses revealed costs were robust to changes of model inputs. Comparative effectiveness could not be assessed validly despite numerous clinical publications and RCTs, as the study populations after first-line anti-VEGF treatment were heterogenous.

CONCLUSIONS: In summary, the 3-year cost-cost comparison demonstrates that steroidal implants can provide significant cost savings versus intravitreal anti-VEGF treatment for center-involving DME. Single application of the long-lasting FAc implant was most cost-efficient of the intravitreal injections therapies currently approved for DME.