Since the introduction of aflibercept, ranibizumab and bevacizumab, the frequency of anti-VEGF injection procedures has been increasing. 

A recent study of anti-VEGF injections examined trends in distribution and usage of anti-VEGF agents, using data from the Centers for Medicare & Medicaid Services on Medicare Plan B beneficiaries from 2012 to 2015.1 In this observational cohort study, the researchers evaluated over 2.5 million injections. Of these, 870,843 were with aflibercept; 697,412 were with ranibizumab; and 1,147,432 were with bevacizumab.

The study found that just 3 percent of ophthalmologists account for between 17 and 31 percent of the total number of injections. The researchers also saw an increase in aflibercept injections (a 69.4-percent increase) that coincided with decreases in ranibizumab (7.1 percent) and bevacizumab injections (17.1 percent). 

Discussing the results, study co-author Shriji Patel, MD, Vanderbilt University School of Medicine, says, “Initially when we started this, we figured to some extent there was going to be a top-heavy distribution, just because there are practitioners that are very busy. They’re going to do a lot of injections and probably skew the trend upward.”

The variability in the cost of these therapies has garnered national attention. “The approximately 40-fold price differences between these anti-VEGF therapies, in the context of comparable proven efficacy for AMD, diabetic macular edema and retinal vein occlusion alongside the growing economic burden of health-care costs, warrant an exploration of feasible, cost-effective stewardship,” the researchers say. Aflibercept costs $1,850 for 2 mg and ranibizumab costs $1,170 for 0.3 mg and $1,950 for 0.5 mg. Both are FDA-approved. Bevacizumab, used off-label, costs $60 for 1.25 mg, according to the researchers. The study authors note that all three agents are “equally effective with regard to visual gains” and have “relatively [equivalent] clinical outcomes and safety data.”

They speculate on what drives the choice of agent. “I think a lot of it is preference,” Dr. Patel says. “Many practitioners have a good experience with a certain type of medication: It works, it’s comfortable in their hand. It might be how they were trained. In medicine, what you’re used to and what you’re comfortable with drives a lot of practice patterns, and our suspicion is that plays a key role in some of the numbers.” In the paper, the authors also note that rebates can make a difference as well. “Rarely discussed manufacturer rebates in the form of volume discounts to certain practices further complicate decision making regarding choice of anti-VEGF agent. These financial motivations affecting [the] choice of anti-VEGF agent must not be overlooked,” the researchers write.

Ultimately, despite the high costs of these injections, Dr. Patel reminds us that “the medication cost pales in comparison to the cost of the vision saved. Even though the Medicare costs are high, it’s much less costly than taking care of patients who have gone blind for years and years.”

In another study, a different group of researchers analyzed the usage of glaucoma medications.2 They found that, despite the increase in glaucoma medication use recorded in several other developed countries, topical intraocular pressure-lowering medication use in the United States remained stable from 1999 to 2014. 

Researchers conducted a series of eight surveys of U.S. residents every two years from 1999 to 2014, asking patients if they’d used or taken a prescribed medication in the past month. The team found no change in the number of Americans using topical IOP-lowering medications, with 1.4 percent of respondents on the medications between 1999 and 2000, as well as 2013 and 2014. However, there was a significant increase in the use of prostaglandin analogs and combination medications, and a decrease in the use of beta-blockers.

The authors say the steady level of drug use “is particularly remarkable, as Medicare part D was implemented in 2006 in the middle of this study period and increased the coverage for prescription drugs among Medicare beneficiaries.”   REVIEW


1. Berkowitz S, Sternberg P, Feng M, et al. Analysis of anti–vascular endothelial growth factor injection claims data in US Medicare Part B beneficiaries from 2012 to 2015. JAMA Ophthalmol. June 20, 2019. [Epub ahead of print]

2. Lowry EA, Chansangpatch S, Lin SC, et al. Use of topical intraocular pressure lowering medications in the United States population: Results from the NHANES study 1999-2014. J Glaucoma. June 24, 2019. [Epub ahead of print]