A Field-Based Cost-Effectiveness Study of Aflibercept and Bevacizumab in Treat-and-Extend Versus Pro Re Nata Protocols for Diabetic Macular Edema in Iraq

Rawaa M Jabbar; Ali Azeez Al-Jumaili; Aymen D Jaafar; William R Doucette

doi:10.1007/s40261-026-01527-1

Diabetic macular edema (DME) is a leading cause of vision impairment in individuals with diabetes, often treated with anti-vascular endothelial growth factor (anti-VEGF) therapies, such as Avastin (bevacizumab) and Eylea (aflibercept). The study objective is to assess the cost-effectiveness of bevacizumab and aflibercept under treat-and-extend (T&E) and pro re nata (PRN) regimens in managing DME in a real-world clinical setting. A field-based retrospective study was conducted at a public tertiary eye hospital in Baghdad, Iraq, from October 2024 through March 2025. The study employed a retrospective design, extracting clinical and treatment data from patients' medical records. Additional economic and sociodemographic information was collected through face-to-face interviews conducted by the first author between October 2024 and March 2025. A total of 394 adult patients with DME were included and categorized into six groups; two loading doses groups (LD)-LD Avastin (n = 206) and LD Eylea (n = 188)-and four maintenance doses (MD) groups-T&E Avastin (n = 139), T&E Eylea (n = 124), PRN Avastin (n = 67), and PRN Eylea (n = 64). Clinical outcomes included best-corrected visual acuity (BCVA; measured as logarithm of the minimum angle of resolution [log MAR]) and central macular thickness (CMT). Costs were calculated from the payer's perspective, incorporating medication, and patient costs. Incremental cost-effectiveness ratios (ICERs) were computed for each regimen. The study included 394 patients, each with one eye affected by DME, categorized into six groups. Based on the chosen LD, 206 patients received six monthly LD of Avastin, and 188 patients received five monthly LD of Eylea. Thereafter, on the basis of the maintenance treatment regimen chosen (MD), 67 patients were assigned to the PRN Avastin treatment group, 64 patients were assigned to the PRN Eylea treatment group, 139 patients were assigned to the T&E Avastin group, and 124 patients were assigned to the T&E Eylea group. During the loading phase, Eylea LD achieved a significantly greater mean utility gain than Avastin LD (0.0909 ± 0.0117 versus 0.0221 ± 0.0106; p = 0.0001). In the maintenance phase, both T&E regimens provided significantly higher utility gains than PRN strategies. PRN Avastin yielded the lowest utility gain (0.0066 ± 0.0072), while PRN Eylea showed modest improvement (0.0278 ± 0.0148; p = 0.0001). Despite superior utility outcomes, Eylea-based regimens exceeded the willingness-to-pay threshold, whereas T&E Avastin remained the most cost-effective option. The study suggests that Avastin under the T&E regimen is the most cost-effective treatment for DME, providing significant savings while maintaining effective management of the condition. These findings can guide therapeutic decision-making for DME in resource-limited settings and countries.

A Field-Based Cost-Effectiveness Study of Aflibercept and Bevacizumab in Treat-and-Extend Versus Pro Re Nata Protocols for Diabetic Macular Edema in Iraq

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