Long-term sustained-release therapy pays off in management of chronic, vision-threatening disease.
Special to Modern Retina®
Noninfectious uveitis (NIU) comprises a group of diseases characterized by inflammation of the uvea and the surrounding tissue. NIU affects approximately 300,000 adults in the United States, with a majority being of working age.1 The goals of NIU treatment are to control inflammation, reduce tissue damage, and potentially restore vision loss, while minimizing adverse effects.2 Treatment of NIU is often challenging due to significant variability in the disease presentation and the presence of accompanying systemic disorders.
The current standard of care in NIU treatment includes corticosteroids, which can be delivered via local or systemic routes. Systemic therapy may be desirable in managing NIU with concomitant systemic disease and/or when both eyes are affected. However, systemic corticosteroid treatment is associated with the risk of steroid-related adverse effects. Systemic and local (intra/periocular) steroids also require frequent dosing.
Sustained-release intraocular corticosteroid implants provide an efficacious, long-lasting, and local treatment option for NIU. The implants have particular advantages for the relatively young patient population affected by NIU, who may be challenged to return for frequent follow-up visits or wish to avoid systemic treatment because of concerns about fertility. In this category, Retisert (fluocinolone acetonide 0.59 mg, Bausch + Lomb) and Yutiq (fluocinolone acetonide 0.18 mg, EyePoint) both provide the drug for up to 3 years.
Retisert is implanted via a surgical procedure, whereas the smaller YUTIQ implant is delivered by an in-office intravitreal injection. Both implants help reduce the recurrence of uveitis, improve or stabilize vision, and limit the need for concomitant anti-inflammatory medications.3,4
Although both implants are associated with risks of IOP elevation and cataract development, these risks are generally lower with the lower-dose Yutiq than Retisert3,4 and can be minimized by identifying steroid responders with a trial of sub-tenon/intraocular triamcinolone or intraocular dexamethasone.
Treatment with the sustained-release Yutiq implant can reduce recurrence of uveitis and the need for additional adjunctive anti-inflammatory therapies and provide substantial improvement to patients’ vision and quality of life. Although it stands to reason that using a single-dose, sustained release corticosteroid implant such as Yutiq would provide an overall benefit, formal cost-effectiveness analysis helps test this assumption and guide beneficiary decisions.
The largest payers in the United Kingdom and United States are the National Health Service and the Department of Health & Human Services, respectively. In the US, the Medicare program cost was $644 billion in 2019, corresponding to 15% of federal spending, and Medicare spending has increased, on average, by 4.8% per year since 2010.5,6
To manage the challenge of increased health care costs, governments could increase taxes or divert tax dollars toward health care and away from other vital parts of society, such as education and transportation. As no such policy is easy to implement, cost-effectiveness analyses can be applied to help optimize the use of health care resources.
In cost-effectiveness analyses, costs are determined using historical data and/or mathematical models and are then assessed in the context of health outcomes to determine whether one intervention could be more favorable than an alternative (eg, the standard of care). Incremental cost-effectiveness ratios (ICER) describe the difference in mean costs of 2 interventions divided by differences in the mean outcomes.
In context of NIU, a more desirable therapy may be one that offers cost savings while providing the same visual outcome and a longer duration. In addition to directly benefiting patients with NIU, a more cost-effective treatment allows scarce health care resources to be allocated elsewhere, thus indirectly benefiting all patients and society as a whole.
The UK’s National Institute for Health and Care Excellence (NICE) recently initiated a cost-effectiveness analysis that compared the fluocinolone acetonide (FA) intravitreal implant 0.18 mg (Yutiq in the US) against the dexamethasone intravitreal implant 0.7 mg (Ozurdex) for treatment of recurrent NIU.7
The study used results from a 36-month parallel, randomized, double-blind trial that compared FA implant with sham injection3 and evaluated 3 scenario analyses, each assuming a different level of efficacy for the dexamethasone implant (HR, dexamethasone vs sham, 0.456 [derived from an earlier cost-effectiveness study]; HR, dexamethasone vs FA implant, 1 and 0.7). Additional assumptions also were incorporated into a de novo Markov model to carry out the cost-effectiveness assessment.
The study found that the FA implant extendedly dominated the dexamethasone implant in the first set of analyses, whereas dexamethasone dominated and extendedly dominated the FA implant in the second and third, respectively. Across all analyses, the ICER of the FA implant vs sham injection/standard of care ranged from £12,325 to £30,153 ($16,896 to $41,335) per quality-adjusted life-year (QALY).
Additional analyses found that the FA implant was dominant (more effective, lower cost) in some scenarios, with most ICERs below £20,000 ($27,417) per QALY gained. Based on these additional analyses, the NICE Appraisal Committee recommended the FA implant as a cost-effective use of NHS resources for recurrent NIU affecting the posterior segment.
The study had several limitations. First, it was unclear to the study authors whether FA implants would be administered as a first, second, or third treatment line in the treatment pathway, which would determine the most relevant comparator. Second, it was unclear whether subsequent FA implants should be considered, which would change the scope of the appraisal.
In addition, the model structure may not have adequately represented the natural course of the disease and the effect of treatment on visual acuity, and it only accounted for a single, treated eye, whereas NIU may often develop into a bilateral disease. Finally, no quality-of-life data were captured in the clinical study of the FA implant on which the model was based.
In my practice, I have found the FA implant (Yutiq) to be an effective treatment for NIU, and I discuss the option with patients who have chronic and/or recurrent NIU affecting the posterior segment and have previously responded to shorter-duration intraocular steroid injections without associated IOP elevation. In general, I prefer localized treatment over systemic therapy, especially in patients with unilateral disease and no extraocular inflammatory findings. In my experience, Yutiq offers long-term control of intraocular inflammation and macular edema.
One major drawback of modeling-based cost-effectiveness analyses is the reliance on assumptions that may not be truly representative of routine clinical practice. In the real world, treatment must be individualized; the clinical course of each case is unique and may well deviate from the drug label in efficacy and complications. In addition, cultural/geographical variations in clinical practice patterns also can alter the course of treatment. Still, although some assumptions and limitations are inherent in cost-effectiveness analyses, this research provides evidence on which to base decisions about the value of care.