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Lucentis fiona godlee
1.
BMJ 2012;344:e3162 doi:
10.1136/bmj.e3162 (Published 2 May 2012) Page 1 of 1 Editor's Choice EDITOR'S CHOICE Avastin versus Lucentis Fiona Godlee editor, BMJ Drug treatment for age related macular degeneration is one of Whatever the motivation, the company has done all it can to medicine’s success stories. As Ning Cheung and colleagues limit the use of bevacizumab outside cancer, most notably by explain (doi:10.1136/bmj.e2970), anti-vascular endothelial not applying for regulatory approval for use in patients with growth factors are preserving and restoring vision to millions macular degeneration. Some health systems are finding ways around the world. But a related and less edifying story is stealing round this, as Campbell and colleagues explain. But the the limelight: ranibuzimab (Lucentis) versus bevacizumab combination of legal threats, safety concerns, and financial (Avastin). It casts a shadow over this great medical advance incentives to use ranibuzimab has maintained the more and puts the world’s drug development and licensing systems expensive drug’s lucrative market. Sales in the US in 2010 under the spotlight. topped $1.8bn. In its anti-cancer drug, bevacizumab, drug developer Genentech In the UK, as Ingrid Torjesen reports (doi:10.1136/bmj.e3012), has created what may be the world’s first “not me” (as opposed efforts are under way to get bevacizumab approved for use in to “me too”) drug, say Robert Campbell and colleagues (doi:10. macular degeneration despite resistance from Novartis. The 1136/bmj.e2941). Despite evidence that it works in macular National Institute for Health and Clinical Excellence has said degeneration, the manufacturers and marketers (Roche in the it could appraise the drug if asked to by the Department of US, Novartis in the UK and elsewhere) are actively discouraging Health. Campbell and colleagues report that the department is its use for this condition, even going so far as taking legal action waiting for the results of the IVAN trial in the UK, due to be to prevent such off-label use. Why? Because they want people published this month. But it is unlikely to resolve the safety to use their other drug, ranibuzimab, which is licensed for concerns. Neither this nor the CATT trial was big enough to treating macular degeneration. detect small but clinically relevant differences in adverse The bottom line is that ranibuzimab is about 12 times more outcomes such as stroke, they say. Long term postmarketing expensive: Cheung and colleagues report that the UK could surveillance is needed for that. save close to £300m (€368m; $485m) a year if it were standard So what’s to be done in the best interests of patients and the treatment. So are Roche and Novartis simply fighting to protect public purse? Campbell and colleagues call for clear guidance their profits? They say no, that they are also protecting patients to use bevacizumab from professional organisations, a review from the cheaper drug’s higher risk profile. Although data from of policies that discourage off-label use if there is good evidence the publicly funded CATT trial in the US found similar for a drug’s use, and better communication among health effectiveness and safety for the two drugs in treating macular technology assessors in different parts of the world. degeneration, the safety of bevacizumab remains a worry. Concerns relate to its greater systemic absorption and the fact Cite this as: BMJ 2012;344:e3162 that it has to be decanted into smaller quantities for intraocular © BMJ Publishing Group Ltd 2012 injection, which introduces the risk of infection. fgodlee@bmj.com For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
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