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UK AMD/DR EMR REPORT IX: comparative effectiveness of predominantly as needed (PRN) ranibizumab versus continuous aflibercept in UK clinical practice
  1. Aaron Y Lee1,2,
  2. Cecilia S Lee1,
  3. Catherine A Egan3,4,
  4. Clare Bailey5,
  5. Robert L Johnston6,
  6. Salim Natha7,
  7. Robin Hamilton3,
  8. Rehna Khan8,
  9. Sahar Al-Husainy9,
  10. Christopher Brand10,
  11. Toks Akerele11,
  12. Martin Mckibbin12,
  13. Louise Downey13,
  14. Adnan Tufail3,4
  1. 1 Department of Ophthalmology, University of Washington, Seattle, Washington, USA
  2. 2 Moorfields Eye Hospital NHS Foundation Trust, London, UK
  3. 3 UCL Institute of Ophthalmology, London, UK
  4. 4 The NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation TrustLondonUK, London, UK
  5. 5 Bristol Eye Hospital, Bristol, UK
  6. 6 Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
  7. 7 Wrightington, Wigan and Leigh NHS Foundation Trust, Lancashire, UK
  8. 8 Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
  9. 9 Heart of England NHS Foundation Trust, Solihull, UK
  10. 10 Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
  11. 11 Hinchingbrooke Health Care NHS Trust, Huntingdon, UK
  12. 12 Leeds Teaching Hospitals NHS Trust, Leeds, UK
  13. 13 Hull and East Yorkshire Hospitals NHS Foundation Trust, Hull, UK
  1. Correspondence to Dr Cecilia S Lee, Department of Ophthalmology, University of Washington, Box 359608, 325 Ninth Avenue, Seattle, WA 98104, USA; leecs2{at}, jung.cecilia{at}


Aims To compare the effectiveness of continuous aflibercept versus pro re nata (PRN) ranibizumab therapy for neovascular age-related macular degeneration (nAMD).

Methods Multicentre, national electronic medical record (EMR) study on treatment naive nAMD eyes undergoing PRN ranibizumab or continuous (fixed or treat and extend (F/TE)) aflibercept from 21 UK hospitals. Anonymised data were extracted, and eyes were matched on age, gender, starting visual acuity (VA) and year of starting treatment. Primary outcome was change in vision at 1 year.

Results 1884 eyes (942 eyes in each group) were included. At year 1, patients on PRN ranibizumab gained 1.6 ETDRS (Early Treatment Diabetic Retinopathy Study) letters (95% CI 0.5 to 2.7, p=0.004), while patients on F/TE aflibercept gained 6.1 letters (95% CI 5.1 to 7.1, p=2.2e-16). Change in vision at 1 year of the F/TE aflibercept group was 4.1 letters higher (95% CI 2.5 to 5.8, p=1.3e-06) compared with the PRN ranibizumab group after adjusting for age, starting VA, gender and year of starting therapy. The F/TE aflibercept group had significantly more injections compared with the PRN ranibizumab group (7.0 vs 5.8, p<2.2e-16), but required less clinic visits than the PRN ranibizumab group (10.8 vs 9.0, p<2.2e-16). Cost-effectiveness analysis showed an incremental cost-effectiveness ratio of 58 047.14 GBP/quality-adjusted life year for continuous aflibercept over PRN ranibizumab.

Conclusion Aflibercept achieved greater VA gains at 1 year than ranibizumab. The observed VA differences are small and likely to be related to more frequent treatment with aflibercept, suggesting that ranibizumab should also be delivered by F/TE posology.

  • Age related macular degeneration
  • anti-VEGF therapy
  • ranibizumab
  • aflibercept

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  • Contributors All the authors have contributed to the planning, conduct and reporting of the work described in the article.

  • Funding CSL was supported by the National Eye Institute (NEI) (K23EY024921). RH, CAE and AT were supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NEI, NHS, the NIHR or the Department of Health. This work was supported in part by an unrestricted research award by Novartis Pharmaceuticals.

  • Competing interests AYL has received grants from Novartis, Microsoft and Nvidia. RLJ is the Medical Director of Medisoft Limited, which developed the EMR from which data were extracted. RH has received grants and speaker fees from Novartis, Allergan, Bayer and Ellex. LD has received speaker fees from Novartis, Bayer, Allergan and Alimera. CAE has received speaker fees from Heidelberg Engineering and Haag-Streit UK. AT has served on Advisory Boards for Allergan, Bayer, Genetech, GlaxoSmithKline, Novartis and Roche.

  • Patient consent Only anonymised database analyses were performed and hence consent was not required from the patients.

  • Provenance and peer review Not commissioned; externally peer reviewed.