Ophthalmologists should be able to prescribe bevacizumab, says royal collegeBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5139 (Published 06 November 2017) Cite this as: BMJ 2017;359:j5139
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As there are significant savings available, surely NHS England could use some of that money to set up a trial to compare bevacizumab with the alternatives. They would be paying for the medications in any case. The only added costs would be to those ophthalmologists doing the work and to the administrators of the trial.
Competing interests: No competing interests
Well done to the Royal College of Ophthalmologists for taking a definitive view on this long standing subject. There are four areas that would move this issue on substantially
The law in this space might be clarified. I’d guess that can only happen in court. There may be a role for DH there, I'm not sure.
Or at least GMC might be asked to clarify their position in light of what's happening ECJ wise, and taking into account the more nuanced arguments put forward by Ferner and Aronson in their recent article.
Seems that whilst the law and regulatory system are rightly designed to protect patient safety, this is a rather peculiar scenario where safety is assured (surely a Cochrane review is enough).
As an (important) aside, the need to maintain high standard in manufacture (akin to current MHRA specials licence) for those places making ophthalmic doses should be maintained, that goes without saying
This would give prescribers (and to a lesser extent employing trusts and commissioners) some surety on where they stand.
The continuing discrepancy in regulatory terms between what seems to be the case in private practice vs NHS practice seems untenable to me
Secretary of state might consider a referral to apply for Market Authorisation of avastin in ophthalmic indications. I believe there is precedent for this – Gulf War vaccine. Maybe others
Secretary of State NICE should refer avastin, as proprietary agent, for consideration in a TA for all the indictions lucentis or eylea is currently recommended for. This was one of the recommendations of the 2010 multi stakeholder workshop.
At that time there probably wasn’t enough primary evidence of effectiveness of avastin available for a robust recommendation on AMD to be made (was a long time before IVAN or CATT year 1 data was available). This was also a long time before there was any substantial use of aVEGF in other eye conditions.
Times are obviously different now. There’s more than enough evidence to make for a robust recommendation on effectiveness of avastin.
The Moja et al 2014 Cochrane review on safety will also be available to the committee
Some NHS commissioners may question whether that can be refunded for all the investment in aVEGF over the years. I accept that would be exceptionally unlikely to happen, but I’d hazard it runs to many £billions by now. The recently published paper by Hollingworth et al gives some important insight into that.
As I’ve maintained throughout this saga, I bear the two pharma companies who have an important interest in this one no ill will. They have been acting in the interests of their shareholders. It is of course complex and different stakeholders will have very different views. However, the NHS must also act in the interests of the population as a whole and the opportunity cost of not using avastin just can't be justified in my view.
Unlicensed and off-label uses of medicines:definitions and clarification of terminology https://www.ncbi.nlm.nih.gov/pubmed/28779556
Report of NICE exploratory workshop
Hollingworth et al
Competing interests: I have undertaken work for Bayer Opthalmology and Bayer CVD Medicine Over 4 years ago My employer was reimbursed for my time