Lucentis is Here- Now What?

Lucentis has been approved and is available for use at a cost of around $2000 per dose. Many retinal experts have been using intravitreal Avastin for almost a year now and are pleased with the results. Avastin is much cheaper, around $100 a dose or less, depending on the compounding pharmacy. Doctors are wondering whether Lucentis is worth the difference in price. Patients, who often have to come up with th 20% co-pay, are wondering the same thing.

I asked my friend, David M. Brown* about Lucentis versus Avastin. Dr. Brown and his colleagues have been the leading recruiters in most of Genentech’s trials on Lucentis. He estimates that his group has given about 1700 injections of Lucentis. The group has also given Avastin to many patients who were not eligible for one of the trials. Following are my questions, (in italics), with his answers:

1. Is Lucentis better than Avastin?

I think it is. After the first injection of Lucentis, about 70% of patients come back at one month and have no fluid in or under the retina. That figure jumps to about 90% after two injections and 95% after three injections.
After the first injection of Avastin, I would estimate that about 40% of patients have no fluid by one month. After the second and subsequent injections of Avastin, about 70% have no fluid but that percentage seems to level off even after additional injections. So I think Lucentis works faster and in more patients than Avastin.

2. How many injections of Lucentis will a patient need?

It’s very variable. I would roughly estimate that the average AMD patient would need 5-7 injections of Lucentis the first year and then maybe 4-6 injections the second year. We had patients in the MARINA trial though, who still got recurrent fluid after 24 monthly injections.

3. So how will you treat the average patient with AMD?

I think that I’ll start with three monthly injections even if the patient has no fluid on the OCT after the first dose. My goal is to get rid of every bit of fluid in the retina, under the retina, and under the RPE and I mean every bit of fluid. If they are completely dry after the third injection, I’ll ask the patient to return in six weeks or anytime they have new symptoms. If they are dry, I’ll see them again in six weeks. If they stay dry, I will gradually lengthen the time between visits to two and then three months.

4. What if they still have fluid after three injections or develop a recurrence of fluid?

Then I’ll give them another round of injections, maybe three again.

5. So you’re willing to give injections every month for years if necessary?

I’m willing since many of these patients regain excellent vision. We’re starting a trial however, to see if half light dose or quarter light dose PDT along with Lucentis can get rid of the CNV permanently and not hurt the vision. We’re trying to see if PDT can selectively damage the new blood vessels and spare the surrounding choroid.

6. Anything else out there that looks promising?

The VEGF trap made by Regeneron seems to work well but it will be hard pressed to work any better than Lucentis since Lucentis gets rid of the fluid so quickly. If the VEGF trap could be injected less often than once a month though, or stops the leakage permanently, then that would be an advantage.

Thank you, Dr. Brown. This is valuable information.


*Greater Houston Retinal Research Center, Vitreoretinal Consultants, Methodist Hospital, Houston, Texas