Sir,

We read the article by Brand1 with interest; however, we believe that the role of bevacizumab was underestimated in the patient-centric approach of retinal vascular diseases treatment. In fact, although bevacizumab has not been authorised by any Health Authority worldwide, its off-label use for a variety of chorioretinal disorders has gained global acceptance, and now it is the most commonly used anti-VEGF drug all over the world. Its lower cost of treatment, approximately $40 per dose compared with approximately $2000 per dose for ranibizumab, largely explains its more frequent widespread use over the latter.2 Paradoxically, despite the increasing number of indications and patients under anti-VEGF treatment, the price of ranibizumab has barely declined. Moreover, although the content of a single-dose vial of ranibizumab is two to three times larger than that needed for single use, due to the dead space in the tuberculin syringe, a significant portion of the drug is unused and wasted.

Similarly, the 2-year CATT study3 results have recently reported the non-inferiority of bevacizumab as compared with ranibizumab, providing the first-level 1 evidence for the use of bevacizumab in most people with neovascular AMD who will never have the opportunity to receive ranibizumab because of cost. This is particularly the case for developing countries, in which the high unit cost of ranibizumab over bevacizumab has limited its use after licensing.4 The real dilemma in these countries is not between ranibizumab and bevacizumab, but between bevacizumab and no treatment. There, people cannot afford the treatment and, in this perspective, bevacizumab seems to be a miracle drug. Therefore, it seems that regulators in certain countries should be forced to reconsider their policies that make it illegal to use drugs off-label, particularly when so many of their citizens cannot afford ranibizumab.5 With primary-care trusts under financial pressure, an increasing number are considering, allowing ophthalmologists to use the cheaper bevacizumab for certain ocular conditions. This low-cost alternative to ranibizumab would have a rapid impact of reducing incident global blindness, and is certainly an important alternative in the patient-centric approach of retinal vascular diseases treatment.