国际眼科时讯
药物治疗的方案悬而未决
PREMED 研究中抗VEGF 药物选择的是贝伐单抗，因其为荷兰以及其他欧洲国家使用最频繁的药物，我们使用常规剂量，每次1.25 mg。对于曲安奈德，我们常规在手术后结膜下注射40 mg。目前我们无法推荐任何特殊的剂量。基于理论上以及部分小样本研究建议术前用药。因此，我们推荐术前开始用药，术后继续用药，停药时间尚未确定。但是，我们已决定研究证明不同治疗方式的效果，不久之后可能有些研究将会说药物需要使用4 周还是2 周就足够了。但这不是该研究的主要目的，选择药物剂量是一件很困难的事情，目前的趋势是减少给药频率，尤其是NSAIDs。
Bevacizumab is the anti-VEGF of choice in PREMED study because it is the treatment used most often in the Netherlands and other European countries. We use it at the regular dose 1.25mg per injection. Or we use a dose of 40mg of triamcinolone acetonide at the end of surgery as a subconjunctival injection. But at this moment we cannot recommend any specific dosing. There are some indications that treatment should start preoperatively, but this is based on theoretical grounds mainly, or on small studies. So our advice would be to start treatment pre-operatively and continue post-operatively for a yet undecided duration. We have made a choice to prove the effect of various treatments and later on other studies will maybe show whether instead of four weeks duration, two weeks is sufficient. But that is not the major aim of this study, so it is difficult to decide on type of dosage and so on. The trend is towards less frequent dosing especially for the NSAIDs
预防过程的成本效用分析
如果想做更好的成分效用分析，则必须采用研究的长期结果，这是针对卫生政策制订的评估。其次，在研究的短期结果中我们可以分析生活质量，但如果短期生活质量结果未受到影响，那么成本效用分析则徒劳无功。例如，青光眼的治疗，需要现在开始治疗来预防将来致盲。实验性的短期成本效用研究并没有多大作用，还可能会误导政策制订者。这一点政策制订者应当意识到。第三，结果的选择非常重要。我们可以使用生活质量指标，或者很多成本效用研究中推荐的EQ-5D，但是都不适用于眼科学，应避免使用EQ-5D，因为它会让眼科学对成本效用研究产生理解偏差。我们应采取长期观察，选择正确的结果，这非常重要，但很难向政策制订者解释，因为他们往往在成本效用分析方法上坚持自己的教条观点。
When looking at the cost-effectiveness, one should realize that the cost-effectiveness component of the study applies over only a short period of time. If you wish to do a better cost-effectiveness analysis, the long-term outcomes must be taken into account. That is a comment targeted at health policy makers. Secondly, in the shortterm, one could ask to monitor quality of life (which we do), but if you don’t have an impact on the quality of life then in the short-term costeffectiveness analysis it may turn out that you are very costly with hardly any effect. Take the example of glaucoma treatment , needing to be started now in order to prevent blindness in the future. Any short-term cost-effectiveness study based on the trial is not very helpful and it may bias policy makers in making correct decisions. I think that is a message that should be noted by policy makers. Thirdly, the choice of outcome is very important. We could use quality of life. Then we have the EQ-5D, which is commonly recommended in several cost-effectiveness studies, but we know that in ophthalmology it is not the best to use. We should avoid using the EQ-5D because it may bias the interpretation of a costeffectiveness analysis for ophthalmology. We should take the long-term perspective and we should choose the right outcome. That is always important and something that is difficult to explain to a health policy maker because they stick to a certain dogma in their approach to cost-effectiveness.
