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Lorés-Motta L, Riaz M, Grunin M, Corominas J, van Asten F, Pauper M, Leenders M, Richardson AJ, Muether P, Cree AJ, Griffiths HL, Pham C, Belanger MC, Meester-Smoor MA, Ali M, Heid IM, Fritsche LG, Chakravarthy U, Gale R, McKibbin M, Inglehearn CF, Schlingemann RO, Omar A, Chen J, Koenekoop RK, Fauser S, Guymer RH, Hoyng CB, de Jong EK, Lotery AJ, Mitchell P, den Hollander AI, Baird PN, Chowers I. Association of Genetic Variants With Response to Anti-Vascular Endothelial Growth Factor Therapy in Age-Related Macular Degeneration. JAMA Ophthalmol 2018; 136:875-884. [PMID: 29852030 PMCID: PMC6142943 DOI: 10.1001/jamaophthalmol.2018.2019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 04/02/2018] [Indexed: 02/04/2023]
Abstract
Importance Visual acuity (VA) outcomes differ considerably among patients with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) drugs. Identification of pharmacogenetic associations may help clinicians understand the mechanisms underlying this variability as well as pave the way for personalized treatment in nAMD. Objective To identify genetic factors associated with variability in the response to anti-VEGF therapy for patients with nAMD. Design, Setting, and Participants In this multicenter genome-wide association study, 678 patients with nAMD with genome-wide genotyping data were included in the discovery phase; 1380 additional patients with nAMD were genotyped for selected common variants in the replication phase. All participants received 3 monthly injections of bevacizumab or ranibizumab. Clinical data were evaluated for inclusion/exclusion criteria from October 2014 to October 2015, followed by data analysis from October 2015 to February 2016. For replication cohort genotyping, clinical data collection and analysis (including meta-analysis) was performed from March 2016 to April 2017. Main Outcomes and Measures Change in VA after the loading dose of 3 monthly anti-VEGF injections compared with baseline. Results Of the 2058 included patients, 1210 (58.8%) were women, and the mean (SD) age across all cohorts was 78 (7.4) years. Patients included in the discovery cohort and most of the patients in the replication cohorts were of European descent. The mean (SD) baseline VA was 51.3 (20.3) Early Treatment Diabetic Retinopathy Study (ETDRS) score letters, and the mean (SD) change in VA after the loading dose of 3 monthly injections was a gain of 5.1 (13.9) ETDRS score letters (ie, 1-line gain). Genome-wide single-variant analyses of common variants revealed 5 independent loci that reached a P value less than 10 × 10-5. After replication and meta-analysis of the lead variants, rs12138564 located in the CCT3 gene remained nominally associated with a better treatment outcome (ETDRS letter gain, 1.7; β, 0.034; SE, 0.008; P = 1.38 × 10-5). Genome-wide gene-based optimal unified sequence kernel association test of rare variants showed genome-wide significant associations for the C10orf88 (P = 4.22 × 10-7) and UNC93B1 (P = 6.09 × 10-7) genes, in both cases leading to a worse treatment outcome. Patients carrying rare variants in the C10orf88 and UNC93B1 genes lost a mean (SD) VA of 30.6 (17.4) ETDRS score letters (ie, loss of 6.09 lines) and 26.5 (13.8) ETDRS score letters (ie, loss of 5.29 lines), respectively, after 3 months of anti-VEGF treatment. Conclusions and Relevance We propose that there is a limited contribution of common genetic variants to variability in nAMD treatment response. Our results suggest that rare protein-altering variants in the C10orf88 and UNC93B1 genes are associated with a worse response to anti-VEGF therapy in patients with nAMD, but these results require further validation in other cohorts.
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Affiliation(s)
- Laura Lorés-Motta
- Department of Ophthalmology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Moeen Riaz
- Centre for Eye Research Australia, Department of Surgery in Ophthalmology, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
- Public Health Genomics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michelle Grunin
- Department of Ophthalmology, Hebrew University Hadassah Medical School, Hadassah Medical Center–Hebrew University, Jerusalem, Israel
| | - Jordi Corominas
- Department of Ophthalmology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Human Genetics, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Freekje van Asten
- Division of Epidemiology and Clinical Application, National Eye Institute, National Institutes of Health, Bethesda, Maryland
- Neurobiology, Neurodegeneration, and Repair Laboratory, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Marc Pauper
- Department of Ophthalmology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Human Genetics, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mathieu Leenders
- Department of Ophthalmology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andrea J. Richardson
- Centre for Eye Research Australia, Department of Surgery in Ophthalmology, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Philipp Muether
- Department of Ophthalmology, University Hospital of Cologne, Cologne, Germany
| | - Angela J. Cree
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, England
| | - Helen L. Griffiths
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, England
| | - Connie Pham
- Department Ophthalmology, McGill University Health Centre, Montreal, Québec, Canada
| | | | | | - Manir Ali
- Section of Ophthalmology and Neuroscience, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, England
| | - Iris M. Heid
- Department of Genetic Epidemiology, University of Regensburg, Regensburg, Germany
| | - Lars G. Fritsche
- Norwegian University of Science and Technology, Trondheim, Norway
| | | | | | | | - Chris F. Inglehearn
- Section of Ophthalmology and Neuroscience, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, England
- Eye Clinic, St James’s University Hospital, Leeds, England
| | - Reinier O. Schlingemann
- Department of Ophthalmology, Ocular Angiogenesis Group, Academic Medical Center, Amsterdam, the Netherlands
- Netherlands Institute for Neuroscience, Amsterdam, the Netherlands
| | - Amer Omar
- Montreal Retina Institute, Westmount, Québec, Canada
| | - John Chen
- Department of Pediatric Surgery, McGill University Health Centre, Montreal, Québec, Canada
- Department of Human Genetics, McGill University Health Centre, Montreal, Québec, Canada
- Department of Ophthalmology, McGill University Health Centre, Montreal, Québec, Canada
| | - Robert K. Koenekoop
- Department of Pediatric Surgery, McGill University Health Centre, Montreal, Québec, Canada
- Department of Human Genetics, McGill University Health Centre, Montreal, Québec, Canada
- Department of Ophthalmology, McGill University Health Centre, Montreal, Québec, Canada
| | - Sascha Fauser
- Department of Ophthalmology, University Hospital of Cologne, Cologne, Germany
- Roche Pharma Research and Early Development, Hoffmann–La Roche, Basel, Switzerland
| | - Robyn H. Guymer
- Centre for Eye Research Australia, Department of Surgery in Ophthalmology, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Carel B. Hoyng
- Department of Ophthalmology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eiko K. de Jong
- Department of Ophthalmology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andrew J. Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, England
| | - Paul Mitchell
- Centre for Vision Research, Department of Ophthalmology and Westmead Millennium Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Anneke I. den Hollander
- Department of Ophthalmology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Human Genetics, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul N. Baird
- Centre for Eye Research Australia, Department of Surgery in Ophthalmology, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Itay Chowers
- Department of Ophthalmology, Hebrew University Hadassah Medical School, Hadassah Medical Center–Hebrew University, Jerusalem, Israel
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van Asten F, Michels CTJ, Hoyng CB, van der Wilt GJ, Klevering BJ, Rovers MM, Grutters JPC. The cost-effectiveness of bevacizumab, ranibizumab and aflibercept for the treatment of age-related macular degeneration-A cost-effectiveness analysis from a societal perspective. PLoS One 2018; 13:e0197670. [PMID: 29772018 PMCID: PMC5957378 DOI: 10.1371/journal.pone.0197670] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The discussion on the use of bevacizumab is still ongoing and often doctors are deterred from using bevacizumab due to legal or political issues. Bevacizumab is an effective, safe and inexpensive treatment option for neovascular age-related macular degeneration (AMD), albeit unregistered for the disease. Therefore, in some countries ophthalmologists use the equally effective but expensive drugs ranibizumab and aflibercept. We describe the economic consequences of this dilemma surrounding AMD treatment from a societal perspective. METHODS We modelled cost-effectiveness of treatment with ranibizumab (as-needed), aflibercept (bimonthly) and bevacizumab (as-needed). Effectiveness was estimated by systematic review and meta-analysis. The drug with the most favourable cost-effectiveness profile compared to bevacizumab was used for threshold analyses. First, we determined how much we overspend per injection. Second, we calculated the required effectiveness to justify the current price and the reasonable price for a drug leading to optimal vision. Finally, we estimated how much Europe overspends if bevacizumab is not first choice. RESULTS Bevacizumab treatment costs €27,087 per year, about €4,000 less than aflibercept and €6,000 less than ranibizumab. With similar effectiveness for all drugs as shown by meta-analysis, bevacizumab was the most cost-effective. Aflibercept was chosen for threshold analyses. Aflibercept costs €943 per injection, but we determined that the maximum price to be cost-effective is €533. Alternatively, at its current price, aflibercept should yield about twice the visual gain. Even when optimal vision can be achieved, the maximum price for any treatment is €37,453 per year. Most importantly, Europe overspends €335 million yearly on AMD treatment when choosing aflibercept over bevacizumab. CONCLUSION Bevacizumab is the most cost-effective treatment for AMD, yet is not the standard of care across Europe. The registered drugs ranibizumab and aflibercept lead to large overspending without additional health benefits. Health authorities should consider taking steps to implement bevacizumab into clinical practice as first choice.
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Affiliation(s)
- Freekje van Asten
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Charlotte T. J. Michels
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carel B. Hoyng
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Jan van der Wilt
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B. Jeroen Klevering
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M. Rovers
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P. C. Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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Wiesinger K, Reinelt P, Ennemoser A, Edelmayr M, Schönherr U. [What can anti-VEGF therapy achieve in clinical routine? : Effectiveness of anti-VEGF therapy in patients with macular diseases in clinical routine on 1492 eyes in Austria]. Ophthalmologe 2016; 114:639-645. [PMID: 27815675 DOI: 10.1007/s00347-016-0389-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this user observational study was to illustrate the effectiveness of intravitreal operative medication administration (IVOM) in the clinical routine. DESIGN A monocentric, single arm, prospective study. MATERIAL AND METHODS Included in this study were all patients in whom a macular edema was diagnosed during an ophthalmological examination at the Barmherzigen Brüdern Hospital in Linz from November 2012 to August 2014 and who were treated as outpatients or day clinic patients with IVOM using anti-vascular endothelial growth factor (VEGF). The parameters measured during the clinical routine were as follows: best corrected visual acuity (BCVA) using the early treatment diabetic retinopathy study (ETDRS) chart, central optical coherence tomography (OCT) thickness, diagnosis and possible prior treatment with IVOM. Following diagnosis, the IVOM was administered in 6‑week intervals and a final control with measurement of the named parameters (approximately 19 weeks after diagnosis). If edema was present a further 3‑stage series (19 weeks) was initiated. In the case of a "dry" condition the further controls were performed by a private practitioner and the patient only presented again if macular edema reoccurred. A control of the patients with "dry" results at regular intervals was not planned. RESULTS A total of 1492 eyes from 1184 patients with an average age of 75.6 ± 11.3 years were included in the study according to the abovenamed criteria. Choroidal neovascularization (CNV) with age-related macular degeneration (AMD) was diagnosed in 879 eyes and 314 eyes were treated for diabetic macular edema (DME). Of the eyes 122 (8.2%) were affected by branch vein thrombosis (AVT) and 63 (4.2%) from central vein thrombosis (CVT). In 47 (3.2%) eyes macular edema with myopic CNV (mCNV) was detected and 67 eyes (4.5%) were not further classified under "others". In all groups a gain in letters could be achieved in the EDTRS chart even after the first IVOM series: AMD + 3.4, DME + 1.3, AVT + 6.1, CVT + 10.1 and mCNV + 7.0. Patients who were treated with IVOM for the first time showed on average a better response than those previously treated with IVOM. CONCLUSION As in many other studies our data also underline the necessity for intravitreal injections for treatment of macular edema. Even if a 6‑week interval does not nowadays correspond to the current guidelines, we could achieve a stabilization of vision and do not shy away from comparison with large studies, such as the Marina study. In order to provide the increasing numbers of patients the best treatment in the future, an attempt at targeted implementation of resources must be made and if necessary symptoms which can be conservatively treated should be delegated to the private sector.
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Affiliation(s)
- K Wiesinger
- Krankenhaus Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich.
| | - P Reinelt
- Krankenhaus Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich
| | - A Ennemoser
- Krankenhaus Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich
| | - M Edelmayr
- Krankenhaus Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich
| | - U Schönherr
- Krankenhaus Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich
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Hermann MM, van Asten F, Muether PS, Smailhodzic D, Lichtner P, Hoyng CB, Kirchhof B, Grefkes C, den Hollander AI, Fauser S. Polymorphisms in vascular endothelial growth factor receptor 2 are associated with better response rates to ranibizumab treatment in age-related macular degeneration. Ophthalmology 2013; 121:905-10. [PMID: 24365177 DOI: 10.1016/j.ophtha.2013.10.047] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 10/22/2013] [Accepted: 10/28/2013] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Intravitreal anti-vascular endothelial growth factor (VEGF) injections are currently the standard treatment for neovascular age-related macular degeneration (AMD), but a broad range of response rates has been observed. We evaluated the association of single nucleotide polymorphisms (SNPs) in VEGF genes and their receptors (VEGFR) with the response rate to ranibizumab in 366 patients with neovascular AMD. DESIGN Case series study. PARTICIPANTS A total of 366 eyes of 366 patients with neovascular AMD. METHODS Visual acuity (VA) was determined at baseline, after 3 monthly ranibizumab injections, and after 1 year of treatment. Genotyping of 126 SNPs in the genes encoding VEGF family members VEGFA, VEGFB, VEGFC, VEGFD (FIGF), and placental growth factor (PGF); VEGF receptors VEGFR1 (FLT1), VEGFR2 (KDR), and VEGFR3 (FLT4); and the gene encoding pigment epithelium-derived factor (PEDF) (SERPINF1) was performed. MAIN OUTCOME MEASURES The changes in VA after 3 injections and after 1 year of treatment and their association with VEGF and VEGFR genotypes. RESULTS Univariate analyses of variance (ANOVAs) revealed a significant effect of SNP rs4576072 in the VEGFR2 gene on VA change after 12 months (F[1,235] = 14.05; P = 0.02). A stepwise linear regression analysis returned a model (P = 0.01) with SNPs rs4576072 and rs6828477 in the VEGFR2 gene as independent predictors for VA change after 12 months, with a mean increase in VA of 0.26 on the logarithm of the minimum angle of resolution (logMAR) scale in patients with 3 contributing minor alleles compared with a loss of 0.03 logMAR in patients with no minor allele. CONCLUSIONS Polymorphisms in the VEGFR2/KDR gene significantly influence visual outcome in patients receiving ranibizumab treatment for neovascular AMD. This study shows that genetic variation partially explains the wide range of response to ranibizumab treatment, which in the future might help clinicians tailoring medical interventions to individual needs.
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Affiliation(s)
- Manuel M Hermann
- Department of Ophthalmology, University Hospital of Cologne, Cologne, Germany
| | - Freekje van Asten
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Philipp S Muether
- Department of Ophthalmology, University Hospital of Cologne, Cologne, Germany
| | - Dzenita Smailhodzic
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Peter Lichtner
- Institute of Human Genetics, Helmholtz Zentrum München-Deutsches Forschungszentrum für Gesundheit und Umwelt, Neuherberg, Germany
| | - Carel B Hoyng
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Bernd Kirchhof
- Department of Ophthalmology, University Hospital of Cologne, Cologne, Germany
| | - Christian Grefkes
- Max Planck Institute for Neurological Research, Neuromodulation and Neurorehabilitation Group, Cologne, Germany; Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Anneke I den Hollander
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Department of Human Genetics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sascha Fauser
- Department of Ophthalmology, University Hospital of Cologne, Cologne, Germany.
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