Anti-VEGF Therapies and Blood Pressure: More Than Meets the Eye

Safety monitoring of ophthalmic biologics: a systematic review of pre- and postmarketing safety data

PURPOSE

The present study evaluates the safety of the biologics approved for the treatment of ocular diseases.

METHODS

The European medicines agency Website was searched to identify biologics with approved ophthalmologic therapeutic indications. A systematic search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and the International Clinical Trials Registry Platform up to December 2013. Pre-marketing, phase III randomized controlled trials (RCT), postmarketing clinical trials, observational longitudinal studies, and case reports involving adverse events (AE) were included. Methodological quality was assessed by Downs & Black checklist. All European spontaneous reports of AE included in the Eudravigilance up to December 2013 were also considered. AE were classified as ocular (related and non-related with the injection procedure) and non-ocular (related or non-related with vascular endothelial growth factor inhibition). Incidences of all reported AEs were estimated.

RESULTS

Pegaptanib, ranibizumab, and aflibercept were identified as ophthalmic biologics. Fourteen premarketing RCT, 7 postmarketing clinical trials, 31 observational studies, along with 31 case reports and 7,720 spontaneous reports were identified and included in this study. Both in pre- and postmarketing settings, ocular AEs were more frequent than non-ocular AEs. Premarketing safety data inform the most common AEs. Postmarketing studies suggest an increased number of events such as retinal pigmented epithelium tears (0.6%-24%), thromboembolic events (0.8%-5%), and mortality (2.8%-4%).

CONCLUSIONS

This study highlights the need to properly evaluate the risk for rare, serious, and long-term AEs, such as thromboembolic events, since they can lead to imbalances in the benefit-risk ratio of biologics in ophthalmology.

Age-related macular degeneration, anti-vascular endothelial growth factor agents, and short-term mortality: a postmarketing medication safety and surveillance study

PURPOSE

To compare short-term (1 year) survival of subjects treated for exudative age-related macular degeneration (AMD) with those with AMD who received no treatment.

METHODS

This was a case-control study. Beneficiaries of the Veterans Health Administration aged ≥55 years with a diagnosis of AMD in fiscal years 2007-2009 were included in this study. Veterans Health Administration clinical and pharmacy data sets were linked with a national Veterans Health Administration mortality registry. Anti-vascular endothelial growth factor exposure was identified through pharmacy records, coupled to procedure code for intravitreous injection and diagnosis code of exudative AMD. Control group consisted of patients with coded diagnosis of dry AMD and no pharmacy claims for case-defining medications. Cox proportional hazard model was adjusted for age, gender, number of injections, and ocular and medical comorbidities. The main outcome measure was hazard of death according to medication exposure.

RESULTS

A total of 3,210 patients received intravitreous injections for exudative AMD. There were 117,364 nonexposed patients with dry AMD. Twelve-month all-cause mortality in the exposed and control groups were 3.9% and 4.5%, respectively. When adjusted for age, gender, and ocular and medical comorbidities, the death hazard was 0.89 (95% confidence interval, 0.74-1.06). The risk of all-cause mortality was similar for patients receiving bevacizumab and ranibizumab.

CONCLUSION

Twelve-month all-cause mortality in a population of predominately men with exudative AMD and a high prevalence of medical comorbidities was unaffected by exposure to therapeutic levels of vitreous bevacizumab and ranibizumab. Commonly used anti-vascular endothelial growth factor agents for exudative AMD do not adversely impact short-term survival in men.

Identifying subtypes of patients with neovascular age-related macular degeneration by genotypic and cardiovascular risk characteristics

BACKGROUND

One of the challenges in the interpretation of studies showing associations between environmental and genotypic data with disease outcomes such as neovascular age-related macular degeneration (AMD) is understanding the phenotypic heterogeneity within a patient population with regard to any risk factor associated with the condition. This is critical when considering the potential therapeutic response of patients to any drug developed to treat the condition. In the present study, we identify patient subtypes or clusters which could represent several different targets for treatment development, based on genetic pathways in AMD and cardiovascular pathology.

METHODS

We identified a sample of patients with neovascular AMD, that in previous studies had been shown to be at elevated risk for the disease through environmental factors such as cigarette smoking and genetic variants including the complement factor H gene (CFH) on chromosome 1q25 and variants in the ARMS2/HtrA serine peptidase 1 (HTRA1) gene(s) on chromosome 10q26. We conducted a multivariate segmentation analysis of 253 of these patients utilizing available epidemiologic and genetic data.

RESULTS

In a multivariate model, cigarette smoking failed to differentiate subtypes of patients. However, four meaningfully distinct clusters of patients were identified that were most strongly differentiated by their cardiovascular health status (histories of hypercholesterolemia and hypertension), and the alleles of ARMS2/HTRA1 rs1049331.

CONCLUSIONS

These results have significant personalized medicine implications for drug developers attempting to determine the effective size of the treatable neovascular AMD population. Patient subtypes or clusters may represent different targets for therapeutic development based on genetic pathways in AMD and cardiovascular pathology, and treatments developed that may elevate CV risk, may be ill advised for certain of the clusters identified.

The asthmatic athlete: inhaled Beta-2 agonists, sport performance, and doping

The asthmatic athlete has a long history in competitive sport in terms of success in performance and issues related to doping. Well documented are detailed objective tests used to evaluate the athlete with symptoms of asthma or airway hyperresponsiveness and the medical management. Initiated at the 2002 Salt Lake City Games, the International Olympic Committee's Independent Asthma Panel required testing to justify the use of inhaled beta-2 agonists (IBAs) in Olympic athletes and has provided valuable guidelines to the practicing physician. This program was educational and documented the variability in prevalence of asthma and/or airway hyperresponsiveness and IBA use between different sports and different countries. It provided a standard of care for the athlete with respiratory symptoms and led to the discovery that asthmatic Olympic athletes outperformed their peers at both Summer and Winter Olympic Games from 2002 to 2010. Changes to the World Anti-Doping Agency's Prohibited List in 2010 permitted the use of 2 IBA produced by the same pharmaceutical company. All others remain prohibited. However, there is no pharmacological difference between the permitted and prohibited IBAs. As a result of these changes, asthmatic athletes are being managed differently based on a World Anti-Doping Agency directive that has no foundation in pharmacological science or in clinical practice.