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Kang EYC, Lin TY, Garg SJ, Wang NK, Chen LJ, Huang PW, Chan MJ, Chen KJ, Wu WC, Lai CC, Hwang YS. The Association of Intravitreal Injections of Different Anti-Vascular Endothelial Growth Factor with Systemic Outcomes in Diabetic Patients. J Pers Med 2023; 13:544. [PMID: 36983725 PMCID: PMC10057023 DOI: 10.3390/jpm13030544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/12/2023] [Accepted: 03/15/2023] [Indexed: 03/22/2023] Open
Abstract
This retrospective cohort study aimed to assess the systemic effects of three commonly available anti-vascular endothelial growth factor intravitreal injections in patients with diabetes, using data taken from a multi-institutional database in Taiwan. Patient data were sourced from the multi-institutional Chang Gung Research Database. Participants were divided into groups based on treatment with bevacizumab, ranibizumab, or aflibercept. Baseline characteristics were matched among the groups by the inverse probability of treatment weighting. The incidence rate of outcome events was calculated as the number of events divided by 100 person-years of follow-up. The cumulative incidence function was used to estimate the incidence rate of the outcome events among groups. The incidence of ischemic stroke was higher in the ranibizumab group than the bevacizumab and aflibercept groups (1.65, 0.92, and 0.61 per 100 person-years, respectively). The incidence of major adverse lower-limb events was higher in the bevacizumab group (2.95), followed by ranibizumab (2.00) and aflibercept (0.74). Major bleeding was relatively higher in bevacizumab (12.1) compared to ranibizumab (4.3) and aflibercept (3.8). All-cause death was higher for both bevacizumab (3.26) and aflibercept (2.61) when compared to ranibizumab (0.55), and all-cause admission was found to be highest with bevacizumab (58.6), followed by aflibercept (30.2), and ranibizumab (27.6). The bevacizumab group demonstrated a greater decrease in glycated hemoglobin compared to the baseline level (-0.33%). However, a few differences in the clinical condition between the groups were still observed after matching. In conclusion, this study suggests that different anti-vascular endothelial growth factor agents may be associated with various and differing systemic adverse events. The differences might also be attributed to differences in patient characteristics and clinical status.
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Affiliation(s)
- Eugene Yu-Chuan Kang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
| | - Tzu-Yi Lin
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Education, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Sunir J. Garg
- MidAtlantic Retina, The Retina Service of Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Nan-Kai Wang
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY 10032, USA
| | - Lee-Jen Chen
- Department of Ophthalmology, Mackay Memorial Hospital, Taipei 104, Taiwan
| | - Pei-Wei Huang
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
- Department of Oncology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Ming-Jen Chan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Kuan-Jen Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chi-Chun Lai
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Yih-Shiou Hwang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Ophthalmology, Jen-Ai Hospital Dali Branch, Taichung 412, Taiwan
- Department of Ophthalmology, Xiamen Chang Gung Memorial Hospital, Xiamen 361000, China
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Ou SH, Yin CH, Chung TL, Chen HY, Chen CL, Chen JS, Lee PT. Intravitreal Vascular Endothelial Growth Factor Inhibitor Use and Renal Function Decline in Patients with Diabetic Retinopathy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14298. [PMID: 36361175 PMCID: PMC9657653 DOI: 10.3390/ijerph192114298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 06/16/2023]
Abstract
Adverse renal effects of systemic vascular endothelial growth factor (VEGF) inhibitor treatment are well documented. We aimed to identify associations between intravitreal VEGF inhibitor use and renal function decline in patients with diabetic retinopathy. We included 625 patients with diabetic retinopathy for regular renal function follow-ups and grouped them according to intravitreal therapy (67 with and 558 without treatment). We used a generalized estimating equation model to identify renal function decline risk factors. Increased age (p = 0.02), insulin use (p = 0.01), hypertension (p < 0.01), and ischemic heart disease (p < 0.01) were associated with significantly decreased estimated glomerular filtration rates (eGFRs) in patients with diabetic retinopathy after 1-year follow-up. Compared to the control group, patients who received intravitreal VEGF inhibitor injections showed a declining eGFR trend in the repeated measurement model without statistical significance (p = 0.06). In subgroup analysis, patients with initial eGFR ≤ 30 mL/min/1.73 m2 who received intravitreal VEGF inhibitors had significantly decreased renal function (p < 0.01) compared to those without treatment. Intravitreal VEGF inhibitor injection was associated with renal function deterioration among patients with diabetic retinopathy and advanced chronic kidney disease. Strategies to monitor renal function after treatment should be considered in these high-risk populations.
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Affiliation(s)
- Shih-Hsiang Ou
- Division of Nephrology, Department of Internal Medicine, Pingtung Veterans General Hospital, Pingtung 900, Taiwan
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Institute of Health Care Management, National Sun Yat-sen University, Kaohsiung 804, Taiwan
| | - Tung-Ling Chung
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
| | - Hsin-Yu Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
| | - Chien-Liang Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
| | - Jin-Shuen Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Faculty of Medicine, School of Medicine, National Defense Medicine Center, Taipei 114, Taiwan
| | - Po-Tsang Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
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Uludag G, Hassan M, Matsumiya W, Pham BH, Chea S, Trong Tuong Than N, Doan HL, Akhavanrezayat A, Halim MS, Do DV, Nguyen QD. Efficacy and safety of intravitreal anti-VEGF therapy in diabetic retinopathy: what we have learned and what should we learn further? Expert Opin Biol Ther 2022; 22:1275-1291. [PMID: 35818801 PMCID: PMC10863998 DOI: 10.1080/14712598.2022.2100694] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 07/08/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Diabetic retinopathy (DR) is one of the most frequent microvascular complications of diabetes that can lead to blindness. Laser treatment has been the gold standard treatment for diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) for many years. Recently, the role of vascular endothelial growth factor (VEGF) has been established in the pathogenesis of DR, and the use of intravitreal anti-VEGF therapy has gained popularity for the management of DR. AREAS COVERED This review includes a brief overview of the efficacy and safety of currently available (bevacizumab, ranibizumab, and aflibercept) and potential future (brolucizumab, faricimab, and KSI-301) anti-VEGF agents in patients with DR based mainly on publicly available data from phase 1, 2 and 3 clinical trials. EXPERT OPINION Clinical trials investigating the efficacy of intravitreal bevacizumab, ranibizumab, and aflibercept injections demonstrated favorable functional and anatomical outcomes in patients with DME. Moreover, the use of these anti-VEGF agents showed a significant improvement in the severity of DR. Recent clinical research for future anti-VEGF molecules aims to provide higher target-protein binding affinity and prolonged therapeutic effect. Brolucizumab, faricimab, and KSI-301 are three novel anti-VEGF agents that demonstrate promising data for the management of DME and potentially DR.
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Affiliation(s)
- Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Wataru Matsumiya
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Brandon Huy Pham
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami, Miami, FL, USA
| | - Sophaktra Chea
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Hien Luong Doan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Muhammad Sohail Halim
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Ocular Imaging Research and Reading Center, Sunnyvale, CA, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Increased mortality after intravitreal injections of anti-VEGF for neovascular AMD among patients with prior stroke or acute myocardial infarction. Eye (Lond) 2022; 36:153-159. [PMID: 33654317 PMCID: PMC8727623 DOI: 10.1038/s41433-021-01416-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 12/09/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To evaluate whether intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) in neovascular age-related macular degeneration (nAMD) patients with prior stroke or acute myocardial infarction (AMI) are associated with increased mortality. METHODS From 2005 to 2013, nAMD patients in the Taiwan National Health Insurance Research Database who received IVI of anti-VEGF and had a diagnosis of stroke/AMI prior to their first injections were defined as the IVI group. The mortality of the IVI group during the study period was compared to that of the non-IVI group, which consisted of nAMD patients who had prior stroke/AMI but were never exposed to anti-VEGF. The IVI group and the non-IVI group were 1-4 matched according to propensity score (PS), which was derived from age, sex, date of stroke/AMI and comorbidities. PS-adjusted Cox regression analyses were used to estimate the hazard ratio (HR) for mortality associated with IVI of anti-VEGF. Subgroup analyses were also performed according to the interval between stroke/AMI and IVI (≤6 months, 6 months to 1 year, 1-2 years, >2 years). RESULTS There were 3384 individuals in the IVI group and 13,536 individuals in the non-IVI group. The IVI group had a significantly higher mortality risk (adjusted HR = 2.37; 95% confidence interval (CI), 2.14-2.62) than the non-IVI group. Subgroup analyses revealed that elevated mortality was significant when anti-VEGF was injected within 1 year after stroke/AMI. CONCLUSIONS We found an increased mortality risk associated with IVI of anti-VEGF in nAMD patients with prior stroke/AMI compared to the mortality risk of nAMD patients with prior stroke/AMD but without exposure to anti-VEGF.
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Ngo Ntjam N, Thulliez M, Paintaud G, Salvo F, Angoulvant D, Pisella PJ, Bejan-Angoulvant T. Cardiovascular Adverse Events With Intravitreal Anti-Vascular Endothelial Growth Factor Drugs: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Ophthalmol 2021; 139:2778626. [PMID: 33856414 PMCID: PMC8050790 DOI: 10.1001/jamaophthalmol.2021.0640] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/15/2021] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Systemic safety of intravitreal anti-vascular endothelial growth factor (anti-VEGF) is a matter of debate and regular updates are necessary. OBJECTIVE To evaluate systemic adverse events (SAEs) associated with intravitreal anti-VEGF drugs compared with non-anti-VEGF treatments in patients with ocular diseases. DATA SOURCES Electronic searches were conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases from inception to July 7, 2020. STUDY SELECTION Randomized clinical trials conducted in adults with retinal diseases who received intravitreal anti-VEGF drugs. DATA EXTRACTION AND SYNTHESIS Studies and treatment characteristics and outcome data were extracted and analyzed, and study quality was evaluated. MAIN OUTCOMES AND MEASURES Main outcomes were major cardiovascular events (MACEs) and total mortality. Secondary outcomes included nonocular hemorrhage, components of MACEs, other cardiovascular outcomes, serious SAEs, and all SAEs. RESULTS A total of 74 randomized clinical trials were analyzed: 32 trials (43%) included 14 190 patients with age-related macular degeneration (AMD), 24 (32%) included 5424 patients with diabetic retinopathy (diabetic macular edema or proliferative diabetic retinopathy), 17 trials (23%) included 3757 patients with retinal vein occlusion, and 1 trial (1%) included 122 patients with myopic choroidal neovascularization. Anti-VEGF drug administration did not increase MACEs compared with control agents (odds ratio [OR], 1.16; 95% CI, 0.85-1.58) or total mortality (OR, 1.27; 95% CI, 0.82-1.96). There was an interaction (subgroup difference, P = .04) in mortality risk depending on the underlying disease with an increase (OR, 1.80; 95% CI, 1.03-3.16; P = .04) in the risk of death in patients with diabetic retinopathy; however, no increase was observed in patients with AMD or retinal vein occlusion. Administration of anti-VEGF drugs increased the risk of nonocular hemorrhage (OR, 1.46; 95% CI, 1.01-2.10), mainly in patients with AMD. CONCLUSIONS AND RELEVANCE Intravitreal anti-VEGF was not associated with an increase in MACEs in the trials examined herein. Increased mortality in patients with diabetes and nonocular hemorrhages, especially in those with AMD, could represent a safety signal, but the evidence was not strong. However, continued surveillance of SAEs remains warranted.
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Affiliation(s)
- Nadège Ngo Ntjam
- Hospital Pharmacy, CHRU de Tours, Tours, France
- EA 4245, T2I (Transplantation, Immunity & Inflammation), Université de Tours, Tours, France
- Medical Pharmacology Department, CHRU de Tours, Tours, France
| | - Marie Thulliez
- Ophthalmology Department, CHU de Montpellier, Montpellier, France
| | - Gilles Paintaud
- EA 4245, T2I (Transplantation, Immunity & Inflammation), Université de Tours, Tours, France
- Medical Pharmacology Department, CHRU de Tours, Tours, France
| | - Francesco Salvo
- Medical Pharmacology Department, CHU Pellegrin, Bordeaux, France
- Bordeaux Population Health Research Center, U1219, Université de Bordeaux, Bordeaux, France
| | - Denis Angoulvant
- EA 4245, T2I (Transplantation, Immunity & Inflammation), Université de Tours, Tours, France
- Cardiology Department, CHRU de Tours, Tours, France
| | | | - Theodora Bejan-Angoulvant
- EA 4245, T2I (Transplantation, Immunity & Inflammation), Université de Tours, Tours, France
- Medical Pharmacology Department, CHRU de Tours, Tours, France
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Ahmed N, Rehman HU, Rafique M, Hamza MS, Mirza HA. Incidence of Acute Endophthalmitis After Intravitreal Bevacizumab Injection at a Tertiary Care Hospital in Lahore. Cureus 2021; 13:e13185. [PMID: 33717729 PMCID: PMC7943056 DOI: 10.7759/cureus.13185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We aimed to assess the incidence, management, and visual outcome of acute endophthalmitis in patients following intravitreal bevacizumab injection in a tertiary care setup. It was a prospective and single-center database study. PATIENTS AND METHODS Patients receiving intravitreal bevacizumab injections for various retinal vascular diseases from January 2019 to September 2020. The study was carried out at the Institute of Ophthalmology, Mayo Hospital, Lahore over a period of 21 months. Preformed bevacizumab injections were administered intravitreally on patients of various retinal vascular diseases under strict aseptic measures and by following the standard guidelines. The patients were put on follow-ups for a duration of four weeks to see any signs of acute endophthalmitis. RESULTS A total of 3051 injections were administered in 1104 eyes of 743 patients during the above-mentioned study period. The incidence of endophthalmitis was found to be 0.0328% (1/3051). The patient, who developed endophthalmitis, was treated with topical and intravitreal antibiotics followed by vitrectomy that resulted in clinically significant improvement in vision. CONCLUSION Incidence of acute endophthalmitis following intravitreal bevacizumab injection was low and could be prevented by taking strict aseptic measures during administration.
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Affiliation(s)
- Nasir Ahmed
- Department of Ophthalmology, King Edward Medical Univeristy, Mayo Hospital, Lahore, PAK
| | - Hafeez Ur Rehman
- Department of Ophthalmology, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Memoona Rafique
- Department of Ophthalmology, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Muhammad S Hamza
- Department of Ophthalmology, King Edward Medical University, Mayo Hospital, Lahore, PAK
| | - Huma A Mirza
- Department of Ophthalmology, King Edward Medical University, Mayo Hospital, Lahore, PAK
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Jeon HL, Byun SJ, Pratt NL, Sultana J, Park SJ, Shin JY. Cardiovascular risk in patients receiving ranibizumab for exudative age-related macular degeneration: a nationwide self-controlled case-series study. Br J Ophthalmol 2020; 105:543-548. [PMID: 32522792 DOI: 10.1136/bjophthalmol-2020-316373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 11/03/2022]
Abstract
AIMS To identify the association between ranibizumab and risk of stroke and acute myocardial infarction (AMI) in patients with exudative age-related macular degeneration (AMD). METHODS We identified patients aged ≥45 years who received ranibizumab for exudative AMD from the Korean National Health Insurance database. Of these, we selected patients suffering stroke or AMI for the self-controlled case series. We estimated incidence rate ratios (IRR) for stroke or AMI by comparing incidence rates of ranibizumab-exposed periods to that of baseline using conditional Poisson regression. The risks of haemorrhagic and ischaemic strokes were also calculated separately. RESULTS Among 33 134 patients receiving ranibizumab, 2397 patients had stroke or AMI. The risk of stroke (IRR=0.83, 95% CI 0.75 to 0.91) was not increased during the overall exposed period; however, there was a marginally elevated risk in ≥57 days exposed period (IRR=1.14, 95% CI 1.001 to 1.31). When analysing by the types of stroke, no increased risks of haemorrhagic (IRR=1.01, 95% CI 0.80 to 1.26) and ischaemic stroke (IRR=0.78, 95% CI 0.71 to 0.86) were observed during the exposed period, although the risks of ischaemic and haemorrhagic stroke were slightly elevated during ≥57 days exposed period. We could not find an association between ranibizumab and AMI. CONCLUSIONS Ranibizumab intravitreal injections did not increase the overall risk of stroke or AMI. Although the cardiovascular risk in patient receiving ranibizumab seems to be low, continuous monthly use of ranibizumab for high-risk patients should be judged carefully.
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Affiliation(s)
- Ha-Lim Jeon
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Seong Jun Byun
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea.,Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Janet Sultana
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Sicily, Italy
| | - Sang Jun Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
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8
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Jose V, Radhakrishna S, Pipalava P, Singh I. Bevacizumab for eye diseases - Legal, regulatory, and ethical overview. Indian J Pharmacol 2020; 51:377-383. [PMID: 32029959 PMCID: PMC6984021 DOI: 10.4103/ijp.ijp_413_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/12/2019] [Accepted: 12/23/2019] [Indexed: 01/14/2023] Open
Abstract
Vascular endothelial growth factor (VEGF) inhibitors, ranibizumab, aflibercept, and pegaptanib are approved treatments for certain eye diseases that occurs especially in the elderly. These drugs are mostly inaccessible due to their high cost. Bevacizumab is a VEGF inhibitor, approved for cancer treatment. Being a cheaper alternative, it is extensively used off-label as an intravitreal injection for the treatment of eye diseases. In this article, we have analyzed similarities and differences between bevacizumab and ranibizumab, and potential long-term safety concerns with off-label use of bevacizumab. We also analyzed legal, regulatory, and ethical background of off-label use and provided recommendations to resolve this issue. Based on the extensive clinical data, actions taken, and recommendations provided by agencies such as the National Institute for Health and Care Excellence, International Council of Ophthalmology, United Kingdom and Thailand regulatory agency, intravitreal bevacizumab has adequate evidence for controlled licensing. Claiming better safety for ranibizumab at the expense of nonaffordability cannot be considered a positive risk-benefit scenario. Intravitreal bevacizumab is being used and will continue to be used off-label, if not regulatory controlled. Licensing will ensure the availability of intravitreal bevacizumab to the patients with eye diseases, without any legal or ethical concerns for the clinicians, and will also assist in generating long-term safety data. Safest delivery formulation and dosage form should be considered for approval. Both the regulatory agency and technical experts should join and take critical decision, which will be a big step forward to making a cost-effective drug available to the public.
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Affiliation(s)
- Vinu Jose
- Clinical Development and Medical Affairs, Intas Pharmaceuticals Ltd. (Biopharma), Ahmedabad, Gujarat, India
| | - Swetha Radhakrishna
- Clinical Development and Medical Affairs, Intas Pharmaceuticals Ltd. (Biopharma), Ahmedabad, Gujarat, India
| | - Parag Pipalava
- Clinical Development and Medical Affairs, Intas Pharmaceuticals Ltd. (Biopharma), Ahmedabad, Gujarat, India
| | - Inderjeet Singh
- Clinical Development and Medical Affairs, Intas Pharmaceuticals Ltd. (Biopharma), Ahmedabad, Gujarat, India
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Costagliola C, Morescalchi F, Duse S, Romano D, Mazza G, Parmeggiani F, Bartollino S, Semeraro F. Systemic thromboembolic adverse events in patients treated with intravitreal anti-VEGF drugs for neovascular age-related macular degeneration: an update. Expert Opin Drug Saf 2019; 18:803-815. [DOI: 10.1080/14740338.2019.1643838] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Ciro Costagliola
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, Campobasso, Italy
| | - Francesco Morescalchi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Sarah Duse
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Romano
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppina Mazza
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Parmeggiani
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Silvia Bartollino
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, Campobasso, Italy
| | - Francesco Semeraro
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Kumluang S, Ingsrisawang L, Sangroongruangsri S, Chaikledkaew U, Ratanapakorn T, Ruamviboonsuk P, Taweebanjongsin W, Choovuthayakorn J, Thoongsuwan S, Hanutsaha P, Kulvichit K, Ratanapojnard T, Wongsawad W, Leelahavarong P, Teerawattananon Y. A real-world study of effectiveness of intravitreal bevacizumab and ranibizumab injection for treating retinal diseases in Thailand. BMC Ophthalmol 2019; 19:82. [PMID: 30922350 PMCID: PMC6439979 DOI: 10.1186/s12886-019-1086-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 03/06/2019] [Indexed: 01/05/2023] Open
Abstract
Background To evaluate the effectiveness of intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) in actual practice for treating patients with retinal diseases in Thailand. Methods A prospective, multi-centre, observational study was conducted among eight hospitals in their ophthalmology outpatient departments. Participants consisted of patients who had previously not received any IVB or IVR treatment between 2013 and 2014. The primary outcome measurement was the change in best-corrected visual acuity (BCVA) at the end of the follow-up period compared to baseline. Results There were 1629 treatment-naïve patients for the pro re nata (PRN) treatment pattern and 226 treatment-naive patients for the three-injections (3Inj) treatment pattern. BCVA improvements were found in 35% of the PRN group and 47% of the 3Inj group; however, it was not clinically meaningful between the IVB and IVR groups (P-value = 0.568 for PRN, P-value = 0.103 for 3Inj). A multivariable logistic regression (using the propensity score) showed that positive factors associated with vision improvement for the PRN pattern were the number of drug injections, having retinal vein occlusion, and under 60 years of age, while good BCVA at baseline was a negative predictive factor. For the 3Inj pattern, under 60 years of age and baseline BCVA were statistically significant predictors. Nonetheless, diabetes mellitus (DM) without other comorbidities was a statistically significant predictor of low response to vision improvement compared to DM with other comorbidities. Conclusions This study was the first observational, prospective study to evaluate the real-life effectiveness of IVB and IVR in Thailand. The majority of participants who used IVB or IVR showed improvements in BCVA after treatment. Further evaluation such as long-term follow-ups and subsequent comparison of effectiveness between IVB and IVR should be investigated due to the limited sample of IVR patients. Trial registration Thai Clinical Trial Registry TCTR20141002001. Registered 02 October 2014 (retrospectively registered).
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Affiliation(s)
- Suthasinee Kumluang
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
| | - Lily Ingsrisawang
- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand.
| | - Sermsiri Sangroongruangsri
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand.,Social and Administrative Pharmacy Excellence Research (SAPER) Unit, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Usa Chaikledkaew
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand.,Social and Administrative Pharmacy Excellence Research (SAPER) Unit, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Tanapat Ratanapakorn
- Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | | | - Janejit Choovuthayakorn
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Somanus Thoongsuwan
- Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Prut Hanutsaha
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kittisak Kulvichit
- Vitreo-Retina Research Unit, Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thitiporn Ratanapojnard
- Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Warapat Wongsawad
- Department of Ophthalmology, Mettapracharak (Wat Rai Khing) Hospital, Nakornprathom, Thailand
| | - Pattara Leelahavarong
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
| | - Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
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