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Creer R, Boonarpha N, Gould G, Rajai A, Chhabra R. Real-world experience of using stereotactic radiotherapy combined with anti-vascular endothelial growth factor to treat neovascular AMD. Graefes Arch Clin Exp Ophthalmol 2024; 262:2411-2419. [PMID: 38446199 DOI: 10.1007/s00417-024-06429-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION Adjunctive treatment or longer-acting drugs are required to treat nAMD to help ease burdens for patients and hospital clinics alike. Stereotactic therapy is one such option, providing a reduction in the number of injections over time. OBJECTIVE To determine the clinical outcomes in a cohort of patients with nAMD receiving a combination therapy of stereotactic radiotherapy (SRT) with intravitreal anti-VEGF injections (IVI). METHOD A retrospective analysis of 74 patients with nAMD, who had received IVI and SRT (16 Gray maximum dose to the macula) at a large tertiary university eye hospital, between March 2018 and September 2019 was performed. The number of IVIs, visual acuity (VA), and central retinal thickness (CRT) were evaluated at 12, 24, and 36 months after patients received SRT and compared to the same time interval prior to SRT. RESULTS Follow-up data at 12, 24, and 36 months following and prior to SRT was available for 74, 48, and 22 patients respectively. Overall there was a significant reduction in the number of injections post-SRT. Twelve months following SRT, the median number of IVI was reduced by 1 (p < 0.05). The reduction in the median number of IVI was significantly reduced by 3 and 6 injections at 24- and 36-month follow-up respectively (p < 0.05). The CRT was significantly reduced post-SRT compared to the baseline values at all time periods. There was no statistically significant difference in VA at 12-month follow-up compared to baseline. The VA, however, significantly decreased at 24- and 36-month follow-up (p < 0.05). CONCLUSION A therapy combining SRT with IVI has shown an overall reduction in the number of injections required in nAMD patients at 12, 24, and 36 months following SRT compared to IVI treatment alone. These real-world outcomes are comparable to other studies while also confirming the maintenance of the reduced frequency of required IVI for patients with nAMD.
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Affiliation(s)
- Rosalind Creer
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, M13 9WL, UK.
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Nattapon Boonarpha
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, M13 9WL, UK
| | - Gemma Gould
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, M13 9WL, UK
| | - Azita Rajai
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, M13 9WL, UK
| | - Ramandeep Chhabra
- Manchester Royal Eye Hospital and Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust Manchester, Manchester, M13 9WL, UK
- School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Samacá-Samacá D, Hernández-Castillo C, Prieto-Pinto L, Rodríguez F, Sardi C, Ocampo H, Kock J, Hernández F. Efficacy and safety of faricimab for neovascular age-related macular degeneration: a systematic review and network meta-analysis. BMJ Open Ophthalmol 2024; 9:e001702. [PMID: 39043575 PMCID: PMC11268043 DOI: 10.1136/bmjophth-2024-001702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/06/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of faricimab compared with other anti-vascular endothelial growth factor (anti-VEGF) agents in treating neovascular age-related macular degeneration (nAMD) patients. METHODS AND ANALYSIS A systematic review (SR) was conducted up to January 2023. Network meta-analyses (NMA) were performed, including sensitivity and subgroup analyses for naïve population. Outcomes included changes in visual acuity (Early Treatment of Diabetic Retinopathy Study [ETDRS] letters), anatomical changes, frequency of injections and adverse events. The Cochrane Collaboration guidelines and the Confidence in Network Meta-Analysis framework were used for the SR and the certainty of evidence, respectively. RESULTS From 4128 identified records through electronic databases and complementary searches, 63 randomised controlled trials (RCTs) met the eligibility criteria, with 42 included in the NMA. Faricimab showed a significant reduction in the number of annual injections compared with most fixed and flexible anti-VEGF treatment regimens, while showing no statistically significant differences in visual acuity through ETDRS letter gain, demonstrating a comparable efficacy. Retinal thickness results showed comparable efficacy to other anti-VEGF agents, and inferior only to brolucizumab. Results also showed that more patients treated with faricimab were free from post-treatment retinal fluid compared with aflibercept every 8 weeks, and both ranibizumab and bevacizumab, in the fixed and pro re nata (PRN) assessed schedules. Faricimab showed a comparable safety profile regarding the risk of ocular adverse events and serious ocular adverse events (SOAE), except for the comparison with brolucizumab quarterly, in which faricimab showed a significant reduction for SOAE risk. CONCLUSION Faricimab showed a comparable clinical benefit in efficacy and safety outcomes, with a reduction in annual injections compared with fixed and flexible anti-VEGF drug regimens, representing a valuable treatment option for nAMD patients. PROSPERO REGISTRATION NUMBER CRD42023394226.
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Affiliation(s)
| | | | | | - Francisco Rodríguez
- FUNDONAL, Bogota, Colombia
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá D.C, Colombia
| | - Carolina Sardi
- Instituto Nacional de Investigación en Oftalmología, Medellín, Colombia
| | | | - Joshua Kock
- Evidence Generation, Roche Colombia, Bogotá D.C, Colombia
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Śpiewak D, Drzyzga Ł, Dorecka M, Wyględowska-Promieńska D. Summary of the Therapeutic Options for Patients with Dry and Neovascular AMD. J Clin Med 2024; 13:4227. [PMID: 39064267 PMCID: PMC11278184 DOI: 10.3390/jcm13144227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Age-related macular degeneration (AMD) is the leading cause of irreversible blindness worldwide and a severe medical and social problem. The steadily increasing number of patients is related to the aging of the population. So far, many factors affecting the development of AMD have been identified, which can be divided into non-modifiable, including genetic factors, age, and sex, and modifiable or environmental factors, such as smoking, poor diet, and hypertension. Early stages of age-related macular degeneration are characterized by fundus drusen and abnormalities in the retinal pigment epithelium. In late stages, geographic atrophy and choroidal neovascularization (CNV) are observed. The treatment of AMD, especially its advanced forms, is very challenging. Intensive research has made it possible to treat advanced stages of the dry form of AMD with pegcetacoplan and avacincaptad pegol, new drugs approved for use in the US. Pegcetacoplan targets the C3 and avacincaptad pegol targets the C5, the pivotal proteins of the complement cascade. The drugs are administered by intravitreal injection. The gold standard for neovascular AMD (nAMD) consists of intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drugs such as bevacizumab, ranibizumab, aflibercept, brolucizumab, and faricimab. Treatment can be administered according to the fixed, pro-re-nata, and treat-and-extend regimens. The latter seems to have the best effect on improving visual acuity (VA) and the maximum therapeutic benefit. The search continues for the best ways to deliver intravitreal drugs. Current methods include sustained-release implants and hydrogel platforms for drug release, while the most promising future pathways for treating dry and nAMD are stem cell and gene therapy.
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Affiliation(s)
- Dorota Śpiewak
- Department of Ophthalmology, Prof. K. Gibiński University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland
- Clinical Ophthalmology Center Okolux, 40-754 Katowice, Poland
| | - Łukasz Drzyzga
- Department of Ophthalmology, Prof. K. Gibiński University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland
- Clinical Ophthalmology Center Okolux, 40-754 Katowice, Poland
| | - Mariola Dorecka
- Department of Ophthalmology, Prof. K. Gibiński University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland
- Department of Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-287 Katowice, Poland
| | - Dorota Wyględowska-Promieńska
- Department of Ophthalmology, Prof. K. Gibiński University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland
- Department of Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-287 Katowice, Poland
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Roubelat FP, Barioulet L, Varenne F, Escudier C, Meyer P, Gomane C, Butterworth J, Pagot-Mathis V, Fournié P, Gualino V, Soler V. The Reinforced Treat-and-Extend Protocol for Exudative Age-Related Macular Degeneration: Retrospective Assessment of 24-Month Real-World Outcomes in France. Ophthalmol Ther 2024; 13:1647-1667. [PMID: 38625500 PMCID: PMC11109064 DOI: 10.1007/s40123-024-00938-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/13/2024] [Indexed: 04/17/2024] Open
Abstract
INTRODUCTION The aim of this work is to evaluate the real-world outcomes of the reinforced treat-and-extend (RTE) protocol for the treatment of exudative age-related macular degeneration with intravitreal injections of aflibercept or ranibizumab (anti-vascular endothelial growth factor therapies). METHODS This was a retrospective review of patients from two tertiary ophthalmology centers in France initiating the RTE protocol between February 2018 and June 2021. The primary outcome was change in best-corrected visual acuity (BCVA) after 24 months. Secondary outcomes were change in central retinal thickness (CRT), recurrence, and management-related factors (injection interval, number of injections/consultations). Outcomes were additionally evaluated after protocol changes (strict versus modified RTE protocol groups). RESULTS Sixty-eight patients (72 eyes) were included (68% females; mean age 82.2 ± 7.8 years). After 24 months, mean BCVA significantly improved (65.22 ± 14 vs. 71.96 ± 13 Early Treatment Diabetic Retinopathy Study letters; p < 0.001) and CRT significantly decreased (388.6 ± 104 vs. 278.8 ± 51 μM; p < 0.001) with 21% of eyes showing signs of exudation. Over the 24 months, a mean total of 14.9 ± 4.0 injections and 8.6 ± 1.4 consultations were performed. Mean 24-month injection interval was 7.9 ± 2.3 weeks. Initial and 24-month ophthalmic outcomes for eyes in the strict (47%) versus modified (53%) groups were not significantly different, but mean time interval to first recurrence of disease activity was significantly shorter for the modified group (7.3 ± 2.4 vs. 9.9 ± 2.5 weeks; p < 0.001). Patients in the strict RTE group received significantly less injections (13.9 ± 3.6 vs. 16.5 ± 3.9; p = 0.006) and mean 24-month injection interval was significantly longer (9.5 ± 2.7 vs. 6.5 ± 2.1 weeks; p < 0.001). Consultation number was similar (8.5 ± 1.9 vs. 8.8 ± 1.6; p = 0.93). Treatment with aflibercept versus ranibizumab did not influence ophthalmic or management outcomes. CONCLUSIONS The RTE protocol, even when modified, reduced consultations but improved ophthalmic outcomes. The RTE protocol could reduce hospital visits and overall burden while also encouraging better patient compliance. Video Abstract available for this article. VIDEO ABSTRACT Vincent Soler and François-Philippe Roubelat summarize the Reinforced Treat-and-Extend Protocol and main results (MP4 225022 KB).
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Affiliation(s)
- François-Philippe Roubelat
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Lisa Barioulet
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Fanny Varenne
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Clément Escudier
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Pauline Meyer
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Clément Gomane
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Jacqueline Butterworth
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Véronique Pagot-Mathis
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Pierre Fournié
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
- Faculty of Medicine, University of Toulouse III, Toulouse, France
| | - Vincent Gualino
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
- Ophthalmology Department, Clinique Honoré-Cave, Montauban, France
| | - Vincent Soler
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France.
- Faculty of Medicine, University of Toulouse III, Toulouse, France.
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Grassi MO, Viggiano P, Borrelli E, Boscia G, Molfetta T, Malerba MG, D'Addario M, Giancipoli E, Alessio G, Boscia F. Comparative Study on Anti-VEGF in Wet Age-Related Macular Degeneration in the Setting Based on Lean Methodology from the Bari Intravitreal Injection Registry (BIVIR). Ophthalmol Ther 2024; 13:1619-1634. [PMID: 38619788 PMCID: PMC11109068 DOI: 10.1007/s40123-024-00927-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/29/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Optimizing treatment protocols for wet age-related macular degeneration (wAMD) is an ongoing challenge, as it involves a delicate balance between achieving therapeutic efficacy and minimizing invasive procedures' frequency. This study aimed to apply the Lean methodology and evaluate the effectiveness of this new setting on intravitreal therapy for wAMD, employing different anti-vascular endothelial growth factors (VEGF) drugs (bevacizumab, brolucizumab, aflibercept, ranibizumab), drawing data from the Bari Intravitreal Injections Registry (BIVIR). METHODS This was a retrospective, monocentric, nonrandomized, comparative study. Lean methodology was employed to design the new setting and the BIVIR collected information from electronic medical records. Clinical data of four groups, stratified based on the first-line anti-VEGF agents used, were compared. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) changes were compared between the four groups at 3 and 12 months. RESULTS Out of 4990 eyes and 41,323 intravitreal injections (IVs) recorded in BIVIR, 1421 eyes of 1182 patients were included. The mean number of IVs in first year was 6.1 ± 2.5, with no significant differences among the four subgroups. The mean change in BCVA was + 6.2 letters [95% confidence interval (CI) 5.6-6.8] after two IVs, and + 5.9 (95% CI 5.1-6.8) letters after three IVs; at three months, brolucizumab was associated with a greater mean increase in BCVA than bevacizumab (p = 0.050); aflibercept (p = 0.044) and ranibizumab p = 0.047). At the 1-year follow-up, the mean change was + 6.3 letters (95% CI 5.4-7.2), brolucizumab and ranibizumab were associated with a superior improvement in BCVA compared to aflibercept (p = 0.033). Regarding the CRT, a significant reduction was observed in the subgroup treated with brolucizumab at the 3-month follow-up, compared to bevacizumab (p = 0.003), aflibercept (p = 0.015), and ranibizumab (p < 0.001); Aflibercept exhibited a superior effect than ranibizumab (p = 0.001). At 1-year follow-up, aflibercept resulted in a more significant reduction of macular thickness compared to ranibizumab (p = 0.016) while no significant differences were observed among the other drugs. CONCLUSIONS Our practical experience showed the effectiveness of the new setting in the treatment of wAMD. This comparative study at 1 year suggested a predominant brolucizumab efficacy on functional outcomes. In addition, brolucizumab and aflibercept appeared to have similar efficacy in fluid control.
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Affiliation(s)
- Maria Oliva Grassi
- DIBRAIN Department, University of Bari, Piazza Giulio Cesare, 11, Bari, Italy.
| | - Pasquale Viggiano
- DIBRAIN Department, University of Bari, Piazza Giulio Cesare, 11, Bari, Italy
| | - Enrico Borrelli
- Vita-Salute San Raffaele University Milan, Milan, Italy
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Boscia
- DIBRAIN Department, University of Bari, Piazza Giulio Cesare, 11, Bari, Italy
| | - Teresa Molfetta
- DIBRAIN Department, University of Bari, Piazza Giulio Cesare, 11, Bari, Italy
| | | | - Maria D'Addario
- DIBRAIN Department, University of Bari, Piazza Giulio Cesare, 11, Bari, Italy
| | - Ermete Giancipoli
- UOC Oftalmologia, Dipartimento di Scienze Mediche e Chirurgiche, University of Foggia, Foggia, Italy
| | - Giovanni Alessio
- DIBRAIN Department, University of Bari, Piazza Giulio Cesare, 11, Bari, Italy
| | - Francesco Boscia
- DIBRAIN Department, University of Bari, Piazza Giulio Cesare, 11, Bari, Italy
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Meng T, Sudarjat H, Momin M, Ma JX, Xu Q. Development of uniform fenofibrate-loaded biodegradable microparticle by membrane emulsification. Int J Pharm 2024; 650:123675. [PMID: 38061500 PMCID: PMC10843658 DOI: 10.1016/j.ijpharm.2023.123675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/09/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Abstract
Fenofibrate has shown therapeutic effects on diabetic retinopathy. However, fenofibrate can be rapidly cleared from the eye after a single intravitreal injection. Here, we aim to develop fenofibrate loaded PLGA microparticles (Feno-MP) with high drug loading and sustained in vitro release up to 6 months suitable for intravitreal injection. First, orthogonal array experimental design was applied for formulation optimization. The selected formulation parameters were used to formulate Feno-MP using homogenization method and direct membrane emulsification method. Both methods generated Feno-MP with high drug loading and sustained in vitro drug release more than 140 days. Unlike the polydisperse Feno-MP prepared using homogenization method, membrane emulsification method generated Feno-MP with uniform size distribution. By controlling the membrane pore size, 1.5 µm, 8 µm and 16 µm Feno-MP were formulated and we found that larger Feno-MP demonstrated higher drug loading, more sustained drug release in vitro with less burst drug release than the smaller Feno-MP. In conclusion, we developed Feno-MP with high drug loading and sustained release profile, and elucidated that changing the particle size could have notable impacts on drug loading and release kinetics. Formulating Feno-MP with uniform size distribution by membrane emulsification method would benefit the batch-to-batch repeatability.
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Affiliation(s)
- Tuo Meng
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Hadi Sudarjat
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Mohammad Momin
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Jian-Xing Ma
- Department of Biochemistry, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Qingguo Xu
- Department of Pharmaceutics, Virginia Commonwealth University, Richmond, VA 23298, USA; Department of Ophthalmology, Virginia Commonwealth University, Richmond, VA 23298, USA; Center for Pharmaceutical Engineering, and Institute for Structural Biology, Drug Discovery & Development (ISB3D), Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA.
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Wong DHT, Li KKW. Fixed Quarterly Dosing of Aflibercept after Loading Doses in Neovascular Age-Related Macular Degeneration in Chinese Eyes. J Clin Med 2023; 13:145. [PMID: 38202151 PMCID: PMC10779643 DOI: 10.3390/jcm13010145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/16/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
We aimed to investigate the success rate of planned fixed quarterly aflibercept injections after three loading doses (QDA3L) to achieve stability without recurrence in neovascular age-related macular degeneration (nAMD) at a tertiary eye centre. A retrospective study was conducted over five years (2017-2021) by including all consecutive cases of nAMD treated with three initial aflibercept injections four weeks apart, followed by planned injection appointments every 12 to 16 weeks starting from week 20. The primary endpoint was to determine the proportion of patients who maintained disease inactivity at week 52 and week 104. A total of 40 eyes of 40 patients were included. The overall mean age was 80.8, with a male preponderance. The overall success rate in our study population was 52.9% and 53.6% at week 52 and week 104, respectively. The fovea remained dry at 85.3% at week 52 and 82.1% at week 104, and 85.3% and 85.7% of subjects lost fewer than 15 ETDRS letters at week 52 and week 104, respectively. While this study does not suggest the superiority of this regimen, the success and failure rates obtained in our study can be used in the counselling process for this particular fixed treatment regimen for nAMD.
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Affiliation(s)
- Daniel H. T. Wong
- Department of Ophthalmology, United Christian Hospital, Hospital Authority, Hong Kong, China
- Department of Ophthalmology, Tseung Kwan O Hospital, Hospital Authority, Hong Kong, China
- Department of Ophthalmology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kenneth K. W. Li
- Department of Ophthalmology, United Christian Hospital, Hospital Authority, Hong Kong, China
- Department of Ophthalmology, Tseung Kwan O Hospital, Hospital Authority, Hong Kong, China
- Department of Ophthalmology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Takahashi VKL, Balbino M, Ruppert ADP, de Carvalho LS, Seixas RCS. Lost to follow-up of patients who received intravitreal anti-vascular endothelial growth factor therapy to treat four different retina disorders in an individual center in Brazil. SAGE Open Med 2023; 11:20503121231199655. [PMID: 37808513 PMCID: PMC10559699 DOI: 10.1177/20503121231199655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/21/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives To identify risk factors for loss to follow-up in periodic intravitreal anti-vascular endothelial growth factor injections for the treatment patients with diabetic macular edema, subretinal neovascularization, age-related macular degeneration, and retinal vein occlusion in a single eye center in São Paulo, Brazil. Methods This was a retrospective longitudinal study that gathered information from 992 patients who required intravitreal anti-vascular endothelial growth factor drugs over 6 months. The authors included age, eye disease, laterality, monthly income, distance, and payment mode as risk factors. Results Two hundred and seventy patients (29.93%) were lost to follow-up. Multivariate analysis showed age, monthly income, eye involvement, and type of medical assistance independently associated with loss to follow-up. The odds of loss to follow-up were greater among older patients than those less than 50 years (reference), p < 0.001. The odds of loss to follow-up were greater among patients who received unilateral treatment than those who received bilateral injections (p = 0.013). Concerning gross monthly income, there were no differences in the odds of the four salary strata; the data also indicate an absence of difference in the three strata of patients' distance to the clinic. Considering the diagnosis, only age-related macular degeneration showed greater odds of loss to follow-up (p = 0.016). Finally, the data suggest greater odds of loss to follow-up in private patients than in those on a health care plan (p < 0.001). Conclusion Loss to follow-up is paramount because many patients may remain unassisted concerning their eye diseases. Identifying the risk factors is crucial to enforcing measures to increase adherence and the long-term success of the treatment.
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Alharbi AD, Alotayk NI, Alaboudi AA, Alammar AY, Aldekhail MI, Alharbi MA, Alsamel TA, Aljutayli MA, Aljarbou AM, Aljameeli OM. Prevalence and Visual Consequences of Non-adherent Patients Receiving Anti-vascular Endothelial Growth Factor (VEGF) Injections at King Fahad Specialist Hospital (KFSH), Qassim Region. Cureus 2023; 15:e44340. [PMID: 37779785 PMCID: PMC10538945 DOI: 10.7759/cureus.44340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Anti-vascular endothelial growth factor (VEGF) injection treatment is a widely utilized therapy for various retinal diseases, including diabetic macular edema (DME). Therefore, the importance of compliance and follow-up should be discussed with the patient. There have been no studies conducted in the Qassim region to estimate the prevalence of patients missing their anti-VEGF appointments. To fulfill this need, we conducted this study to evaluate the compliance rate of patients treated with anti-VEGF injections for DME as well as to determine the visual consequences of the delay in anti-VEGF treatment in the Qassim region. METHODOLOGY This observational retrospective cohort study was conducted at King Fahad Specialist Hospital (KFSH) in the Qassim region of Saudi Arabia. We extracted all file numbers of patients who were using intravitreal anti-VEGF injections to treat DME. The data were managed and analyzed using the IBM Statistical Package for the Social Sciences (SPSS) software (IBM Corp., Armonk, NY, USA). RESULTS In the current study, we were able to collect data from 198 patients who received anti-VEGF treatment in the hospital. Among the participants, 57.6% were male, with a mean age of 61.7 years old (standard deviation (SD) = 10.23). Among the patients, we found that the rate of non-adherence to the anti-VEGF injection was 54.5%, and those patients delayed their scheduled doses for more than 56 days. In 47.5% of the patients, delaying or stopping their appointments had no known reason; however, blepharitis was the main reason for delaying or stopping the dose in 27.7% of the patients, followed by endophthalmitis in 18.7% of the patients. There is no significant difference between before and after stopping the treatment, considering visual acuity (VA) or optical coherence tomography (OCT). However, regarding the disease progression, we found that 15 out of the 30 patients had worsened in the OCT after they missed their injections (mean increase in the VA was 6.069 (SD = 97.45), t = -0.278, P = 0.783, and decrease in the OCT was -14.9667 (SD = 133.87, P = 0.454). CONCLUSION There is a high rate of patients who missed their appointments for an anti-VEGF injection. This resulted in the worsening of OCT in half of the 30 patients who were enrolled in the visual consequences study, which had a negative impact on treatment and disease progression.
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Lees JS, Dobbin SJH, Elyan BMP, Gilmour DF, Tomlinson LP, Lang NN, Mark PB. A systematic review and meta-analysis of the effect of intravitreal VEGF inhibitors on cardiorenal outcomes. Nephrol Dial Transplant 2022:6786281. [PMID: 36318455 DOI: 10.1093/ndt/gfac305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Vascular endothelial growth factor inhibitors (VEGFi) have transformed the treatment of many retinal diseases, including diabetic maculopathy. Increasing evidence supports systemic absorption of intravitreal VEGFi and development of significant cardiorenal side effects. METHODS Systematic review and meta-analysis (PROSPERO: CRD42020189037) of randomised controlled trials of intravitreal VEGFi treatments (bevacizumab, ranibizumab and aflibercept) for any eye disease. Outcomes of interest were cardiorenal side effects (hypertension, proteinuria, kidney function decline and heart failure). Fixed-effects meta-analyses were conducted where possible. RESULTS There were 78 trials (81 comparisons; 13 175 participants) that met criteria for inclusion: 47% were trials in diabetic eye disease. Hypertension (29 trials; 8570 participants) was equally common in VEGFi and control groups (7.3 versus 5.4%; RR 1.08 [0.91; 1.28]). New or worsening heart failure (10 trials; 3384 participants) had similar incidence in VEGFi and control groups (RR 1.03 [0.70; 1.51]). Proteinuria (5 trials; 1902 participants) was detectable in some VEGFi-treated participants (0.2%) but not controls (0.0%; RR 4.43 [0.49; 40.0]). Kidney function decline (9 trials; 3471 participants) was similar in VEGFi and control groups. In participants with diabetic eye disease, risk of all-cause mortality was higher in VEGFi-treated participants (RR 1.62 [1.04; 2.46]). CONCLUSION In trials of intravitreal VEGFi, we did not identify an increased risk of cardiorenal outcomes, though these outcomes were reported in only a minority of cases. There was an increased risk of death in VEGFi-treated participants with diabetic eye disease. Additional scrutiny of post-licensing observational data may improve recognition of safety concerns in VEGFi-treated patients.
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Affiliation(s)
- Jennifer S Lees
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Sciences, University of Glasgow, Glasgow, UK
| | - Stephen J H Dobbin
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Sciences, University of Glasgow, Glasgow, UK
| | - Benjamin M P Elyan
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Ninian N Lang
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Sciences, University of Glasgow, Glasgow, UK
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Sciences, University of Glasgow, Glasgow, UK
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11
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Iyer PG, Albini TA. Review of Intraocular Inflammation After Antivascular Endothelial Growth Factor Agents. Int Ophthalmol Clin 2022; 62:35-47. [PMID: 35752884 DOI: 10.1097/iio.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Wang Y, Fung NSK, Lam WC, Lo ACY. mTOR Signalling Pathway: A Potential Therapeutic Target for Ocular Neurodegenerative Diseases. Antioxidants (Basel) 2022; 11:antiox11071304. [PMID: 35883796 PMCID: PMC9311918 DOI: 10.3390/antiox11071304] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023] Open
Abstract
Recent advances in the research of the mammalian target of the rapamycin (mTOR) signalling pathway demonstrated that mTOR is a robust therapeutic target for ocular degenerative diseases, including age-related macular degeneration (AMD), diabetic retinopathy (DR), and glaucoma. Although the exact mechanisms of individual ocular degenerative diseases are unclear, they share several common pathological processes, increased and prolonged oxidative stress in particular, which leads to functional and morphological impairment in photoreceptors, retinal ganglion cells (RGCs), or retinal pigment epithelium (RPE). mTOR not only modulates oxidative stress but is also affected by reactive oxygen species (ROS) activation. It is essential to understand the complicated relationship between the mTOR pathway and oxidative stress before its application in the treatment of retinal degeneration. Indeed, the substantial role of mTOR-mediated autophagy in the pathogenies of ocular degenerative diseases should be noted. In reviewing the latest studies, this article summarised the application of rapamycin, an mTOR signalling pathway inhibitor, in different retinal disease models, providing insight into the mechanism of rapamycin in the treatment of retinal neurodegeneration under oxidative stress. Besides basic research, this review also summarised and updated the results of the latest clinical trials of rapamycin in ocular neurodegenerative diseases. In combining the current basic and clinical research results, we provided a more complete picture of mTOR as a potential therapeutic target for ocular neurodegenerative diseases.
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The negative impact of COVID-19 pandemic on age-related macular degeneration patients treated with intravitreal bevacizumab injections. Int Ophthalmol 2022; 42:3387-3395. [PMID: 35604624 PMCID: PMC9125960 DOI: 10.1007/s10792-022-02337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 04/18/2022] [Indexed: 11/09/2022]
Abstract
Purpose COVID-19 emerged in the end of 2019 and was declared a worldwide pandemic shortly after. Social distancing and lockdowns resulted in lower compliance in intravitreal injections and office visits. We aimed to assess clinical outcomes among patients who missed these visits compared to those who arrived as planned. Methods Patients who missed or were late to office visits or intravitreal injections were defined as non-adherent and were compared to adherent patients. Our main outcomes were the need for subsequent injections, mean change in best-corrected visual acuity (BCVA), and central macular thickness (CMT). Results This study included 77 patients (24 adherent and 53 non-adherent). The mean BCVA remained stable during the study period for the adherent group (p = 0.159) and worsened in the non-adherent group (p < 0.001). Changes in CMT and maximum thickness were not significant for either group. A higher proportion of patients in the non-adherent group needed subsequent intravitreal injections (49% vs 20%, p = 0.014). Conclusion The findings demonstrate the negative implications of the COVID-19 pandemic and the effect of deferring bevacizumab injections among individuals with age-related macular degeneration. This emphasizes the importance of a scheduled follow-up, also during a pandemic. Supplementary Information The online version contains supplementary material available at 10.1007/s10792-022-02337-y.
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Garweg JG, Traine PG, Garweg RA, Wons J, Gerhardt C, Pfister IB. Continued anti-VEGF treatment does not prevent recurrences in eyes with stable neovascular age-related macular degeneration using a treat-and-extend regimen: a retrospective case series. Eye (Lond) 2022; 36:862-868. [PMID: 33941877 PMCID: PMC8956692 DOI: 10.1038/s41433-021-01562-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 04/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The continuation of anti-vascular endothelial growth factor (anti-VEGF) treatment after achieving stability in patients with neovascular age-related macular degeneration has generally been advocated. In our own patients, we thought to assess whether continued anti-VEGF treatment is capable of preventing recurrences. METHODS In this retrospective observational case series, patients with stable disease either opted to continue treatment every 12-14 weeks (Group 1) or stopped treatment with subsequent follow-up visits every 8-12 weeks (Group 2). RESULTS Of the 103 eyes of 103 patients achieving stability, 49 eyes continued treatment (Group 1), whereas treatment was stopped in 54 eyes undergoing regular follow-up (Group 2). Recurrent disease was observed in 21 (42.9%) and 33 (61.1%) cases in Group 1 and Group 2, respectively (p = 0.08). Time between achieving stable disease and recurrence was comparable between Group 1 and Group 2 (11.1 ± 8.2 months vs. 9.2 ± 6.7 months; p = 0.43). The number of visits between achieving stability and disease recurrence was similar, but not the number of injections (3.5 ± 2.0 vs. 0.2 ± 0.4; p < 0.001). CONCLUSIONS Continuing anti-VEGF therapy after achieving functional and morphological stability every 12-14 weeks does not prevent recurrences. Patients deserve to be informed of a potential lifetime risk of recurrences, even under continued therapy.
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Affiliation(s)
- Justus G. Garweg
- grid.491651.eSwiss Eye Institute, Rotkreuz, and Berner Augenklinik am Lindenhofspital, Bern, Switzerland ,grid.411656.10000 0004 0479 0855Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland ,grid.5734.50000 0001 0726 5157University of Bern, Bern, Switzerland
| | - Peter G. Traine
- grid.491651.eSwiss Eye Institute, Rotkreuz, and Berner Augenklinik am Lindenhofspital, Bern, Switzerland ,Private Practice, Steffisburg, Switzerland
| | | | - Juliana Wons
- grid.491651.eSwiss Eye Institute, Rotkreuz, and Berner Augenklinik am Lindenhofspital, Bern, Switzerland
| | - Christin Gerhardt
- grid.491651.eSwiss Eye Institute, Rotkreuz, and Berner Augenklinik am Lindenhofspital, Bern, Switzerland ,grid.5734.50000 0001 0726 5157University of Bern, Bern, Switzerland
| | - Isabel B. Pfister
- grid.491651.eSwiss Eye Institute, Rotkreuz, and Berner Augenklinik am Lindenhofspital, Bern, Switzerland
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15
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Bridge arch-shaped subretinal fluid in neovascular age-related macular degeneration - evolution and outcomes. Retina 2022; 42:1012-1019. [PMID: 35152246 DOI: 10.1097/iae.0000000000003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To study factors leading to bridge arch-shaped subretinal fluid (SRF) on optical coherence tomography (OCT) in wet age-related macular degeneration and evaluate its anatomical and functional outcomes. METHODS In this single-center, retrospective study, patients with bridge arch-shaped SRF and choroidal neovascular membrane (CNVM) were included. RESULTS We identified 623 eyes in 431 patients with chronic CNVM and 24 (4%) eyes in 21 patients showed bridge arch-shaped SRF. Mean age of patients was 69.19 ± 12.0 years. Type 1 CNVM was noted in 79% cases before development of bridge arch-shaped SRF. Mean ETDRS letters visual acuity was 53.93 ± 32.19. Time interval to develop bridge arch-shaped SRF was 21.9 ± 30.63 months. Mean number of intravitreal anti-VEGF injections given before developing bridge arch-shaped SRF was 6.5 ± 7.09. During development of bridge arch-shaped SRF, visual acuity reduced by -20.57 ± 31.13 letters (p=0.033) and fibrotic type 2 CNVM (n=18, 75%) was noted. RPE tear was noted in 8 (33%) eyes. At final visit, further reduction in visual acuity of -7.136 ± 13.73 ETDRS letters (p=0.011) after developing bridge arch-shaped SRF was seen. Mean number of injections given after developing bridge arch shaped SRF was 4.76 ± 3.76. CONCLUSION Bridge arch-shaped SRF is an uncommon finding seen in eyes with type 2 chronic CNVMs. Presence of RPE breach and tear and non-aggressive treatment regimen with intravitreal anti-VEGF injections could be responsible for its pathogenesis. It is a marker of fibrotic enlargement, leading to poor visual outcomes despite showing favourable therapeutic response.
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William A, Dias Blak M, Eshref A, Gekeler F, Schatz A, Gekeler K. Chromatic Full-Field Stimulus Thresholds in Patients with Treatment-Naive Age-Related Macular Degeneration. Clin Ophthalmol 2022; 16:223-229. [PMID: 35125864 PMCID: PMC8809673 DOI: 10.2147/opth.s346291] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/17/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose To evaluate retinal sensitivity using chromatic full-field stimulus thresholds (FST) in patients with treatment naive exudative age-related macular degeneration (e-ARMD) before and during the first intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment. Patients and Methods After general ophthalmological examinations to diagnose patients with e-ARMD the FST, the central foveal thickness (FCt) and the visual acuity were assessed in 20 eyes of 20 patients during this prospective study. Examinations were performed before and during the first treatment series with three intravitreal anti-VEGF injections. Normal values for FST were assessed in 19 eyes of 19 healthy subjects. Results were analyzed using Student’s two-tailed t-test and Pearson’s correlation coefficients between all functional parameters. Results At baseline and before the 1st intravitreal anti-VEGF treatment, a moderately significant negative correlation between VA and FCt was found in the e-ARMD group (p = 0.02, r = −0.45 and p = 0.03, r = −0.45), respectively. After the 2nd intravitreal anti-VEGF injection, no significant correlation between VA and FCt was found (p = 0.12). However, a significant correlation between FCt and blue FST was evident (p = 0.04, r = 0.4). After the 3rd intravitreal anti-VEGF treatment, there was no correlation evident between VA and FCt (p = 0.31) but a high significant correlation between FCt and FST using red (p = 0.01, r = 0.53), green (p = 0.002, r = 0.6) and blue light (p = 0.007, r = 0.66). Conclusion During anti-VEGF treatment in patients with e-ARMD, the FST test showed higher significant correlations with the morphology measured by FCt, as it is the case for VA. These findings support that the FST test might serve as a valuable diagnostic tool for monitoring patients with e-ARMD and enhance functional assessment of retinal function under treatment with anti-VEGF.
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Affiliation(s)
- Antony William
- Department of Ophthalmology, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Altan Eshref
- Department of Ophthalmology, Klinikum Stuttgart, Stuttgart, Germany
| | - Florian Gekeler
- Department of Ophthalmology, Klinikum Stuttgart, Stuttgart, Germany
- Centre for Ophthalmology, University Hospital Tuebingen, Tuebingen, Germany
| | - Andreas Schatz
- Department of Ophthalmology, Klinikum Stuttgart, Stuttgart, Germany
- Centre for Ophthalmology, University Hospital Tuebingen, Tuebingen, Germany
- Correspondence: Andreas Schatz, Department of Ophthalmology, University Hospital Tuebingen, Tuebingen, Elfriede –Alhorn-Straße 7, Tuebingen, 72076, Germany, Tel +4970712988088, Email
| | - Katrin Gekeler
- Department of Ophthalmology, Klinikum Stuttgart, Stuttgart, Germany
- Centre for Ophthalmology, University Hospital Tuebingen, Tuebingen, Germany
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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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Khanani AM, Guymer RH, Basu K, Boston H, Heier JS, Korobelnik JF, Kotecha A, Lin H, Silverman D, Swaminathan B, Willis JR, Yoon YH, Quezada-Ruiz C. TENAYA and LUCERNE. OPHTHALMOLOGY SCIENCE 2021; 1:100076. [PMID: 36246941 PMCID: PMC9559073 DOI: 10.1016/j.xops.2021.100076] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/30/2021] [Accepted: 11/10/2021] [Indexed: 11/19/2022]
Abstract
Purpose To describe the design and rationale of the phase 3 TENAYA (ClinicalTrials.gov identifier, NCT03823287) and LUCERNE (ClinicalTrials.gov identifier, NCT03823300) trials that aimed to assess efficacy, safety, and durability of faricimab, the first bispecific antibody for intraocular use, which independently binds and neutralizes both angiopoietin-2 and vascular endothelial growth factor-A (VEGF-A) versus aflibercept in patients with neovascular age-related macular degeneration (nAMD). Design Identical, global, double-masked, randomized, controlled, phase 3 clinical trials. Participants Adults with treatment-naïve nAMD. Methods These trials were designed to evaluate patients randomized to receive faricimab 6.0 mg up to every 16 weeks after 4 initial every-4-week doses or aflibercept 2.0 mg every 8 weeks after 3 initial every-4-week doses. The initial doses in the faricimab arm were followed by individualized fixed treatment intervals up to week 60, based on disease activity assessment at weeks 20 and 24, guided by central subfield thickness, best-corrected visual acuity (BCVA), and investigator assessment. The primary efficacy end point was BCVA change from baseline averaged over weeks 40, 44, and 48. Secondary end points included the proportion of patients receiving every-8-week, every-12-week, and every-16-week faricimab and anatomic outcomes. Safety outcomes included incidence and severity of ocular and nonocular adverse events. From week 60, faricimab-treated patients followed a personalized treatment interval (PTI), a novel protocol-driven treat-and-extend regimen with interval adjustment from every 8 weeks to every 16 weeks based on individualized treatment response measured by anatomic criteria, functional criteria, and investigator assessment of patients’ disease activity. Main Outcome Measures Rationale for trial design and PTI approach. Results The TENAYA and LUCERNE trials were the first registrational trials in nAMD to test fixed dosing regimens up to every 16 weeks based on patients' disease activity in year 1 and incorporate a PTI paradigm during year 2. The PTI approach was designed to tailor treatment intervals to individual patient needs, to reflect clinical practice treatment practice, and to reduce treatment burden. Conclusions The innovative trial design rationale for the TENAYA and LUCERNE trials included maximizing the benefits of angiopoietin-2 blockade through dosing up to every 16 weeks and PTI regimens based on patients' disease activity while fulfilling health authority requirements for potential registrational efforts.
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Affiliation(s)
- Arshad M. Khanani
- Sierra Eye Associates, Reno, Nevada
- Reno School of Medicine, University of Nevada, Reno, Nevada
| | - Robyn H. Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia
| | - Karen Basu
- Roche Products (Ireland) Limited, Dublin, Ireland
| | | | | | - Jean-François Korobelnik
- Ophthalmology Department, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
- University of Bordeaux, INSERM, BPH, U1219, Bordeaux, France
| | | | - Hugh Lin
- Genentech, Inc., South San Francisco, California
| | | | | | | | - Young Hee Yoon
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Carlos Quezada-Ruiz
- Genentech, Inc., South San Francisco, California
- Clinica de Ojos Garza Viejo, San Pedro Garza Garcia, Nuevo Leon, Mexico
- Correspondence: Carlos Quezada-Ruiz, MD, Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080.
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Luu KT, Seal J, Green M, Winskill C, Attar M. Effect of Anti-VEGF Therapy on the Disease Progression of Neovascular Age-Related Macular Degeneration: A Systematic Review and Model-Based Meta-Analysis. J Clin Pharmacol 2021; 62:594-608. [PMID: 34783362 PMCID: PMC9305109 DOI: 10.1002/jcph.2002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/11/2021] [Indexed: 11/25/2022]
Abstract
Anti–vascular endothelial growth factor (VEGF) therapy is used to slow the disease progression of neovascular age‐related macular degeneration. Due to the treatment burden of frequent intravitreal injections, anti‐VEGFs are often used on treat and extend protocols rather than the labeled frequency. The current goal of anti‐VEGF drug development is to minimize treatment burden by reducing the number of intravitreal injections. The purpose of this systemic review and model‐based meta‐analysis (MBMA) was to (1) perform modeling to describe the disease progression of neovascular age‐related macular degeneration in the absence of treatment, as well as in the presence of abicipar, aflibercept, brolucizumab, or ranibizumab intervention; (2) and to simulate virtual head‐to‐head comparisons among the drugs with an extended dose schedule of once every 12 weeks (Q12). Data sources were PubMed, internal Allergan data, www.clinicaltrials.gov, and www.clinicaltrialsregister.eu. Eligibility assessment was performed by 2 independent review authors. Randomized, controlled trials that had at least 1 arm with an anti‐VEGF (aflibercept, abicipar, bevacizumab, brolucizumab, pegaptanib, or ranibizumab), a control arm of placebo or anti‐VEGF, a treatment duration of at least 4 months, reported best‐corrected visual acuity data, and at least 20 patients were included. A total of 22 trials, consisting of 55 arms, from across 9500+ subjects and 500+ best‐corrected visual acuity observations were used to develop the model. Consistent with reported data, results from the model showed that abicipar Q12 underperformed ranibizumab (every 4 weeks), aflibercept (every 4 weeks), and brolucizumab (every 8 weeks/Q12) labeled dosing schedules. However, when all drugs were virtually tested using the extended schedule, abicipar outperformed ranibizumab and aflibercept and produced a similar week 52 change from baseline as brolucizumab. Predicted week 52 changes from baseline were 5.92 ± 1.02, 3.04 ± 1.61, 6.61 ± 0.284, and 3.02 ± 2.35 best‐corrected visual acuity letters for abicipar, aflibercept, brolucizumab, and ranibizumab, respectively, using the Q12 schedule. Results demonstrate the feasibility of Q12 dosing with clinically meaningful letter gains for abicipar and brolucizumab. The model developed under this MBMA has utility for exploring different regimens for existing or novel anti‐VEGF agents.
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Anti-VEGF and Other Novel Therapies for Neovascular Age-Related Macular Degeneration: An Update. BioDrugs 2021; 35:673-692. [PMID: 34655434 DOI: 10.1007/s40259-021-00499-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 12/30/2022]
Abstract
Age-related macular degeneration (AMD) is a leading cause of visual impairment and blindness in older adults. The prognosis for the neovascular type of advanced AMD improved with the introduction of biological drugs with antiangiogenic properties, beginning with off-label bevacizumab, which was first used intravitreally in 2006. These drugs target newly formed vessels that grow beneath the center of the retina, causing loss of central vision, and they can help to maintain or improve vision. Repeated intravitreal injections are needed to achieve prolonged inhibition of proangiogenic cytokines, primarily vascular endothelial growth factor (VEGF). Major regulatory agencies have approved several molecules for AMD treatment, including ranibizumab, aflibercept, and brolucizumab. The development of further drugs was mainly targeted at prolonging anti-VEGF inhibition-thus reducing the frequency of injections-and expanding the biological targets of proangiogenic cytokine inhibition. Finally, biosimilars are already being marketed in some countries, allowing the containment of costs of AMD treatment, which are growing steadily in many settings because of the need for long-term treatment. This review summarizes the properties and clinical profiles of anti-VEGF biological drugs that are approved to treat neovascular AMD as well as ongoing research on molecules that may be marketed in the near future.
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Corazza P, D'Alterio FM, Kabbani J, Alam MMR, Mercuri S, Orlans HO, Younis S. Long-term outcomes of intravitreal anti-VEGF therapies in patients affected by neovascular age-related macular degeneration: a real-life study. BMC Ophthalmol 2021; 21:300. [PMID: 34391401 PMCID: PMC8364685 DOI: 10.1186/s12886-021-02055-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/26/2021] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To describe real-life data from wet age-related macular degeneration (AMD) patients treated with anti-vascular endothelial growth factors (VEGFs) and to compare our results with previous studies and clinical trials. METHODS This retrospective monocentric cohort study analyzed 865 eyes of 780 wet-AMD patients treated with an anti-VEGF treat-and-extend regimen over a long-term follow-up period. Aflibercept and Ranibizumab were considered first-line agents whereas Bevacizumab was reserved for use on a compassionate basis in patients not meeting treatment criteria. All patients underwent a best corrected visual acuity (BCVA) assessment at each follow-up visit. RESULTS One-year follow-up figures were available for 82.5% of patients, whilst follow-up data was recorded for 55.6%, 37.6%, 25.1%, and 15.0% of the cohort at years 2, 3, 4, and 5 respectively. Patients treated with Bevacizumab received fewer yearly injections than those treated with Ranibizumab. However, no significant difference in the number of injections per year was detected in other comparisons between groups. Whilst our data showed no significant difference in mean BCVA between the three groups, there was a gradual deterioration of visual function over time for the patient cohort as a whole. CONCLUSION No significant differences between the 3 anti-VEGF molecules were recorded in wet-AMD patients in real-life conditions. Despite the long-term therapy, we found a slight reduction in visual function especially after the third year of treatment.
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Affiliation(s)
- Paolo Corazza
- Western Eye Hospital, Imperial College Healthcare NHS Trust, 171 Marylebone Rd, London, NW1 5QH, UK.
- Imperial College Ophthalmology Research Group (ICORG), Imperial College, London, UK.
| | - Francesco Maria D'Alterio
- Western Eye Hospital, Imperial College Healthcare NHS Trust, 171 Marylebone Rd, London, NW1 5QH, UK
- Imperial College Ophthalmology Research Group (ICORG), Imperial College, London, UK
| | | | - Mostafa Mohamed Ragheb Alam
- Western Eye Hospital, Imperial College Healthcare NHS Trust, 171 Marylebone Rd, London, NW1 5QH, UK
- Tanta University, Tanta, Egypt
| | - Stefano Mercuri
- Western Eye Hospital, Imperial College Healthcare NHS Trust, 171 Marylebone Rd, London, NW1 5QH, UK
| | - Harry Otway Orlans
- Western Eye Hospital, Imperial College Healthcare NHS Trust, 171 Marylebone Rd, London, NW1 5QH, UK
| | - Saad Younis
- Western Eye Hospital, Imperial College Healthcare NHS Trust, 171 Marylebone Rd, London, NW1 5QH, UK
- Imperial College Ophthalmology Research Group (ICORG), Imperial College, London, UK
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22
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Effect of COVID-19 Lockdown in Spain on Structural and Functional Outcomes of Neovascular AMD Patients. J Clin Med 2021; 10:jcm10163551. [PMID: 34441845 PMCID: PMC8397186 DOI: 10.3390/jcm10163551] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022] Open
Abstract
This is a retrospective single-center study of patients with neovascular age-related macular degeneration whose follow-up was delayed due to COVID-19 pandemic with at least three months between visits in Madrid, Spain. The purpose of the study was to evaluate best corrected visual acuity (BCVA) changes and try to identify features in optical coherence tomography (OCT) that could be related to more profound visual loss. It included 270 eyes. The two last visits before lockdown were used for comparison with the visit after lockdown. BCVA changed from 60.2 ± 18.2 to 55.9 ± 20.5 ETDRS letters. 29% of the eyes lost more than 5 letters. OCT was active in 67% of eyes before lockdown and in 80.4% after lockdown. Multiple lineal analysis showed that patients whose OCT before lockdown presented with a combination of intra and subretinal fluid were more likely to suffer a greater visual loss (p = 0.002). These patients should be encouraged to not miss any visits in case a new lockdown is imposed.
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Choi YJ, Yoo WS, Cho YW, Choi YJ, Chung IY. One-year Outcomes of a Treat-and-extend of Ranibizumab for Naive Exudative Age-related Macular Degeneration: Retrospective Analysis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2021. [DOI: 10.3341/jkos.2021.62.7.939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose: This study investigated the 1-year outcomes of a treat-and-extend regimen of ranibizumab for exudative age-related macular degeneration and examined the clinical results when drug treatment was changed within the same period. Methods: This retrospective analysis included 32 eyes first diagnosed with wet age-related macular degeneration and treated for more than 1 year with a treat-and-extend regimen of ranibizumab, as well as 24 eyes treated by changing from ranibizumab to aflibercept within the same period. The injection number, maximum injection interval, change in central retinal thickness, and best-corrected visual acuity were assessed in all eyes. Results: In 32 eyes that received a treat-and-extend regimen of ranibizumab, the mean best-corrected visual acuity improved from 59.46 ± 15.13 to 68.00 ± 12.48 at 12 months (p < 0.0001). The mean central retinal thickness decreased from 409 ± 141 μm to 273 ± 89 μm at 12 months (p < 0.0001). The average number of injections per year was 7.2 ± 0.85. One complication related to the 12 months of injections was a tear in the retinal pigment epithelium; no systemic complications were observed. Of 24 eyes that underwent a change in medication, the rate of maintenance or improvement in initial visual acuity was 83% (10 eyes). The central retinal thickness was initially 371.58 ± 109.96 μm, but improved to 290.33 ± 58.66 μm in 12 eyes that received three injections of aflibercept. Conclusions: At 1 year, good outcomes were obtained using treat-and-extend ranibizumab for exudative age-related macular degeneration. When the treatment was changed to aflibercept within the same period, vision was often maintained and short-term anatomical improvement was evident.
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Hykin PG, Staurenghi G, Wiedemann P, Wolf S, Liew SHM, Desset-Brethes S, Staines H, Li J, Lai TYY. RANIBIZUMAB 0.5 MG TREATMENT IN ADOLESCENTS WITH CHOROIDAL NEOVASCULARIZATION: SUBGROUP ANALYSIS DATA FROM THE MINERVA STUDY. Retin Cases Brief Rep 2021; 15:348-355. [PMID: 30395119 PMCID: PMC8219082 DOI: 10.1097/icb.0000000000000825] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of ranibizumab 0.5 mg in adolescent patients with any choroidal neovascularization etiology enrolled in the 12-month MINERVA study. METHODS In the open-label, non-randomized study arm, ranibizumab 0.5 mg was administered to five adolescents (aged 13-17 years). The findings were assessed descriptively as individual case reports at Month 12. Best-corrected visual acuity changes, central subfield thickness, treatment exposure, and safety were described over 12 months. RESULTS Baseline choroidal neovascularization etiologies of the study eye included choroidal neovascularization secondary to Best disease (n = 2), idiopathic chorioretinopathy (n = 2), and optic disk drusen (n = 1). At Months 2, 6, and 12, the observed mean best-corrected visual acuity changes in the study eye from baseline were +9.2, +16.6, and +16.6 letters, respectively, and the observed mean central subfield thickness change from baseline was -31.4, -87.6, and -116.4 μm, respectively. Adolescent patients received a mean of three (range, 2-5) ranibizumab injections in the study eye. No adverse events or serious adverse events related to ranibizumab were reported. CONCLUSION Ranibizumab 0.5 mg treatment was beneficial in improving visual acuity and stabilizing or reducing central subfield thickness in five adolescents with differing choroidal neovascularization etiologies requiring infrequent injection. No new safety findings were observed over 12 months.
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Affiliation(s)
- Philip G. Hykin
- NIHR Biomedical Centre for Research in Ophthalmology, Moorfields Eye Hospital, London, United Kingdom
| | - Giovanni Staurenghi
- Department of Biomedical and Clinical Science Luigi Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Peter Wiedemann
- University of Leipzig, Klinik und Poliklinik für Augenheilkunde, Leipzig, Germany
| | - Sebastian Wolf
- Department Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Harry Staines
- Sigma Statistical Services, Balmullo, St Andrews, Scotland, United Kingdom; and
| | - Jun Li
- Novartis Pharma AG, Basel, Switzerland
| | - Timothy Y. Y. Lai
- Sigma Statistical Services, Balmullo, St Andrews, Scotland, United Kingdom; and
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Bowditch E, Chu E, Hong T, Chang AA. Treat and extend paradigm in management of neovascular age-related macular degeneration: current practice and future directions. EXPERT REVIEW OF OPHTHALMOLOGY 2021. [DOI: 10.1080/17469899.2021.1933439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Ellie Bowditch
- Sydney Retina Clinic & Day Surgery, Sydney, New South Wales, Australia
| | - Eugenia Chu
- Sydney Retina Clinic & Day Surgery, Sydney, New South Wales, Australia
| | - Thomas Hong
- Sydney Retina Clinic & Day Surgery, Sydney, New South Wales, Australia
| | - Andrew A. Chang
- Sydney Retina Clinic & Day Surgery, Sydney, New South Wales, Australia
- University of Sydney, Department of Ophthalmology, Sydney Institute of Vision Science, Sydney, New South Wales, Australia
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Iyer PG, Albini TA. Drug-related adverse effects of antivascular endothelial growth factor agents. Curr Opin Ophthalmol 2021; 32:191-197. [PMID: 33770015 DOI: 10.1097/icu.0000000000000757] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antivascular endothelial growth factor (VEGF) agents have provided historic therapeutic breakthroughs in the treatment of retinal disease. New anti-VEGF agents are emerging for the treatment of retinal vascular diseases. Both systemic and ocular adverse effect need to be understood in managing patients. This review aims to highlight the adverse effects seen with routine use of bevacizumab, ranibizumab and aflibercept, as well as with new medications such as brolucizumab and abicipar. RECENT FINDINGS We review the recent findings of intraocular inflammation (IOI) of brolucizumab and abicipar in the context of the efficacy and safety reported with the routine anti-VEGF agents. Specifically, brolucizumab has been reported to cause occlusive retinal vasculitis in the setting of IOI, which has not been seen in other anti-VEGF medications. In addition, abicipar appears to cause IOI at a higher rate of patients than other anti-VEGF agents have previously. SUMMARY Newer anti-VEGF agents pose a significant risk of adverse events not seen with routine anti-VEGF agents.
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Affiliation(s)
- Prashanth G Iyer
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
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Sharma S, Gupta V, Maiti A, Natesh S, Saxena S, Dave V, Parmar V, Sampangi R, Murthy H, Dharwadkar S, Yadav NK, Joshi S, Mayor R, Ratra D, Basu S, Goel N, Chaturvedi A, Patel R, Jose V. Safety and efficacy of Razumab™ (world's first biosimilar ranibizumab) in wet age-related macular degeneration: a post-marketing, prospective ASSET study. Int J Retina Vitreous 2021; 7:24. [PMID: 33762008 PMCID: PMC7992797 DOI: 10.1186/s40942-021-00293-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 03/09/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Razumab™ (world's first biosimilar ranibizumab) is approved for several macular disorders including wet age-related macular degeneration (AMD). We evaluated the safety and efficacy of biosimilar ranibizumab in wet AMD. METHODS This prospective, multicentre, rAnibizumab bioSimilar Safety Efficacy postmarkeTing (ASSET) study enrolled patients aged ≥ 50 years with wet AMD having best-corrected visual acuity (BCVA) between 20/40 and 20/320. The patients received intravitreal biosimilar ranibizumab 0.5 mg every 4 weeks for 24 weeks. Safety endpoints included the incidence of adverse events (AEs), serious AEs (SAEs), and immunoreactivity after 6 months. The efficacy endpoints were the proportion of patients who lose fewer than 15 letters, increase in BCVA, change in central retinal thickness (CRT), and change in Visual Function Questionnaire-25 (VFQ-25) score, from baseline to 24 weeks. RESULTS Of the 126 enrolled patients, majority (95.24%) of the patients received all 6 doses of biosimilar ranibizumab (total 3 mg). Nineteen AEs were reported (n = 16; 12.7%); majority (78.9%) were mild. There were no serious AEs reported, except one AE of death which was unrelated to the study drug. None of the patients discontinued the study due to an AE. The most common ocular AE was increase in intraocular pressure (4 events) and non-ocular AE was pyrexia (5 events). A total of 7.9% (10/126) patients prior to dosing and 7.1% (9/126) patients post-treatment were positive for anti-ranibizumab antibodies. No AEs suggestive of immunogenicity were noted. At 24-weeks, 97.60% patients in the intent-to-treat (ITT) population (N = 125) and 97.41% patients in the per-protocol (PP) population (N = 116) lost < 15 letters from baseline visual acuity. In the ITT and PP populations, 31.20% and 32.76% patients, respectively, showed improved visual acuity by ≥ 15 letters. Significant improvements in BCVA (mean difference: 8.8, 9.2, p < 0.001 for ITT, PP) and VFQ-25 (8.5, 9.2, p < 0.001 for ITT, PP) were seen; CRT reduced significantly (125 µm, 119.3 µm, p < 0.001 for ITT, PP). CONCLUSION Razumab™ (world's first biosimilar ranibizumab) was well-tolerated without new safety concerns and significantly improved visual acuity in wet AMD patients. Trial registration CTRI/2016/03/006739. Registered 18 March 2016-Prospectively registered, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=13141&EncHid=&userName=2016/03/006739.
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Affiliation(s)
- Shashikant Sharma
- Medical Affairs, Intas Pharmaceuticals Ltd, Ahmedabad, Gujarat, India.
| | - Vishali Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aniruddha Maiti
- Susrut Eye Foundation & Research Centre, Kolkata, West Bengal, India
| | | | - Sandeep Saxena
- Department of Ophthalmology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Vivek Dave
- L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Vimal Parmar
- PBMA's H. V. Desai Eye Hospital, Pune, Maharashtra, India
| | - Raju Sampangi
- Gurushree Hi-Tech Multi Speciality Hospital, Bangalore, Karnataka, India
| | - Hemanth Murthy
- Retina Institute of Karnataka, Bangalore, Karnataka, India
| | - Sandhya Dharwadkar
- K.R. Hospital, Mysore Medical College & Research Institute, Mysore, India
| | | | | | - Rahul Mayor
- Dr. Shroff's Charity Eye Hospital, New Delhi, India
| | | | - Soumyava Basu
- L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Neha Goel
- ICARE Eye Hospital & Post Graduate Institute, Noida, Uttar Pradesh, India
- Eye7 Chaudhary Eye Centre, New Delhi, India
| | - Alok Chaturvedi
- Medical Affairs, Intas Pharmaceuticals Ltd, Ahmedabad, Gujarat, India
| | - Ronak Patel
- Department of Biostatistics and Programming, Lambda Therapeutic Research Ltd., Ahmedabad, Gujarat, India
| | - Vinu Jose
- Clinical Development & Medical Affairs, Intas Pharmaceuticals Ltd. (Biopharma), Ahmedabad, Gujarat, India
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Khanani AM, Patel SS, Ferrone PJ, Osborne A, Sahni J, Grzeschik S, Basu K, Ehrlich JS, Haskova Z, Dugel PU. Efficacy of Every Four Monthly and Quarterly Dosing of Faricimab vs Ranibizumab in Neovascular Age-Related Macular Degeneration: The STAIRWAY Phase 2 Randomized Clinical Trial. JAMA Ophthalmol 2021; 138:964-972. [PMID: 32729897 PMCID: PMC7489851 DOI: 10.1001/jamaophthalmol.2020.2699] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Question How does extended dosing with faricimab compare with monthly ranibizumab in treating patients with neovascular age-related macular degeneration? Findings In this phase 2 randomized clinical trial of faricimab in 76 patients, vision gains from baseline were +9.6, +10.1, and +11.4 letters for the monthly ranibizumab, faricimab every-12-weeks, and faricimab every-16-weeks arms, respectively, at week 52. Meaning Through simultaneous neutralization of angiopoietin-2 and vascular endothelial growth factor A, faricimab maintains initial vision and anatomic improvements comparable with ranibizumab in neovascular age-related macular degeneration; the findings support pursuing extended interval dosing with faricimab in phase 3 trials as a potential alternative to more frequently dosed anti–vascular endothelial growth factor therapy. Importance Faricimab neutralizes angiopoietin-2 and vascular endothelial growth factor A via both simultaneous and independent binding. Objective To evaluate extended dosing with faricimab, the first bispecific antibody designed for intraocular use, in patients with neovascular age-related macular degeneration. Design, Setting, and Participants This phase 2 randomized clinical trial was a 52-week multicenter, active comparator–controlled, parallel-group study. Study participants were enrolled in 25 sites in the US from January and March 2017 with treatment-naive choroidal neovascularization secondary to neovascular age-related macular degeneration and best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter score of 73 (approximate Snellen equivalent, 20/40) to 24 (approximate Snellen equivalent, 20/320). Analysis began January 2017 and ended March 2018. Interventions Participants were randomized 1:2:2 to receive intravitreal ranibizumab, 0.5 mg, every 4 weeks or faricimab, 6.0 mg, every 12 or 16 weeks. Participants in the faricimab arms initially received 4 monthly injections of faricimab. No rescue injections were allowed. Participants randomized to dosing every 16 weeks were assessed for disease activity at week 24 using prespecified criteria. Those with no active disease continued dosing every 16 weeks through trial end; participants with disease activity continued received dosing every 12 weeks. Main Outcomes and Measures Mean change in BCVA from baseline at week 40. Results Of 76 participants enrolled (mean [SD] age, 78.5 [8.5] years; age range, 56-94 years; 41 women [58%]; 69 white [97%]), 16 (21.0%) were randomized to ranibizumab every 4 weeks, 29 (38.2%) to faricimab every 12 weeks, and 31 (40.8%) to faricimab every 16 weeks. At week 24, 12 weeks after their last initiation injection, 65% (36 of 55) of all faricimab-treated participants had no disease activity. At week 40, adjusted mean BCVA gains from baseline (Early Treatment Diabetic Retinopathy Study letters) were +11.4 (80% CI, 7.8-15.0), +9.3 (80% CI, 6.4-12.3), and +12.5 (80% CI, 9.9-15.1) for the ranibizumab every 4 weeks, faricimab every 12 weeks, and faricimab every 16 weeks arms, respectively. Participants received a mean (SD) total of 12.9 (0.25), 6.7 (0.91), and 6.2 (093) injections, for the ranibizumab every 4 weeks, faricimab every 12 weeks, and faricimab every 16 weeks arms, respectively, through week 52. The secondary BCVA and anatomical imaging end points supported the primary end point and were comparable with ranibizumab every 4 weeks. No new or unexpected safety signals were identified. Conclusions and Relevance At week 52, faricimab dosing every 16 weeks and every 12 weeks resulted in maintenance of initial vision and anatomic improvements comparable with monthly ranibizumab. These results suggest a role for simultaneous neutralization of angiopoietin-2 and vascular endothelial growth factor A in providing sustained efficacy through extended durability, warranting further investigation. Trial Registration ClinicalTrials.gov Identifier: NCT03038880
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Affiliation(s)
- Arshad M Khanani
- Sierra Eye Associates, Reno, Nevada.,Reno School of Medicine, University of Nevada, Reno
| | | | - Philip J Ferrone
- Long Island and Queens Vitreoretinal Consultants, PC, Great Neck, New York
| | - Aaron Osborne
- Genentech Inc, South San Francisco, California.,now with Adverum Biotechnologies Inc, Menlo Park, California
| | - Jayashree Sahni
- Roche Innovation Center Basel, Roche Pharma Research and Early Development, F. Hoffmann-La Roche, Basel, Switzerland
| | | | - Karen Basu
- Genentech Inc, South San Francisco, California.,now with Roche Products (Ireland), Dublin, Ireland
| | - Jason S Ehrlich
- Genentech Inc, South San Francisco, California.,now with Kodiak Sciences Inc, Palo Alto, California
| | | | - Pravin U Dugel
- Retinal Consultants of Arizona, Phoenix.,USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles.,now with IVERIC bio, New York, New York
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29
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Bedar MS, Kellner U. [Treatment of secondary glaucoma following intravitreal anti-VEGF therapy with the XEN® gel stent and mitomycin C]. Ophthalmologe 2020; 118:1128-1133. [PMID: 33236197 DOI: 10.1007/s00347-020-01265-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recurrent treatment with intravitreal anti-VEGF (vascular endothelial growth factor) administration can in rare cases lead to secondary glaucoma that is difficult to adjust. The goal of this case series was to analyze the treatment results of the XEN® gel stent in combination with mitomycin C. METHODS The long-term follow-up over a period of 18 months was evaluated for 3 eyes in 3 patients that underwent treatment with a XEN® gel stent in combination with mitomycin C as a surgical procedure to reduce intraocular pressure. RESULTS The eyes had a baseline pressure of 21-31 mm Hg with 3-5 antiglaucoma medications following 15-25 intravitreal injections. In all 3 eyes a pressure drop of almost 50% to 9-14 mm Hg could be achieved after 18 months with complete discontinuation of all local and systemic medications to reduce intraocular pressure in 2 of the 3 eyes. In 1 eye a choroidal detachment occurred for 2 weeks postoperatively. In another eye a surgical revision of conjunctival penetration was carried out. In two eyes needling was necessary due to scarring. In 2 out of 3 eyes, further intravitreal treatment (9 and 13 respectively) was necessary due to the macular disease but no further increase in intraocular pressure occurred. CONCLUSION The XEN® gel stent in combination with mitomycin C is a therapeutic option for difficult to adjust secondary glaucoma following intravitreal anti-VEGF therapy. A continuation of intravitreal anti-VEGF therapy did not lead to a recurrent increase of intraocular pressure.
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Affiliation(s)
- Mohammad Seleman Bedar
- AugenZentrum Siegburg, MVZ Augenärztliches Diagnostik & Therapiecentrum Siegburg GmbH, Europaplatz 3, 53721, Siegburg, Deutschland.
| | - Ulrich Kellner
- AugenZentrum Siegburg, MVZ Augenärztliches Diagnostik & Therapiecentrum Siegburg GmbH, Europaplatz 3, 53721, Siegburg, Deutschland.,RetinaScience, Bonn, Deutschland
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30
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Ricci F, Bandello F, Navarra P, Staurenghi G, Stumpp M, Zarbin M. Neovascular Age-Related Macular Degeneration: Therapeutic Management and New-Upcoming Approaches. Int J Mol Sci 2020; 21:ijms21218242. [PMID: 33153227 PMCID: PMC7662479 DOI: 10.3390/ijms21218242] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/24/2020] [Accepted: 10/30/2020] [Indexed: 12/11/2022] Open
Abstract
Age-related macular degeneration (AMD) constitutes a prevalent, chronic, and progressive retinal degenerative disease of the macula that affects elderly people and cause central vision impairment. Despite therapeutic advances in the management of neovascular AMD, none of the currently used treatments cures the disease or reverses its course. Medical treatment of neovascular AMD experienced a significant advance due to the introduction of vascular endothelial growth factor inhibitors (anti-VEGF), which dramatically changed the prognosis of the disease. However, although anti-VEGF therapy has become the standard treatment for neovascular AMD, many patients do not respond adequately to this therapy or experience a slow loss of efficacy of anti-VEGF agents after repeated administration. Additionally, current treatment with intravitreal anti-VEGF agents is associated with a significant treatment burden for patients, caregivers, and physicians. New approaches have been proposed for treating neovascular AMD. Among them, designed ankyrin repeat proteins (DARPins) seem to be as effective as monthly ranibizumab, but with greater durability, which may enhance patient compliance with needed injections.
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Affiliation(s)
- Federico Ricci
- Department of Experimental Medicine, University Tor Vergata, Viale Oxford, 00133 Rome, Italy
- Correspondence: ; Tel.: +39-33-5663-3319
| | - Francesco Bandello
- Scientific Institute San Raffaele, University Vita Salute, 20132 Milan, Italy;
| | - Pierluigi Navarra
- Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
- Department of Pharmacology, Medical School, Catholic University, 00198 Rome, Italy
| | | | - Michael Stumpp
- Molecular Partners AG—Wagistrasse, 14 8952 Zurich-Schlieren, Switzerland;
| | - Marco Zarbin
- Institute of Ophthalmology and Visual Science, Rutgers-New Jersey Medical School, Newark, NJ 07103, USA;
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López Gálvez MI, Arias Barquet L, S. Figueroa M, García‐Layana A, Ruiz Moreno JM, Fernandez Rodríguez M, García Arumí J, Amat Peral P, Ascaso Puyuelo J, Armada Maresca F, Cervera Taulet E, Torres Imaz R, Gutierrez Sánchez E, Cordovés Dorta LM, Esteban González E, Velilla Osés S, Abengoechea Hernández S, Ruiz Miguel M, Basauri Rementería E, Caballos Castilla R, Villavilla Castillo J, López Guajardo L, Gallego Pinazo R, Araiz Iribarren JJ, Rodriguez García L, Cabrera López F, López Garrido JA, López‐Herrera ML, Alforja Castiella MS, Ruiz Moreno Ó, Martinez Alday N, Fernández‐Vega Sanz Á, Garcia Campos J. Bimonthly, treat-and-extend and as-needed ranibizumab in naïve neovascular age-related macular degeneration patients: 12-month outcomes of a randomized study. Acta Ophthalmol 2020; 98:e820-e829. [PMID: 32190990 DOI: 10.1111/aos.14399] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 02/20/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE To assess the noninferiority of the treat-and-extend (T&E) and fixed bimonthly regimens of 0.5 mg intravitreal ranibizumab as compared with the pro re nata (PRN) in naïve patients with neovascular age-related macular degeneration (nAMD). METHODS Phase IV, randomized, 12-month, multicentre trial. Patients aged ≥50 years with nAMD and visual impairment [best-corrected visual acuity (BCVA) between 23 and 78 Early Treatment Diabetic Retinopathy Study (ETDRS) letters] were eligible. Patients (one eye per patient) were randomized to bimonthly, n = 103, T&E, n = 99 or PRN, n = 104. Noninferiority was established at five letters ETDRS. RESULTS The mean (95% CI) difference in BCVA at 12 months was 7.2 (4.2-10.2), 6.4 (2.9-9.8), and 8.0 (51.1-11.0) in the bimonthly, T&E and PRN, respectively. The bimonthly or T&E regimens were not inferior to the PRN scheme. All regimens were associated with a significant reduction of central subfield thickness and volume. The mean (95% CI) number of injections in the bimonthly regimen (7.6, 7.5-7.7) was similar as compared with the PRN regimen (7.4, 6.7-8.0) (p = 0.159) but lower than in the T&E regimen (9.3, 8.9-9.7) (p < 0.001). CONCLUSION At 12 months, bimonthly and T&E ranibizumab were noninferior to PRN in naïve nAMD.
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Affiliation(s)
| | - Lluís Arias Barquet
- Department of Ophthalmology Hospital Universitari de Bellvitge L’Hospitalet de Llobregat Barcelona Spain
| | - Marta. S. Figueroa
- Department of Ophthalmology Hospital Universitario Ramón y Cajal Madrid Spain
| | | | - José M. Ruiz Moreno
- Department of Ophthalmology Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
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32
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Shelankova AV, Budzinskaya MV. [Anti-VEGF therapy in the treatment of neovascularization secondary to angioid streaks (a case report)]. Vestn Oftalmol 2020; 136:219-225. [PMID: 32880143 DOI: 10.17116/oftalma2020136042219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article presents a clinical case of using anti-VEGF therapy in the treatment of retinal neovascularization consequent to angioid streaks (AS). Angioid streaks are linear breaks or divergences in an abnormally brittle or calcified Bruch's membrane. The development of choroidal neovascularization (CNV) due to AS is one of the most serious complications of the disease and the main cause of visual impairment, especially in active middle-aged patients. Currently, determination of the morphology and activity of CNV is done using multimodal macular imaging methods such as optical coherence tomography of the retina (OCT), optical coherence tomography angiography (OCT-A), fluorescin angiography (FA), indocyanine green angiography (ICGA) and autofluorescence. With the discovery of anti-VEGF therapy, it became possible to improve and stabilize functional results in this group of patients.
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33
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Ye L, Jiaqi Z, Jianchao W, Zhaohui F, Liang Y, Xiaohui Z. Comparative efficacy and safety of anti-vascular endothelial growth factor regimens for neovascular age-related macular degeneration: systematic review and Bayesian network meta-analysis. Ther Adv Chronic Dis 2020; 11:2040622320953349. [PMID: 32953000 PMCID: PMC7475790 DOI: 10.1177/2040622320953349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 08/06/2020] [Indexed: 01/05/2023] Open
Abstract
Background: As a debilitating neurodegenerative disease, neovascular age-related macular degeneration (nAMD) accounts for more than 90% of severe visual loss or legal blindness among AMD patients. Anti-vascular endothelial growth factor (VEGF) had been applied widely in nAMD treatment. To date, debate regarding efficacy and safety still exists among different anti-VEGF regimens as management of nAMD. To provide substantial evidence for clinical nAMD treatment, this study ranks the priority of anti-VEGF regimens via Bayesian network meta-analysis (NMA), comparing data collected from randomized controlled trials (RCTs). Methods: We searched PubMed Central, MEDLINE Ovid, Embase Ovid, ISRCTN, ICTRP and ClinicalTrials. gov from a database established until 1 April 2019 systematically for anti-VEGF regimens. Bayesian NMA with random-effect was conducted to compare efficacy and safety and rank priority of anti-VEGF regimens. The primary efficacy and safety outcomes were the proportion of patients gaining 15 or more letters, and the incidence of arterial thromboembolic (ATC) events. The effect measure is the standard mean difference (SMD), or the odds ratio (OR) with their 95% confidence interval (CI). The study protocol is registered with PROSPERO, number CRD42019132243. Results: We obtained 6467 citations and identified 29 RCTs including 13,596 participants; 86% of these trials were low risk or of uncertain risk bias. In NMA, ORs compared with sham injection for the proportion of patients gaining 15 or more letters (12,699 participants from 23 trials) ranged from 4.05 [95% Bayesian credible interval (CrI) 1.62–10.11] for ranibizumab quarterly regimen to 8.57 (95% CrI 4.66–15.73) for a ranibizumab treat-and-extend regimen. No difference was found between sham injection and anti-VEGF regimens for ATC events (11,500 participants from 18 trials). Results for the primary outcome did not substantially change in sensitivity analyses after removing studies at high risk of bias and small sample size (n < 100), respectively. Conclusion: The treat-and-extend regimen of ranibizumab and aflibercept are the preferred anti-VEGF regimens for nAMD. Bevacizumab treat-and-extend regimens need more head-to-head comparisons with other regimens or sham injection for advanced application. The treat-and-extend regimen proved to be the most effective regimen for each anti-VEGF drug in the NMA. Pegaptanib every 6 weeks and Conbercept quarterly are unable to satisfy the best corrected visual acuity (BCVA) improvement requirement of nAMD patients.
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Affiliation(s)
- Lu Ye
- Ophthalmology Department, The Second Affiliated Hospital, Medical College, Xi'an Jiaotong University, Xi'an, PR China
| | - Zhao Jiaqi
- Ophthalmology Department, The Second Affiliated Hospital, Medical College, Xi'an Jiaotong University, Xi'an, PR China
| | - Wang Jianchao
- Ophthalmology Department, The Second Affiliated Hospital, Medical College, Xi'an Jiaotong University, Xi'an, PR China
| | - Feng Zhaohui
- Ophthalmology Department, The Second Affiliated Hospital, Medical College, Xi'an Jiaotong University, Xi'an, PR China
| | - Yao Liang
- Ophthalmology Department, The Second Affiliated Hospital, Medical College, Xi'an Jiaotong University, Xi'an, PR China
| | - Zhang Xiaohui
- Ophthalmology Department, The Second Affiliated Hospital, Medical College, Xi'an Jiaotong University, No. 157 Xiwu Road, Xi'an, 710004, PR China
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Kiss S, Campbell J, Almony A, Shih V, Serbin M, LaPrise A, Wykoff CC. Management and Outcomes for Neovascular Age-Related Macular Degeneration. Ophthalmology 2020; 127:1179-1188. [DOI: 10.1016/j.ophtha.2020.02.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 10/24/2022] Open
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Leys AM, Ramboer E, Favreau M, Denhaerynck K, MacDonald K, Abraham I, Brié H. Long-Term Ranibizumab Treatment in Neovascular Age-Related Macular Degeneration: A Belgian Subanalysis from the Global Real-World LUMINOUS TM Study. Clin Ophthalmol 2020; 14:1473-1481. [PMID: 32581505 PMCID: PMC7277576 DOI: 10.2147/opth.s242547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Purpose To evaluate long-term, real-world treatment patterns and outcomes of ranibizumab 0.5 mg for neovascular age-related macular degeneration (nAMD) in a Belgian cohort. Patients and Methods This Belgian (BE) cohort of the 5-year global observational LUMINOUS study included 229 patients with nAMD. Outcomes included visual acuity (VA), central retinal thickness (CRT) and safety. Results The mean age was 79.5±7.7 years. The majority of patients (67.7%) were female and all patients were Caucasian. Most patients previously received ranibizumab with only 17.5% of patients being treatment-naïve. The injection frequency declined over time irrespective of prior treatment status (p<0.0001), with treatment-naïve eyes receiving a mean of 4.2±2.9 yearly injections and prior-ranibizumab eyes 3.6±2.7. Regression analysis confirmed first-year VA increases for treatment-naïve eyes (p=0.002) followed by a slight decrease of -1.8 letters per year. For prior-ranibizumab eyes, the visual changes over 1 year were statistically non-significant (p=0.90) but declined slightly after year one (p<0.0001). Anatomically, the CRT of treatment-naïve eyes decreased over time from baseline (p<0.0001), whereas the CRT of prior-ranibizumab eyes remained stable (p=0.43). No new safety findings were identified. Conclusion LUMINOUS-BE reconfirms the well-characterized benefit-risk profile of ranibizumab for nAMD treatment. The observed low injection frequency reflects a need for more rigorous treatment in real-world settings. Clinical Trial Registration NCT01318941.
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Affiliation(s)
- Anita M Leys
- Department of Ophthalmology, Universitair Ziekenhuis Gasthuisberg, KULeuven, Leuven, Belgium.,Oogartsen, Alken, Belgium
| | | | | | - Kris Denhaerynck
- Matrix45, Tucson, AZ, USA.,Department of Public Health, University of Basel, Basel, Switzerland
| | | | - Ivo Abraham
- Matrix45, Tucson, AZ, USA.,Center for Health Outcomes and Pharmacoeconomic Research, University of Arizona, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA.,Department of Family and Community Medicine, College of Medicine - Tucson, University of Arizona, Tucson, AZ, USA
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Kung FF, Starr MR, Bui YT, Mejia CA, Bakri SJ. Long-Term Follow-up of Patients with Exudative Age-Related Macular Degeneration Treated with Intravitreal Anti-Vascular Endothelial Growth Factor Injections. Ophthalmol Retina 2020; 4:1047-1053. [PMID: 32439455 DOI: 10.1016/j.oret.2020.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine the long-term visual outcomes and intravitreal injection burden of patients with exudative age-related macular degeneration (AMD) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections. DESIGN Retrospective cohort study. PARTICIPANTS Patients with exudative AMD treated with intravitreal anti-VEGF injections with annual office visits for at least 7 years. METHODS Snellen visual acuity was measured at baseline and then annually until the last year of follow-up. The number of injections was recorded on an annual basis during each year of follow-up. MAIN OUTCOME MEASURES The change in the frequency of injections over time along with the change in visual acuity each year from the baseline visit through 7 years. RESULTS During this period, 533 eyes of 429 patients were treated for exudative AMD. Of these, 391 eyes (73%) met the inclusion criteria of annual office visits and received a mean of 5.8 ± 2.5 intravitreal injections per year. The baseline mean visual acuity was 0.6 ± 0.5 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/80), and the 7-year visual acuity was 0.8 ± 0.6 logMAR (Snellen equivalent, 20/126; P < 0.0001). When compared with the 142 eyes that did not undergo an office visit for a continuous 12-month period, eyes with annual office visits showed similar baseline mean visual acuity (0.7 logMAR vs. 0.6 logMAR; P = 0.2102), but more injections per year (P < 0.0001). Of the 533 total eyes, 124 eyes (23%) maintained better than 20/40 visual acuity at 7 years. These eyes received more injections overall per year (6.5 vs. 5.5 injections per year; P = 0.0007). CONCLUSIONS In a real-world setting, eyes that maintained consistent, long-term follow-up received significantly more intravitreal injections per year than eyes with inconsistent follow-up. Eyes with 20/40 or better vision at study conclusion received more injections per year than eyes with worse than 20/40 vision.
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Affiliation(s)
- Felix F Kung
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew R Starr
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Yvonne T Bui
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Camilo A Mejia
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sophie J Bakri
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
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Li E, Donati S, Lindsley KB, Krzystolik MG, Virgili G. Treatment regimens for administration of anti-vascular endothelial growth factor agents for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2020; 5:CD012208. [PMID: 32374423 PMCID: PMC7202375 DOI: 10.1002/14651858.cd012208.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is one of the leading causes of permanent blindness worldwide. The current mainstay of treatment for neovascular AMD (nAMD) is intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents: aflibercept, ranibizumab, and off-label bevacizumab. Injections can be given monthly, every two or three months ('extended-fixed'), or as needed (pro re nata (PRN)). A variant of PRN is 'treat-and-extend' whereby injections are resumed if recurrence is detected and then delivered with increasing intervals. Currently, injection frequency varies among practitioners, which underscores the need to characterize an optimized approach to nAMD management. OBJECTIVES To investigate the effects of monthly versus non-monthly intravitreous injection of an anti-VEGF agent in people with newly diagnosed nAMD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, and three trials registers from 2004 to October 2019; checked references; handsearched conference abstracts; and contacted pharmaceutical companies to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared different treatment regimens for anti-VEGF agents in people with newly diagnosed nAMD. We considered standard doses only (ranibizumab 0.5 mg, bevacizumab 1.25 mg, aflibercept 2.0 mg, or a combination of these). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for trial selection, data extraction, and analysis. MAIN RESULTS We included 15 RCTs. The total number of participants was 7732, ranging from 37 to 2457 in each trial. The trials were conducted worldwide. Of these, six trials exclusively took place in the US, and three included centers from more than one country. Eight trials were at high risk of bias for at least one domain and all trials had at least one domain at unclear risk of bias. Seven trials (3525 participants) compared a PRN regimen with a monthly injection regimen, of which five trials delivered four to eight injections using standard PRN and three delivered nine or 10 injections using a treat-and-extend regimen in the first year. The overall mean change in best-corrected visual acuity (BCVA) at one year was +8.8 letters in the monthly injection group. Compared to the monthly injection, there was moderate-certainty evidence that the mean difference (MD) in BCVA change at one year for the standard PRN subgroup was -1.7 letters (95% confidence interval (CI) -2.8 to -0.6; 4 trials, 2299 participants), favoring monthly injections. There was low-certainty evidence of a similar BCVA change with the treat-and-extend subgroup (0.5 letters, 95% CI -3.1 to 4.2; 3 trials, 1226 participants). Compared to monthly injection, there was low-certainty evidence that fewer participants gained 15 or more lines of vision with standard PRN treatment at one year (risk ratio (RR) 0.87, 95% CI 0.76 to 0.99; 4 trials, 2299 participants) and low-certainty evidence of a similar gain with treat-and-extend versus monthly regimens (RR 1.11, 95% CI 0.91 to 1.36; 3 trials, 1169 participants). The mean change in central retinal thickness was a decrease of -166 μm in the monthly injection group; the MD compared with standard PRN was 21 μm (95% CI 6 to 32; 4 trials, 2215 participants; moderate-certainty evidence) and with treat-and extend was 22 μm (95% CI 37 to -81 μm; 2 trials, 635 participants; low-certainty evidence), in favor of monthly injection. Only one trial (498 participants) measured quality of life and reported no evidence of a difference between regimens, but data could not be extracted (low-certainty evidence). Both PRN regimens (standard and 'treat-and-extend') used fewer injections than monthly regimens (standard PRN: MD -4.6 injections, 95% CI -5.4 to -3.8; 4 trials, 2336 participants; treat-and-extend: -2.4 injections, 95% CI -2.7 to -2.1 injections; moderate-certainty evidence for both comparisons). Two trials provided cost data (1105 participants, trials conducted in the US and the UK). They found that cost differences between regimens were reduced if bevacizumab rather than aflibercept or ranibizumab were used, since bevacizumab was less costly (low-certainty evidence). PRN regimens were associated with a reduced risk of endophthalmitis compared with monthly injections (Peto odds ratio (OR) 0.13, 95% CI 0.04 to 0.46; 6 RCTs, 3175 participants; moderate-certainty evidence). Using data from all trials included in this review, we estimated the risk of endophthalmitis with monthly injections to be 8 in every 1000 people per year. The corresponding risk for people receiving PRN regimens was 1 in every 1000 people per year (95% CI 0 to 4). Three trials (1439 participants) compared an extended-fixed regimen (number of injections reported in only one large trial: 7.5 in one year) with monthly injections. There was moderate-certainty evidence that BCVA at one year was similar for extended-fixed and monthly injections (MD in BCVA change compared to extended-fixed group: -1.3 letters, 95% CI -3.9 to 1.3; RR of gaining 15 letters or more: 0.94, 95% CI 0.80 to 1.10). The change in central retinal thickness was a decrease of 137 μm in the monthly group; the MD with the extended-fixed group was 8 μm (95% CI -11 to 27; low-certainty evidence). The frequency of endophthalmitis was lower in the extended-fixed regimen compared to the monthly group, but this estimate was imprecise (RR 0.19, 95% CI 0.03 to 1.11; low-certainty evidence). If we assumed a risk of 8 cases of endophthalmitis in 1000 people receiving monthly injections over one year, then the corresponding risk with extended-fixed regimen was 2 in 1000 people (95% CI 0 to 9). Other evidence comparing different extended-fixed or PRN regimens yielded inconclusive results. AUTHORS' CONCLUSIONS We found that, at one year, monthly regimens are probably more effective than PRN regimens using seven or eight injections in the first year, but the difference is small and clinically insignificant. Endophthalmitis is probably more common with monthly injections and differences in costs between regimens are higher if aflibercept or ranibizumab are used compared to bevacizumab. This evidence only applies to settings in which regimens are implemented as described in the trials, whereas undertreatment is likely to be common in real-world settings. There are no data from RCTs on long-term effects of different treatment regimens.
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Affiliation(s)
- Emily Li
- Transitional Year Residency Program, Signature Healthcare Brockton Hospital, Brockton, MA, USA
| | - Simone Donati
- Department of Surgical and Morphological Sciences, Section of Ophthalmology, University of Insubria, Varese-Como, Varese, Italy
| | - Kristina B Lindsley
- Life Sciences, Oncology, & Genomics, IBM Watson Health, Baltimore, Maryland, USA
| | - Magdalena G Krzystolik
- Department of Ophthalmology, Retina Service, Mass Eye and Ear Infirmary, Providence, RI, USA
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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Ryu SY, Kim J, Kim DW, Chung EJ. Association between Ranibizumab Injections and Risk of Acute Myocardial Infarction in Age-related Macular Degeneration: A Case-crossover Study. KOREAN JOURNAL OF OPHTHALMOLOGY 2020; 34:150-157. [PMID: 32233149 PMCID: PMC7105783 DOI: 10.3341/kjo.2019.0120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/13/2019] [Accepted: 12/02/2019] [Indexed: 11/23/2022] Open
Abstract
PURPOSE This study aimed to evaluate the risk of acute myocardial infarction (AMI) associated with intravitreal ranibizumab in age-related macular degeneration (AMD). METHODS This nationwide retrospective case-crossover study using data from the Korean National Health Insurance Service database included patients diagnosed with exudative AMD using the registration code for exudative AMD (V201) from 2009 to 2014. We identified all incident AMI cases among these exudative AMD cases from inpatient claims and defined the index date as the date of hospitalization. For each patient, we defined the case period as one to 60 days and four control periods as 121 to 180, 181 to 240, 241 to 300, and 301 to 361 days, respectively, before the index date. A prescription of ranibizumab was searched for during the case and control periods. We calculated the adjusted odds ratios and their 95% confidence intervals using a conditional logistic regression model. RESULTS From a cohort of patients with exudative AMD (n = 41,860), a total of 181 AMI patients with exudative AMD were included. Among all the patients, 11.05% were treated during the 2 months preceding the index date as compared with 8.29% to 9.39% treated during control periods. The adjusted odds ratio of AMI associated with intravitreal ranibizumab during the preceding 2 months was 1.22 (95% confidence interval, 0.673-2.213; p = 0.5124). Analyses based on case periods of 15 days and 1 month yielded similar results. CONCLUSIONS Intravitreal ranibizumab injection does not appear to increase the risk of hospitalization for AMI within 60 days in exudative AMD patients.
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Affiliation(s)
- Sun Young Ryu
- Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jiwon Kim
- Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Dong Wook Kim
- Department of Big Data, National Health Insurance Service, Wonju, Korea
| | - Eun Jee Chung
- Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
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Kim HM, Park YJ, Lee S, Son JY, Hong HK, Ham MH, Jin X, Chung JY, Park KH, Park KD, Woo SJ. Intraocular Pharmacokinetics of 10-fold Intravitreal Ranibizumab Injection Dose in Rabbits. Transl Vis Sci Technol 2020; 9:7. [PMID: 32818095 PMCID: PMC7396190 DOI: 10.1167/tvst.9.4.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/13/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose To investigate intraocular pharmacokinetics of 10-fold dose of intravitreally injected ranibizumab compared with the conventional dose in an experimental model. Methods Ranibizumab 30 µL at 10 mg/mL (conventional) and 100 mg/mL (10-fold) doses was injected separately into each eye of 28 rabbits. Ranibizumab concentrations in the aqueous humor, vitreous, and retina were estimated at each time period after injection, using enzyme-linked immunosorbent assay. The pharmacokinetic properties of ranibizumab were determined using a one-compartment model in all three ocular tissues. The time–concentration profile and predictive trends were plotted to determine drug efficacy in the retina. Results Maximum concentrations after conventional and 10-fold dosing were observed in the retina at 1 and 4 days after injection, respectively. The half-life of ranibizumab after conventional and 10-fold dosing did not differ in the anterior chamber and vitreous, whereas the half-life was prolonged approximately twice with the 10-fold dose in the retina (36.74 h vs. 76.85 h) and serum (91.93 h vs. 179.01 h). Similarly, the estimated time for ranibizumab concentration in the retina over 27 ng/mL (minimum effective concentration of ranibizumab) was prolonged approximately twice with the 10-fold dose (1315 h [55 days] vs. 2393 h [100 days]). No adverse effects were observed in either group. Conclusions The retinal half-life and concentration of ranibizumab in rabbit eyes were increased approximately twice after a 10-fold dose compared with the conventional dose. This finding indicates a possibility to lengthen the injection interval to improve the efficacy of ranibizumab in human eyes. Translational Relevance Our results highlight the potential for clinical application of a high-dose (10-fold) of anti-VEGF agents to prolong the intravitreal injection intervals, simultaneously improving the drug efficacy.
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Affiliation(s)
- Hyeong Min Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young Joo Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Simin Lee
- Department of Ophthalmology, SNU-SMG Boramae Medical Center, Seoul, Republic of Korea
| | - Joo Young Son
- Department of Ophthalmology, SNU-SMG Boramae Medical Center, Seoul, Republic of Korea
| | - Hye Kyoung Hong
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Min Hee Ham
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Xuanyou Jin
- Department of Molecular Science and Technology, Ajou University, Suwon, Republic of Korea
| | - Jae Yong Chung
- Department of Molecular Science and Technology, Ajou University, Suwon, Republic of Korea
| | - Kyu Hyung Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ki Dong Park
- Department of Ophthalmology, SNU-SMG Boramae Medical Center, Seoul, Republic of Korea
| | - Se Joon Woo
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Luu KT, Seal JR, Attar M. A Mechanistic and Translational Pharmacokinetic-Pharmacodynamic Model of Abicipar Pegol and Vascular Endothelial Growth Factor Inhibition. J Pharmacol Exp Ther 2020; 373:184-192. [DOI: 10.1124/jpet.119.263178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/12/2020] [Indexed: 01/20/2023] Open
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Horani M, Mahmood S, Aslam TM. A Review of Macular Atrophy of the Retinal Pigment Epithelium in Patients with Neovascular Age-Related Macular Degeneration: What is the Link? Part II. Ophthalmol Ther 2020; 9:35-75. [PMID: 31907843 PMCID: PMC7054566 DOI: 10.1007/s40123-019-00227-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction To explore the potential link between macular atrophy (MA) of the retinal pigment epithelium (RPE) in patients with neovascular age-related macular degeneration (nAMD) and anti-vascular endothelial growth factor (anti-VEGF) treatment. Methods Through a balanced overview of the field from a largely clinical perspective, we looked at available evidence on the topic of MA correlation with anti-VEGF therapy and examined possible risk factors for MA development in the context of nAMD treatment with anti-VEGF. Results Links have been reported to connect both MA incidence and progression to treatment frequency and to the anti-VEGF drug type. Conclusions All reports agree on the fact that de novo development of MA in anti-VEGF-treated eyes is frequent and multifactorial. Research data shows an expansion of atrophy during anti-VEGF treatment. There are mixed conclusions about the correlation of MA incidence or progression with treatment-related risk factors. It mostly appears that there is no straightforward link. More clinical research is still needed to further understand this association.
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Affiliation(s)
- Mania Horani
- Manchester Royal Eye Hospital, Manchester University Foundation NHS Trust, Manchester, UK.
| | - Sajjad Mahmood
- Manchester Royal Eye Hospital, Manchester University Foundation NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Tariq M Aslam
- Manchester Royal Eye Hospital, Manchester University Foundation NHS Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, School of Health Sciences, The University of Manchester, Manchester, UK
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Fenner BJ, Ting DSW, Tan ACS, Teo K, Chan CM, Mathur R, Yeo IYS, Wong TY, Wong EYM, Cheung CMG. Real-World Treatment Outcomes of Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy in Asians. Ophthalmol Retina 2019; 4:403-414. [PMID: 31953109 DOI: 10.1016/j.oret.2019.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/06/2019] [Accepted: 10/28/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the 12-month outcomes of treatment-naïve eyes with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) after initiation of intravitreal anti-vascular endothelial growth factor (VEGF) monotherapy or combination therapy with verteporfin photodynamic therapy (PDT). DESIGN A 12-month single-center, retrospective, comparative, nonrandomized cohort study. PARTICIPANTS Patients with AMD or PCV who initiated intravitreal anti-VEGF therapy during 2015. METHODS Demographics, visual outcomes, OCT, and treatment data were collected at baseline and months 1, 3, 6, and 12 after treatment initiation. Multivariate analysis was performed to identify baseline features predictive of visual maintenance and improvement after 12 months of treatment. MAIN OUTCOME MEASURES Primary end point was visual acuity (VA) change from baseline to month 12. Secondary end points were treatment exposure and change in central subfield thickness on OCT. RESULTS A total of 364 patients (165 AMD and 199 PCV) were included. Baseline vision was 41 and 43 logarithm of the minimum angle of resolution (logMAR) letters for AMD and PCV patients, respectively. Patients with AMD and PCV received 5.5 and 5.3 injections (5.0 monotherapy vs. 5.6 combination therapy; mean, 1.2 PDT sessions), respectively. Patients with AMD gained 4.7 logMAR letters after 12 months (P = 0.002), whereas PCV patients gained 6.6 logMAR letters (P = 0.001) and 10.8 logMAR letters (P < 0.001) for monotherapy and combination therapy, respectively. Only patients with presenting VA of fewer than 35 letters (Snellen equivalent, 6/60) achieved significant visual improvement (10.4 letters for AMD, 17.1 letters for PCV with monotherapy, and 35.5 letters for PCV with combination therapy). Predictors of VA gain included number of intravitreal injections (AMD and PCV adjusted odds ratio, 12.1 [P = 0.001] and 12.5 [P = 0.004] for ≥7 injections, respectively) and baseline VA of 20 logMAR letters or fewer (adjusted odds ratio, 3.8 and 10.6 for AMD and PCV, respectively). Age, gender, race, use of PDT or focal laser therapy, and central subfield thickness were not predictive of significant visual gain at 12 months. CONCLUSIONS In Asian patients, treatment of AMD with anti-VEGF therapy yielded 12-month visual outcomes comparable with those of other real-world studies from Western populations but poorer than those of controlled trials. In contrast, for PCV eyes, anti-VEGF monotherapy and combination therapy with PDT yielded comparable outcomes as those of controlled clinical trials.
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Affiliation(s)
- Beau J Fenner
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore
| | - Daniel S W Ting
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Anna C S Tan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Kelvin Teo
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Choi Mun Chan
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Ranjana Mathur
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Ian Y S Yeo
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Tien Y Wong
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Edmund Y M Wong
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore
| | - Chui Ming Gemmy Cheung
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Republic of Singapore; Duke-NUS Graduate Medical School, Eye Academic Clinical Program, Singapore, Republic of Singapore.
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Tufail A, Margaron P, Guerin T, Larsen M. Visual benefit versus visual gain: what is the effect of baseline covariants in the treatment arm relative to the control arm? A pooled analysis of ANCHOR and MARINA. Br J Ophthalmol 2019; 104:672-677. [PMID: 31562118 PMCID: PMC7212932 DOI: 10.1136/bjophthalmol-2018-313682] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 07/03/2019] [Accepted: 07/25/2019] [Indexed: 11/10/2022]
Abstract
Background This study aimed to elucidate visual benefits of ranibizumab in patients with neovascular age-related macular degeneration (nAMD) compared with control arms and identify factors affecting response. Methods This is a post-hoc pooled analysis of two phase III studies, ANCHOR and MARINA, of ranibizumab for the treatment of nAMD. ANCHOR included 83 international sites. MARINA included 96 sites in the USA. Analysis included patients (control, n=323; ranibizumab, n=332) with nAMD and a baseline best-corrected visual acuity (BCVA) of ≥35–<85 letters. Results Patients receiving ranibizumab achieved an adjusted mean BCVA superiority of 18.9 and 21.2 letters over 12 and 24 months, respectively, compared with control. Ranibizumab treatment, higher baseline BCVA, lower age and smaller lesion size were positively associated with the ability to achieve BCVA >69 letters. Patients with the highest baseline BCVA had lowest BCVA gains. Ranibizumab treatment, lower baseline BCVA, lower age and smaller lesion size were identified as significant predictors of BCVA gain from baseline at month 24 (all p<0.0001). However, the difference in mean BCVA gains at month 24 between treatment and control groups was similar for all baseline BCVA subgroups (≥35–<55 letters, 21.9 letters; ≥55–<70 letters, 25.2 letters; ≥70–<85 letters, 19.3 letters). Conclusions Higher baseline BCVA is associated with lower BCVA gains but a greater likelihood of achieving good final BCVA >69 letters due to smaller gains needed to achieve response. Visual benefits, including maintenance of visual acuity (VA), final VA achieved and relative gain compared with natural disease progression, should be considered when assessing treatment response in nAMD.
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Affiliation(s)
- Adnan Tufail
- Medical Retina, Moorfields Eye Hospital & Institute of Ophthalmology UCL, London, UK
| | | | | | - Michael Larsen
- Department of Ophthalmology, Rigshospitalet & Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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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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Ferro Desideri L, Barra F, Ferrero S, Traverso CE, Nicolò M. Clinical efficacy and safety of ranibizumab in the treatment of wet age-related macular degeneration. Expert Opin Biol Ther 2019; 19:735-751. [DOI: 10.1080/14712598.2019.1627322] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Lorenzo Ferro Desideri
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Carlo Enrico Traverso
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Massimo Nicolò
- University Eye Clinic of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Macula Onlus Foundation, Genoa, Italy
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Ciulla TA, Hussain RM, Pollack JS, Williams DF. Visual Acuity Outcomes and Anti-Vascular Endothelial Growth Factor Therapy Intensity in Neovascular Age-Related Macular Degeneration Patients: A Real-World Analysis of 49 485 Eyes. Ophthalmol Retina 2019; 4:19-30. [PMID: 31324588 DOI: 10.1016/j.oret.2019.05.017] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/20/2019] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This study assessed anti-vascular endothelial growth factor (VEGF) therapy intensity and its relationship with visual acuity (VA) change in real-world neovascular age-related macular degeneration (nAMD) patients. DESIGN This retrospective analysis was performed on a large database of aggregated, longitudinal, de-identified electronic medical records from a geographically and demographically diverse sample of patients of United States retina specialists (Vestrum Health Retina Database). PARTICIPANTS Treatment-naïve nAMD patients who underwent anti-VEGF injections between January 1, 2012, and October 31, 2016, were eligible if follow-up data were available before October 31, 2017. METHODS Age, gender, anti-VEGF treatment type, number of treatments, and VA were extracted from the database. MAIN OUTCOME MEASURE Mean VA change assessed at 1 year and stratified based on number of anti-VEGF injections received over 1 year. RESULTS In this analysis, 49 485 eyes were included. The mean age was 80.9 years, and 64% were female. Mean baseline VA was 53.8 letters (Snellen equivalent, 20/80). At 1 year, after a mean of 7.3 anti-VEGF injections, there was a mean gain of 1 letter (0.95 letter; 95% confidence interval [CI] for change in VA, +0.77 to +1.13 letter; P < 0.001). When stratified by anti-VEGF agent, the mean VA changes were nearly identical at 1 year. There was a linear relationship between mean letters gained and mean number of injections, between 4 and 10 injections over 1 year, with 4 or fewer or 10 or more injections associated with loss of vision or a plateau, respectively. Greater mean 1-year change in VA also trended with worse baseline VA; those patients with better VA at presentation tended to be particularly vulnerable to vision loss. Those who received the fewest injections tended to be older and have worse baseline VA. CONCLUSIONS Real-world nAMD patients receive fewer anti-VEGF injections and experience worse visual outcomes compared with patients receiving fixed, frequent therapy in randomized controlled trials. Mean change in VA correlates with treatment intensity at 1 year, but with ceiling effects related to treatment intensity and baseline VA. Older patients and those with poor baseline VA may be particularly prone to undertreatment.
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Affiliation(s)
- Thomas A Ciulla
- Indiana University School of Medicine and Midwest Eye Institute, Indianapolis, Indiana.
| | - Rehan M Hussain
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - John S Pollack
- Rush University Medical Center and Illinois Retina Associates, Chicago, Illinois; Vestrum Health, Naperville, Illinois
| | - David F Williams
- Vestrum Health, Naperville, Illinois; VitreoRetinal Surgery, PA, Minneapolis, Minnesota
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The Systemic Safety of Ranibizumab in Patients 85 Years and Older with Neovascular Age-Related Macular Degeneration. Ophthalmol Retina 2019; 2:667-675. [PMID: 31047375 DOI: 10.1016/j.oret.2018.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 01/11/2018] [Accepted: 01/18/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Ranibizumab safety is well established for treatment of neovascular age-related macular degeneration (nAMD), but less is known about the risk of systemic serious adverse events (SAEs), specifically among patients with heightened baseline risk due to age (≥85 years). This analysis examines whether patients ≥85 years of age versus those <85 years experience an increased risk of key systemic SAEs during intravitreal ranibizumab treatment for nAMD. DESIGN Retrospective, pooled analysis of safety data from 5 phase III/IIIb multicenter randomized clinical trials in patients with nAMD: ANCHOR, MARINA, PIER, SAILOR, and HARBOR. PARTICIPANTS Patients with nAMD receiving ranibizumab (n = 4347) or control (sham/verteporfin photodynamic therapy, n = 441) treatment included in the safety-evaluable set of the 5 trials. METHODS The incidence of nonocular SAEs was analyzed stratified by age (<85 years [n = 3795] vs ≥85 years [n = 993]), treatment (control, ranibizumab 0.3 mg, ranibizumab 0.5 mg, ranibizumab 2.0 mg), and injection frequency (monthly, as needed [PRN]). MAIN OUTCOME MEASURES Incidence of key systemic SAEs, defined as total nonocular SAEs, deaths, cardiovascular events, cerebrovascular (CBV) events, and Antiplatelet Trialists' Collaboration events. RESULTS The MARINA and ANCHOR trials had greater rates of key SAEs for patients ≥85 years versus those <85 years. Ranibizumab exposure did not increase the risk of most SAEs in elderly patients; for CBV events and death, the effect of ranibizumab versus control treatment for age ≥85 years was not interpretable due to small number of events (CBV: n = 2, 2, 5 for control, ranibizumab 0.3 mg, and ranibizumab 0.5 mg, respectively; death: n = 2, 4, 5, respectively). Across all 5 trials, an increased risk was found for age ≥85 years versus <85 years for the marketed dose of ranibizumab 0.5 mg. In the HARBOR trial, increased rates of key SAEs (excluding total nonocular SAEs) for age ≥85 years versus <85 years were observed with monthly dosing but not with PRN dosing; event rates were similar for 2.0 mg versus 0.5 mg. CONCLUSIONS Consistent with general trends, the risk of key systemic SAEs was associated with age ≥85 years versus <85 years, but not with ranibizumab drug exposure. The difference between monthly versus PRN was inconclusive. There was no evidence of a dose effect. Interpretation of this retrospective analysis is limited because it was not prospectively powered for statistically definitive conclusions.
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Nguyen CL, Gillies MC, Nguyen V, Daien V, Cohn A, Banerjee G, Arnold J. Characterization of Poor Visual Outcomes of Neovascular Age-related Macular Degeneration Treated with Anti–Vascular Endothelial Growth Factor Agents. Ophthalmology 2019; 126:735-742. [DOI: 10.1016/j.ophtha.2018.11.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 10/05/2018] [Accepted: 11/30/2018] [Indexed: 11/24/2022] Open
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Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2019; 3:CD005139. [PMID: 30834517 PMCID: PMC6419319 DOI: 10.1002/14651858.cd005139.pub4] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the most common cause of uncorrectable severe vision loss in people aged 55 years and older in the developed world. Choroidal neovascularization (CNV) secondary to AMD accounts for most cases of AMD-related severe vision loss. Intravitreous injection of anti-vascular endothelial growth factor (anti-VEGF) agents aims to block the growth of abnormal blood vessels in the eye to prevent vision loss and, in some instances, to improve vision. OBJECTIVES • To investigate ocular and systemic effects of, and quality of life associated with, intravitreous injection of three anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) versus no anti-VEGF treatment for patients with neovascular AMD• To compare the relative effects of one of these anti-VEGF agents versus another when administered in comparable dosages and regimens SEARCH METHODS: To identify eligible studies for this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (searched January 31, 2018); MEDLINE Ovid (1946 to January 31, 2018); Embase Ovid (1947 to January 31, 2018); the Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to January 31, 2018); the International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com/editAdvancedSearch - searched January 31, 2018); ClinicalTrials.gov (www.clinicaltrials.gov - searched November 28, 2018); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en - searched January 31, 2018). We did not impose any date or language restrictions in electronic searches for trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated pegaptanib, ranibizumab, or bevacizumab versus each other or versus a control treatment (e.g. sham treatment, photodynamic therapy), in which participants were followed for at least one year. DATA COLLECTION AND ANALYSIS Two review authors independently screened records, extracted data, and assessed risks of bias. We contacted trial authors for additional data. We compared outcomes using risk ratios (RRs) or mean differences (MDs). We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 16 RCTs that had enrolled a total of 6347 participants with neovascular AMD (the number of participants per trial ranged from 23 to 1208) and identified one potentially relevant ongoing trial. Six trials compared anti-VEGF treatment (pegaptanib, ranibizumab, or bevacizumab) versus control, and 10 trials compared bevacizumab versus ranibizumab. Pharmaceutical companies conducted or sponsored four trials but funded none of the studies that evaluated bevacizumab. Researchers conducted these trials at various centers across five continents (North and South America, Europe, Asia, and Australia). The overall certainty of the evidence was moderate to high, and most trials had an overall low risk of bias. All but one trial had been registered prospectively.When compared with those who received control treatment, more participants who received intravitreous injection of any of the three anti-VEGF agents had gained 15 letters or more of visual acuity (risk ratio [RR] 4.19, 95% confidence interval [CI] 2.32 to 7.55; moderate-certainty evidence), had lost fewer than 15 letters of visual acuity (RR 1.40, 95% CI 1.27 to 1.55; high-certainty evidence), and showed mean improvement in visual acuity (mean difference 6.7 letters, 95% CI 4.4 to 9.0 in one pegaptanib trial; mean difference 17.8 letters, 95% CI 16.0 to 19.7 in three ranibizumab trials; moderate-certainty evidence) after one year of follow-up. Participants treated with anti-VEGF agents showed improvement in morphologic outcomes (e.g. size of CNV, central retinal thickness) compared with participants not treated with anti-VEGF agents (moderate-certainty evidence). No trial directly compared pegaptanib versus another anti-VEGF agent and followed participants for one year; however, when compared with control treatments, ranibizumab and bevacizumab each yielded larger improvements in visual acuity outcomes than pegaptanib.Visual acuity outcomes after bevacizumab and ranibizumab were similar when the same RCTs compared the same regimens with respect to gain of 15 or more letters of visual acuity (RR 0.95, 95% CI 0.81 to 1.12; high-certainty evidence) and loss of fewer than 15 letters of visual acuity (RR 1.00, 95% CI 0.98 to 1.02; high-certainty evidence); results showed similar mean improvement in visual acuity (mean difference [MD] -0.5 letters, 95% CI -1.5 to 0.5; high-certainty evidence) after one year of follow-up, despite the substantially lower cost of bevacizumab compared with ranibizumab. Reduction in central retinal thickness was less among bevacizumab-treated participants than among ranibizumab-treated participants after one year (MD -11.6 μm, 95% CI -21.6 to -1.7; high-certainty evidence); however, this difference is within the range of measurement error, and we did not interpret it to be clinically meaningful.Ocular inflammation and increased intraocular pressure (IOP) after intravitreal injection were the most frequently reported serious ocular adverse events. Researchers reported endophthalmitis in less than 1% of anti-VEGF-treated participants and in no cases among control groups. The occurrence of serious systemic adverse events was comparable across anti-VEGF-treated groups and control groups; however, the numbers of events and trial participants may have been insufficient to show a meaningful difference between groups (evidence of low- to moderate-certainty). Investigators rarely measured and reported data on visual function, quality of life, or economic outcomes. AUTHORS' CONCLUSIONS Results of this review show the effectiveness of anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) in terms of maintaining visual acuity; studies show that ranibizumab and bevacizumab improved visual acuity in some eyes that received these agents and were equally effective. Available information on the adverse effects of each medication does not suggest a higher incidence of potentially vision-threatening complications with intravitreous injection of anti-VEGF agents compared with control interventions; however, clinical trial sample sizes were not sufficient to estimate differences in rare safety outcomes. Future Cochrane Reviews should incorporate research evaluating variable dosing regimens of anti-VEGF agents, effects of long-term use, use of combination therapies (e.g. anti-VEGF treatment plus photodynamic therapy), and other methods of delivering these agents.
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Affiliation(s)
- Sharon D Solomon
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | | | - Magdalena G Krzystolik
- Mass Eye and Ear InfirmaryDepartment of Ophthalmology, Retina Service1 Randall Square, Suite 203ProvidenceRhode IslandUSA02904
| | - Barbara S Hawkins
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
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Schlesinger EB, Bernards DA, Chen HH, Feindt J, Cao J, Dix D, Romano C, Bhisitkul RB, Desai TA. Device design methodology and formulation of a protein therapeutic for sustained release intraocular delivery. Bioeng Transl Med 2019; 4:152-163. [PMID: 30680326 PMCID: PMC6336666 DOI: 10.1002/btm2.10121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 12/28/2022] Open
Abstract
Despite years of effort, sustained delivery of protein therapeutics remains an unmet need due to three primary challenges - dose, duration, and stability. The work presented here provides a design methodology for polycaprolactone reservoir-based thin film devices suitable for long-acting protein delivery to the back of the eye. First, the challenge of formulating highly concentrated protein in a device reservoir was addressed by improving stability with solubility-reducing excipients. Next, predictive correlations between design parameters and device performance were developed to provide a methodology to achieve a target product profile. Prototype devices were designed using this methodology to achieve desired device size, release rate, therapeutic payload, and protein stability, assessed by in vitro studies. Finally, prototype tolerability was established in a non-human primate model. The design methodology presented here is widely applicable to reservoir-based sustained delivery devices for proteins and provides a general device design framework.
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Affiliation(s)
- Erica B. Schlesinger
- Graduate Program in BioengineeringUniversity of CaliforniaSan FranciscoCA 94158
- Formulation Development GroupRegeneron PharmaceuticalsTarrytownNY 10591
| | - Daniel A. Bernards
- Dept. of Bioengineering and Therapeutic SciencesUniversity of CaliforniaSan FranciscoCA 94158
| | - Hunter H. Chen
- Formulation Development GroupRegeneron PharmaceuticalsTarrytownNY 10591
| | - James Feindt
- Formulation Development GroupRegeneron PharmaceuticalsTarrytownNY 10591
| | - Jingtai Cao
- Ophthalmology ResearchRegeneron PharmaceuticalsTarrytownNY 10591
| | - Daniel Dix
- Formulation Development GroupRegeneron PharmaceuticalsTarrytownNY 10591
| | - Carmelo Romano
- Ophthalmology ResearchRegeneron PharmaceuticalsTarrytownNY 10591
| | | | - Tejal A. Desai
- Graduate Program in BioengineeringUniversity of CaliforniaSan FranciscoCA 94158
- Dept. of Bioengineering and Therapeutic SciencesUniversity of CaliforniaSan FranciscoCA 94158
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