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Zhou R, Lu P, He M, Chen J, Shi Y, Han F, Cai Y. A real-world disproportionality analysis of anti-VEGF drugs from the FDA Adverse Event Reporting System. Expert Opin Drug Saf 2024; 23:363-371. [PMID: 37665052 DOI: 10.1080/14740338.2023.2250717] [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: 02/26/2023] [Accepted: 07/10/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND The association between anti-vascular endothelial growth factor (VEGF) drugs and ocular adverse events (AEs) has been reported, but large real-world studies of their association with systemic AEs are still lacking. METHODS A disproportionality analysis of reports from the FDA Adverse Event Reporting System from January 2004 to September 2021 was conducted to detect the significant ADR signals with anti-VEGF drugs (including aflibercept, bevacizumab, brolucizumab, pegaptanib, and ranibizumab). RESULTS A total of 2980 reported cases with 7125 drug-AEs were included. Five drugs were all associated with eye disorders, and pegaptanib and ranibizumab were also associated with cardiac disorders. For ranibizumab, pegaptanib, bevacizumab and aflibercept, the proportions of cardiac AEs were 8.57%, 5.62%, 3.43% and 3.20%, respectively, and the proportions of central nervous AEs were 8.81%, 7.41, 5.86% and 5.68%, respectively. In multiple comparisons, ranibizumab was significantly higher than bevacizumab and aflibercept in the proportion of cardiac AEs (P < 0.001), and ranibizumab was significantly higher than aflibercept in central nervous AEs (P < 0.001). CONCLUSIONS Our findings support the associations between anti-VEGF drugs and ocular AEs, cardiac AEs, and central nervous AEs. After intravitreal injection, attention should not only be paid to ocular symptoms, but also to systemic symptoms.
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Affiliation(s)
- Ruishan Zhou
- School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Peiwen Lu
- School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Mingxiu He
- School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Junheng Chen
- School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yiyang Shi
- School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Fangfang Han
- School of Medical Information and Engineering, Guangdong Pharmaceutical University, Guangzhou, China
- NMPA Key Laboratory for Technology Research and Evaluation of Pharmacovigilance, Guangzhou, China
| | - Yongming Cai
- School of Medical Information and Engineering, Guangdong Pharmaceutical University, Guangzhou, China
- NMPA Key Laboratory for Technology Research and Evaluation of Pharmacovigilance, Guangzhou, China
- Guangdong Provincial Traditional Chinese Medicine Precision Medicine Big Data Engineering Technology Research Center, Guangzhou, China
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2
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Willms JO, Mitchell K, Shashtri M, Sundin O, Liu X, Panthagani P, Tran P, Navarro S, Sniegowski C, Shaik AA, Chaudhury T, Reid TW, Bergeson SE. Minocycline and Diacetyl Minocycline Eye Drops Reduce Ocular Neovascularization in Mice. Transl Vis Sci Technol 2023; 12:10. [PMID: 38064336 PMCID: PMC10709801 DOI: 10.1167/tvst.12.12.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 09/24/2023] [Indexed: 12/18/2023] Open
Abstract
Purpose To evaluate the efficacy of minocycline and a novel, modified minocycline analogue that lacks antimicrobial action, diacetyl minocycline (DAM), on choroidal neovascularization (CNV) in mice of both sexes. Methods CNV was induced via laser injury in female and male C57BL/6J mice. Minocycline, DAM, or saline was administered via topical eye drops twice a day for 2 weeks starting the day after laser injury. CNV volume was measured using immunohistochemistry labeling and confocal microscopy. Results Minocycline reduced lesion volume by 79% (P ≤ 0.0004) in female and male mice. DAM reduced lesion volume by 73% (P ≤ 0.001) in female and male mice. There was no significant difference in lesion volume between minocycline and DAM treatment groups or between female and male mice. Conclusions Both minocycline and DAM eye drops significantly reduced laser-induced CNV lesion volume in female and male mice. While oral tetracyclines have been shown to mitigate pathologic neovascularization in both preclinical studies and clinical trials, the present data are the first to suggest that tetracycline derivatives may be effective to reduce pathologic CNV when administered via topical eye drops. However, the action is unrelated to antimicrobial action. Targeted delivery of these medications via eye drops may reduce the potential for systemic side effects. Translational Relevance Topical administration of minocycline and/or DAM via eye drops may represent a novel therapeutic strategy for disorders involving pathologic CNV.
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Affiliation(s)
- Joshua O. Willms
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kelly Mitchell
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Olof Sundin
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Xiaobo Liu
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Praneetha Panthagani
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Phat Tran
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Stephany Navarro
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Colton Sniegowski
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Abdul A. Shaik
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Tristin Chaudhury
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Ted W. Reid
- Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Susan E. Bergeson
- Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Ma H, Wei H, Zou C, Zhu G, Gao Q, Zhang N, Wang B. Anti-VEGF Drugs in Age-Related Macular Degeneration: A Focus on Dosing Regimen-Related Safety and Efficacy. Drugs Aging 2023; 40:991-1007. [PMID: 37863867 DOI: 10.1007/s40266-023-01068-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/22/2023]
Abstract
Age-related macular degeneration (AMD) is one of the main causes of visual impairment and severe visual loss, and can progress to two advanced forms-neovascularization and atrophic. The field of anti-AMD drugs has undergone huge developments in recent years, from single-target intravitreal administration to current clinical studies with multi-target and non-invasive agents, offering interesting new pharmacological opportunities for the treatment of this disease. Hence, we summarize some of the approved anti-vascular endothelial growth factor (VEGF) drugs for neovascular AMD, especially their structural characteristics, clinical manifestations, dosing regimens, and safety issues of the anti-VEGF drugs highlighted. In addition, advances in atrophic AMD drug research are also briefly described.
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Affiliation(s)
- Haibei Ma
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hai Wei
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chunpu Zou
- School of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guoqin Zhu
- SPH Xingling Sci. & Tech. Pharmaceutical Co. Ltd., Shanghai, China
| | - Qi Gao
- SPH Xingling Sci. & Tech. Pharmaceutical Co. Ltd., Shanghai, China.
| | - Ning Zhang
- Experiment Center for Science and Technology, Shanghai University of Traditional Chinese Medicine, 1200 Cai-lun Rd, Shanghai, China.
| | - Bing Wang
- Center for Pharmaceutics Research, Shanghai Institute of Materia Medica Chinese Academy of Sciences, 501 Hai-ke Rd, Shanghai, China.
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Frederiksen KH, Stokholm L, Frederiksen PH, Jørgensen CM, Möller S, Kawasaki R, Peto T, Grauslund J. Cardiovascular morbidity and all-cause mortality in patients with retinal vein occlusion: a Danish nationwide cohort study. Br J Ophthalmol 2023; 107:1324-1330. [PMID: 35537802 PMCID: PMC10447393 DOI: 10.1136/bjophthalmol-2022-321225] [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: 02/01/2022] [Accepted: 04/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS Associations between retinal vein occlusion (RVO) and subsequent cardiovascular disease (CVD) or mortality have not been evaluated in a recent cohort, after novel therapeutic options have increased referrals for treatment of the condition. We aimed to evaluate overall and subtype-stratified risk of CVD and all-cause mortality following RVO and assess any alterations after the introduction of angiostatic therapy in Denmark in 2011. METHODS This nationwide, registry-based cohort study from 1998 to 2018 evaluated 4 194 781 individuals. Hazard ratios (HRs) were reported for RVO as an overall measure and subclassified as branch and central RVO. RESULTS Patients with RVO (n=15 665) were median 71.8 years old at the time of exposure and 50.7% were women. RVO associated with incident CVD (adjusted HR 1.13, 95% CI 1.09 to 1.17) but not mortality (adjusted HR 1.00, 95% CI 0.97 to 1.03). Almost similar risks of CVD were found for patients with branch and central RVO (adjusted HRs 1.14, 95% CI 1.03 to 1.25, and 1.12, 95% CI 1.00 to 1.25, respectively), but only patients with central RVO exhibited increased mortality (adjusted HR 1.12, 95% CI 1.04 to 1.21). Risk of CVD, especially non-ischaemic, was higher for patients diagnosed after 2011 (adjusted HRs 1.24, 95% CI 1.15 to 1.33 vs 1.06, 95% CI 1.01 to 1.12). CONCLUSION In a cohort of the Danish population aged 40 years or more, patients with RVO had a 13% increased risk of incident CVD compared with unexposed individuals. Risk of CVD was increased after 2011, when intravitreal angiostatic treatment was introduced and referral practices altered.
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Affiliation(s)
- Katrine Hartmund Frederiksen
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lonny Stokholm
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network, Odense University Hospital, Odense, Denmark
| | - Peter Hartmund Frederiksen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Sören Möller
- Open Patient data Exploratory Network, Odense University Hospital, Odense, Denmark
| | - Ryo Kawasaki
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Vision Informatics, Osaka University School of Medicine, Osaka, Japan
| | - Tunde Peto
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Jakob Grauslund
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Chou YI, Chang HY, Lin MY, Tseng CH, Wang TJ, Lin IC. Risk analysis for patients with arterial thromboembolic events after intravitreal ranibizumab or aflibercept injections. Sci Rep 2023; 13:7597. [PMID: 37165045 PMCID: PMC10172364 DOI: 10.1038/s41598-023-34128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents have been increasingly applied in the treatment of retinal neovascular diseases. Concerns have arisen that these intravitreal agents may be associated with a potential risk of arterial thromboembolic (ATE) events. We conducted a retrospective, nationwide population-based cohort study to analyze the risks for ATE events in patients receiving intravitreal ranibizumab (IVR) or intravitreal aflibercept (IVA). Data (2011-2018) were obtained from Taiwan's National Health Insurance Research Database. Cox proportional-hazards model was used to identify the risk factors for ATEs. Of the total 3,469 patients, 1393 and 2076 patients received IVR and IVA, respectively. In our result, 38 ATEs occurred within 6 months after IVR or IVA. The risk of ATEs was lower in patients receiving IVR than in those receiving IVA (adjusted hazard ratio [aHR], 0.27; 95% confidence interval [CI], 0.11-0.66). Patients with coronary artery disease (CAD) exhibited a higher risk of ATEs than did those without CAD (aHR, 3.47; 95% CI, 1.41-8.53). The risk of ATEs was higher in patients with an event of acute myocardial infarction (AMI) or ischemic stroke (IS) within 6 months prior to index IVI than in those without recent AMI/IS events (aHR, 23.8; 95% CI, 7.35-77.2 and IS: aHR, 290.2; 95% CI, 103.1-816.4). In conclusion, compared with IVA, IVR was associated with a lower risk of ATEs. When strategies for anti-VEGF agents are devised, risk factors, such as CAD and a history of AMI or IS within 6 months should be considered. Further large-scale studies are warranted to elucidate the safety of anti-VEGF injections.
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Affiliation(s)
- Yun-I Chou
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hao-Yun Chang
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Meng-Yin Lin
- Department of Ophthalmology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Ophthalmology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ching-Han Tseng
- Department of Ophthalmology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Ophthalmology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tsung-Jen Wang
- Department of Ophthalmology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Ophthalmology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - I-Chan Lin
- Department of Ophthalmology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Department of Ophthalmology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Stefansson E, Loftsson T, Larsen M, Papp A, Kaarniranta K, Munk MR, Dugel P, Tadayoni R. Topical treatment of diabetic macular edema using dexamethasone ophthalmic suspension: A randomized, double-masked, vehicle-controlled study. Acta Ophthalmol 2023; 101:22-33. [PMID: 35848336 DOI: 10.1111/aos.15215] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate topical dexamethasone ophthalmic suspension OCS-01 (Oculis SA, Lausanne, Switzerland) in diabetic macular edema (DME). METHODS This was a multicenter, double-masked, parallel-group, randomized, Phase 2 study. Patients aged 18-85 years with DME of <3 years duration, ETDRS central subfield thickness ≥ 310 μm by SD-OCT, and ETDRS letter score ≤ 73 and ≥ 24 in the study eye were randomized 2:1 to OCS-01 or matching vehicle, 1 drop 3 times/day for 12 weeks. Efficacy was evaluated as change from baseline to Week 12 of ETDRS letter score and central macular thickness (CMT). The primary analysis used a linear model with baseline ETDRS letters as a covariate, and missing data imputed using multiple imputation pattern mixture model techniques. Active treatment was considered superior to vehicle if the one-sided p-value was <0.15 and the difference in mean change from baseline in ETDRS letters was >0. RESULTS Mean CMT showed a greater decrease from baseline with OCS-01 (N = 99) than vehicle (N = 45) at Week 12 (-53.6 vs -16.8 μm, p = 0.0115), with significant differences favouring OCS-01 from Weeks 2 to 12. OCS-01 was well-tolerated, and increased intraocular pressure was the most common adverse event. Mean change in ETDRS letter score from baseline to Week 12 met the p was +2.6 letters with topical OCS-01 and 1 letter with vehicle (p = 0.125). In a post-hoc analysis, there was a greater difference in patients with baseline BCVA ≤65 letters, the OCS-01 group improved 3.8 letters compared with 0.9 letters with vehicle. CONCLUSION Topical OCS-01 was significantly more effective than vehicle in improving central macular thickness in patients with DME. Visual improvement was better in eyes with lower baseline vision.
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Affiliation(s)
| | | | - Michael Larsen
- Eye Department, Rigshospitalet - Glostrup, Copenhagen, Denmark
| | - András Papp
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Kai Kaarniranta
- University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Marion R Munk
- Inselspital, University Hospital Bern, Bern, Switzerland.,Bern Photographic Reading Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Pravin Dugel
- Keck School of Medicine, USC Roski Eye Institute, Los Angeles, California, USA
| | - Ramin Tadayoni
- Service d'Ophtalmologie Paris, Hopital Lariboisière, Paris, France
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Chiu HI, Chou YB, Lin TC, Chiou SH, Chen SJ, Hwang DK. Temporal fluctuations of cardiovascular parameters after intravitreal injections. J Chin Med Assoc 2022; 85:1088-1092. [PMID: 36343274 DOI: 10.1097/jcma.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Despite the effectiveness of intravitreal injection (IVI) of anti-vascular endothelial growth factor in treating retinal diseases, there remains a paucity of evidence on potential systemic risks associated with this procedure. This study aims to investigate cardiovascular parameters and the risk of hypertensive urgency after IVIs. METHODS Patients who received IVIs for retinal/macular diseases were enrolled retrospectively. Patients who received cataract surgeries were enrolled as controls. Systolic and diastolic blood pressure (BP) and heart rate were measured 10 minutes before, immediately after, and more than 30 minutes after IVIs and cataract surgery. Multivariate analysis was performed to evaluate risk factors for hypertensive urgency. RESULTS Seventy patients who received IVIs and 95 patients who received cataract surgeries were enrolled. A higher preoperative systolic BP was found in the IVI groups than in the control group (147.0 ± 22.9 vs 136.3 ± 21.8 mmHg, respectively). The patients who received IVIs had a higher increase in perioperative systolic BP immediately after the procedure than the controls (17.43 ± 20.53 mmHg vs 9.11 ± 18.92 mmHg, p = 0.009). The IVI procedure (odds ratio [OR] 4.84, p = 0.008), preoperative systolic BP ≥160 mmHg (OR 17.891, p = 0.001, compared to preoperative systolic BP <140 mmHg), and underlying hypertension (OR 3.305, p = 0.041) were risk factors for hypertensive urgency immediately after the IVIs. CONCLUSION We found a transient increase in BP after IVIs, which may have been associated with hypertensive urgency and related cardiovascular disorders in older patients and in those with relevant comorbidities. Clinicians should pay more attention to these patients before performing IVIs.
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Affiliation(s)
- Hsun-I Chiu
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yu-Bai Chou
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tai-Chi Lin
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shih-Hwa Chiou
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Chang YH, Chien LN, Chen WT, Lin IC. Comparison of risks of arterial thromboembolic events and glaucoma with ranibizumab and aflibercept intravitreous injection: A nationwide population‐based cohort study. PLoS One 2022; 17:e0267088. [PMID: 35436315 PMCID: PMC9015139 DOI: 10.1371/journal.pone.0267088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background
To compare intravitreal aflibercept injection with intravitreal ranibizumab injection for the risk of major arterial thromboembolic events (ATEs) and glaucoma.
Methods
This retrospective, nationwide cohort study investigated 15 611 and 3867 patients aged >50 years with at least one pharmacy claim for intravitreal ranibizumab injection and aflibercept injection between 2011 and 2016, respectively. The inverse probability of treatment weighting method was performed to adjust the baseline difference between the two groups and the hazard risk of adverse events was estimated using the Cox proportional regression model.
Results
No significant difference was noted between intravitreal ranibizumab and aflibercept injection for arterial thromboembolic risk, including ischemic stroke and acute myocardial infarction, during a 2-year follow-up (adjusted hazard ratio (HR): 0.87, 95% confidence interval (CI): 0.53–1.42; P = .583). Subgroup analyses revealed that patients age >65 years (adjusted HR: 0.64, 95% CI: 0.45–0.92) and those without coronary artery disease (adjusted HR: 0.59, 95% CI: 0.37–0.95) had significantly lower arterial thromboembolic risk in the aflibercept group than in the ranibizumab group. Additionally, the risk of glaucoma development after intravitreal injection did not significantly differ between the two groups (adjusted HR: 0.63, 95% CI: 0.37–1.06; P = .084).
Conclusions
No significant differences in the risk of major ATEs and glaucoma were found between ranibizumab and aflibercept, and aflibercept might be safe for use in elderly patients.
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Affiliation(s)
- Yin-Hsi Chang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Li-Nien Chien
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Wan-Ting Chen
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
| | - I-Chan Lin
- Department of Ophthalmology, Taipei Medical University, Shuang Ho Hospital, New Taipei, Taiwan
- Department of Ophthalmology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Reibaldi M, Fallico M, Avitabile T, Marolo P, Parisi G, Cennamo G, Furino C, Lucenteforte E, Virgili G. Frequency of intravitreal anti-vascular endothelial growth factor injections and risk of death: a systematic review with meta-analysis. Ophthalmol Retina 2021; 6:369-376. [PMID: 34974177 DOI: 10.1016/j.oret.2021.12.019] [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] [Received: 10/24/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 01/11/2023]
Abstract
TOPIC To investigate whether an increasing number of intravitreal anti-vascular endothelial growth factor (VEGF) injections is associated with a higher mortality risk. CLINICAL RELEVANCE The issue of systemic safety of intravitreal anti-VEGF therapy has been long discussed. Evidence from meta-analyses of randomized studies has shown no increased risk of mortality in overall population, while some warning signal of higher mortality were found in diabetic patients exposed to intense and prolonged treatment. Concerns have been raised as to whether an increasing number of anti-VEGF injections could be associated with a higher mortality. METHODS Randomized clinical trials enrolling arms with different intensity of anti-VEGF therapy were searched. The incidence rate ratio (IRR) of death with 95% confidence interval (CI) for receiving 5 injections was the primary outcome measure. The relationship between the number of injections and all-cause mortality was investigated. Separate regression analyses were conducted to investigate this relationship in subgroups of studies with different diseases and drugs. RESULTS Fifty-two trials were included. An overall mortality rate of 1.02% and 3.36% was recorded at 12 and 24 months, respectively. Univariate regression showed that a larger number of injections was not associated with a significant increase in mortality both at 12 months (IRR=1.16,95%CI=0.87-1.53;p=0.31) and at 24 months (IRR=1.05,95%CI=0.95-1.15;p=0.34). According to subgroup analyses, a higher risk was marginally associated with an increasing number of injections in diabetic macular edema (DME) studies at 24 months (IRR=1.17,95%CI=1.02-1.33;p=0.03). CONCLUSION No significant influence of anti-VEGF treatment intensity on mortality was shown, supporting a message of reassurance over safety concerns of this therapy. Marginal evidence of a higher risk associated with a more intense treatment was found in DME patients.
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Affiliation(s)
- Michele Reibaldi
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, Turin, Italy
| | - Matteo Fallico
- Department of Ophthalmology, University of Catania, Catania, Italy.
| | | | - Paola Marolo
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, Turin, Italy
| | - Guglielmo Parisi
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, Turin, Italy
| | - Gilda Cennamo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Claudio Furino
- Department of Ophthalmology, University of Bari, Bari, Italy
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze and Careggi, Italy; Centre for Public Health, Queen's University of Belfast, Northern Ireland, United Kingdom
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Risk factors for emerging intraocular inflammation after intravitreal brolucizumab injection for age-related macular degeneration. PLoS One 2021; 16:e0259879. [PMID: 34871313 PMCID: PMC8648104 DOI: 10.1371/journal.pone.0259879] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 10/29/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose To analyze the risk factors associated with emerging intraocular inflammation (IOI) after intravitreal brolucizumab injection (IVBr) to treat age-related macular degeneration (AMD). Methods This study included 93 eyes of 90 patients. The incidence of emerging IOI was analyzed. The patients were classified into IOI or non-IOI groups, and background clinical characteristics in each group were compared. Results IOI occurred in 14 eyes of 14 cases (16%; five women, nine men [5:9]; IOI group) after IVBr; contrastingly, no IOI occurred in 76 patients (10 women, 66 men [10:66]; non-IOI group). The mean ages in IOI and non-IOI groups were 79.4 ± 8.1 and 73.8 ± 8.9 years old, respectively, and the average age in the IOI group was significantly higher than that in the non-IOI group (P = 0.0425). In addition, the percentages of females in the IOI and non-IOI groups were 43% and 13%, respectively, and IOI occurred predominantly in females (odds ratio: 4.95, P = 0.0076). Moreover, the prevalence of diabetes in the IOI and non-IOI groups was 64% and 32%, respectively, with a significant difference (odds ratio: 3.90, P = 0.0196). In contrast, the prevalence of hypertension in the IOI and non-IOI groups was 36% and 57%, respectively, with no significant difference (P = 0.15). Conclusion The comparison of clinical profiles of IOI or non-IOI cases in IVBr treatment for AMD suggests that the risk factors for IOI are old age, female sex, and history of diabetes; however, IOI with vasculitis or vascular occlusion in this cohort does not seem to cause severe visual impairment. Further studies are required to investigate potential risk factors for IOI.
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11
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Reibaldi M, Fallico M, Avitabile T, Bonfiglio V, Russo A, Castellino N, Parisi G, Longo A, Pulvirenti A, Boscia F, Virgili G. Risk of Death Associated With Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: A Systematic Review and Meta-analysis. JAMA Ophthalmol 2021; 138:50-57. [PMID: 31750861 DOI: 10.1001/jamaophthalmol.2019.4636] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although intravitreal anti-vascular endothelial growth factor (VEGF) treatment represents the first-line therapy for many retinal diseases, the issue of their systemic safety is debatable. Objectives To assess whether intravitreal anti-VEGF therapy might be associated with increased risk of mortality and which variables are associated with the increase. Data Sources PubMed, MEDLINE, and Embase databases, the Cochrane Library, and ClinicalTrials.gov were systematically searched from inception to May 6, 2019. Study Selection Randomized clinical trials comparing intravitreal anti-VEGF treatment with control groups and with follow-up of at least 6 months were selected. Data Extraction and Synthesis Data were independently collected by 2 investigators. Meta-analyses were conducted using the frequentist and Bayesian methods. For the frequentist approach, random- and fixed-effects models were used, with random-effects models considered the primary technique. Odds ratios (ORs) with 95% CIs were computed. For the bayesian approach, uninformative and informative priors were used. Odds ratios with 95% credible intervals (CrIs) were computed. Meta-regression analyses were based on random-effects models. Main Outcomes and Measures The primary outcome measure was the all-cause death rate. Secondary outcomes included meta-regression analyses on the following variables: type of drug, number of injections, follow-up time, diagnosis, and cardiovascular risk. Results Of 2336 studies identified, 34 unique studies with 8887 unique participants were included in the present meta-analysis. For the frequentist analysis, fixed- and random-effects models yielded similar estimates (ORs, 1.34 [95% CI, 0.95-2.07; P = .09] and 1.34 [95% CI, 0.89-2.01; P = .17], respectively). For the Bayesian approach, noninformative and informative priors yielded similar results (ORs, 1.34 [95% CrI, 0.79-2.34; 0.13 probability of OR≤1.00] and 1.40 [95% CrI, 0.82-2.32; 0.11 probability of OR≤1.00], respectively). Meta-regression analyses showed the following risk for 1 injection more: frequentist OR of 1.12 (95% CI, 1.04-1.22; P = .005) and Bayesian OR of 1.06 (95% CrI, 0.98-1.15; 0.06 probability of OR≤1.00). Conclusions and Relevance In this study, no difference was found in the mortality rate between intravitreal anti-VEGF treatment and control groups. Additional data seem warranted to determine whether the mortality rate is increased in patients receiving a greater number of injections.
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Affiliation(s)
- Michele Reibaldi
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Matteo Fallico
- Department of Ophthalmology, University of Catania, Catania, Italy.,Eye Unit, Southampton University Hospital, Southampton, United Kingdom
| | | | | | - Andrea Russo
- Department of Ophthalmology, University of Catania, Catania, Italy
| | | | - Guglielmo Parisi
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Antonio Longo
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Alfredo Pulvirenti
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesco Boscia
- Department of Ophthalmology, University of Sassari, Sassari, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Firenze and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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12
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Tsai HR, Lu JW, Chen LY, Chen TL. Application of Janus Kinase Inhibitors in Atopic Dermatitis: An Updated Systematic Review and Meta-Analysis of Clinical Trials. J Pers Med 2021; 11:jpm11040279. [PMID: 33917069 PMCID: PMC8067719 DOI: 10.3390/jpm11040279] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/01/2021] [Accepted: 04/04/2021] [Indexed: 12/12/2022] Open
Abstract
Janus kinase (JAK) inhibitors are promising treatments for atopic dermatitis (AD). The aim of this study was to assess the efficacy and safety of JAK inhibitors for AD treatment via the “Grading of Recommendations Assessment, Development, and Evaluation” approach. We identified 15 randomized controlled trials comparing oral or topical JAK inhibitors against placebo to treat AD. A random-effects meta-analysis was performed, and the numbers-needed-to-treat (NNTs)/numbers-needed-to-harm (NNHs) were calculated. Patients treated with JAK inhibitors were associated with higher rates of achieving eczema area and severity index-75 (rate ratio (RR): 2.84; 95% confidence interval (CI): 2.20–3.67; I2: 38.9%; NNT = 3.97), Investigator’s Global Assessment response (RR: 2.99; 95% CI: 2.26–3.95; I2: 0%; NNT = 5.72), and pruritus numerical rating scale response (RR: 2.52; 95% CI: 1.90–3.35; I2: 39.4%; NNT = 4.91) than those treated with placebo. Moreover, patients treated with JAK inhibitors had a higher risk of treatment-emergent adverse events (RR: 1.14; 95% CI: 1.02–1.28; I2: 52%; NNH = 14.80) but not adverse events leading to drug discontinuation. According to the evidence-based results, JAK inhibitors are potentially effective strategies (certainty of evidence: “moderate”) for treating AD with tolerable side effects (certainty of evidence: “low”). Nevertheless, long-term follow-up is required.
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Affiliation(s)
- Hou-Ren Tsai
- Department of Medical Education, Medical Administration Office, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan;
| | - Jing-Wun Lu
- Department of Physical Medicine and Rehabilitation, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan;
| | - Li-Yu Chen
- Library of Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan;
| | - Tai-Li Chen
- Department of Medical Education, Medical Administration Office, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan;
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-983-249-828
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13
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Abstract
PURPOSE To determine the dose-response characteristics of the antivascular endothelial growth factor agents ranibizumab and aflibercept in neovascular age-related macular degeneration using published randomized trials and observational series. METHODS Literature review of published series from 2006 to 2018 as determined from electronic searches of PubMed and the Cochrane Library. Data extracted included treatment strategy, frequency, and first year visual acuity response. Monthly or bimonthly treatment schedules were classified as Fixed, pro re nata studies as PRN, treat and extend as TE, and when no strategy was listed, as Variable. RESULTS Of 2062 citations retrieved, 96 were deemed eligible; these 96 citations provided 120 data points of dose frequency versus visual acuity change in Year 1 of treatment. The dose-response curve was nonlinear, but a log transform of the number of injections per year yielded a linear relationship defined by the expression, Letters of Improvement = -6.66 + 15.7*log (number of injections Year 1). After accounting for the number of injections neither the drug used (ranibizumab or aflibercept) nor the strategy used (Fixed, pro re nata, treat and extend, or Variable) were significant predictors of acuity change. As a group, studies using the pro re nata approach had the lowest number of injections and the worst acuity improvements as a treatment strategy. CONCLUSION There seems to be a predictable, mathematically defined relationship between dose frequency and visual acuity change at 1 year in neovascular age-related macular degeneration. The performance of current treatment efforts, as suggested by reported series and Medicare claims data, seems to be substandard.
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14
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Gao L, Liu J, Zhang P, Ma J, Wang H. Clinical outcomes of 1 + PRN and 3 + Q3M regimens of intravitreal conbercept injection for exudative age-related macular degeneration. Sci Rep 2020; 10:8010. [PMID: 32409739 PMCID: PMC7224199 DOI: 10.1038/s41598-020-65000-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 04/21/2020] [Indexed: 11/13/2022] Open
Abstract
This retrospective study aimed to analyze the clinical outcomes of two regimens of intravitreal injections of conbercept [1+pro re nata (PRN) and 3 + Q3M] for the therapy of exudative age-related macular degeneration (AMD). In total, 105 eyes diagnosed with exudative AMD were enrolled. The eyes in the 1+PRN group (n = 51) received intravitreal injection of conbercept one time, followed by PRN retreatment. The eyes in the 3 + Q3M group (n = 54) received intravitreal injection of conbercept on three consecutive monthly, subsequently, once every three months for three times. After treatment, patients were followed up for 12 months. The best-corrected visual acuity (BCVA), central retinal thickness (CRT), and choroidal neovascularization (CNV) leakage area were compared before and after treatment. Moreover, the number of injections and adverse reactions were recorded. Compared with the 1+PRN group, BCVA was significantly improved and CRT was remarkably decreased in the 3 + Q3M group at 3, 6 and 12 months after operation. The disappeared or reduced CNV leakage area (93%) of the 3 + Q3M group was higher than that of the 1 + PRN group at the last follow-up. Moreover, the mean numbers of conbercept injections of the 1 + PRN group were less than the 3 + Q3M group. During the follow-up, there were no serious adverse reactions or ocular complications. This study reveals that intravitreal injection of conbercept using 3 + Q3M regimen has certain advantages than 1 + PRN regimen in extending drug delivery interval, improving patient’s vision, and reducing CRT.
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Affiliation(s)
- Lei Gao
- Department of Ophthalmology, Jinan 2nd People's Hospital, Shandong Province, Jinan, 250001, China
| | - Jian Liu
- Department of Ophthalmology, Jinan 2nd People's Hospital, Shandong Province, Jinan, 250001, China
| | - Peng Zhang
- Department of Ophthalmology, Jinan 2nd People's Hospital, Shandong Province, Jinan, 250001, China
| | - Jianhua Ma
- Department of Ophthalmology, Shandong Invalids General Hospital, Shandong Province, Jinan, 250001, China
| | - Hong Wang
- Department of Ophthalmology, Qilu Hospital, Shandong University, Shandong Province, Jinan, 250001, China.
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15
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Kim J, Kim DW, Kim DH, Ryu SY, Chung EJ. Risk of stroke associated with intravitreal ranibizumab injections in age-related macular degeneration: a nationwide case-crossover study. Eye (Lond) 2020; 35:601-607. [PMID: 32367002 DOI: 10.1038/s41433-020-0911-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To evaluate the risk of stroke associated with intravitreal ranibizumab in age-related macular degeneration (AMD). METHODS A nationwide retrospective case-crossover study was performed using data from the Korean National Health Insurance Service (KNHIS) database, which included patients with exudative AMD in South Korea (n = 41,860). The index date was the date of hospitalization for stroke. We defined the case period as 60 days and four control periods before the index date. A pharmacy prescription database was searched for ranibizumab use during the case and control periods. We calculated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) with a conditional logistic regression model. RESULTS A total of 865 patients with AMD and incident stroke were included. Of all the patients, 12.02% had been treated during the preceding 60-day case period, compared with 9.25-10.29% during control periods. The adjusted OR of stroke associated with intravitreal ranibizumab during the case period was 1.285 (95% CI 0.979-1.686) (p = 0.07). In the subgroup analysis, the risk of hemorrhagic stroke had an OR of 2.252 (95% CI 1.068-4.749, p = 0.033). Further analyses based on patient gender, age, and different risk periods of 15 and 30 days yielded no increase in the risk of stroke associated with intravitreal ranibizumab. CONCLUSIONS This case-crossover analysis revealed no evidence of increased risk of hospitalization for stroke within 60 days of intravitreal ranibizumab injection in AMD patients. A secondary analysis indicated the possibility of an increased risk of hemorrhagic stroke, with borderline significance. Further research is needed regarding the underlying biological mechanisms and drug safety.
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Affiliation(s)
- 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
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sun Young Ryu
- Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Eun Jee Chung
- Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
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16
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Ang JL, Ah-Moye S, Kim LN, Nguyen V, Hunt A, Barthelmes D, Gillies MC, Mehta H. A systematic review of real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion. Eye (Lond) 2020; 34:1770-1796. [PMID: 32313172 PMCID: PMC7608462 DOI: 10.1038/s41433-020-0861-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 02/19/2020] [Accepted: 03/24/2020] [Indexed: 01/10/2023] Open
Abstract
This review assessed the real-world evidence of the management of macular oedema secondary to branch retinal vein occlusion (BRVO). A meta-analysis of 2530 eyes from 48 real-world studies of therapies for macular oedema secondary to BRVO was conducted. Baseline characteristics, visual, anatomical and safety outcomes were recorded. The weighted mean and weighted estimates from random-effects models were calculated for visual acuity (VA) and central subfield thickness (CST) changes at 6, 12 and 24 months. Primary outcome was change in VA (logMAR letters) at 12 months. Study quality was assessed using the quality appraisal checklist for case series developed by Institute of Health Economics. The mean baseline VA for the pooled data was 54.0 (51.5, 56.5) letters and the mean baseline CST was 501.3 (483.5, 519.1) µm. The random-effects estimate for mean (95% CI) change in VA was 14.6 (12.5, 16.7) letters at 12 months (n = 1727). The random-effects estimate for mean (95% CI) change in CST was -181.7 (-230.7, -132.7) µm at 12 months (n = 1325). The quality of studies varied considerably. Ocular and systemic adverse events were discussed in 79% and 42% of treatment arms respectively, with possible under-reporting. Visual and anatomical gains achieved in the real-world for anti-VEGF therapy were not as impressive as seminal RCTs, possibly due to reduced injection frequency in the real world and differences in baseline characteristics. There is an urgent need for consensus on the minimum efficacy, treatment burden and safety data to collect to strengthen the real-world evidence base.
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Affiliation(s)
- Juan Lyn Ang
- Ophthalmology Department, Royal Free London NHS Foundation Trust, London, UK
| | - Sarah Ah-Moye
- Ophthalmology Department, Royal Free London NHS Foundation Trust, London, UK
| | - Leah N Kim
- Macular Research Group, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Vuong Nguyen
- Macular Research Group, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Adrian Hunt
- Macular Research Group, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Daniel Barthelmes
- Macular Research Group, Save Sight Institute, University of Sydney, Sydney, NSW, Australia.,Department of Ophthalmology, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Mark C Gillies
- Macular Research Group, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Hemal Mehta
- Ophthalmology Department, Royal Free London NHS Foundation Trust, London, UK. .,Macular Research Group, Save Sight Institute, University of Sydney, Sydney, NSW, Australia.
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17
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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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18
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Sultana J, Scondotto G, Cutroneo PM, Morgante F, Trifirò G. Intravitreal Anti-VEGF Drugs and Signals of Dementia and Parkinson-Like Events: Analysis of the VigiBase Database of Spontaneous Reports. Front Pharmacol 2020; 11:315. [PMID: 32226387 PMCID: PMC7080978 DOI: 10.3389/fphar.2020.00315] [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: 12/03/2019] [Accepted: 03/03/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Since vascular endothelial growth factor (VEGF) regulates several aspects of the central nervous system, particularly in dopaminergic neurons, VEGF inhibitors may be linked to Parkinson-like events and dementia, or variants of these diseases. Two recent case reports have found a potential link between intravitreal anti-VEGF use and Parkinson's disease (PD) and dementia. Aim To evaluate disproportionality in a large spontaneous reporting database concerning intravitreal anti-VEGF drugs and PD or dementia, and related conditions. Methods Using VigiBase, individual case safety reports (ICSRs) attributed to intravitreal ranibizumab, aflibercept, pegaptanib, and bevacizumab were identified from 2010 to 2016. Within Standardised Narrow Medical Dictionary for Regulatory Activities (MedDRA®) Queries (SMQs) for "Parkinson-like events" and "Dementia," suspected events were identified using preferred terms (PTs). The Proportional Reporting Ratio (PRR) was estimated with the lower 95% confidence intervals (CIs) for all drug-event pairs with ≥3 suspected events. The vigiGrade completeness score was reported for the ICSRs. The analyses were repeated, including only persons aged 65 and over. Results Out of 18.9 million ICSRs, 7,945 (0.004%) concerned intravitreal anti-VEGF drugs. Of these, 27 (0.34%) were identified concerning the SMQs "Dementia" (N = 17, 62.96%) and "Parkinson-like events" (N = 10, 37.94%) in persons of all ages. Among persons age 65 and over, 4,758 (59.88% of relevant ICSRs) ICSRs were identified for anti-VEGF drugs. When restricting disproportionality analysis to persons aged 65 and over, no disproportionality was seen for any of the drug-event pairs at the level of SMQ. However, on analysing disproportionality by PT, a potential signal emerged for intravitreal ranibizumab and Parkinson's disease [N = 6 ICSRs; PRR: 3.05 (95% CI: 1.36-6.81)]. In general, the vigiGrade completeness score was low for all the ICSRs of interest, as no ICSR had a score >0.8. Conclusion Present findings suggest a potential signal for Parkinson's disease related to intravitreal ranibizumab. This is supported by several biologically plausible mechanisms but requires confirmation through pharmacoepidemiological studies, especially because of the low number of cases.
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Affiliation(s)
- Janet Sultana
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy
| | - Giulia Scondotto
- Unit of Clinical Pharmacology, A.O.U. "G. Martino", Messina, Italy
| | | | - Francesca Morgante
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.,Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Gianluca Trifirò
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy.,Unit of Clinical Pharmacology, A.O.U. "G. Martino", Messina, Italy.,Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, Netherlands
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19
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Porta M, Striglia E. Intravitreal anti-VEGF agents and cardiovascular risk. Intern Emerg Med 2020; 15:199-210. [PMID: 31848994 DOI: 10.1007/s11739-019-02253-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/03/2019] [Indexed: 12/20/2022]
Abstract
Antagonists of Vascular Endothelial Growth Factor (Anti-VEGF) are widely administered by intravitreal injection for the treatment of ocular pathologies such as Age-related Macular Degeneration, Diabetic Macular Edema, Proliferative Diabetic Retinopathy and occlusion of retinal vessels. Anti-VEGF agents, in particular bevacizumab, were introduced in oncology to inhibit tumor-induced angiogenesis feeding neoplastic tissues. Subsequently, other specific agents were developed for intraocular administration. Whereas systemic administration of anti-VEGF agents in oncology is burdened by increased risk of arterial hypertension and embolism, agents administered for ophthalmic indications are delivered locally into the eye globe in much smaller quantities. Nevertheless, clinical observations have raised the possibility that, even in these conditions, anti-VEGF agents may increase cardiovascular risk in patients who, being elderly and/or diabetic, are intrinsically prone to such events. This paper aims at reviewing the current knowledge on VEGF and its pharmacologic antagonists from mechanistic and side effect points of view, with specific reference to patients with sight-threatening conditions. Internists should be aware of the need to collaborate with ophthalmologists and pharmacovigilance operators to define as best as possible the risk/benefit balance of intravitreal agents in patients who might lose their sight if left untreated, or increase their risk of suffering a cardiovascular event if treated.
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Affiliation(s)
- Massimo Porta
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy.
| | - Elio Striglia
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy
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20
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Gao L, Tao Y, Liu M, Li L, Zhang P, Wang H, Zhang L. Different conbercept injection strategies for the treatment of exudative age-related macular degeneration: A retrospective cohort study. Medicine (Baltimore) 2020; 99:e19007. [PMID: 32049795 PMCID: PMC7035057 DOI: 10.1097/md.0000000000019007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Conbercept is a novel anti-vascular endothelial growth factor for the treatment of age-related macular degeneration (AMD). The most optimal injection strategy is unknown. To assess the effectiveness of intravitreal injection of conbercept using the 3 + pro re nata (PRN) and 3 + Q3 M strategies for the treatment of exudative AMD.From January 2015 to January 2018, patients confirmed with exudative AMD at Qilu Hospital of Shandong University were included in this retrospective study. Intravitreal injection of 0.5 mg of conbercept was conducted either with the 3 + PRN or 3 + Q3 M strategy. Best-corrected visual acuity (BCVA), intraocular pressure, and optical coherence tomography were conducted at 1 and 2 weeks, then every month. fundus fluorescein angiography examination was conducted every 3 months.There were 106 eyes from 106 patients. The number of follow-ups (3 + Q3 M: 12.4 ± 1.3 vs 3 + PRN: 12.9 ± 1.6, P = .079) and the follow-up time (3 + Q3 M: 12.7 ± 0.6 vs 3 + PRN: 12.5 ± 0.7 months, P = .121) were similar in the 2 groups. The number of injections was less in 3 + PRN than 3 + Q3 M (5.3 ± 1.0 vs 6.0 ± 0.0, P < .001) The BCVA at months 7 and 9 to 12 in the 3 + Q3 M (n = 51) group were lower than for 3 + PRN (n = 55) (all P < .05). The CRT at months 9 to 12 in the 3 + Q3 M group was lower than in the 3 + PRN group (all P < .05). There were no differences between the 2 groups regarding the exudation area during follow-up. No serious treatment-related ocular complications or serious systemic adverse events were found.The 3 + PRN and 3 + Q3 M strategies of intravitreal injection of conbercept are effective in treating exudative AMD. The 3 + Q3 M strategy needs more injection but is more effective in increasing visual acuity and reducing macular CRT than the 3 + PRN strategy.
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Affiliation(s)
- Lei Gao
- Department of Ophthalmology, Qilu Hospital, Shandong University
- Department of Ophthalmology, Jinan 2nd People′s Hospital
| | - Yuan Tao
- Department of Ophthalmology, Jinan 2nd People′s Hospital
| | - Min Liu
- Department of Ophthalmology, Jinan Lixia District People's Hospital
| | - Linlin Li
- Department of Ophthalmology, Jinan Shanghe County People's Hospital, Jinan, Shandong 251600, China
| | - Peng Zhang
- Department of Ophthalmology, Jinan 2nd People′s Hospital
| | - Hong Wang
- Department of Ophthalmology, Qilu Hospital, Shandong University
| | - Linna Zhang
- Department of Ophthalmology, Qilu Hospital, Shandong University
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21
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Tounakaki O, Tsakou Α, Malamas A, Chrisoula D, Ioannis S, Elias Z. Assessment of reporting quality of meta-analyses of randomized controlled trials in neovascular age-related macular degeneration published from April 2014 to May 2018 using prisma statement. Int Ophthalmol 2020; 40:1163-1180. [DOI: 10.1007/s10792-019-01282-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/31/2019] [Indexed: 01/10/2023]
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22
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Kida T, Osuka S, Fukumoto M, Sato T, Harino S, Oku H, Ikeda T. Long-Term Follow-Up Changes of Central Choroidal Thickness Thinning after Repeated Anti-VEGF Therapy Injections in Patients with Central Retinal Vein Occlusion-Related Macular Edema with Systemic Hypertension. Ophthalmologica 2019; 243:102-109. [PMID: 31851998 DOI: 10.1159/000504754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 11/13/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE We investigated the thinning of central choroidal thickness (CCT) following intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drugs to treat central retinal vein occlusion (CRVO)-related macular edema in patients with and without systemic hypertension (HT) to assess the influence of repeated anti-VEGF therapy and HT on the choroid in CRVO eyes. METHODS We conducted a retrospective study involving 27 patients with CRVO-related macular edema from January 2014 to July 2017, with follow-ups exceeding 18 months. Visual acuity (VA), central retinal thickness (CRT), and CCT were evaluated before and after initial anti-VEGF drug treatment during follow-up. RESULTS The mean follow-up period was 35.2 months. Seventeen (63.0%) patients had HT. At 1 month after treatment, VA had improved in 21 (77.8%) patients, and CRT had decreased in 25 (92.6%). At the final visit, 22 (81.5%) showed improved VA, 19 (70.4%) had resolved macular edema, and the CCT had gradually become thinner with additional drug injections in all the patients. Furthermore, the mean CCT in HT patients (209.0 µm) was significantly lower than in non-HT patients (256.1 µm), and the mean injections were 7.8 and 5.3, respectively (p = 0.2067). CONCLUSION The CCTs were thinner in eyes with HT than in eyes without HT both before and after the repeated anti-VEGF injections.
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Affiliation(s)
- Teruyo Kida
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan,
| | - Shou Osuka
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | - Masanori Fukumoto
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | - Takaki Sato
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | | | - Hidehiro Oku
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
| | - Tsunehiko Ikeda
- Department of Ophthalmology, Osaka Medical College, Takatsuki, Japan
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Berger V, Munk MR, Lersch F, Wolf S, Ebneter A, Zinkernagel MS. Association of Intravitreal Injections With Blood Pressure Increase: The Following Excitement and Anxiety Response Under Intravitreal Injection Study. JAMA Ophthalmol 2019; 137:87-90. [PMID: 30383158 DOI: 10.1001/jamaophthalmol.2018.4892] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Despite the unquestionable effectiveness of anti-vascular endothelial growth factor therapy (VEGF), there is ongoing controversy about potential systemic adverse effects. Besides the direct adverse effects of anti-VEGF agents, other factors associated with the injection itself, such as perioperative blood pressure fluctuations, may contribute to adverse events. Objective To determine blood pressure fluctuations during intravitreal injections. Design, Setting, and Participants Prospective observational study at a tertiary referral center (Department of Ophthalmology, University Hospital Bern, Bern, Switzerland). Consecutive patients scheduled for intravitreal injections were recruited. Data were analyzed between October 2017 and January 2018. Main Outcomes and Measures Systolic and diastolic blood pressure, pulse rate, and oxygen saturation were recorded before, during, and after the intravitreal injection. An anxiety questionnaire was completed by all participants. Multivariate regression analysis was used to investigate potential factors associated with blood pressure rise during injections. Results Two hundred one patients (92 women and 109 men) were included in this study, with a mean age of 68 years (range, 18-93 years). Mean (SD) systolic blood pressure increased from a baseline of 150 (20) mm Hg to 162 (24) mm Hg following the preparation procedure to 168 (24) mm Hg during the injection (P < .001). Mean (SD) diastolic blood pressure increased from 78 (14) mm Hg to 83 (37) mm Hg to 83 (16) mm Hg, respectively (P = .009). Mean (SD) pulse frequency increased from 76 (13) bpm to 80 (13) bpm (P = .005). In total, 23 patients (11%) had a systolic blood pressure greater than 200 mm Hg. This subgroup of patients had a mean (SD) perioperative systolic blood pressure increase from 182 (19) mm Hg to 214 (12) mm Hg, resulting in an increase of 32 (20) mm Hg (P < .001). Age and anxiety were to be next associated with systolic blood pressure rise. Conclusions and Relevance The intravitreal injection process is associated with a transient increase in blood pressure. Most of the increase occurs following the preparation before the injection itself. This may constitute a risk factor for cardiovascular or cerebrovascular complications during treatment and could be of particular relevance in patients at high risk for such events and those receiving frequent injections. Future work may be needed to determine whether, in patients at risk for cardiovascular or cerebrovascular events, perioperative blood pressure monitoring or antihypertensive therapy needs to be considered.
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Affiliation(s)
- Vanessa Berger
- Department of Ophthalmology, Inselspital, Bern University Hospital, Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Marion R Munk
- Department of Ophthalmology, Inselspital, Bern University Hospital, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Bern Photographic Reading Center, University of Bern, Bern, Switzerland
| | - Friedrich Lersch
- Department of Anesthesiology, Inselspital, University of Bern, Bern, Switzerland
| | - Sebastian Wolf
- Department of Ophthalmology, Inselspital, Bern University Hospital, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Bern Photographic Reading Center, University of Bern, Bern, Switzerland
| | - Andreas Ebneter
- Department of Ophthalmology, Inselspital, Bern University Hospital, Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Martin S Zinkernagel
- Department of Ophthalmology, Inselspital, Bern University Hospital, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Bern Photographic Reading Center, University of Bern, Bern, Switzerland
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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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Kodjikian L, Bellocq D, Bandello F, Loewenstein A, Chakravarthy U, Koh A, Augustin A, de Smet MD, Chhablani J, Tufail A, García-Layana A, Sudhalkar A, Mathis T. First-line treatment algorithm and guidelines in center-involving diabetic macular edema. Eur J Ophthalmol 2019; 29:573-584. [DOI: 10.1177/1120672119857511] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Management of center-involving diabetic macular edema represents a real therapeutic challenge. Diabetic macular edema is the leading cause of visual acuity impairment in diabetic patients. Since the advent of intravitreal drugs, management of diabetic macular edema has significantly evolved. The historical grid laser photocoagulation is no longer recommended as first-line treatment of diabetic macular edema owing to the findings of the pivotal randomized controlled trials, and anti-vascular endothelial growth factor therapy has emerged as first-line therapy. Steroids also represent a valid treatment option in the management of naïve diabetic macular edema and their efficacy has also been confirmed in several studies. The optimal treatment for diabetic macular edema should consider both general and ophthalmological comorbidities. Patient compliance and motivation should also be carefully evaluated as some treatments require monthly follow-up. Based on recent literature evidence, the present review provides clinicians with a first-line treatment algorithm for center-involving diabetic macular edema tailored to the patient’s individual characteristics.
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Affiliation(s)
- Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
- CNRS UMR Mateis, Villeurbanne, France
| | - David Bellocq
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Francesco Bandello
- Department of Ophthalmology, University Vita-Salute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Anat Loewenstein
- Division of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sydney A. Fox chair of ophthalmology, Tel Aviv University, Tel Aviv, Israel
| | - Usha Chakravarthy
- Department of Ophthalmology, Queen’s University Belfast, Belfast, Northern Ireland
| | - Adrian Koh
- Eye and Retina Surgeons, Singapore, Singapore
- Singapore National Eye Centre, Singapore, Singapore
| | | | | | - Jay Chhablani
- Smt Kanuri Santhamma Centre for Vitreoretinal Diseases, LV Prasad Eye Institute, Hyderabad, India
| | - Adnan Tufail
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | | | - Aditya Sudhalkar
- Raghudeep Eye Hospital, Iladevi Cataract Centre, Ahmedabad, India
| | - Thibaud Mathis
- Department of Ophthalmology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
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Urbančič M, Gardašević Topčić I. Dexamethasone implant in the management of diabetic macular edema from clinician's perspective. Clin Ophthalmol 2019; 13:829-840. [PMID: 31190726 PMCID: PMC6526171 DOI: 10.2147/opth.s206769] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/04/2019] [Indexed: 12/17/2022] Open
Abstract
The aim of this article is to provide an overview of characteristics and principles of use of dexamethasone implant in patients with diabetic macular edema (DME). The condensed information about patient selection, dosing, and postinjection management is provided to make the clinician’s decisions easier in real-life practice. DME is a common complication of diabetes and the leading cause of visual loss in the working-age population. Inflammation plays an important role in the pathogenesis of DME. The breakdown of the blood–retinal barrier involves the expression of inflammatory cytokines and growth factors, including vascular endothelial growth factor (VEGF). Steroids have proved to be effective in the treatment of DME by blocking the production of VEGF and other inflammatory cytokines, by inhibiting leukostasis, and by enhancing the barrier function of vascular endothelial cell tight junctions. Dexamethasone intravitreal implant has demonstrated efficacy in the treatment of DME resistant to anti-VEGF therapy and in vitrectomized eyes. Data from clinical trials suggest that dexamethasone implant can be considered as first-line treatment in pseudophakic eyes. Dexamethasone implant is also the first-line therapy in patients not suited for anti-VEGF therapy, pregnant women, and patients unable to return for frequent monitoring. It has been shown that the maximum effect of dexamethasone implant on visual gain and retinal thickness occurs approximately 2 months after injection. Various treatment regimens are used in real-life situations, and reported reinjection intervals were usually <6 months. The number of retreatments needed decreased over time. Treatment algorithms should be personalized. Postinjection management and follow-up should consider potential adverse events such as intraocular pressure elevation and cataract.
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Affiliation(s)
- Mojca Urbančič
- Eye Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
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27
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Rebeiz AG, Mahfoud Z, Abdul Fattah M, Saad A, Safar A, Bashshur ZF. Change in cardiac troponin T level after intravitreal anti-vascular endothelial growth factor treatment: Prospective pilot study. Eur J Ophthalmol 2019; 30:563-569. [DOI: 10.1177/1120672119832171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Evaluate subclinical myocardial injury associated with intravitreal anti-vascular endothelial growth factor therapy by measuring serum high-sensitivity cardiac troponin T. Methods: This is a prospective pilot comparative study conducted at American University of Beirut Medical Center, Beirut, Lebanon. In total, 40 consecutive patients were randomized to receive either intravitreal bevacizumab or ranibizumab. Patients received three consecutive monthly injections of the assigned drug, then continued treatment as needed. Systemic concentrations of high-sensitivity cardiac troponin T and vascular endothelial growth factor were obtained at baseline, week 9, and week 24. Primary endpoint measure was change in high-sensitivity cardiac troponin T levels compared to baseline. Secondary endpoint measure was change in systemic vascular endothelial growth factor levels. Results: There was no significant difference in high-sensitivity cardiac troponin T levels over time ( p = 0.227) within each treatment group and no significant difference between treatments at any time point ( p = 0.276). There was a significant decrease in plasma vascular endothelial growth factor levels at week 9 ( p = 0.001) and week 24 ( p < 0.001) compared to baseline. In the ranibizumab group, vascular endothelial growth factor levels were not significantly different at weeks 9 and 24 compared to baseline ( p = 0.708 and p = 0.117, respectively). There was a significant association between the number of bevacizumab injections from weeks 8 to 24 and the decrease in vascular endothelial growth factor levels at week 24 ( R = −0.67, p = 0.032). This correlation was not observed in the ranibizumab group ( R = −0.341, p = 0.141). Conclusion: Repeated intravitreal bevacizumab or ranibizumab did not influence serum high-sensitivity cardiac troponin levels. Intravitreal bevacizumab but not ranibizumab lowered free-systemic vascular endothelial growth factor levels, which was observed in this study to be inversely related to the number of bevacizumab injections.
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Affiliation(s)
- Abdallah G Rebeiz
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Ziyad Mahfoud
- Department of Global and Public Health, Weill Cornell Medical College, Doha, Qatar
| | | | - Alain Saad
- Damien Gatinel’s Department of Ophthalmology, Rothschild Foundation, Paris, France
| | - Ammar Safar
- Department of Ophthalmology, American Hospital Dubai, Dubai, UAE
| | - Ziad F Bashshur
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon
- Vitreoretinal Service, Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
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Sun MM, Chan AM, Law SM, Duarte S, Diaz-Aguilar D, Wadehra M, Gordon LK. Epithelial Membrane Protein-2 (EMP2) Antibody Blockade Reduces Corneal Neovascularization in an In Vivo Model. Invest Ophthalmol Vis Sci 2019; 60:245-254. [PMID: 30646013 PMCID: PMC6336205 DOI: 10.1167/iovs.18-24345] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022] Open
Abstract
Purpose Pathologic corneal neovascularization is a major cause of blindness worldwide, and treatment options are currently limited. VEGF is one of the critical mediators of corneal neovascularization but current anti-VEGF therapies have produced limited results in the cornea. Thus, additional therapeutic agents are needed to enhance the antiangiogenic arsenal. Our group previously demonstrated epithelial membrane protein-2 (EMP2) involvement in pathologic angiogenesis in multiple cancer models including breast cancer and glioblastoma. In this paper, we investigate the efficacy of anti-EMP2 immunotherapy in the prevention of corneal neovascularization. Methods An in vivo murine cornea alkali burn model was used to study pathologic neovascularization. A unilateral corneal burn was induced using NaOH, and subconjunctival injection of either anti-EMP2 antibody, control antibody, or sterile saline was performed after corneal burn. Neovascularization was clinically scored at 7 days postalkali burn, and eyes were enucleated for histologic analysis and immunostaining including VEGF, CD31, and CD34 expression. Results Anti-EMP2 antibody, compared to control antibody or vehicle, significantly reduced neovascularization as measured by clinical score and central cornea thickness, as well as by histologic reduction of neovascularization, decreased CD34 staining, and decreased CD31 staining. Incubation of corneal limbal cells in vitro with anti-EMP2 blocking antibody significantly decreased EMP2 expression, VEGF expression and secretion, and cell migration. Conclusions This work demonstrates the effectiveness of EMP2 as a novel target in pathologic corneal neovascularization in an animal model and supports additional investigation into EMP2 antibody blockade as a potential new therapeutic option.
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Affiliation(s)
- Michel M. Sun
- Department of Ophthalmology, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California, United States
| | - Ann M. Chan
- Department of Ophthalmology, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California, United States
| | - Samuel M. Law
- Department of Ophthalmology, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California, United States
| | - Sergio Duarte
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States
| | - Daniel Diaz-Aguilar
- Department of Ophthalmology, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California, United States
| | - Madhuri Wadehra
- Departments of Pathology and Laboratory Medicine, and Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States
| | - Lynn K. Gordon
- Department of Ophthalmology, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California, United States
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Mitchell P, Liew G, Gopinath B, Wong TY. Age-related macular degeneration. Lancet 2018; 392:1147-1159. [PMID: 30303083 DOI: 10.1016/s0140-6736(18)31550-2] [Citation(s) in RCA: 829] [Impact Index Per Article: 138.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 06/12/2018] [Accepted: 06/29/2018] [Indexed: 12/13/2022]
Abstract
Age-related macular degeneration is a leading cause of visual impairment and severe vision loss. Clinically, it is classified as early-stage (medium-sized drusen and retinal pigmentary changes) to late-stage (neovascular and atrophic). Age-related macular degeneration is a multifactorial disorder, with dysregulation in the complement, lipid, angiogenic, inflammatory, and extracellular matrix pathways implicated in its pathogenesis. More than 50 genetic susceptibility loci have been identified, of which the most important are in the CFH and ARMS2 genes. The major non-genetic risk factors are smoking and low dietary intake of antioxidants (zinc and carotenoids). Progression from early-stage to late-stage disease can be slowed with high-dose zinc and antioxidant vitamin supplements. Intravitreal anti-vascular endothelial growth factor therapy (eg, ranibizumab, aflibercept, or bevacizumab) is highly effective at treating neovascular age-related macular degeneration, and has markedly decreased the prevalence of visual impairment in populations worldwide. Currently, no proven therapies for atrophic disease are available, but several agents are being investigated in clinical trials. Future progress is likely to be from improved efforts in prevention and risk-factor modification, personalised medicine targeting specific pathways, newer anti-vascular endothelial growth factor agents or other agents, and regenerative therapies.
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Affiliation(s)
- Paul Mitchell
- Centre for Vision Research, Department of Ophthalmology, Westmead Institute for Medical Research, University of Sydney, Australia.
| | - Gerald Liew
- Centre for Vision Research, Department of Ophthalmology, Westmead Institute for Medical Research, University of Sydney, Australia
| | - Bamini Gopinath
- Centre for Vision Research, Department of Ophthalmology, Westmead Institute for Medical Research, University of Sydney, Australia
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-National University of Singapore, Singapore
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Downie LE, Makrai E, Bonggotgetsakul Y, Dirito LJ, Kristo K, Pham MAN, You M, Verspoor K, Pianta MJ. Appraising the Quality of Systematic Reviews for Age-Related Macular Degeneration Interventions: A Systematic Review. JAMA Ophthalmol 2018; 136:1051-1061. [PMID: 29978192 DOI: 10.1001/jamaophthalmol.2018.2620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Importance Age-related macular degeneration (AMD) is a leading cause of vision impairment. It is imperative that AMD care is timely, appropriate, and evidence-based. It is thus essential that AMD systematic reviews are robust; however, little is known about the quality of this literature. Objectives To investigate the methodological quality of systematic reviews of AMD intervention studies, and to evaluate their use for guiding evidence-based care. Evidence Review This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All studies that self-identified as a systematic review in their title or abstract or were categorized as a systematic review from a medical subject heading and investigated the safety, efficacy and/or effectiveness of an AMD intervention were included. Comprehensive electronic searches were performed in Ovid MEDLINE, Embase, and the Cochrane Library from inception to March 2017. Two reviewers independently assessed titles and abstracts, then full-texts for eligibility. Quality was assessed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool. Study characteristics (publication year, type of intervention, journal, citation rate, and funding source) were extracted. Findings Of 983 citations retrieved, 71 studies (7.6%) were deemed eligible. The first systematic review relating to an AMD intervention was published in 2003. More than half were published since 2014. Methodological quality was highly variable. The mean (SD) AMSTAR score was 5.8 (3.2) of 11.0, with no significant improvement over time (r = -0.03; 95% CI, -0.26 to 0.21; P = .83). Cochrane systematic reviews were overall of higher quality than reviews in other journals (mean [SD] AMSTAR score, 9.9 [1.2], n = 15 vs 4.7 [2.2], n = 56; P < .001). Overall, there was poor adherence to referring to an a priori design (22 articles [31%]) and reporting conflicts of interest in both the review and included studies (16 articles [23%]). Reviews funded by government grants and/or institutions were generally of higher quality than industry-sponsored reviews or where the funding source was not reported. Conclusions and Relevance There are gaps in the conduct of systematic reviews in the field of AMD. Enhanced endorsement of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement by refereed journals may improve review quality and improve the dissemination of reliable evidence relating to AMD interventions to clinicians.
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Affiliation(s)
- Laura E Downie
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Eve Makrai
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Yokim Bonggotgetsakul
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Lucy J Dirito
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Kresimir Kristo
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Minh-An N Pham
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Mina You
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Karin Verspoor
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - Michael J Pianta
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
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Zarbin MA, Francom S, Grzeschik S, Tuomi L, Haskova Z, Macfadden W, Margaron P, Snow H, Cruess A, Staurenghi G, Dunger-Baldauf C. Systemic Safety in Ranibizumab-Treated Patients with Neovascular Age-Related Macular Degeneration: A Patient-Level Pooled Analysis. Ophthalmol Retina 2018; 2:1087-1096. [PMID: 31047547 DOI: 10.1016/j.oret.2018.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 04/15/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022]
Abstract
TOPIC This study evaluated the cardiovascular/cerebrovascular safety profile of ranibizumab 0.5 mg versus sham ± verteporfin in patients with neovascular age-related macular degeneration (nAMD). In addition, comparisons of ranibizumab 0.3 mg with sham and ranibizumab 0.5 mg to 0.3 mg were performed. CLINICAL RELEVANCE Intravitreal anti-vascular endothelial growth factor (VEGF) agents carry potential increased systemic risks, including cardiovascular or cerebrovascular events. Pooled safety analyses allow better interpretation of safety outcomes seen in individual clinical trials, especially for less common events. To our knowledge, this is the largest patient-level pooled analysis of patients with nAMD treated with ranibizumab. METHODS Patient-level pooled analysis of data from 7 Genentech- and Novartis-sponsored phase II, III, and IV studies in nAMD that were completed by December 31, 2013. Pairwise comparisons (primary comparison: ranibizumab 0.5 mg [globally approved dose for nAMD] vs. sham or verteporfin) were performed using Cox proportional hazard regression (hazard ratios [HRs], 95% confidence intervals [CIs]) and rates per 100 patient-years. Standardized Medical Dictionary for Regulatory Activities queries (SMQs) and extended searches were used to identify relevant safety endpoints, including arterial thromboembolic events (ATEs), myocardial infarction (MI), stroke or transient ischemic attack (TIA), stroke (excluding TIA), vascular deaths, and major vascular events as defined by the Antiplatelet Trialists' Collaboration (APTC). RESULTS The HRs (95% CIs) for the primary comparison of ranibizumab 0.5 mg (n=480) versus sham or verteporfin (n=462) were 1.16 (0.72-1.88) for ATE, 1.33 (0.59-2.97) for MI, 1.43 (0.54-3.77) for stroke excluding TIA, 1.25 (0.61-2.55) for stroke or TIA, 0.57 (0.18-1.78) for vascular death, and 1.12 (0.64-1.98) for APTC events. Hazard ratio 95% CIs included 1, indicating no significant treatment differences, for all endpoints for comparison of ranibizumab 0.5 mg versus sham or verteporfin. CONCLUSIONS The rates of cardiovascular and cerebrovascular events were low in these patients with nAMD and not clinically meaningfully different for patients treated with ranibizumab 0.5 mg versus sham or verteporfin, which supports the favorable benefit-risk profile of ranibizumab in the patient population with nAMD. Pooling these studies allows an analysis with higher power and precision compared with individual study analyses.
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Affiliation(s)
- Marco A Zarbin
- Institute of Ophthalmology and Visual Science, Rutgers-New Jersey Medical School, Rutgers University, Newark, New Jersey.
| | | | | | - Lisa Tuomi
- Genentech, Inc, South San Francisco, California
| | | | | | | | | | - Alan Cruess
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Giovanni Staurenghi
- Department of Biomedical and Clinical Science "Luigi Sacco," Sacco Hospital, University of Milan, Milan, Italy
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Trifirò G, Marcianò I, Cutroneo PM, Spina E, Mirabelli E, Trombetta CJ, Morgante F. Long-Term Intravitreal Ranibizumab as a Potential Additional Risk Factor for Neurodegeneration in Parkinson's Disease: A Case Report. Front Pharmacol 2018; 9:608. [PMID: 29937731 PMCID: PMC6003275 DOI: 10.3389/fphar.2018.00608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/21/2018] [Indexed: 12/17/2022] Open
Abstract
In November 2012, a 72-year old patient was diagnosed with left eye wet age-related macular degeneration. The patient received three monthly intravitreal injections of ranibizumab, with complete resolution of retinal hemorrhage and edema and reinstatement of visual acuity. In May 2015, symptomatic relapse was detected. The patient was again treated with intravitreal ranibizumab, with overall six injections till the end of February 2016. In May 2016, the patient complained of left hand resting tremor, bradykinesia, and postural rigidity of head and trunk. A diagnosis of clinically established PD was made based on new criteria of the Movement Disorders Society. Single Photon Emission Computerized Tomography of the Dopamine Transporter with (123I) ioflupane documented a low Dopamine Transporter (DAT) uptake mostly in the right striatum. Due to the documented protective role of vascular endothelial growth factor (VEGF) on the dopaminergic neurons, intensive intravitreal injections of the anti-VEGF agent ranibizumab may have played as an additional risk factor accelerating the neurodegeneration process related to PD and the onset of the related clinical signs and symptoms.
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Affiliation(s)
- Gianluca Trifirò
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy
| | - Ilaria Marcianò
- Unit of Clinical Pharmacology, Azienda Ospedaliera Universitaria Policlinico "G. Martino" - Messina, Italy
| | - Paola M Cutroneo
- Unit of Clinical Pharmacology, Azienda Ospedaliera Universitaria Policlinico "G. Martino" - Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Eliana Mirabelli
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy
| | - Costantino J Trombetta
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy
| | - Francesca Morgante
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.,Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
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EFFECTS OF INTERNAL LIMITING MEMBRANE PEELING COMBINED WITH REMOVAL OF IDIOPATHIC EPIRETINAL MEMBRANE: A Systematic Review of Literature and Meta-Analysis. Retina 2018; 37:1813-1819. [PMID: 28207608 DOI: 10.1097/iae.0000000000001537] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the effects on postoperative prognosis of internal limiting membrane (ILM) peeling in conjunction with removal of idiopathic epiretinal membranes (ERMs). METHODS MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE were systematically searched for studies that compared ILM peeling with no ILM peeling in surgery to remove idiopathic ERM. Outcome measures were best-corrected visual acuity, central macular thickness, and ERM recurrence. Studies that compared ILM peeling with no ILM peeling for the treatment of idiopathic ERM were selected. RESULTS Sixteen studies that included 1,286 eyes were selected. All the included studies were retrospective or prospective comparative studies; no randomized controlled study was identified. Baseline preoperative best-corrected visual acuity and central macular thickness were equal between ILM peeling and no ILM peeling groups. Postoperatively, there was no statistically significant difference in best-corrected visual acuity (mean difference 0.01 logarithm of the minimum angle of resolution [equivalent to 0.5 Early Treatment Diabetic Retinopathy Study letter]; 95% CI -0.05 to 0.07 [-3.5 to 2.5 Early Treatment Diabetic Retinopathy Study letters]; P = 0.83) or central macular thickness (mean difference 13.13 μm; 95% CI -10.66 to 36.93; P = 0.28). However, the recurrence rate of ERM was significantly lower with ILM peeling than with no ILM peeling (odds ratio 0.25; 95% CI 0.12-0.49; P < 0.0001). CONCLUSION Currently available evidence in the literature indicates that additional ILM peeling in vitrectomy for idiopathic ERM could result in a significantly lower ERM recurrence rate, but it does not significantly influence postoperative best-corrected visual acuity and central macular thickness.
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Attal R, Lazareth I, Angelopoulos G, Priollet P. Ranibizumab and digital ischemia. JOURNAL DE MÉDECINE VASCULAIRE 2018; 43:65-69. [PMID: 29425544 DOI: 10.1016/j.jdmv.2017.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 11/23/2017] [Indexed: 11/18/2022]
Abstract
Case report of a patient with age-related macular degeneration whose digital ischemia can most plausibly be attributed to ranibizumab. PURPOSE To report ranibizumab as the probable cause of digital ischemia in a patient treated for age-related macular degeneration. METHODS Single-patient case report. RESULTS An 83-year-old woman with an unremarkable medical history suffered acute ischemia in her left hand with necrosis of the distal phalange of the fifth finger after six intravitreal injections of ranibizumab. Her etiological work-up was negative. Her condition improved after endovascular revascularization and remained good at six months' follow-up after three months of dual antithrombotic therapy (low molecular weight heparin then rivaroxaban, both with aspirin) followed by rivaroxaban alone and four courses of intravenous iloprost. CONCLUSION The increased incidence of peripheral arterial thromboembolic events in patients under ranibizumab treatment is slight but significant, with 0.8-5% of patients affected, most of which suffer strokes. These events seem to occur at a random time after ranibizumab treatment is initiated and no reliable marker has yet been identified. The most probable cause of digital ischemia in our patient was ranibizumab.
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Affiliation(s)
- R Attal
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 75014 Paris, France.
| | - I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 75014 Paris, France
| | - G Angelopoulos
- Service de radiologie interventionnelle, hôpital privé de Parly-II, 78150 Le-Chesnay, France
| | - P Priollet
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 75014 Paris, France
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Abstract
Blockade of vascular endothelial growth factor (VEGF) signaling, whether via sequestration of free VEGF or via inhibition of the tyrosine kinases activated by VEGF, is associated with decreased nitric oxide (NO) and prostaglandin-I 2 (PG-I 2) production along with vascular endothelial cell death. Systemic administration of drugs that block VEGF signaling (eg, for cancer treatment) is associated with systemic complications such as hypertension and thrombosis. Evidence regarding the risk of systemic serious adverse events after intravitreal injection of anti-VEGF agents in patients with diabetic macular edema or neovascular age-related macular degeneration is inconsistent, in part because of study design limitations (eg, bias of ascertainment through strict enrollment criteria and/or inadequate power to identify the risk of low frequency events). Studies involving patients at high risk of arteriothrombotic events (eg, patients with diabetic macular edema) who have high exposure to intravitreal anti-VEGF therapy (eg, monthly aflibercept or ranibizumab injection) demonstrate an increased risk of all-cause mortality compared with randomized controls. The pharmacokinetics of anti-VEGF drug clearance from the systemic circulation and the documented sustained reduction in free plasma VEGF levels after intravitreal aflibercept and bevacizumab injection are consistent with these findings. Although the frequency of systemic serious adverse events after intravitreal anti-VEGF therapy is low, some patients may be at higher risk (eg, those with recent stroke or multiple strokes), and physicians may wish to take special measures with these patients to minimize the risk of systemic complications.
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Affiliation(s)
- Marco A Zarbin
- Institute of Ophthalmology and Visual Science, Rutgers-New Jersey Medical School, Newark, New Jersey
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Altinkaynak H, Kars ME, Kurkcuoglu PZ, Ugurlu N. Blood coagulation parameters after intravitreal injection of aflibercept in patients with neovascular age-related macular degeneration. Int Ophthalmol 2017; 38:2397-2402. [PMID: 29027065 DOI: 10.1007/s10792-017-0741-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 10/05/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this study was to evaluate the effect of intravitreal injection of aflibercept (IVA) on blood coagulation tests in neovascular age-related macular degeneration (AMD) patients. METHODS Thirty-four patients with neovascular AMD (study group) and 32 healthy individuals (control group) were enrolled. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were measured at different times in patients with neovascular AMD. RESULTS The levels of PT and aPTT after IVA were decreased at 1 month after the first injection and 1 month after the second injection compared to the baseline measurement in the study group. CONCLUSIONS IVA may cause a decrease in the levels of PT and aPTT at 1 month after the first injection and 1 month after the second injection although these results are not statistically significant in our study.
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Affiliation(s)
- Hasan Altinkaynak
- Department of Ophthalmology, Ankara Atatürk Education and Research Hospital, Ankara, Turkey.
| | - Meltem Ece Kars
- Department of Ophthalmology, Yıldırım Beyazıt University, Ankara Atatürk Education and Research Hospital, Ankara, Turkey
| | | | - Nagihan Ugurlu
- Department of Ophthalmology, Yıldırım Beyazıt University, Ankara Atatürk Education and Research Hospital, Ankara, Turkey
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Bucher F, Zhang D, Aguilar E, Sakimoto S, Diaz-Aguilar S, Rosenfeld M, Zha Z, Zhang H, Friedlander M, Yea K. Antibody-Mediated Inhibition of Tspan12 Ameliorates Vasoproliferative Retinopathy Through Suppression of β-Catenin Signaling. Circulation 2017; 136:180-195. [DOI: 10.1161/circulationaha.116.025604] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/22/2017] [Indexed: 12/31/2022]
Abstract
Background:
Anti-angiogenic biologicals represent an important concept for the treatment of vasoproliferative diseases. However, the need for continued treatment, the presence of nonresponders, and the risk of long-term side effects limit the success of existing therapeutic agents. Although Tspan12 has been shown to regulate retinal vascular development, nothing is known about its involvement in neovascular disease and its potential as a novel therapeutic target for the treatment of vasoproliferative diseases.
Methods:
Rodent models of retinal neovascular disease, including the mouse model of oxygen-induced retinopathy and the very low density lipoprotein receptor knockout mouse model were analyzed for Tspan/β-catenin regulation. Screening of a phage display of a human combinatorial antibody (Ab) library was used for the development of a high-affinity Ab against Tspan12. Therapeutic effects of the newly developed Ab on vascular endothelial cells were tested in vitro and in vivo in the oxygen-induced retinopathy and very low density lipoprotein receptor knockout mouse model.
Results:
The newly developed anti-Tspan12 Ab exhibited potent inhibitory effects on endothelial cell migration and tube formation. Mechanistic studies confirmed that the Ab inhibited the interaction between Tspan12 and Frizzled-4 and effectively modulates β-catenin levels and target genes in vascular endothelial cells. Tspan12/β-catenin signaling was activated in response to acute and chronic stress in the oxygen-induced retinopathy and very low density lipoprotein receptor mouse model of proliferative retinopathy. Intravitreal application of the Ab showed significant therapeutic effects in both models without inducing negative side effects on retina function. Moreover, combined intravitreal injection of the Ab with a known vascular endothelial growth factor inhibitor, Aflibercept, resulted in significant enhancement of the therapeutic efficacy of each monotherapy. Combination therapy with the Tspan12 blocking antibody can be used to reduce anti-vascular endothelial growth factor doses, thus decreasing the risk of long-term off-target effects.
Conclusions:
Tspan12/β-catenin signaling is critical for the progression of vasoproliferative disease. The newly developed anti-Tspan12 antibody has therapeutic effects in vasoproliferative retinopathy and can enhance the potency of existing anti- vascular endothelial growth factor agents.
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Affiliation(s)
- Felicitas Bucher
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Ding Zhang
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Edith Aguilar
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Susumu Sakimoto
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Sophia Diaz-Aguilar
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Mauricio Rosenfeld
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Zhao Zha
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Hongkai Zhang
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Martin Friedlander
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
| | - Kyungmoo Yea
- From Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, CA (F.B., E.A., S.S., S.D.-A., M.R., Z.Z., H.Z., M.F., K.Y.); and Shanghai Institute for Advanced Immunological Studies, ShanghaiTech University, China (D.Z., K.Y.)
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Tuuminen R, Uusitalo-Järvinen H, Aaltonen V, Hautala N, Kaipiainen S, Laitamäki N, Ollila M, Rantanen J, Välimäki S, Sipilä R, Laukkala T, Komulainen J, Tommila P, Immonen I, Tuulonen A, Kaarniranta K. The Finnish national guideline for diagnosis, treatment and follow-up of patients with wet age-related macular degeneration. Acta Ophthalmol 2017; 95:1-9. [PMID: 28686003 DOI: 10.1111/aos.13501] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Age-related macular degeneration (AMD) is the main cause of visual impairment in developed countries. Several improvements in the visualization of posterior segment of the eye together with the introduction of intravitreal anti-VEGF treatment have revolutionized the prognosis of the wet form of AMD (wAMD). Increasing incidence of wAMD together with the limited resources of society and of the healthcare system poses challenges for the provision and development of care. In context of these current aspects, we aimed to set evidence-based medical guidelines for diagnosis, treatment and follow-up of patients with wAMD.
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Affiliation(s)
- Raimo Tuuminen
- Department of Ophthalmology; Kymenlaakso Central Hospital; Kotka Finland
- Helsinki Retina Research Group; University of Helsinki; Helsinki Finland
- Patient Insurance Centre; Helsinki Finland
| | | | - Vesa Aaltonen
- Department of Ophthalmology; Turku University Hospital; Turku Finland
| | - Nina Hautala
- Department of Ophthalmology; Oulu University Hospital; Oulu Finland
- Medical Research Center; University of Oulu; Oulu Finland
| | - Sulevi Kaipiainen
- Department of Ophthalmology; North Karelian Central Hospital; Joensuu Finland
| | - Nina Laitamäki
- Department of Ophthalmology; Kanta-Häme Central Hospital; Hämeenlinna Finland
| | - Marko Ollila
- Department of Ophthalmology; Lapland Central Hospital; Rovaniemi Finland
| | - Jari Rantanen
- Department of Ophthalmology; Satakunta Central Hospital; Pori Finland
| | - Satu Välimäki
- Department of Ophthalmology; Päijät-Häme Central Hospital; Lahti Finland
| | - Raija Sipilä
- The Finnish Medical Society Duodecim; Helsinki Finland
| | | | | | - Petri Tommila
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Ilkka Immonen
- Department of Ophthalmology; Helsinki University Hospital; Helsinki Finland
| | - Anja Tuulonen
- Tays Eye Centre; Tampere University Hospital; Tampere Finland
| | - Kai Kaarniranta
- Department of Ophthalmology; Kuopio University Hospital; Kuopio Finland
- Department of Ophthalmology; Institute of Clinical Medicine; University of Eastern Finland; Kuopio Finland
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Constable IJ, Lai CM, Magno AL, French MA, Barone SB, Schwartz SD, Blumenkranz MS, Degli-Esposti MA, Rakoczy EP. Gene Therapy in Neovascular Age-related Macular Degeneration: Three-Year Follow-up of a Phase 1 Randomized Dose Escalation Trial. Am J Ophthalmol 2017; 177:150-158. [PMID: 28245970 DOI: 10.1016/j.ajo.2017.02.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 01/23/2023]
Abstract
PURPOSE To assess the safety of rAAV.sFlt-1 subretinal injection in neovascular age-related macular degeneration (wet AMD) over 36 months. DESIGN Phase 1 dose escalation trial. METHODS Eight subjects with advanced, treatment-experienced wet AMD were randomly assigned (3:1) to treatment and non-gene therapy control groups. Eligible subjects were ≥65 years, had wet AMD, and had best-corrected visual acuity (BCVA) 10/200 to 20/80 in the study eye and 20/200 or better in the other eye. Three of the treatment group subjects received low-dose (1 × 1010 vector genomes) and 3 high-dose (1 × 1011 vector genomes) rAAV.sFLT-1 via subretinal injection. Study monitoring was monthly to the primary endpoint at month 12 and then protocol-driven follow-up study visits were conducted at months 18 and 36. All subjects received intravitreal ranibizumab at baseline and at week 4, and retreatment injections at subsequent visits based on prespecified criteria for active wet AMD. The primary endpoint was ocular and systemic safety, but exploratory data including BCVA, retinal center point thickness, and the number of ranibizumab retreatments at and between study visits were also analyzed. RESULTS Six of the 8 subjects completed the 36-month study. Subretinal injection with pars plana vitrectomy was well tolerated in this cohort. No ocular or systemic safety signals were observed during the long-term follow-up period. Exploratory data analysis suggests stability of wet AMD over the 36-month period. CONCLUSIONS Subretinal delivery of rAAV.sFLT-1 was well tolerated and demonstrated a favourable safety profile through month 36. Thus, rAAV.sFLT-1 could be safely considered for future evaluation in the treatment of wet AMD.
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Affiliation(s)
- Ian J Constable
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, The University of Western Australia, Crawley, Western Australia, Australia; Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Chooi-May Lai
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, The University of Western Australia, Crawley, Western Australia, Australia
| | - Aaron L Magno
- Lions Eye Institute, Nedlands, Western Australia, Australia
| | - Martyn A French
- School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Western Australia, Australia; Department of Clinical Immunology, Royal Perth Hospital and PathWest Laboratory Medicine, Perth, Australia
| | | | | | - Mark S Blumenkranz
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Mariapia A Degli-Esposti
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, The University of Western Australia, Crawley, Western Australia, Australia
| | - Elizabeth P Rakoczy
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, The University of Western Australia, Crawley, Western Australia, Australia.
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Espino Barros A, Amram AL, Derham AM, Smith SV, Lee AG. Management of ischemic optic neuropathies. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1291341] [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: 10/20/2022]
Affiliation(s)
- Angelina Espino Barros
- Department of Ophthalmology, Centro Médico Zambrano Hellion, San Pedro Garza García, México
| | - Alec L. Amram
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
| | - Angeline Mariani Derham
- Department of Ophthalmology, University of Texas Health Science Center San Antonio School of Medicine, San Antonio, TX, USA
| | - Stacy V. Smith
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Andrew G. Lee
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York City, NY, USA
- Section of Ophthalmology, UT MD Anderson Cancer Center, Houston, TX, USA
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
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McGuinness MB, Karahalios A, Finger RP, Guymer RH, Simpson JA. Age-Related Macular Degeneration and Mortality: A Systematic Review and Meta-Analysis. Ophthalmic Epidemiol 2017; 24:141-152. [DOI: 10.1080/09286586.2016.1259422] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Myra B. McGuinness
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
- Department of Ophthalmology, University of Melbourne, East Melbourne, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Robert P. Finger
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
- Department of Ophthalmology, University of Melbourne, East Melbourne, Australia
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Robyn H. Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
- Department of Ophthalmology, University of Melbourne, East Melbourne, Australia
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Yashkin AP, Hahn P, Sloan FA. Introducing Anti-Vascular Endothelial Growth Factor Therapies for AMD Did Not Raise Risk of Myocardial Infarction, Stroke, and Death. Ophthalmology 2016; 123:2225-31. [PMID: 27523614 DOI: 10.1016/j.ophtha.2016.06.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To assess the effect of availability of anti-vascular endothelial growth factor (VEGF) therapy on mortality and hospitalizations for acute myocardial infarction (AMI) and stroke over a 5-year follow-up period in United States Medicare beneficiaries newly diagnosed with exudative age-related macular degeneration (AMD) in 2006 compared with control groups consisting of beneficiaries (1) newly diagnosed with exudative AMD at a time when anti-VEGF therapy was not possible and (2) newly diagnosed with nonexudative AMD. DESIGN Retrospective cohort study. PARTICIPANTS Beneficiaries newly diagnosed with exudative and nonexudative AMD in 2000 and 2006 selected from a random longitudinal sample of Medicare 5% claims and enrollment files. METHODS Beneficiaries with a first diagnosis of exudative AMD in 2006 were the treatment group; beneficiaries newly diagnosed with exudative AMD in 2000 or nonexudative AMD in 2000 or 2006 were control groups. To deal with potential selection bias, we designed an intent-to-treat study, which controlled for nonadherence to prescribed regimens. The treatment group consisted of patients with clinically appropriate characteristics to receive anti-VEGF injections given that the therapy is available, bypassing the need to monitor whether treatment was actually received. Control groups consisted of patients with clinically appropriate characteristics but first diagnosed at a time when the therapy was unavailable (2000) and similar patients but for whom the therapy was not clinically indicated (2000, 2006). We used a Cox proportional hazard model. MAIN OUTCOME MEASURES All-cause mortality and hospitalization for AMI and stroke during follow-up. RESULTS No statistically significant changes in probabilities of death and hospitalizations for AMI and stroke within a 5-year follow-up period were identified in exudative AMD beneficiaries newly diagnosed in 2006, the beginning of widespread anti-VEGF use, compared with 2000. As an alternative to our main analysis, which excluded beneficiaries from nonexudative AMD group who received anti-VEGF therapies during follow-up, we performed a sensitivity analysis with this group of individuals reincluded (11% of beneficiaries newly diagnosed with nonexudative AMD in 2006). Results were similar. CONCLUSIONS Introduction of anti-VEGF agents in 2006 for treating exudative AMD has not posed a threat of increased risk of AMI, stroke, or all-cause mortality.
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Affiliation(s)
| | | | - Frank A Sloan
- Department of Economics, Duke University, Durham, North Carolina.
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Shiba T, Takahashi M, Yoshida I, Taniguchi H, Matsumoto T, Hori Y. Arteriosclerotic Changes after Intravitreal Injections of Anti-Vascular Endothelial Growth Factor Drugs in Patients with Exudative Age-Related Macular Degeneration. Ophthalmologica 2016; 235:225-32. [PMID: 27082736 DOI: 10.1159/000445388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/10/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study was to determine whether multiple intravitreal injections of anti-vascular endothelial growth factor (VEGF) drugs for age-related macular degeneration (AMD) exacerbate systemic arteriosclerosis, using the cardio-ankle vascular index (CAVI) and intima-media thickness (IMT). METHODS We analyzed the data of 45 AMD patients who received intravitreal injections of anti-VEGF drugs (ranibizumab and/or aflibercept) and underwent systemic evaluations at baseline and after treatment. Reevaluation was conducted at ≥12 months from the initial treatment. RESULTS The total number of intravitreal injections of overall anti-VEGF drugs was significantly correlated with x0394;serum cystatin C. The cumulative number of aflibercept injections was identified as an independent protective factor for x0394;CAVI. An increase in the cumulative number of intravitreal injections of overall anti-VEGF drugs was identified as a protective factor for x0394;mean IMT. CONCLUSION Repeated intravitreal injections of an anti-VEGF drug for AMD may lead to morphological and functional changes in large arteries.
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Affiliation(s)
- Tomoaki Shiba
- Department of Ophthalmology, School of Medicine, Toho University, Tokyo, Japan
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Amadio M, Govoni S, Pascale A. Targeting VEGF in eye neovascularization: What's new? Pharmacol Res 2016; 103:253-69. [DOI: 10.1016/j.phrs.2015.11.027] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 11/19/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
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Ziemssen F, Sobolewska B, Deissler H, Deissler H. Safety of monoclonal antibodies and related therapeutic proteins for the treatment of neovascular macular degeneration: addressing outstanding issues. Expert Opin Drug Saf 2015; 15:75-87. [PMID: 26568279 DOI: 10.1517/14740338.2016.1121232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The vascular endothelial growth factor (VEGF) inhibitors most widely used to treat neovascular age-dependent macular degeneration (nAMD) are different proteins with structural features potentially relevant to adverse effects (AEs). Two of these are also established in cancer therapy (with higher dosages and AEs). The importance of ocular AE and extraocular activities is still a subject of controversy and ongoing research. AREAS COVERED Potential risks of intraocular VEGF inhibition based on prospective studies, in vitro investigations, pharmacokinetics, and hints from anti-cancer treatment. EXPERT OPINION nAMD is a frequently observed chronic clinical condition severely affecting the visual function of elderly persons. Intravitreal injection of VEGF-inactivating proteins is highly effective to prevent loss of vision. Anti-VEGF therapy is well tolerated, and low rates of ocular and systemic AEs in smaller trials suggest a very high benefit/risk ratio. The proteins established in nAMD therapy show similar efficacies. In the controversy over the off-label use of bevacizumab purely on grounds of much lower cost, the small, but potentially relevant differences between the available drugs are easily either dramatized (by pharmaceutical companies) or trivialized (by health insurances) and even political interference is involved. Facing the lack of a convincing body of evidence regarding safety, further long-term study results seem necessary.
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Affiliation(s)
- Focke Ziemssen
- a Center for Ophthalmology , Eberhard Karl University , D-72076 Tuebingen , Germany
| | - Bianka Sobolewska
- a Center for Ophthalmology , Eberhard Karl University , D-72076 Tuebingen , Germany
| | - Heidrun Deissler
- b Department of Ophthalmology , Univeristy of Ulm , D-89075 Ulm , Germany
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Schlenker MB, Thiruchelvam D, Redelmeier DA. Intravitreal anti-vascular endothelial growth factor treatment and the risk of thromboembolism. Am J Ophthalmol 2015; 160:569-580.e5. [PMID: 26116264 DOI: 10.1016/j.ajo.2015.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/14/2015] [Accepted: 06/16/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the subsequent risk of thromboembolic events in patients receiving intravitreal ranibizumab and bevacizumab for age-related macular degeneration or macular edema. DESIGN Population-based crossover analysis with self-matched historical control data. METHODS setting: Ontario, Canada, between April 1, 2006, and March 31, 2013. STUDY POPULATION Consecutive patients 65 and older who initiated intravitreal treatment (N = 57 919). INTERVENTION Intravitreal injection of ranibizumab or bevacizumab. MAIN OUTCOME MEASURES Emergency visits for thromboembolic events spanning 1-4 years before treatment were compared to 1 year after treatment. Also examined were other secondary events including hip fractures, congestive heart failure, angina, falls, depression, cholecystitis, and total emergencies, as well as a control group following cataract surgery. RESULTS A total of 57 919 patients were included who accounted for 1858 thromboembolic emergencies (48 per month) during the 3-year Baseline interval and 1077 thromboembolic emergencies (83 per month) during the 1-year Subsequent interval after initiating treatment. The absolute change in risk equaled an increase from 10.7 to 18.6 per 1000 patients annually after initiation of treatment (rate ratio 1.74; 95% confidence interval 1.58-1.92; P < .0001). The relative increase was particularly pronounced for ischemic stroke (rate ratio 2.18; 95% confidence interval 1.94-2.46; P < .0001). The observed increase exceeded trends due to aging, applied across patients with diverse characteristics, occurred with each medication (ranibizumab and bevacizumab), was not apparent for emergencies unrelated to thromboembolic events, and did not occur in a control group following cataract surgery. CONCLUSIONS Intravitreal anti-vascular endothelial growth factor medications ranibizumab and bevacizumab may contribute to systemic thromboembolic events in patients aged 65 years or older.
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Affiliation(s)
- Matthew B Schlenker
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Canada.
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Canada; Institute for Clinical Evaluative Sciences in Ontario, Toronto, Canada
| | - Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, Canada; Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Canada; Institute for Clinical Evaluative Sciences in Ontario, Toronto, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
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Boisguérin P, Deshayes S, Gait MJ, O'Donovan L, Godfrey C, Betts CA, Wood MJA, Lebleu B. Delivery of therapeutic oligonucleotides with cell penetrating peptides. Adv Drug Deliv Rev 2015; 87:52-67. [PMID: 25747758 PMCID: PMC7102600 DOI: 10.1016/j.addr.2015.02.008] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/23/2015] [Accepted: 02/25/2015] [Indexed: 12/15/2022]
Abstract
Oligonucleotide-based drugs have received considerable attention for their capacity to modulate gene expression very specifically and as a consequence they have found applications in the treatment of many human acquired or genetic diseases. Clinical translation has been often hampered by poor biodistribution, however. Cell-penetrating peptides (CPPs) appear as a possibility to increase the cellular delivery of non-permeant biomolecules such as nucleic acids. This review focuses on CPP-delivery of several classes of oligonucleotides (ONs), namely antisense oligonucleotides, splice switching oligonucleotides (SSOs) and siRNAs. Two main strategies have been used to transport ONs with CPPs: covalent conjugation (which is more appropriate for charge-neutral ON analogues) and non-covalent complexation (which has been used for siRNA delivery essentially). Chemical synthesis, mechanisms of cellular internalization and various applications will be reviewed. A comprehensive coverage of the enormous amount of published data was not possible. Instead, emphasis has been put on strategies that have proven to be effective in animal models of important human diseases and on examples taken from the authors' own expertise.
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Affiliation(s)
- Prisca Boisguérin
- Centre de Recherche de Biochimie Macromoléculaire, UMR 5237 CNRS, 1919 Route de Mende, 34293 Montpellier, France.
| | - Sébastien Deshayes
- Centre de Recherche de Biochimie Macromoléculaire, UMR 5237 CNRS, 1919 Route de Mende, 34293 Montpellier, France
| | - Michael J Gait
- Medical Research Council, Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge CB2 0QH, UK
| | - Liz O'Donovan
- Medical Research Council, Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge CB2 0QH, UK
| | - Caroline Godfrey
- University of Oxford, Department of Physiology, Anatomy and Genetics, South Parks Road, Oxford OX1 3QX, UK
| | - Corinne A Betts
- University of Oxford, Department of Physiology, Anatomy and Genetics, South Parks Road, Oxford OX1 3QX, UK
| | - Matthew J A Wood
- University of Oxford, Department of Physiology, Anatomy and Genetics, South Parks Road, Oxford OX1 3QX, UK
| | - Bernard Lebleu
- UMR 5235 CNRS, Université Montpellier 2, Place Eugene Bataillon, Montpellier 34095, France
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Korobelnik JF, Kleijnen J, Lang SH, Birnie R, Leadley RM, Misso K, Worthy G, Muston D, Do DV. Systematic review and mixed treatment comparison of intravitreal aflibercept with other therapies for diabetic macular edema (DME). BMC Ophthalmol 2015; 15:52. [PMID: 25975823 PMCID: PMC4467379 DOI: 10.1186/s12886-015-0035-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/22/2015] [Indexed: 01/27/2023] Open
Abstract
Background This was an indirect comparison of the effectiveness of intravitreal aflibercept (IVT-AFL) 2 mg every 8 weeks after 5 initial monthly doses (or if different periods, after an initial monthly dosing period) (2q8) and other diabetic macular edema (DME) therapies at doses licensed outside the USA. Methods A comprehensive search was undertaken to source relevant studies. Feasibility networks were prepared to identify viable comparisons of 12-month outcomes between IVT-AFL 2q8 and therapies licensed outside the USA, which were assessed for clinical and statistical homogeneity. Pooled effect sizes (mean difference [MD] and relative risk/risk ratio [RR]) were calculated using fixed- and random-effects models. Indirect comparisons were performed using Bucher analysis. If at least one ‘head-to-head’ study was found then a mixed treatment comparison (MTC) was performed using Bayesian methods. Two 12-month comparisons could be undertaken based on indirect analyses: IVT-AFL 2q8 versus intravitreal ranibizumab (IVR) 0.5 mg as needed (PRN) (10 studies) and IVT-AFL 2q8 versus dexamethasone 0.7 mg implants (three studies). Results There was an increase in mean best-corrected visual acuity (BCVA) with IVT-AFL 2q8 over IVR 0.5 mg PRN by 4.67 letters [95% credible interval (CrI): 2.45–6.87] in the fixed-effect MTC model (10 studies) and by 4.82 letters [95% confidence interval (CI): 2.52–7.11] in the Bucher indirect analysis (four studies). IVT-AFL 2q8 doubled the proportion of patients gaining ≥ 10 Early Treatment Diabetic Retinopathy Study letters at 12 months compared with dexamethasone 0.7 mg implants (RR = 2.10 [95% CI: 1.29–3.40]) in the fixed-effect model. There were no significant differences in safety outcomes between IVT-AFL 2q8 and IVR 0.5 mg PRN or dexamethasone 0.7 mg implants. Conclusions Studies of IVT-AFL 2q8 showed improved 12-month visual acuity measures compared with studies of IVR 0.5 mg PRN and dexamethasone 0.7 mg implants based on indirect comparisons. These analyses are subject to a number of limitations which are inherent in indirect data comparisons. Electronic supplementary material The online version of this article (doi:10.1186/s12886-015-0035-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jean-Francois Korobelnik
- Université Bordeaux, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux; Service d'Ophtalmologie, CHU de Bordeaux, Bordeaux, France.
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Limburg, the Netherlands.
| | - Shona H Lang
- Kleijnen Systematic Reviews Ltd., Escrick Business Park, Escrick, York, England, YO19 6FD, UK.
| | - Richard Birnie
- Kleijnen Systematic Reviews Ltd., Escrick Business Park, Escrick, York, England, YO19 6FD, UK.
| | - Regina M Leadley
- Kleijnen Systematic Reviews Ltd., Escrick Business Park, Escrick, York, England, YO19 6FD, UK.
| | - Kate Misso
- Kleijnen Systematic Reviews Ltd., Escrick Business Park, Escrick, York, England, YO19 6FD, UK.
| | - Gill Worthy
- Kleijnen Systematic Reviews Ltd., Escrick Business Park, Escrick, York, England, YO19 6FD, UK.
| | - Dominic Muston
- Global Health Economics and Outcomes Research, Bayer HealthCare Pharmaceuticals Inc., 100 Bayer Boulevard, Whippany, New Jersey, 07981, USA.
| | - Diana V Do
- Truhlsen Eye Institute, University of Nebraska Medical Center, 985540 Nebraska Medical Center, Omaha, Nebraska, 68198-5540, USA.
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