RETROSPECTIVE REVIEW OF THE EFFICACY OF TOPICAL BROMFENAC (0.09%) AS AN ADJUNCTIVE THERAPY FOR PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

Topical bromfenac in VEGF-driven maculopathies: topical review and meta-analysis

BACKGROUND

Topical non-steroidal anti-inflammatory drugs have the potential to reduce treatment burden and improve outcomes of anti-VEGF therapy for a number of retinal disorders, including neovascular age-related macular degeneration, diabetic macular edema, and retinal vein occlusions. In this review, we focused on the advantages of topical bromfenac as an adjunct to intravitreal anti-VEGF therapy in VEGF-driven maculopathies.

METHODS

Cochrane Library, PubMed, and EMBASE were systematically reviewed to identify the relevant studies of neovascular age-related macular degeneration, diabetic macular edema, macular edema associated with retinal vein occlusion, myopic choroidal neovascularization, and radiation maculopathy which reported changes in central retinal thickness, visual acuity, and the number of anti-VEGF injections needed when anti-VEGF therapy was combined with topical bromfenac.

RESULTS

In total, ten studies evaluating bromfenac as an adjunct to anti-VEGF therapy were identified. Five studies were included in meta-analysis of the number of injections and five studies were included in the analysis of changes in central retinal thickness. A statistically significantly lower number of intravitreal injections (p = 0.005) was required when bromfenac was used as an adjunct to anti-VEGF therapy compared to anti-VEGF monotherapy with pro re nata regimen. At the same time, eyes receiving bromfenac as an adjunct to anti-VEGF therapy demonstrated non-inferior outcomes in central retinal thickness (p = 0.07). Except for one study which reported better visual outcomes with combined treatment, no difference in visual acuity or clinically significant adverse effects were reported.

CONCLUSIONS

This literature review and meta-analysis showed that topical bromfenac can be considered as a safe adjunct to anti-VEGF therapy with a potential to reduce the treatment burden with anti-VEGF drugs requiring frequent injections without compromising improvement of central retinal thickness or visual acuity.

Topical bromfenac as adjunctive treatment with intravitreal ranibizumab for diabetic macular edema

PURPOSE

To determine the safety and efficacy of adding topical bromfenac 0.09% in the treatment of diabetic macular edema.

METHODS

Seventy patients (70 eyes) with center involved diabetic macular edema with macular thickness (300-500 μm) were included. Patients were divided randomly into two groups: 35 eyes in each group. Both groups were treated with intravitreal ranibizumab monthly for three consecutive months. Bromfenac 0.09% eye drops twice daily was added to the treatment of study group for six months from commencement of treatment. The efficacy of topical bromfenac was evaluated by comparing both groups through follow-up period as regards to visual acuity, central and average thickness and the need for re-injection.

RESULTS

Patients treated with topical bromfenac in addition to intravitreal ranibizumab revealed significant improvement in visual acuity, more reduction in central and average macular thickness and less tendency to need reinjection compared to those treated with ranibizumab alone (p 0.013, p 0.010 and p 0.022, respectively). No side effects was encountered with the use of topical bromfenac.

CONCLUSION

Topical bromfenac 0.09% twice a day could enhance and sustain the efficacy of intravitreal ranibizumab in the treatment of diabetic macular edema without increasing the incidence of corneal side effects.

Effects of systemic drugs on the development and progression of age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of severe loss of central vision among people over 50. The pathophysiology of the disease is multifactorial and can be attributed to genetics, aging, inflammation, environmental factors, and lifestyle factors including smoking, diet, obesity, and alcohol consumption. While there is no treatment for dry AMD, the current standard treatment for wet AMD is an intraocular injection of anti-vascular endothelial growth factor-an effective, yet expensive, therapy that requires ongoing treatment. As the aging population continues to grow, and AMD diagnoses continue to rise, new treatments should be explored to reduce vision complications and decrease treatment burdens. Many systemic conditions have progressive pathological changes that may affect AMD, particularly those affecting systemic vasculature like diabetes and cardiovascular status. Consequently, systemic drugs used to treat coexistent systemic diseases may influence some of the pathogenic mechanisms of AMD and lead its progression or delay. In this review we explore the current literature to summarize the findings of the reported effects of antihypertensive, immunosuppressants, cholesterol lowering agents, nonsteroidal anti-inflammatory drugs, dopamine precursors, hypoglycemic agents, and anticoagulants on AMD.

Ocular nonsteroidal inflammatory drugs: where do we stand today?

Since their first introduction in ophthalmology, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) has been exponentially expanded, with numerous therapeutic applications. Despite their controversial history, they have proven their efficacy as anti-inflammatory agents in a variety of diseases. Nowadays, NSAIDs are part of surgical protocols of the most commonly performed ophthalmic operations, such as cataract or ocular surgery. They are universally implicated in the management of conjunctivitis, retinal and choroidal disease and miscellaneous inflammatory diseases. Moreover, although linked with serious adverse events and toxicities, their therapeutic magnitude in Ophthalmology should not be affected. This review systematically portrays the variety of ocular NSAIDs available to date, along with their differences in their way of action, indications and potential side effects in various ophthalmologic conditions.

The Effect of Topical Bromfenac on Intraretinal and Subretinal Fluid in Neovascular Age-Related Macular Degeneration

Purpose:

To report the effect of topical bromfenac, a non-steroidal anti-inflammatory drug (NSAID), in a case of neovascular age-related macular degeneration (AMD).

Methods:

An 85-year-old woman presented with a complaint of visual acuity reduction in the right eye. Comprehensive ophthalmological examination and retinal imaging were performed.

Results:

Best corrected visual acuity was 2/100. Fundus examination showed reticular pseudodrusen and a small hemorrhage in the fovea. Fluorescein angiography showed an active neovascular membrane. Spectral-domain optical coherence tomography (SD-OCT) confirmed diagnosis and revealed subretinal and intraretinal fluid. The patient refused recommended intravitreal anti-vascular endothelial growth factor treatment and received topical bromfenac 0.09% twice daily. Follow-up with SD-OCT showed subretinal followed by intraretinal fluid reduction at 16 weeks after treatment.

Conclusion:

Short-term reduction of subretinal and intraretinal fluid was observed with topical bromfenac monotherapy in neovascular AMD.

Effect of 0.1% Bromfenac for Preventing Macular Edema after Cataract Surgery in Patients with Diabetes

Purpose

To investigate the effect of 0.1% bromfenac sodium hydrate ophthalmic solution for prevention of macular edema after cataract surgery in patients with diabetes.

Methods

A retrospective analysis of 75 patients with diabetes who underwent cataract surgery was performed. Thirty-eight patients (52 eyes) were instilled with 0.1% bromfenac solution (bromfenac group) and 37 patients (46 eyes) were not (control group).

Results

There were no significant preoperative between-group differences. Compared to the control group, at 1 month after surgery, the bromfenac group showed slightly better best-corrected visual acuity (0.12 ± 0.12 vs. 0.32 ± 0.42, p = 0.142), lower central macular thickness (265.58 ± 31.28 vs. 314.15 ± 76.11 µm, p < 0.001), and lower macular volume (8.46 ± 0.60 vs. 9.14 ± 1.53 mm³, p = 0.022). There were no significant differences between the two groups at 4 and 6 months postoperatively (p > 0.05). Mean changes in central macular thickness showed significant differences at 1 and 4 months postoperatively (−1.44 ± 11.72 and 10.44 ± 22.48 µm in bromfenac group vs. 47.19 ± 70.24 and 31.69 ± 48.04 µm in control group, p < 0.001 and p = 0.016) and mean changes in macular volume showed a significant difference at 1 month postoperatively (−0.08 ± 0.47 mm³ in bromfenac group vs. 0.58 ± 1.28 mm³ in control group, p < 0.001). There were no significant differences thereafter (p > 0.05).

Conclusions

Treatment with 0.1% bromfenac sodium hydrate ophthalmic solution showed good efficacy for preventing cystoid macular edema early after cataract surgery in patients with diabetes.

Diabetic retinopathy, a vascular and inflammatory disease: Therapeutic implications

Diabetic retinopathy (DR) is the most common microvascular complication of diabetes and the leading cause of visual impairment in the working-age population in the Western world. Diabetic macular oedema (DME) is one of the major complications of DR. Therapy with intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) drugs has become the gold standard treatment for DR and its complications. However, these drugs have no effect on the pathogenesis of DR and must be administered frequently via invasive intravitreal injections over many years. Thus, there is a pressing need to develop new therapeutic strategies to improve the treatment of this devastating disease. Indeed, an increasing volume of data supports the role of the inflammatory process in the pathogenesis of DR itself and its complications, including both increased retinal vascular permeability and neovascularization. Inflammation may also contribute to retinal neurodegeneration. Evidence that low-grade inflammation plays a critical role in the pathogenesis of DME has opened up new pathways and targets for the development of improved treatments. Anti-inflammatory compounds such as intravitreal glucocorticoids, topical non-steroidal anti-inflammatory drugs (NSAIDs), antioxidants, inflammatory molecule inhibitors, renin-angiotensin system (RAS) blockers and natural anti-inflammatory therapies may all be considered to reduce the rate of administration of antineovascularization agents in the treatment of DR. This report describes the current state of knowledge of the potential role of anti-inflammatory drugs in controlling the onset and evolution of DR and DME.

Combinatorial treatment with topical NSAIDs and anti-VEGF for age-related macular degeneration, a meta-analysis

Inflammation is a key pathogenic factor in age-related macular degeneration (AMD). However, the clinical importance of combining anti-VEGF agents and topical NSAIDs to reduce inflammation remains unclear. In this study, we systematically reviewed clinical trials comparing combined treatment versus anti-VEGF alone in AMD patients. We quantified treatment effects via meta-analysis. The pooled weighted mean difference (WMD, -0.91, 95%CI: -1.39 to -0.42, P = 0.0003) demonstrates that combined treatment may reduce required anti-VEGF injection number, probably by means of decreasing central retina thickness (CRT) (WMD = -22.9, 95% CI: -41.20 to -4.59, P = 0.01). The best corrected visual acuity (BCVA) did not change significantly between these two groups (WMD = - 0.01, 95%CI: -0.23 to 0.20, P = 0.90). Topical NSAIDs slightly increased the incidence of foreign body sensation (Odds Ratio [OR] = 2.63, 95%Cl: 1.06 to 6.52, P = 0.76). Combining topical NSAIDs and anti-VEGF agents may provide a new strategy for AMD treatment.

Bromfenac Eyedrops in the Treatment of Diabetic Macular Edema: A Pilot Study

Purpose

To evaluate the efficacy and safety of topical bromfenac in patients with newly diagnosed diabetic macular edema (DME).

Methods

In this pilot study including 17 patients with monocular, newly diagnosed DME, diagnosis of DME was established by the detection of retinal thickening at or within 500 μm of the center of the macula on ophthalmoscopic examination, according to the Early Treatment Diabetic Retinopathy Study classification. Central macular thickness (CMT) was determined by optical coherence tomography. Bromfenac sodium hydrate 0.9 mg/mL eyedrops were administered in the affected eye twice daily for 30 days. Primary endpoints were changes in best-corrected visual acuity (BCVA) and CMT at the end of therapy.

Results

Topical bromfenac significantly reduced mean CMT, from 465.41 ± 118.47 μm at baseline to 388.88 ± 152.63 μm posttreatment (p = 0.02). There was no significant change in BCVA and differences in mean macular volume fell just short of statistical significance (p = 0.06). Treatment was well-tolerated, and there were no topical or systemic side effects.

Conclusions

Topical bromfenac twice daily may play a role in the reduction of DME. These preliminary results warrant further larger multicenter studies to confirm our findings and establish whether topical bromfenac may be of long-term benefit in the treatment of DME.

Combination of Aflibercept and Bromfenac Therapy in Age-Related Macular Degeneration: A Pilot Study Aflibercept and Bromfenac in AMD

BACKGROUND Among many protocols for treatment of exudative AMD, combined therapy of anti-VEGF agents and non-steroidal anti-inflammatory drugs (NSAIDs) seems to be an ideal alternative to monotherapy based on ranibizumab or bevacizumab. The aim of this study was to evaluate the effectiveness of aflibercept and bromfenac in the treatment of exudative AMD. MATERIAL AND METHODS The study was conducted on a group of 27 patients with exudative AMD who were administered intravitreal aflibercept and topical bromfenac (study group) once a month. Additional injections were administered up to 3 months after the third administration, depending on response to treatment. The control group consisted of subjects treated with aflibercept only. Visual acuity and anatomical outcomes in optical coherence tomography (OCT) were assessed at baseline visit, 4 months after the first dose, and 6 months after the start of the treatment. RESULTS Visual acuity improved over time in the study group and the differences between the groups were statistically significant. No statistically significant differences were found in OCT parameters. CONCLUSIONS Combined therapy of aflibercept and bromfenac in the treatment of wet AMD is more effective than single aflibercept therapy.

Efficacy and vitreous levels of topical NSAIDs

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications and are routinely used for their analgesic, antipyretic, and anti-inflammatory properties. Because of their potent cyclooxygenase-inhibitory activity, they can inhibit pro-inflammatory prostaglandin synthesis, leading to complex inflammatory cascades. NSAIDs have been broadly used systemically for many decades and have recently become commercially available in the form of topical ophthalmic formulations. NSAIDs are weak acids with pKa values mostly between 3.5 and 4.5 and are poorly water-soluble. New, aqueous ophthalmic solutions of NSAIDs that afford better tissue penetration have recently been developed. In ophthalmological practice, topical NSAIDs are mostly used to stabilize pupillary dilation during intraocular surgery, manage postoperative pain and inflammation, and treat pseudophakic cystoid macular edema.

AREAS COVERED

This review focuses on the vitreous penetration of topical NSAIDs and their potential clinical applications in the treatment of retinal diseases.

EXPERT OPINION

A growing body of evidence suggests that NSAIDs may be beneficial in the treatment of age-related macular degeneration, diabetic retinopathy, and ocular tumors. Recent studies from our group and other authors have shown that the vitreous levels of NSAID exceed the median inhibitory concentration, which can significantly decrease vitreous PGE2 levels.

The ocular distribution of (14)C-labeled bromfenac ophthalmic solution 0.07% in a rabbit model

PURPOSE

To evaluate the ocular distribution of an advanced formulation of bromfenac ophthalmic solution. Two studies were conducted in rabbits: 1) a 12-hour parallel-group study comparing the ocular distribution of (14)C-bromfenac ophthalmic solution 0.07%, pH 7.8 with that of (14)C-bromfenac ophthalmic solution 0.09%, pH 8.3, and 2) a 24-hour study evaluating the ocular distribution of (14)C-bromfenac ophthalmic solution 0.07%, pH 7.8.

METHODS

In the 12-hour study, rabbits were randomized to receive 50 μL of (14)C-bromfenac 0.07%, pH 7.8 or 50 μL (14)C-bromfenac 0.09%, pH 8.3 in one eye, whereas, in the 24-hour, study both eyes received 50 μL of (14)C-bromfenac 0.07%, pH 7.8. Ocular tissues were collected at 1, 2, 4, 8, 12 (both studies) and 24 hours (second study only) following drug instillation, and tissue radioactivity was determined using liquid scintillation chromatography.

RESULTS

Measureable levels of bromfenac were observed in all ocular tissues, with the exception of vitreous humor, regardless of formulation. In the 12-hour study, high concentrations of (14)C-bromfenac were found in the sclera, followed by the iris/ciliary body, aqueous humor, choroid, retina, and lens. There was no significant difference between the bromfenac 0.07%, pH 7.8 and bromfenac 0.09%, pH 8.3 formulations in any (14)C-bromfenac tissue levels at any time point, with the exception of in sclera at 2 hours post-instillation (0.451 μg eq/g versus 0.302 μg eq/g, respectively, P<0.001). There was also no significant difference in the total amount of (14)C-bromfenac in the tissues evaluated following instillation of the two formulations. In the 24-hour study evaluating bromfenac 0.07%, pH 7.8 only, high concentrations of (14)C-bromfenac were found 1 hour post-instillation in the cornea (2.402 μg eq/g) and conjunctiva (1.049 μg eq/g), two tissues not evaluated in the 12-hour study. The rank order of (14)C-bromfenac levels in the other ocular tissues was the same as that observed in the 12-hour study, with measureable amounts of (14)C-bromfenac detected through 24 hours in all tissues with the exception of vitreous humor.

CONCLUSION

Bromfenac ophthalmic solution 0.07%, pH 7.8 readily penetrated ocular tissues with levels similar to those of bromfenac ophthalmic solution 0.09%, pH 8.3.

Combination of bevacizumab and bromfenac therapy in age-related macular degeneration: a pilot study

Background

According to recent studies, the newest strategy for the treatment of exudative age-related macular degeneration is to combine anti-VEGF agents with non-steroid anti-inflammatory drugs (NSAIDs) such as nepafenac and bromfenac to decrease the frequency of intravitreal injections. Since most research has focused on ranibizumab, the aim of this study is to evaluate whether an alternative drug such as bevacizumab could lead to similar outcomes.

Material/Methods

The study was conducted on a group of 26 patients who were administered intravitreal bevacizumab and topical bromfenac (study group) and 26 patients with single bevacizumab therapy (control group). Cases that were not qualified for ranibizumab therapy were included in the study group.

Results

The study revealed that the visual acuity and parameters observed in OCT improved more in the study group than in the control group. However, the correlations between the above factors and the frequency of intravitreal injections were statistically significant only in visual acuity.

Conclusions

We recommend the combined therapy of bevacizumab and bromfenac as an alternative and beneficial method of treatment in patients with exudative AMD who do not qualify for ranibizumab therapy. This combined therapy might efficiently reduce the number of intravitreal injections of bevacizumab.

Topical nonsteroidal anti-inflammatory drugs for macular edema

Nonsteroidal anti-inflammatory drugs (NSAIDs) are nowadays widely used in ophthalmology to reduce eye inflammation, pain, and cystoid macular edema associated with cataract surgery. Recently, new topical NSAIDs have been approved for topical ophthalmic use, allowing for greater drug penetration into the vitreous. Hence, new therapeutic effects can be achieved, such as reduction of exudation secondary to age-related macular degeneration or diabetic maculopathy. We provide an updated review on the clinical use of NSAIDs for retinal diseases, with a focus on the potential future applications.

Nonsteroidal anti-inflammatory drugs for retinal disease

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used extensively in ophthalmology for pain and photophobia after photorefractive surgery and to reduce miosis, inflammation, and cystoid macular edema following cataract surgery. In recent years, the US Food and Drug Administration has approved new topical NSAIDs and previously approved NSAIDs have been reformulated. These changes may allow for greater drug penetration into the retina and thereby offer additional therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on the scientific rationale and clinical use of NSAIDs for retinal disease.

Update on twice-daily bromfenac sodium sesquihydrate to treat postoperative ocular inflammation following cataract extraction

Ophthalmic bromfenac sodium sesquihydrate is a topically applied selective cyclooxygenase (COX)-2 inhibitor. It is similar to amfenac, except for a bromine atom at the C(4) of the benzoyl ring position, which markedly affects its in vitro and in vivo potency, extends the duration of anti-inflammatory activity, and enhances its inhibitory effect on COX-2 absorption across the cornea and penetration into ocular tissues. The United States Food and Drug Administration approved bromfenac in 2005 for the treatment of postoperative inflammation and the reduction of ocular pain in patients who have undergone cataract surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs), and among them bromfenac, could be even more effective than steroids at reestablishing the blood-aqueous barrier, as revealed by flare on slit-lamp examination and as quantitatively measured using ocular fluorophotometry. Similar to other NSAIDs, it has a role in inhibiting intraoperative miosis during cataract surgery. However, bromfenac also seems to be useful in other situations, such as refractive surgery, allergic conjunctivitis (not useful in dry eye), choroidal neovascularization, and even ocular oncology. No reports of systemic toxicity have been published and bromfenac has good topical tolerance with a low incidence of adverse effects.

The role of anti-inflammatory agents in age-related macular degeneration (AMD) treatment

Although age-related macular degeneration (AMD) is not a classic inflammatory disease like uveitis, inflammation has been found to have an important role in disease pathogenesis and progression. Innate immunity and autoimmune components, such as complement factors, chemokines, cytokines, macrophages, and ocular microglia, are believed to be heavily involved in AMD development. Targeting these specific inflammatory molecules has recently been explored in an attempt to better understand and treat AMD. Although antivascular endothelial growth factor therapy is the first line of defence against neovascular AMD, anti-inflammatory agents such as corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), immunosuppressive agents (eg, methotrexate and rapamycin), and biologics (eg, infliximab, daclizumab, and complement inhibitors) may provide an adjunct or alternative mechanism to suppress the inflammatory processes driving AMD progression. Further investigation is required to evaluate the long-term safety and efficacy of these drugs for both neovascular and non-neovascular AMD.

Use of nepafenac (Nevanac) in combination with intravitreal anti-VEGF agents in the treatment of recalcitrant exudative macular degeneration requiring monthly injections

Purpose

The purpose of this study is to determine the efficacy of combining topical nepafenac with monthly intravitreal injections of ranibizumab or bevacizumab in the treatment of recalcitrant exudative macular degeneration.

Methods

This was a retrospective, consecutive case series of patients with exudative macular degeneration requiring maintenance therapy of antivascular endothelial growth factor ( anti-VEGF) injections at least every 6 weeks, who were started on topical nepafenac. Despite frequent anti-VEGF dosing, all patients included in the study had persistence of any combination of the following: intraretinal cysts, subretinal fluid, and/or pigment epithelial detachment. Patients underwent pinhole visual acuity, clinical exam, and optical coherence tomography (OCT) at baseline and every follow-up visit. Response to therapy was graded by reviewing quantitative and qualitative OCT data, and statistical analysis was done with paired Student’s t-test.

Results

Twenty-five patients (average age 77; 14 male and 11 female) were reviewed; the mean number of previous injections was 17.4 (range 3–31). Baseline mean visual acuity was 20/55, and final mean visual acuity after 3 months of treatment was 20/51 (P = 0.13). Monthly mean central foveal thickness measurements were 248, 250, 257, and 247 μm (P = 0.53) at baseline, 1, 2, and 3 months, respectively. By the end of the 3-month time point, qualitative OCT findings on 13 patients treated with nepafenac were classified as stable, 10 as better, and 2 as worse.

Conclusions

There was no significant change in visual acuity or quantitative OCT measurements, but there appeared to be a mild trend toward improved anatomy and qualitative OCT findings when topical nepafenac was added to monthly anti-VEGF injections in patients with persistent intraretinal cysts, subretinal fluid, and/or pigment epithelial detachment. Further prospective studies with longer follow-up may be warranted.