One-year outcome of intravitreal ziv-aflibercept therapy for non-responsive neovascular age-related macular degeneration

Retinal fluid is associated with cytokines of aqueous humor in age-related macular degeneration using automatic 3-dimensional quantification

Background: To explain the biological role of cytokines in the eye and the possible role of cytokines in the pathogenesis of neovascular age-related macular degeneration (nAMD) by comparing the correlation between cytokine of aqueous humor concentration and optical coherence tomography (OCT) retinal fluid. Methods: Spectral-domain OCT (SD-OCT) images and aqueous humor samples were collected from 20 nAMD patient's three clinical visits. Retinal fluid volume in OCT was automatically quantified using deep learning--Deeplabv3+. Eighteen cytokines were detected in aqueous humor using the Luminex technology. OCT fluid volume measurements were correlated with changes in aqueous humor cytokine levels using Pearson's correlation coefficient (PCC). Results: The patients with intraretinal fluid (IRF) showed significantly lower levels of cytokines, such as C-X-C motif chemokine ligand 2 (CXCL2) (p = 0.03) and CXCL11 (p = 0.009), compared with the patients without IRF. And the IRF volume was negatively correlated with CXCL2 (r = -0.407, p = 0.048) and CXCL11 (r = -0.410, p = 0.046) concentration in the patients with IRF. Meanwhile, the subretinal fluid (SRF) volume was positively correlated with vascular endothelial growth factor (VEGF) concentration (r = 0.299, p = 0.027) and negatively correlated with interleukin (IL)-36β concentration (r = -0.295, p = 0.029) in the patients with SRF. Conclusion: Decreased level of VEGF was associated with decreased OCT-based retinal fluid volume in nAMD patients, while increased levels of CXCL2, CXCL11, and IL-36β were associated with decreased OCT-based retinal fluid volume in nAMD patients, which may suggest a role for inflammatory cytokines in retinal morphological changes and pathogenesis of nAMD patients.

Ziv-aflibercept for Better Regulating Neovascular Age-Related Macular Degeneration (ZEBRA): A Prospective, Randomized Trial

OBJECTIVE

The purpose of this study is to determine if ziv-aflibercept is a safe and effective maintenance drug for nAMD.

STUDY DESIGN AND METHODS

This is a randomized, prospective, single-blinded trial. Inclusion criteria were active nAMD, prior anti-VEGF treatment, and BCVA ≤20/200. The treatment group received ziv-aflibercept. The control group continued their existing anti-VEGF regimen. The main outcome measures were BCVA, CFT, and safety.

RESULTS

Mean baseline BCVA was 1.58 ± 0.44 logMAR and 1.71 ± 0.39 logMAR in the control (n = 27) and treatment (n = 29) groups, respectively. After 24 months, the mean change in BCVA was 0.11 in the control group (equivalent to a loss of 5 ETDRS letters) and 0.01 logMAR in the treatment group (p = .48). Baseline CFT was 257 ± 33 μm and 247 ± 30 μm in the control and treatment groups, respectively, and after 24 months mean change in CFT was 26 μm and -5 μm (p = .24). There were no ocular or systemic adverse events during the study.

CONCLUSION

Ziv-aflibercept is a safe and effective as a maintenance drug for patients with nAMD. It may represent a cost-effective alternative to aflibercept and second-line therapy for eye resistant bevacizumab or ranibizumab.

Ziv-aflibercept: A cost-effective, off-label, highly potent antagonist of vascular endothelial growth factor

Ziv-aflibercept (Zaltrap^® ), a recombinant fusion protein that binds diffusible vascular endothelial growth factor (VEGF), is approved for the treatment of metastatic colorectal carcinoma. Its molecular structure is the same as aflibercept (Eylea^® ), thus making it an attractive option for the off-label treatment of chorioretinal vascular conditions. Ziv-aflibercept is distributed in 4 and 8 ml vials for intravenous use, and its cost after compounding is similar to bevacizumab. Studies with retinal pigment epithelium cytotoxicity, animal histologic sections and electroretinography have demonstrated its safety, and mathematical modelling combined with over four dozen clinical publications from different ophthalmic centres throughout the world attest to its efficacy. No appreciable differences in visual or anatomic outcomes between 1.25 mg (0.05 ml) and 2.5 mg (1.0 ml) doses have been noted. The long duration of action combined with the low cost make ziv-aflibercept an attractive anti-VEGF treatment option, especially in low- and middle-income countries where its popularity is increasing.

Intravitreal Ziv-Aflibercept : Safety Analysis in Eyes Receiving More Than Ten Intravitreal Injections

Purpose: To report the ocular and systemic adverse events in eyes receiving ≥10 intravitreal ziv-aflibercept (IVZ) injections.Methods: Medical records of patients who received ≥10 IVZ for various chorioretinal conditions with minimum follow up period of 12 months were retrospectively analysed. These eyes received standard dose of IVZ (1.25 mg/0.05 ml) on pro-re-nata (PRN) or treat and extend (T&E) protocol. The primary study outcome was ocular and systemic adverse events related to IVZ injections whereas secondary outcomes were change in best corrected visual acuity (BCVA) and central macular thickness (CMT) on optical coherence tomography (OCT) at last visit compared to baseline. Comparison of BCVA and CMT at baseline and final visit was done using paired t-test.Results: A total of 94 eyes which received a mean ± standard deviation (mean±SD = 14.4 ± 4.6) IVZ injections were studied. A total of 41 eyes were treatment naïve whereas 53 eyes received intravitreal injections in the past with last injection at least 3 months prior. Mean (±SD) follow up period was 26.7 ± 8.7 months. Ocular adverse events were limited with a case each of acute iridocyclitis, endophthalmitis, cataract progression and early epiretinal membrane formation. No systemic events were recorded within a month of IVZ injection. There was a significant improvement in BCVA (p = 0.001) and change in CMT (p = 0.001) at last visit.Conclusion: Ocular use of ziv-aflibercept is safe with limited ocular and systemic side effects. Multiple injections of IVZ can be used in various chorioretinal diseases over the long term.

Safety of intravitreal ziv-aflibercept in choroido-retinal vascular diseases: A randomised double-blind intervention study

AIM

To evaluate the safety of 1.25mg and 2mg intravitreal ziv-aflibercept (IVZ) in Ghanaian eyes with choroido-retinal vascular diseases.

DESIGN

Prospective, randomised, double blind, interventional study.

METHODS

Twenty patients with centre involving macular oedema in diabetic retinopathy, retinal vein occlusion, and neovascular age-related macular degeneration were assigned to 2 groups receiving 3 doses of 1.25mg/0.05ml (group 1) and 2mg/0.08ml IVZ (Group 2) at 4 weekly intervals. Safety data was collected after 30 minutes, 1 and 7 days, and 4, 8 and 12 weeks after injection. Changes in continuous variables were compared using paired t-test and categorical variables were compared using chi-square test of proportions. Repeated-Measures ANOVA with nesting test was used to compare variations in continuous variables by IVZ dose over time. Primary outcome measures were ocular and systemic adverse events at 4 weeks.

RESULTS

Eleven females and nine males, with mean age of 63.2± 7.3 years were included. Ocular adverse events included subconjunctival haemorrhage in 1 eye, intraocular pressure (IOP) >21mmHg at 30 minutes in 6 eyes and mild pain in 3 eyes at 1-day. There was no significant difference in IOP rise between the 2 groups at 30 minutes (p = 0.21). No other ocular or systemic adverse events were observed. There was significant improvement in the best corrected visual acuity (LogMAR) from 0.95±0.6 to 0.6±0.4 (p<0.01) and 0.47±0.3 (p<0.01), reduction in central subfield foveal thickness from 405.9±140 um at baseline to 255.6±75 um (p<0.01) and 238±88 um (p<0.01) at 4 and 12 weeks respectively, although no difference was observed between the 2 groups (p = 0.34).

CONCLUSION

IVZ at 1.25mg and 2mg had similar safety profiles, and did not have any major unexpected adverse events. Further studies with larger cohorts are required to confirm efficacy.

Comparison of intravitreal ziv-aflibercept and bevacizumab monotherapy in treatment-naive polypoidal choroidal vasculopathy

Purpose:

To report the visual and anatomical outcomes of intravitreal ziv-aflibercept (IVZ) and bevacizumab (BVZ) monotherapy in treatment-naive polypoidal choroidal vasculopathy (PCV).

Methods:

This was a retrospective case series of 16 eyes (8 eyes each in IVZ and BVZ groups). The study period was from January 2016 to March 2018. The inclusion criteria were treatment-naive PCV patients who were treated with either IVZ or BVZ monotherapy on pro re nata protocol and followed up monthly for 6 months. The change in best-corrected visual acuity (BCVA), central macular thickness (CMT), and pigment epithelial detachment (PED) height was measured at baseline and 6 months.

Results:

A total of 16 eyes were studied. IVZ group had an improvement in BCVA by 0.15 logarithm of minimum angle of resolution (logMAR; approximately 1.5 lines) at 6 months, whereas BVZ group had a reduction in BCVA by 0.21 logMAR (approximately 2 lines) (P = 0.027). Five patients and one patient in IVZ and BVZ groups, respectively, had ≥5 letters gain of BCVA. IVZ group had significant reduction in PED height (P = 0.048), whereas the change in CMT was not significant at 6 months (P = 0.681). The mean number of injections (2.87 ± 0.83 in IVZ and 2.25 ± 0.89 BVZ group; P = 0.168) and longest treatment-free interval (3.00 ± 2.20 months in IVZ and 2.12 ± 1.96 months in BVZ group; P = 0.41) were not significantly different.

Conclusion:

The visual and anatomical outcomes in terms of PED reduction in treatment-naive PCV patients were better in IVZ group compared with BVZ. IVZ monotherapy is a viable, cost-effective alternative in these patients with good safety profile.

Anti-Vascular Endothelial Growth Factor Treatment for Diabetic Macular Edema in a Real-World Clinical Setting

PURPOSE

To report the long-term outcomes of intravitreal anti-vascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME) in a real-world clinical setting and to assess the efficacy of subsequent alternative treatments in eyes with suboptimal response to anti-VEGF.

DESIGN

Retrospective interventional case series.

METHODS

The medical records of consecutive eyes with center-involving DME, treated between August 2008 and June 2015 with 3 monthly intravitreal anti-VEGF injections-with or without prompt or deferred laser-followed by pro re nata re-treatment, were reviewed. A subgroup of eyes that were unresponsive to the treatment received subsequent alternative therapeutic options, including switching to another anti-VEGF drug, intravitreal injection of dexamethasone, and vitrectomy.

RESULTS

A total of 170 eyes of 129 patients were included in the study. The mean follow-up (FU) was 45.6 months (SD 18; minimum 12-maximum 81). The change in mean best-corrected visual acuity (BCVA) at 1-year FU was +5 ETDRS letters (P < .0001). Improvement in BCVA was statistically significant up to 5 years. Improvement in central macular thickness (CMT) was statistically significant up to the last FU visit. In eyes with suboptimal response, no significant visual improvement was found by switching to another anti-VEGF (P =.4347). Twenty-four eyes treated with intravitreal dexamethasone and 14 with vitrectomy exhibited a significant reduction in CMT with variable functional responses. In these eyes, better BCVA gain was found in cases with an early change of the treatment strategy.

CONCLUSION

The results support treatment with intravitreal anti-VEGF for DME in real-world clinical settings and suggest that an early change of the therapeutic strategy should be considered for eyes unresponsive to the treatment.

Safety of 5914 intravitreal ziv-aflibercept injections

Purpose

To analyse the pooled safety data of intravitreal ziv-aflibercept (IVZ) therapy for various retinal conditions.

Methods

This was a retrospective, observational study which included patients from 14 participating centres who received IVZ. The medical records of patients who received IVZ from March 2015 through October 2017 were evaluated. Patient demographics and ocular details were compiled. Ocular and systemic adverse events that occurred within 1 month of IVZ injections were recorded and defined as either procedure-related or drug-related.

Results

A total of 1704 eyes of 1562 patients received 5914 IVZ injections (mean±SD: 3.73±3.94) during a period of 2.5 years. The age of patients was 60.6±12.8 years (mean±SD) and included diverse chorioretinal pathologies. Both ocular (one case of endophthalmitis, three cases of intraocular inflammation, and one case each of conjunctival thinning/necrosis and scleral nodule) and systemic adverse events (two cases of myocardial infarction, one case of stroke and two deaths) were infrequent.

Conclusion

This constitutes the largest pooled safety report on IVZ use and includes patients from 14 centres distributed across the globe. It shows that IVZ has an acceptable ocular and systemic safety profile with incidences of adverse events similar to those of other vascular endothelial growth factor inhibitory drugs. The analysis supports the continued use of IVZ in various retinal disorders.

Pharmaceutical compounding of aflibercept in prefilled syringes does not affect structural integrity, stability or VEGF and Fc binding properties

Macular edema due to neovascular age-related macular degeneration, diabetes or retinal vein occlusion can cause central vision loss. Intravitreal treatment with antibody-based biopharmaceutical compounds designed to neutralize vascular endothelial growth factor (VEGF) has proven to be an efficient strategy to ameliorate macular edema and restore visual acuity. At the same time, the use of anti-VEGF drugs places an economic burden on the health care system; the drugs are expensive, and repeated injections are usually required to maintain the therapeutic effect. Thus, there is an unmet need for more cost-effective procedures. We here describe how the most recently approved anti-VEGF drug, aflibercept, can be compounded into prefilled sterile syringes and stored for up to 4 weeks without compromising its quality, stability or functional properties, including VEGF and neonatal Fc receptor (FcRn) binding. The novel compounding method for repackaging of aflibercept in sterile plastic syringes can greatly reduce both cost and time spent per patient in the injection room.

Intravitreal Ziv-Aflibercept: Clinical Effects and Economic Impact

During the past decade, drugs that inhibit the actions of vascular endothelial growth factor (VEGF) have become standard-of-care treatment for a variety of chorioretinal vascular conditions. The off-label, intravitreal use of ziv-aflibercept (Zaltrap) has provided clinicians with an additional cost-effective drug. The commercial preparation of ziv-aflibercept contains the same aflibercept (VEGF-trap) molecule as Eylea but has a much higher osmolarity (1000 mOsm/kg vs 300 mOsm/kg). Initial concerns regarding cytotoxicity and long-term safety of intravitreal ziv-aflibercept have been largely negated after a series of publications failed to identify adverse ocular and systemic side effects. Both treatment-naive and anti-VEGF‒resistant cases of neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), retinal vein occlusion (RVO), and choroidal neovascular membrane (CNVM) may respond as well to ziv-aflibercept as to aflibercept. A higher dose of ziv-aflibercept (2 mg in 0.08 mL) does not cause any adverse effects during short-term follow-up period (1 month). Data from various sources suggest that ziv-aflibercept may be as cost effective as bevacizumab, thereby making it an attractive treatment option in low- and middle-income countries. However, problems with off-label use, compounding, and counterfeiting limit its availability in many countries. Data from prospective, randomized, multicenter clinical trials are still required to convince physicians and regulatory bodies of its clinical efficacy and potential as early therapy.