Reporting of Safety Events during Anti-VEGF Treatment: Pharmacovigilance in a Noninterventional Trial

Risk analysis for patients with arterial thromboembolic events after intravitreal ranibizumab or aflibercept injections

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.

Comparison of risks of arterial thromboembolic events and glaucoma with ranibizumab and aflibercept intravitreous injection: A nationwide population‐based cohort study

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.

Discovering the Potential of Natural Antioxidants in Age-Related Macular Degeneration: A Review

Age-related macular degeneration (AMD) is a multifactorial disease associated with anatomical changes in the inner retina. Despite tremendous advances in clinical care, there is currently no cure for AMD. This review aims to evaluate the published literature on the therapeutic roles of natural antioxidants in AMD. A literature search of PubMed, Web of Science and Google Scholar for peer-reviewed articles published between 1 January 2011 and 31 October 2021 was undertaken. A total of 82 preclinical and 18 clinical studies were eligible for inclusion in this review. We identified active compounds, carotenoids, extracts and polysaccharides, flavonoids, formulations, vitamins and whole foods with potential therapeutic roles in AMD. We evaluated the integral cellular signaling pathways including the activation of antioxidant pathways and angiogenesis pathways orchestrating their mode of action. In conclusion, we examined the therapeutic roles of natural antioxidants in AMD which warrant further study for application in clinical practice. Our current understanding is that natural antioxidants have the potential to improve or halt the progression of AMD, and tailoring therapeutics to the specific disease stages may be the key to preventing irreversible vision loss.

Short-term Safety Evaluation of Resident-performed Intravitreal Injection

Purpose: This study evaluated the short-term safety of resident-performed intravitreal injections.Methods: We retrospectively reviewed the medical records of 503 patients (503 eyes) treated for the first time in our hospital from January 2018 to October 2020 via intravitreal bevacizumab, ranibizumab, aflibercept, or triamcinolone acetonide injections by residents or retina specialists. In terms of short-term ophthalmic complications, patients were followed-up 1 day, 1 week, and 1 month after injection.Results: A total of 503 eyes of 503 patients were included. Intravitreal injections were given to 211 and 292 eyes by residents (the resident group) and retina specialists (the retina specialist group), respectively. There were no between-group differences in baseline characteristics except in terms of the indications for injection. Intraocular pressure elevation >5 mmHg occurred in two eyes (0.95%) in the resident group and five (1.71%) in the retina specialist group, but the difference was not statistically significant. Subconjunctival hemorrhage occurred in 29 eyes (13.74%) of the resident group and 32 eyes (10.96%) of the retina specialist group; again, the difference was not statistically significant. No case of noninfectious endophthalmitis occurred in the resident group but two (0.68%) cases occurred in the retina specialist group; again, the difference was not significant. There were two (0.95%) cases of infectious endophthalmitis in the resident group and one (0.34%) case in the retina specialist group; again, the difference was not significant. No corneal erosion, traumatic lens damage, vitreous hemorrhage, or retinal tearing or detachment were noted in either group.Conclusions: Resident-performed intravitreal injections appear to be safe.