Two cases of acute abdomen after an intravitreal injection of bevacizumab

Delayed episode of necrotising enterocolitis in an ex-preterm infant after intravitreal administration of low-dose ranibizumab for the treatment of retinopathy of prematurity

Retinopathy of prematurity (ROP) and necrotising enterocolitis (NEC) are complications of prematurity. Despite being quite different in terms of incidence, pathogenesis and consequences, both share a pathogenic role of aberrant vascularisation: increased in ROP, deficient for NEC. Current therapy for ROP includes the use of anti-vascular endothelial growth factor (anti-VEGF) agents, which are able to interrupt retinal hypervascularity. Despite being delivered intravitreously, anti-VEGF used in ROP can be absorbed into circulation and exert systemic effects. We present here a case of an ex-27 weeks gestational age infant, presenting multiple NEC risk factors, treated at 2 months of age with low-dose ranibizumab, who developed a large bowel NEC episode in the first week after treatment. We believe that this further report of an association between anti-VEGF agents and NEC could be interesting for the identification of children at risk of severe adverse events and stimulating further research on the topic.

Nintedanib and ischemic colitis: Signal assessment with the integrated use of two types of real-world evidence, spontaneous reports of suspected adverse drug reactions, and observational data from large health-care databases

Purpose

Statistical screening of Vigibase, the global database of individual case safety reports, highlighted an association between the MedDRA Preferred Term (PT) “colitis” and nintedanib. Nintedanib is a protein kinase inhibitor authorized in accelerated regulatory procedures for the treatment of idiopathic pulmonary fibrosis (IPF). The aim of this report is to describe the integration of two types of real‐world evidence, spontaneous reports of adverse drug reactions (ADR), and observational health data (OHD) in the assessment of a post‐authorization safety signal of ischemic colitis.

Methods

Assessment of the statistical signal of “nintedanib – colitis” was undertaken using data from VigiBase, OHD from the Observational Heath Data Sciences and Informatics (OHDSI) collaborative, published literature, and openly available regulatory documents. Evidence synthesis was performed to support Bradford Hill criteria in causality assessment.

Results

Evidence for strength of association, specificity, consistency, and analogy was found upon review of the case series. OHD was used to calculate incidence rates of colitis in new users of nintedanib across multiple populations, supportive of consistency, and further evidence for strength of association. Literature review identified support for biological plausibility and analogy. Signal assessment was supplemented with characterization of real‐world users and exploration of potential risk factors using OHD.

Conclusions

An integrated approach using two forms of real‐world data, spontaneous reports of ADRs and data from observational databases allowed a comprehensive and efficient signal assessment of nintedanib and colitis. Further exploration of the complementary use of real‐time OHD in signal assessment could inform more efficient approaches to current signal management practices.

Necrotizing enterocolitis after intravitreal bevacizumab in an infant with Incontinentia Pigmenti - a case report

Background

Incontinentia Pigmenti is a rare disease affecting multiple organs. Fifty of patients show affection of the eye with retinopathy and possible amaurosis being the worst outcome. Treatment has commonly been panretinal laser coagulation but intravitreal application of bevacizumab as VEGF-inhibitor has shown to effectively suppress retinal neovascularization.

Case presentation

A six-week-old female infant with Incontinentia Pigmenti developed a foudroyant necrotizing enterocolitis shortly after intravitreal injection of bevazicumab due to a retinopathy with impending tractional detachment of the left eye. Since the onset of abdominal symptoms occurred immediately after the intravitreal application, a link between the two events seemed likely. Sequential analyses of the VEGF serum concentrations showed a massive suppression of endogenous VEGF with only a very slow recovery over weeks. Such a severe systemic adverse event has not been reported after intravitreal treatment with bevacizumab in an infant.

Conclusion

This case report shows a relevant systemic uptake of bevacizumab after intravitreal application as suppressed VEGF levels show. There seems to be a connection between suppressed VEGF levels and the onset of necrotizing enterocolitis. Therefore, treatment with bevacizumab should be carefully considered and further research is needed to assess this drug’s safety profile.

Ischaemic colitis associated with intravitreal administration of aflibercept: A first case report

In patients with age-related macular degeneration (AMD), the intravitreal injection of antivascular endothelial growth factor (anti-VEGF) agents reduces disease progression and choroidal neovascularization. We report on a first case of ischaemic colitis associated with intravitreal injection of the anti-VEGF agent aflibercept in an 80-year-old female patient. Conservative treatment resulted in a favourable clinical outcome. The anti-VEGF agent was discontinued, and the symptoms did not recur. Although the intravitreal injection of anti-VEGF agents has not previously been linked to the occurrence of ischaemic colitis, consideration of aflibercept's pharmacological properties and the chronological relationship between the administration of this anti-VEGF agent and the occurrence of this systemic adverse event are strongly suggestive of a causal relationship in the present case. Although systemic complications have been rarely associated with intravitreal injections of anti-VEGF agents, physicians should be aware that novel adverse events can still occur in AMD patients treated with anti-VEGF agents.

EDIL3 knockdown inhibits retinal angiogenesis through the induction of cell cycle arrest in vitro

Pathological retinal angiogenesis is one of the most common causes of blindness, with limited treatment options being currently available. Epidermal growth factor (EGF)-like repeat and discoidin I-like domain-containing protein 3 (EDIL3) has been reported to serve an important role in embryonic vasculogenesis and tumor angiogenesis; however, its implication in retinal angiogenesis has yet to be elucidated. The present study aimed to investigate the putative roles of EDIL3 in retinal endothelial cells. RNA interference was used to disrupt the expression of EDIL3 in human retinal endothelial cells (HRECs) in vitro, and the resulting effects were examined. Cell proliferation was assessed using cell counting kit-8 reagent, Cell migration was investigated using a transwell chamber and a tube formation assay was used to study angiogenic capability in vitro. Flow cytometry was used to detect the cell cycle distribution and western blotting was used to study protein expression. The present results demonstrated that silencing EDIL3 expression significantly impaired the proliferative, migratory and tube forming capabilities of HRECs. Furthermore, EDIL3 knockdown was revealed to induce cell cycle arrest at the G₁ phase. Western blot analysis suggested that the possible mechanisms underlying the antiproliferative effects of EDIL3 silencing may involve the inhibition of EGF receptor-mediated pathways, and the suppression of cyclin D1 and cyclin E1 expression in HRECs. In conclusion, the findings of the present study suggested that EDIL3 may be implicated in retinal angiogenesis, and may have potential as a novel therapeutic target for the treatment of pathological angiogenesis.