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Sheth JU, Stewart MW, Narayanan R, Anantharaman G, Chandran K, Lai TYY, Chakravarthy U, Das T. Macular neovascularization. Surv Ophthalmol 2024:S0039-6257(24)00095-X. [PMID: 39222802 DOI: 10.1016/j.survophthal.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 08/22/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
Neovascularization of the macula, a common complication of many chorioretinal diseases such as neovascular age-related macular degeneration, polypoidal choroidal vasculopathy, and pathologic myopia results from increased synthesis of vascular endothelial growth factor (VEGF) by the retinal pigment epithelium and/or Müller cells because of localized ischemia and inflammation. The Consensus on Neovascular AMD Nomenclature (CONAN) study group acknowledged that these vessels may originate from either the choriocapillaris or the retinal microvasculature, prompting them to propose the term 'macular neovascularization' (MNV) to include intraretinal, subretinal, and sub-pigment epithelial neovascularization localized to the macula. MNV frequently appears as a grey-green macular lesion with overlying intraretinal thickening and/or subretinal exudation, causing metamorphopsia, reduced central vision, relative central scotoma, decreased reading speed, and problems with color recognition. Multimodal imaging with optical coherence tomography (OCT), OCT angiography, dye-based angiographies, fundus autofluorescence, and multiwavelength photography help establish the diagnosis and aid in selecting an appropriate treatment. The standard of care for MNV is usually intravitreal anti-VEGF injections, though thermal laser photocoagulation, verteporfin photodynamic therapy, and vitreoretinal surgery are occasionally used. This current review discusses the etiology and clinical features of MNV, the role of multimodal imaging in establishing the diagnosis, and the available therapeutic options.
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Affiliation(s)
- Jay U Sheth
- Department of Vitreoretinal Services, Shantilal Shanghvi Eye Institute, Mumbai, India
| | - Michael W Stewart
- Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida, USA
| | - Raja Narayanan
- Anant Bajaj Retina Institute, Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Hyderabad, India
| | | | - Kiran Chandran
- Department of Vitreoretinal Services, Giridhar Eye Institute, Cochin, India
| | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong, Hong Kong
| | - Usha Chakravarthy
- Department of Ophthalmology and Vision Science, Queen's University of Belfast, Belfast, United Kingdom
| | - Taraprasad Das
- Department of Vitreoretinal Services, Shantilal Shanghvi Eye Institute, Mumbai, India; Anant Bajaj Retina Institute, Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Hyderabad, India
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Estarreja J, Mendes P, Silva C, Camacho P, Mateus V. Off-Label Use of Bevacizumab in Patients Diagnosed with Age-Related Macular Degeneration: A Systematic Review and Meta-Analysis. Pharmaceuticals (Basel) 2024; 17:1000. [PMID: 39204105 PMCID: PMC11357420 DOI: 10.3390/ph17081000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/18/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the leading cause of vision loss in elderly people. Current pharmacological treatment in vascular AMD includes anti-VEGF agents, such as ranibizumab and aflibercept. Additionally, the off-label use of bevacizumab has been shown to be effective and has a lower cost, making it an interesting pharmacological approach; however, there is no consensus about its use. Therefore, this systematic review and meta-analysis aims to evaluate the efficacy, safety, and efficiency of bevacizumab in AMD patients. METHODS This review only focused on randomized controlled clinical trials published in 2010 in the MEDLINE database that compared the effect of bevacizumab with ranibizumab. The risk of bias in each included study was assessed using the CASP Randomised Clinical Trials checklist. RESULTS Twelve studies were included for qualitative synthesis, and nine of them were considered for meta-analysis. Bevacizumab-treated patients showed a significantly reduced neovascularization in a longer spectrum of time; however, they had a higher incidence of endophthalmitis than those treated with ranibizumab. Regarding efficiency, the mean number of administrations was reduced in the treatment with bevacizumab in comparison to ranibizumab. CONCLUSIONS Clinical evidence demonstrates that bevacizumab has efficacy and safety profiles comparable with ranibizumab; however, it is relatively more efficient.
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Affiliation(s)
- João Estarreja
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
| | - Priscila Mendes
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
| | - Carina Silva
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
- Centro de Estatística e Aplicações, Universidade de Lisboa, 1749-016 Lisbon, Portugal
| | - Pedro Camacho
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
| | - Vanessa Mateus
- H&TRC—Health and Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-096 Lisbon, Portugal; (J.E.); (P.M.); (C.S.); (P.C.)
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Av. Professor Gama Pinto, 1649-003 Lisbon, Portugal
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Leitch IM, Gerometta M, Eichenbaum D, Finger RP, Steinle NC, Baldwin ME. Vascular Endothelial Growth Factor C and D Signaling Pathways as Potential Targets for the Treatment of Neovascular Age-Related Macular Degeneration: A Narrative Review. Ophthalmol Ther 2024; 13:1857-1875. [PMID: 38824253 PMCID: PMC11178757 DOI: 10.1007/s40123-024-00973-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/16/2024] [Indexed: 06/03/2024] Open
Abstract
The development of treatments targeting the vascular endothelial growth factor (VEGF) signaling pathways have traditionally been firstly investigated in oncology and then advanced into retinal disease indications. Members of the VEGF family of endogenous ligands and their respective receptors play a central role in vasculogenesis and angiogenesis during both development and physiological homeostasis. They can also play a pathogenic role in cancer and retinal diseases. Therapeutic approaches have mostly focused on targeting VEGF-A signaling; however, research has shown that VEGF-C and VEGF-D signaling pathways are also important to the disease pathogenesis of tumors and retinal diseases. This review highlights the important therapeutic advances and the remaining unmet need for improved therapies targeting additional mechanisms beyond VEGF-A. Additionally, it provides an overview of alternative VEGF-C and VEGF-D signaling involvement in both health and disease, highlighting their key contributions in the multifactorial pathophysiology of retinal disease including neovascular age-related macular degeneration (nAMD). Strategies for targeting VEGF-C/-D signaling pathways will also be reviewed, with an emphasis on agents currently being developed for the treatment of nAMD.
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Affiliation(s)
- Ian M Leitch
- Opthea Limited, 650 Chapel Street, Level 4, Melbourne, VIC, 3141, Australia.
| | - Michael Gerometta
- Opthea Limited, 650 Chapel Street, Level 4, Melbourne, VIC, 3141, Australia
| | - David Eichenbaum
- Retina Vitreous Associates of Florida, St. Petersburg, FL, 33711, USA
| | - Robert P Finger
- Department of Ophthalmology, Medical Faculty Mannheim, University of Heidelberg, 69117, Heidelberg, Germany
| | | | - Megan E Baldwin
- Opthea Limited, 650 Chapel Street, Level 4, Melbourne, VIC, 3141, Australia
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Kazemi MS, Shoari A, Salehibakhsh N, Aliabadi HAM, Abolhosseini M, Arab SS, Ahmadieh H, Kanavi MR, Behdani M. Anti-angiogenic biomolecules in neovascular age-related macular degeneration; therapeutics and drug delivery systems. Int J Pharm 2024; 659:124258. [PMID: 38782152 DOI: 10.1016/j.ijpharm.2024.124258] [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: 04/05/2024] [Revised: 05/10/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024]
Abstract
Blindness in the elderly is often caused by age-related macular degeneration (AMD). The advanced type of AMD known as neovascular AMD (nAMD) has been linked to being the predominant cause of visual impairment in these people. Multiple neovascular structures including choroidal neovascular (CNV) membranes, fluid exudation, hemorrhages, and subretinal fibrosis, are diagnostic of nAMD. These pathological alterations ultimately lead to anatomical and visual loss. It is known that vascular endothelial growth factor (VEGF), a type of proangiogenic factor, mediates the pathological process underlying nAMD. Therefore, various therapies have evolved to directly target the disease. In this review article, an attempt has been made to discuss general explanations about this disease, all common treatment methods based on anti-VEGF drugs, and the use of drug delivery systems in the treatment of AMD. Initially, the pathophysiology, angiogenesis, and different types of AMD were described. Then we described current treatments and future treatment prospects for AMD and outlined the advantages and disadvantages of each. In this context, we first examined the types of therapeutic biomolecules and anti-VEGF drugs that are used in the treatment of AMD. These biomolecules include aptamers, monoclonal antibodies, small interfering RNAs, microRNAs, peptides, fusion proteins, nanobodies, and other therapeutic biomolecules. Finally, we described drug delivery systems based on liposomes, nanomicelles, nanoemulsions, nanoparticles, cyclodextrin, dendrimers, and composite vehicles that are used in AMD therapy.
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Affiliation(s)
- Mir Salar Kazemi
- Biotechnology Research Centre, Venom and Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Iran
| | - Alireza Shoari
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | - Neda Salehibakhsh
- Biotechnology Research Centre, Venom and Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Iran; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Hooman Aghamirza Moghim Aliabadi
- Protein Chemistry Laboratory, Department of Medical Biotechnology, Biotechnology Research Center, Pasteur Institute of Iran, Tehran, Iran
| | - Mohammad Abolhosseini
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Shahriar Arab
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA; Department of Biophysics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mozhgan Rezaei Kanavi
- Ocular Tissue Engineering Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mahdi Behdani
- Biotechnology Research Centre, Venom and Biotherapeutics Molecules Laboratory, Pasteur Institute of Iran, Iran.
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Garg SJ, Hadziahmetovic M. Verteporfin Photodynamic Therapy for the Treatment of Chorioretinal Conditions: A Narrative Review. Clin Ophthalmol 2024; 18:1701-1716. [PMID: 38881707 PMCID: PMC11178081 DOI: 10.2147/opth.s464371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
Photodynamic therapy (PDT) with verteporfin involves intravenous administration of a photosensitizer followed by its laser light activation at the target site to inhibit aberrant choroidal vascularization. This narrative review provides an overview of the role verteporfin PDT plays in the management of chorioretinal conditions. A PubMed literature review of all English-language articles published through October 19, 2023, was conducted to identify relevant references. Verteporfin PDT has been shown to be safe and effective for the treatment of patients with choroidal neovascularization (CNV) due to neovascular age-related macular degeneration and is often used in combination with a vascular endothelial growth factor (VEGF) inhibitor. Additionally, patients with polypoidal choroidal vasculopathy, a subtype of neovascular age-related macular degeneration, also benefit from verteporfin PDT combined with a VEGF inhibitor for improving visual acuity. Verteporfin PDT has also been effective in treating patients with peripapillary CNV, as well as eyes with CNV due to ocular histoplasmosis and pathologic myopia. Reduced dose and/or fluence PDT protocols have been effective in patients with central serous chorioretinopathy while reducing adverse effects. In eyes with choroidal hemangioma, tumor regression and visual outcomes have been improved with verteporfin PDT treatment. Photodynamic therapy with verteporfin continues to play an important role in the management of chorioretinal conditions.
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Affiliation(s)
- Sunir J Garg
- Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
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Yiu G, Gulati S, Higgins V, Coak E, Mascia D, Kim E, Spicer G, Tabano D. Factors Involved in Anti-VEGF Treatment Decisions for Neovascular Age-Related Macular Degeneration: Insights from Real-World Clinical Practice. Clin Ophthalmol 2024; 18:1679-1690. [PMID: 38860119 PMCID: PMC11164198 DOI: 10.2147/opth.s461846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/21/2024] [Indexed: 06/12/2024] Open
Abstract
Background Anti-vascular endothelial growth factor (anti-VEGF) agents are widely prescribed for the treatment of neovascular age-related macular degeneration (nAMD). Although studies have investigated patient choice of anti-VEGF agent, little is known regarding factors that influence physician preference of anti-VEGF agent for their patients. Objective To describe physician rationale and challenges in prescribing anti-VEGF treatments for patients with nAMD. Methods Data were drawn from the Adelphi Real World nAMD Disease Specific Programme™, a cross-sectional survey with retrospective data capture of physicians and their patients with nAMD in the United States between October 2021 and May 2022. Physicians (n = 56) reported data for up to 13 consecutively consulting patients (n = 451), including current anti-VEGF treatments used, factors affecting physicians' choice of anti-VEGF agent and treatment strategy, and restrictions on specific agents. Results Most physicians prefer employing a "treat-and-extend" treatment strategy, over "fixed interval" or "pro re nata" strategies. However, in routine clinical practice, "treat-and-extend" was reported for less than half of nAMD-diagnosed eyes. Top factors influencing physician choice of anti-VEGF agent and treatment strategy included maximizing clinical benefit (eg visual acuity gains and fluid control), patient convenience, and reducing out-of-pocket costs. However, physicians also reported facing substantial roadblocks in prescribing their choice of anti-VEGF agent, including restrictions on approved agents and gaps in insurance coverage. Persistent fluid was the most common physician-selected reason for switching a patient away from an anti-VEGF agent. Conclusion Physicians face barriers to prescribing their preferred anti-VEGF agents in real-world healthcare settings. Overcoming these challenges may improve treatment outcomes for patients with nAMD.
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Affiliation(s)
- Glenn Yiu
- Department of Ophthalmology & Vision Science, University of California, Davis Health, Sacramento, CA, USA
| | - Shilpa Gulati
- New England Retina Consultants, Springfield, MA, USA
| | | | | | | | - Eunice Kim
- Genentech, Inc., South San Francisco, CA, USA
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Cohen JR, Brych SR, Prabhu S, Bi V, Elbaradei A, Tokuda JM, Xiang C, Hokom M, Cui X, Ly C, Amos N, Sun J, Calamba D, Herskovitz J, Capili A, Nourbakhsh K, Merlo A, Carreon J, Wypych J, Narhi LO, Jawa V, Joubert MK. A High Threshold of Biotherapeutic Aggregate Numbers is Needed to Induce an Immunogenic Response In Vitro, In Vivo, and in the Clinic. Pharm Res 2024; 41:651-672. [PMID: 38519817 DOI: 10.1007/s11095-024-03678-2] [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: 09/29/2023] [Accepted: 02/15/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND AND PURPOSE There is concern that subvisible aggregates in biotherapeutic drug products pose a risk to patient safety. We investigated the threshold of biotherapeutic aggregates needed to induce immunogenic responses. METHODS AND RESULTS Highly aggregated samples were tested in cell-based assays and induced cellular responses in a manner that depended on the number of particles. The threshold of immune activation varied by disease state (cancer, rheumatoid arthritis, allergy), concomitant therapies, and particle number. Compared to healthy donors, disease state patients showed an equal or lower response at the late phase (7 days), suggesting they may not have a higher risk of responding to aggregates. Xeno-het mice were used to assess the threshold of immune activation in vivo. Although highly aggregated samples (~ 1,600,000 particles/mL) induced a weak and transient immunogenic response in mice, a 100-fold dilution of this sample (~ 16,000 particles/mL) did not induce immunogenicity. To confirm this result, subvisible particles (up to ~ 18,000 particles/mL, containing aggregates and silicone oil droplets) produced under representative administration practices (created upon infusion of a drug product through an IV catheter) did not induce a response in cell-based assays or appear to increase the rate of adverse events or immunogenicity during phase 3 clinical trials. CONCLUSION The ability of biotherapeutic aggregates to elicit an immune response in vitro, in vivo, and in the clinic depends on high numbers of particles. This suggests that there is a high threshold for aggregates to induce an immunogenic response which is well beyond that seen in standard biotherapeutic drug products.
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Affiliation(s)
- Joseph R Cohen
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA.
| | - Stephen R Brych
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Siddharth Prabhu
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Vivian Bi
- The Department of Biosimilars, Amgen Inc, Thousand Oaks, CA, 91320, USA
| | - Ahmed Elbaradei
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Joshua M Tokuda
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Cathie Xiang
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Martha Hokom
- The Department of Clinical Immunology, Amgen Inc, Thousand Oaks, CA, 91320, USA
- Department of BioAnalytical Sciences, Genentech, Inc, South San Francisco, CA, 94080, USA
| | - Xiaohong Cui
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Claudia Ly
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Nathan Amos
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Jilin Sun
- Translational Safety and Bioanalytical Sciences, Amgen Inc, Thousand Oaks, CA, 91320, USA
| | - Dominador Calamba
- Translational Safety and Bioanalytical Sciences, Amgen Inc, Thousand Oaks, CA, 91320, USA
| | - Jonathan Herskovitz
- The Department of Clinical Immunology, Amgen Inc, Thousand Oaks, CA, 91320, USA
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Allyson Capili
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Kimya Nourbakhsh
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Anthony Merlo
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Julia Carreon
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Jette Wypych
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Linda O Narhi
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA
| | - Vibha Jawa
- The Department of Clinical Immunology, Amgen Inc, Thousand Oaks, CA, 91320, USA
- Department of Pharmacometrics, Disposition & Bioanalysis, Bristol Myers Squibb, Princeton, NJ, 08543, USA
| | - Marisa K Joubert
- The Department of Process Development, Amgen Inc, One Amgen Center Dr, Thousand Oaks, CA, 91320, USA.
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Mulkutkar M, Damani M, Sawarkar S. Polymeric microneedles for the eye: An overview of advances and ocular applications for minimally invasive drug delivery. Eur J Pharm Biopharm 2024; 197:114209. [PMID: 38336234 DOI: 10.1016/j.ejpb.2024.114209] [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: 10/08/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024]
Abstract
Ocular drug delivery is challenging due to the presence of tissue barriers and clearance mechanisms. Most widely used topical formulations need frequent application because of poor permeability, short retention, and low bioavailability. Invasive intraocular injections and implants that deliver drugs at the target site are associated with infections, inflammation, and even vision loss post-use. These gaps can be addressed by a delivery platform that can efficiently deliver drug with minimal tissue damage. Microneedles were introduced as a delivery platform for overcoming dermal barriers with minimal tissue damage. After the successful clinical transition of microneedles in the transdermal drug delivery, they are now being extensively studied for ocular applications. The attributes of minimally invasive application and the capability to deliver a wide range of therapeutics make microneedles an attractive candidate for ocular drug delivery. The current manuscript provides a detailed overview of the recent advancements in the field of microneedles for ocular use. This paper reviews research focusing on polymeric microneedles and their pharmaceutical and biopharmaceutical properties. A brief discussion about their clinical translation and regulatory concerns is also covered. The multitude of research articles supports the fact that microneedles are a potential, minimally invasive drug delivery platform for ophthalmic use.
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Affiliation(s)
- Madhura Mulkutkar
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, Mumbai, India
| | - Mansi Damani
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, Mumbai, India
| | - Sujata Sawarkar
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, Mumbai, India.
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Seo JH, Lee Y. Causal Associations of Glaucoma and Age-Related Macular Degeneration with Cataract: A Bidirectional Two-Sample Mendelian Randomisation Study. Genes (Basel) 2024; 15:413. [PMID: 38674349 PMCID: PMC11049509 DOI: 10.3390/genes15040413] [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: 01/28/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/28/2024] Open
Abstract
Common age-related eye disorders include glaucoma, cataract, and age-related macular degeneration (AMD); however, little is known about their relationship with age. This study investigated the potential causal relationship between glaucoma and AMD with cataract using genetic data from multi-ethnic populations. Single-nucleotide polymorphisms (SNPs) associated with exposure to cataract were selected as instrumental variables (IVs) from genome-wide association studies using meta-analysis data from BioBank Japan and UK Biobank. A bidirectional two-sample Mendelian randomisation (MR) study was conducted to assess the causal estimates using inverse variance weighted, MR-Egger, and MR pleiotropy residual sum and outlier tests. SNPs with (p < 5.0 × 10-8) were selected as IVs for cataract, primary open-angle glaucoma, and AMD. We found no causal effects of cataract on glaucoma or AMD (all p > 0.05). Furthermore, there were no causal effects of AMD on cataract (odds ratio [OR] = 1.02, p = 0.400). However, glaucoma had a substantial causal effect on cataract (OR = 1.14, p = 0.020). Our study found no evidence for a causal relationship of cataract on glaucoma or AMD and a casual effect of AMD on cataract. Nonetheless, glaucoma demonstrates a causal link with cataract formation, indicating the need for future investigations of age-related eye diseases.
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Affiliation(s)
- Je Hyun Seo
- Veterans Medical Research Institute, Veterans Health Service Medical Center, Seoul 05368, Republic of Korea;
| | - Young Lee
- Veterans Medical Research Institute, Veterans Health Service Medical Center, Seoul 05368, Republic of Korea;
- Department of Applied Statistics, Chung-Ang University, Seoul 06974, Republic of Korea
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Maunz A, Barras L, Kawczynski MG, Dai J, Lee AY, Spaide RF, Sahni J, Ferrara D. Machine Learning to Predict Response to Ranibizumab in Neovascular Age-Related Macular Degeneration. OPHTHALMOLOGY SCIENCE 2023; 3:100319. [PMID: 37304043 PMCID: PMC10251067 DOI: 10.1016/j.xops.2023.100319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 06/13/2023]
Abstract
Purpose Neovascular age-related macular degeneration (nAMD) shows variable treatment response to intravitreal anti-VEGF. This analysis compared the potential of different artificial intelligence (AI)-based machine learning models using OCT and clinical variables to accurately predict at baseline the best-corrected visual acuity (BCVA) at 9 months in response to ranibizumab in patients with nAMD. Design Retrospective analysis. Participants Baseline and imaging data from patients with subfoveal choroidal neovascularization secondary to age-related macular dengeration. Methods Baseline data from 502 study eyes from the HARBOR (NCT00891735) prospective clinical trial (monthly ranibizumab 0.5 and 2.0 mg arms) were pooled; 432 baseline OCT volume scans were included in the analysis. Seven models, based on baseline quantitative OCT features (Least absolute shrinkage and selection operator [Lasso] OCT minimum [min], Lasso OCT 1 standard error [SE]); on quantitative OCT features and clinical variables at baseline (Lasso min, Lasso 1SE, CatBoost, RF [random forest]); or on baseline OCT images only (deep learning [DL] model), were systematically compared with a benchmark linear model of baseline age and BCVA. Quantitative OCT features were derived by a DL segmentation model on the volume images, including retinal layer volumes and thicknesses, and retinal fluid biomarkers, including statistics on fluid volume and distribution. Main Outcome Measures Prognostic ability of the models was evaluated using coefficient of determination (R2) and median absolute error (MAE; letters). Results In the first cross-validation split, mean R2 (MAE) of the Lasso min, Lasso 1SE, CatBoost, and RF models was 0.46 (7.87), 0.42 (8.43), 0.45 (7.75), and 0.43 (7.60), respectively. These models ranked higher than or similar to the benchmark model (mean R2, 0.41; mean MAE, 8.20 letters) and better than OCT-only models (mean R2: Lasso OCT min, 0.20; Lasso OCT 1SE, 0.16; DL, 0.34). The Lasso min model was selected for detailed analysis; mean R2 (MAE) of the Lasso min and benchmark models for 1000 repeated cross-validation splits were 0.46 (7.7) and 0.42 (8.0), respectively. Conclusions Machine learning models based on AI-segmented OCT features and clinical variables at baseline may predict future response to ranibizumab treatment in patients with nAMD. However, further developments will be needed to realize the clinical utility of such AI-based tools. Financial Disclosures Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Andreas Maunz
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Laura Barras
- Roche Data & Statistical Sciences, Genentech, Inc, South San Francisco, California
| | - Michael G. Kawczynski
- Roche Personalized Healthcare Program, Genentech, Inc, South San Francisco, California
| | - Jian Dai
- Roche Personalized Healthcare Program, Genentech, Inc, South San Francisco, California
| | - Aaron Y. Lee
- Department of Ophthalmology, School of Medicine, University of Washington, Seattle, Washington
| | | | - Jayashree Sahni
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - Daniela Ferrara
- Roche Personalized Healthcare Program, Genentech, Inc, South San Francisco, California
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11
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Latifi-Navid H, Barzegar Behrooz A, Jamehdor S, Davari M, Latifinavid M, Zolfaghari N, Piroozmand S, Taghizadeh S, Bourbour M, Shemshaki G, Latifi-Navid S, Arab SS, Soheili ZS, Ahmadieh H, Sheibani N. Construction of an Exudative Age-Related Macular Degeneration Diagnostic and Therapeutic Molecular Network Using Multi-Layer Network Analysis, a Fuzzy Logic Model, and Deep Learning Techniques: Are Retinal and Brain Neurodegenerative Disorders Related? Pharmaceuticals (Basel) 2023; 16:1555. [PMID: 38004422 PMCID: PMC10674956 DOI: 10.3390/ph16111555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
Neovascular age-related macular degeneration (nAMD) is a leading cause of irreversible visual impairment in the elderly. The current management of nAMD is limited and involves regular intravitreal administration of anti-vascular endothelial growth factor (anti-VEGF). However, the effectiveness of these treatments is limited by overlapping and compensatory pathways leading to unresponsiveness to anti-VEGF treatments in a significant portion of nAMD patients. Therefore, a system view of pathways involved in pathophysiology of nAMD will have significant clinical value. The aim of this study was to identify proteins, miRNAs, long non-coding RNAs (lncRNAs), various metabolites, and single-nucleotide polymorphisms (SNPs) with a significant role in the pathogenesis of nAMD. To accomplish this goal, we conducted a multi-layer network analysis, which identified 30 key genes, six miRNAs, and four lncRNAs. We also found three key metabolites that are common with AMD, Alzheimer's disease (AD) and schizophrenia. Moreover, we identified nine key SNPs and their related genes that are common among AMD, AD, schizophrenia, multiple sclerosis (MS), and Parkinson's disease (PD). Thus, our findings suggest that there exists a connection between nAMD and the aforementioned neurodegenerative disorders. In addition, our study also demonstrates the effectiveness of using artificial intelligence, specifically the LSTM network, a fuzzy logic model, and genetic algorithms, to identify important metabolites in complex metabolic pathways to open new avenues for the design and/or repurposing of drugs for nAMD treatment.
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Affiliation(s)
- Hamid Latifi-Navid
- Department of Molecular Medicine, National Institute of Genetic Engineering and Biotechnology, Tehran 1497716316, Iran; (H.L.-N.); (M.D.); (N.Z.); (S.P.); (S.T.); (Z.-S.S.)
- Departments of Ophthalmology and Visual Sciences and Cell and Regenerative Biology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Amir Barzegar Behrooz
- Department of Human Anatomy and Cell Science, University of Manitoba College of Medicine, Winnipeg, MB R3T 2N2, Canada;
- Electrophysiology Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran 1416634793, Iran
| | - Saleh Jamehdor
- Department of Virology, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan 6517838636, Iran;
| | - Maliheh Davari
- Department of Molecular Medicine, National Institute of Genetic Engineering and Biotechnology, Tehran 1497716316, Iran; (H.L.-N.); (M.D.); (N.Z.); (S.P.); (S.T.); (Z.-S.S.)
| | - Masoud Latifinavid
- Department of Mechatronic Engineering, University of Turkish Aeronautical Association, 06790 Ankara, Turkey;
| | - Narges Zolfaghari
- Department of Molecular Medicine, National Institute of Genetic Engineering and Biotechnology, Tehran 1497716316, Iran; (H.L.-N.); (M.D.); (N.Z.); (S.P.); (S.T.); (Z.-S.S.)
| | - Somayeh Piroozmand
- Department of Molecular Medicine, National Institute of Genetic Engineering and Biotechnology, Tehran 1497716316, Iran; (H.L.-N.); (M.D.); (N.Z.); (S.P.); (S.T.); (Z.-S.S.)
| | - Sepideh Taghizadeh
- Department of Molecular Medicine, National Institute of Genetic Engineering and Biotechnology, Tehran 1497716316, Iran; (H.L.-N.); (M.D.); (N.Z.); (S.P.); (S.T.); (Z.-S.S.)
- Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5C1, Canada
| | - Mahsa Bourbour
- Department of Biotechnology, Alzahra University, Tehran 1993893973, Iran;
| | - Golnaz Shemshaki
- Department of Studies in Zoology, University of Mysore, Manasagangothri, Mysore 570005, India;
| | - Saeid Latifi-Navid
- Department of Biology, Faculty of Sciences, University of Mohaghegh Ardabili, Ardabil 5619911367, Iran;
| | - Seyed Shahriar Arab
- Biophysics Department, Faculty of Biological Sciences, Tarbiat Modares University, Tehran 1411713116, Iran;
| | - Zahra-Soheila Soheili
- Department of Molecular Medicine, National Institute of Genetic Engineering and Biotechnology, Tehran 1497716316, Iran; (H.L.-N.); (M.D.); (N.Z.); (S.P.); (S.T.); (Z.-S.S.)
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran 1666673111, Iran;
| | - Nader Sheibani
- Departments of Ophthalmology and Visual Sciences and Cell and Regenerative Biology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
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12
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Loewenstein A, Berger A, Daly A, Creuzot-Garcher C, Gale R, Ricci F, Zarranz-Ventura J, Guymer R. Save our Sight (SOS): a collective call-to-action for enhanced retinal care across health systems in high income countries. Eye (Lond) 2023; 37:3351-3359. [PMID: 37280350 PMCID: PMC10630379 DOI: 10.1038/s41433-023-02540-w] [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: 02/07/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/08/2023] Open
Abstract
With a growing aging population, the prevalence of age-related eye disease and associated eye care is expected to increase. The anticipated growth in demand, coupled with recent medical advances that have transformed eye care for people living with retinal diseases, particularly neovascular age-related macular degeneration (nAMD) and diabetic eye disease, has presented an opportunity for health systems to proactively manage the expected burden of these diseases. To do so, we must take collective action to address existing and anticipated capacity limitations by designing and implementing sustainable strategies that enable health systems to provide an optimal standard of care. Sufficient capacity will enable us to streamline and personalize the patient experience, reduce treatment burden, enable more equitable access to care and ensure optimal health outcomes. Through a multi-modal approach that gathered unbiased perspectives from clinical experts and patient advocates from eight high-income countries, substantiated perspectives with evidence from the published literature and validated findings with the broader eye care community, we have exposed capacity challenges that are motivating the community to take action and advocate for change. Herein, we propose a collective call-to-action for the future management of retinal diseases and potential strategies to achieve better health outcomes for individuals at-risk of, or living with, retinal disease.
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Affiliation(s)
- Anat Loewenstein
- Ophthalmology Division, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.
| | - Alan Berger
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Toronto Retina Institute, Toronto, ON, Canada
| | | | | | - Richard Gale
- Hull York Medical School, University of York, York, UK
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Federico Ricci
- Dept. Experimental Medicine - University Tor Vergata of Rome, Rome, Italy
| | - Javier Zarranz-Ventura
- Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- August Pi and Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Robyn Guymer
- Centre for Eye Research, Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, VIC, Australia
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13
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Weng CY, Singh RP, Gillies MC, Regillo CD. Optimizing Visual Outcomes in Patients With Neovascular Age-Related Macular Degeneration: the Potential Value of Sustained Anti-VEGF Therapy. Ophthalmic Surg Lasers Imaging Retina 2023; 54:654-659. [PMID: 37956321 DOI: 10.3928/23258160-20231016-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Neovascular age-related macular degeneration (nAMD) leads to irreversible central vision loss if untreated. Frequent administration of anti-vascular endothelial growth factor (anti-VEGF) injections inhibits disease activity with excellent functional and morphological benefits. However, these injections pose a heavy therapeutic burden, and treatment discontinuation is common. Although current anti-VEGF treatment paradigms, such as treat-and-extend, mitigate treatment burden while still leading to acceptable vision outcomes, they fail to sustain initial vision gains for many. Novel longer-acting anti-VEGF therapies may reduce the overall burden on nAMD patients. Gene therapy might offer a paradigm shift by providing continuous expression of anti-VEGF, potentially decreasing treatment requirements and improving long-term vision outcomes. [Ophthalmic Surg Lasers Imaging Retina 2023;54:654-659.].
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14
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Loewenstein A, Czumbel N, Ernest J, Dusová J, Pearlman J, Nowosielska A. Randomized Trial of Biosimilar XSB-001 versus Reference Ranibizumab in Patients with Neovascular Age-Related Macular Degeneration. Ophthalmol Retina 2023; 7:753-761. [PMID: 37179017 DOI: 10.1016/j.oret.2023.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To evaluate the efficacy, safety, and immunogenicity of a ranibizumab biosimilar candidate (XSB-001) versus reference product (Lucentis) for neovascular age-related macular degeneration (nAMD). DESIGN Phase III, multicenter, randomized, double-masked, parallel-group study. PARTICIPANTS Patients with nAMD. METHODS Eligible patients were randomized (1:1) to receive intravitreal injections of XSB-001 or reference ranibizumab (0.5 mg [0.05 ml]) in the study eye once every 4 weeks for 52 weeks. Efficacy and safety assessments continued through 52 weeks of treatment. MAIN OUTCOME MEASURES Primary end point was change from baseline in best-corrected visual acuity (BCVA) by ETDRS letters at week 8. Biosimilarity was concluded if the 2-sided 90% confidence interval (CI) (United States) or 95% CI (rest of world) for the difference in least-squares (LS) mean change in BCVA at week 8 between treatment groups was within the predefined equivalence margin of ± 3.5 letters. RESULTS In total, 582 patients (n = 292 XSB-001, n = 290 reference ranibizumab) were randomized. Mean age was 74.1 years, most patients (85.2%) were White, and 55.8% were women. Mean BCVA score at baseline was 61.7 and 61.5 ETDRS letters in the XSB-001 and reference ranibizumab groups, respectively. At week 8, the LS mean (standard error [SE]) change in BCVA from baseline was 4.6 (0.5) ETDRS letters in the XSB-001 group and 6.4 (0.5) letters in the reference ranibizumab group (LS mean [SE] treatment difference: -1.8 [0.7] ETDRS letters; 90% CI, -2.9 to -0.7; 95% CI, -3.1 to -0.5). The 90% CI and 95% CI for LS mean difference in change from baseline were within the predefined equivalence margin. At week 52, LS mean (SE) change in BCVA was 6.4 (0.8) and 7.8 (0.8) letters, respectively (LS mean [SE] treatment difference, -1.5 [1.1] ETDRS letters; 90% CI, -3.3 to 0.4; 95% CI, -3.6 to 0.7). There were no clinically meaningful differences between treatments in anatomical, safety, or immunogenicity end points through week 52. CONCLUSIONS XSB-001 demonstrated biosimilarity to reference ranibizumab in patients with nAMD. Treatment with XSB-001 for 52 weeks was generally safe and well tolerated, with a safety profile similar to the reference product. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Anat Loewenstein
- Tel Aviv Medical Center and Tel Aviv University, Tel Aviv, Israel.
| | - Norbert Czumbel
- Jahn Ferenc Dél-Pesti Kórház és Rendelőintézet, Budapest, Hungary
| | - Jan Ernest
- Central Military Hospital, Prague, Czech Republic; Axon Clinical Ltd., Clinical Research Centre, Prague, Czech Republic
| | - Jaroslava Dusová
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Joel Pearlman
- Retina Consultants Medical Group, Sacramento, California
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15
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Ryu W, Park CW, Kim J, Lee H, Chung H. The Bcl-2/Bcl-xL Inhibitor ABT-263 Attenuates Retinal Degeneration by Selectively Inducing Apoptosis in Senescent Retinal Pigment Epithelial Cells. Mol Cells 2023; 46:420-429. [PMID: 37222160 PMCID: PMC10336274 DOI: 10.14348/molcells.2023.2188] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/18/2023] [Accepted: 02/12/2023] [Indexed: 05/25/2023] Open
Abstract
Age-related macular degeneration (AMD) is one of the leading causes of blindness in elderly individuals. However, the currently used intravitreal injections of anti-vascular endothelial growth factor are invasive, and repetitive injections are also accompanied by a risk of intraocular infection. The pathogenic mechanism of AMD is still not completely understood, but a multifactorial mechanism that combines genetic predisposition and environmental factors, including cellular senescence, has been suggested. Cellular senescence refers to the accumulation of cells that stop dividing due to the presence of free radicals and DNA damage. Characteristics of senescent cells include nuclear hypertrophy, increased levels of cell cycle inhibitors such as p16 and p21, and resistance to apoptosis. Senolytic drugs remove senescent cells by targeting the main characteristics of these cells. One of the senolytic drugs, ABT-263, which inhibits the antiapoptotic functions of Bcl-2 and Bcl-xL, may be a new treatment for AMD patients because it targets senescent retinal pigment epithelium (RPE) cells. We proved that it selectively kills doxorubicin (Dox)-induced senescent ARPE-19 cells by activating apoptosis. By removing senescent cells, the expression of inflammatory cytokines was reduced, and the proliferation of the remaining cells was increased. When ABT-263 was orally administered to the mouse model of senescent RPE cells induced by Dox, we confirmed that senescent RPE cells were selectively removed and retinal degeneration was alleviated. Therefore, we suggest that ABT-263, which removes senescent RPE cells through its senolytic effect, has the potential to be the first orally administered senolytic drug for the treatment of AMD.
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Affiliation(s)
- Wonseon Ryu
- Department of Ophthalmology, Konkuk University School of Medicine, Seoul 05029, Korea
| | - Chul-Woo Park
- Department of Ophthalmology, Konkuk University School of Medicine, Seoul 05029, Korea
| | - Junghoon Kim
- Department of Ophthalmology, Konkuk University School of Medicine, Seoul 05029, Korea
| | - Hyungwoo Lee
- Department of Ophthalmology, Konkuk University School of Medicine, Seoul 05029, Korea
- Department of Ophthalmology, Konkuk University Medical Center, Seoul 05030, Korea
| | - Hyewon Chung
- Department of Ophthalmology, Konkuk University School of Medicine, Seoul 05029, Korea
- Department of Ophthalmology, Konkuk University Medical Center, Seoul 05030, Korea
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16
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Cao Y, Langer R, Ferrara N. Targeting angiogenesis in oncology, ophthalmology and beyond. Nat Rev Drug Discov 2023; 22:476-495. [PMID: 37041221 DOI: 10.1038/s41573-023-00671-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 04/13/2023]
Abstract
Angiogenesis is an essential process in normal development and in adult physiology, but can be disrupted in numerous diseases. The concept of targeting angiogenesis for treating diseases was proposed more than 50 years ago, and the first two drugs targeting vascular endothelial growth factor (VEGF), bevacizumab and pegaptanib, were approved in 2004 for the treatment of cancer and neovascular ophthalmic diseases, respectively. Since then, nearly 20 years of clinical experience with anti-angiogenic drugs (AADs) have demonstrated the importance of this therapeutic modality for these disorders. However, there is a need to improve clinical outcomes by enhancing therapeutic efficacy, overcoming drug resistance, defining surrogate markers, combining with other drugs and developing the next generation of therapeutics. In this Review, we examine emerging new targets, the development of new drugs and challenging issues such as the mode of action of AADs and elucidating mechanisms underlying clinical benefits; we also discuss possible future directions of the field.
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Affiliation(s)
- Yihai Cao
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden.
| | - Robert Langer
- David H Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Napoleone Ferrara
- Department of Pathology, University of California San Diego, La Jolla, CA, USA.
- Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA.
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA.
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17
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Ma P, Pan X, Liu R, Qu Y, Xie L, Xie J, Cao L, Chen Y. Ocular adverse events associated with anti-VEGF therapy: A pharmacovigilance study of the FDA adverse event reporting system (FAERS). Front Pharmacol 2022; 13:1017889. [PMID: 36467087 PMCID: PMC9716077 DOI: 10.3389/fphar.2022.1017889] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/07/2022] [Indexed: 07/30/2023] Open
Abstract
Background: The purpose of this study is to identify and characterize ocular adverse events (AEs) that are significantly associated with anti-VEGF drugs for treatment of neovascular age-related macular degeneration and compare the differences between each drug, and provide clinical reference. Methods: Ocular AEs submitted to the US Food and Drug Administration were analyzed to map the safety profile of anti-VEGF drugs. The Pharmacovigilance tools used for the quantitative detection of signals were reporting odds ratio and bayesian confidence propagation neural network. Results: A total of 10,608,503 AE reports were retrieved from FAERS, with 20,836 for ranibizumab, 19,107 for aflibercept, and 2,442 for brolucizumab between the reporting period of Q1, 2004 and Q3, 2021. We found and analyzed the different AEs with the strongest signal in each drug-ranibizumab-macular ischaemia (ROR = 205.27, IC-2SD = 3.70), retinal pigment epithelial tear (ROR = 836.54, IC-2SD = 7.19); aflibercept-intraocular pressure increased (ROR = 31.09, IC-2SD = 4.61), endophthalmitis (ROR = 178.27, IC-2SD = 6.70); brolucizumab-retinal vasculitis (ROR = 2930.41, IC-2SD = 7.47) and/or retinal artery occlusion (ROR = 391.11, IC-2SD = 6.10), dry eye (ROR = 12.48, IC-2SD = 2.88). Conclusion: The presence of AEs should bring clinical attention. The use of anti-VEGF drugs should be based on the patient's underlying or present medical condition to reduce any adverse event associated with the treatment.
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Affiliation(s)
- Pan Ma
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xinmei Pan
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Ruixiang Liu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Ya Qu
- Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Linli Xie
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Jiangchuan Xie
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Liya Cao
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yongchuan Chen
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
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18
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Current and Novel Therapeutic Approaches for Treatment of Neovascular Age-Related Macular Degeneration. Biomolecules 2022; 12:biom12111629. [PMID: 36358978 PMCID: PMC9688017 DOI: 10.3390/biom12111629] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/10/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Age-related macular degeneration AMD is one of the leading causes of blindness in the elderly population. An advanced form of AMD known as neovascular AMD (nAMD) is implicated as the main attributor of visual loss among these patients. The hallmark feature of nAMD is the presence of neovascular structures known as choroidal neovascular membranes (CNVs), along with fluid exudation, hemorrhages, and subretinal fibrosis. These pathological changes eventually result in anatomical and visual loss. A type of proangiogenic factor known as vascular endothelial growth factor (VEGF) has been known to mediate the pathological process behind nAMD. Therefore, therapy has transitioned over the years from laser therapy that ablates the lesions to using Anti-VEGF to target the pathology directly. In this work, we provide an overview of current and emerging therapies for the treatment of nAMD. Currently approved Anti-VEGF agents include ranibizumab, aflibercept, and brolucizumab. Bevacizumab, also an Anti-VEGF agent, is used to manage nAMD even though this is an off-label use. While Anti-VEGF agents have provided a favorable prognosis for nAMD, they are associated with a substantial financial burden for patients and the healthcare system, due to their high cost as well as the need for frequent repeat treatments and visits. Emerging therapies and studies aim to extend the intervals between required treatments and introduce new treatment modalities that would improve patients’ compliance and provide superior results.
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19
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Vyawahare H, Shinde P. Age-Related Macular Degeneration: Epidemiology, Pathophysiology, Diagnosis, and Treatment. Cureus 2022; 14:e29583. [PMID: 36312607 PMCID: PMC9595233 DOI: 10.7759/cureus.29583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/25/2022] [Indexed: 11/24/2022] Open
Abstract
The greatest global root of irremediable amaurosis in the venerable is age-related macular degeneration (AMD), a complex eye condition. Clinically, AMD is characterized as being in an early stage to late stage and initially affects the macula, which is the center of the retina (advanced AMD). Age-related cellular and metabolic imbalance are made worse by the creation of excessive amounts of free radical species, which causes mitochondrial malfunction. As a result, in AMD-affected eyes, the deprivation of melanocytes, confection, and eventually atrophy within the retinal tissue are caused by the continued proliferation of oxidative stress caused by systemic antioxidant capacity depletion. In the urbanized, industrialized world, age-related macular degeneration (AMD) is one of the major causes of central vision loss in the older age group. Although several causes and mechanisms for the dysfunction and degeneration of the retinal pigment epithelium (RPE) have previously been identified, the condition’s symptoms are still not fully understood. Etiopathogenesis is still not entirely understood. As a result, the RPE fails, allowing an accumulation of aberrant misfolded proteins, due to the loss of anatomical control over oppression, altered homeostasis, dysfunctional lipid homeostasis, and failure of mitochondria. Due to the multitude of interconnected processes, numerous complicated therapy combinations will probably be the best option to deliver the best visual outcomes; these combinations will vary depending on the kind and degree of the condition being treated. Undoubtedly, this will lead to the development of customized preventative medications and, hopefully, the revelation of a potential cure. All the mechanisms involved in the etiology of AMD should be continuously probed to create covariates for other contemporaneous or future problems.
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20
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Design, construction and in vivo functional assessment of a hinge truncated sFLT01. Gene Ther 2022; 30:347-361. [PMID: 36114375 DOI: 10.1038/s41434-022-00362-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 08/05/2022] [Accepted: 08/26/2022] [Indexed: 11/08/2022]
Abstract
Gene therapy for the treatment of ocular neovascularization has reached clinical trial phases. The AAV2-sFLT01 construct was already evaluated in a phase 1 open-label trial administered intravitreally to patients with advanced neovascular age-related macular degeneration. SFLT01 protein functions by binding to VEGF and PlGF molecules and inhibiting their activities simultaneously. It consists of human VEGFR1/Flt-1 (hVEGFR1), a polyglycine linker, and the Fc region of human IgG1. The IgG1 upper hinge region of the sFLT01 molecule makes it vulnerable to radical attacks and prone to causing immune reactions. This study pursued two goals: (i) minimizing the immunogenicity and vulnerability of the molecule by designing a truncated molecule called htsFLT01 (hinge truncated sFLT01) that lacked the IgG1 upper hinge and lacked 2 amino acids from the core hinge region; and (ii) investigating the structural and functional properties of the aforesaid chimeric molecule at different levels (in silico, in vitro, and in vivo). Molecular dynamics simulations and molecular mechanics energies combined with Poisson-Boltzmann and surface area continuum solvation calculations revealed comparable free energy of binding and binding affinity for sFLT01 and htsFLT01 to their cognate ligands. Conditioned media from human retinal pigment epithelial (hRPE) cells that expressed htsFLT01 significantly reduced tube formation in HUVECs. The AAV2-htsFLT01 virus suppressed vascular development in the eyes of newborn mice. The htsFLT01 gene construct is a novel anti-angiogenic tool with promising improvements compared to existing treatments.
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21
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Eichenbaum DA, Ahmed A, Hiya F. Ranibizumab port delivery system: a clinical perspective. BMJ Open Ophthalmol 2022; 7:bmjophth-2022-001104. [PMID: 36161829 PMCID: PMC9516155 DOI: 10.1136/bmjophth-2022-001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Age-related macular degeneration (AMD) represents a leading cause of blindness worldwide. Neovascular AMD (nAMD) is a subtype of AMD most frequently treated with intravitreal anti-vascular endothelial growth factor (aVEGF) injections, which has allowed for patients to maintain vision that would have otherwise been lost. However, the need for frequent intravitreal injections for optimal results poses a risk for undertreatment in nAMD patients due to the high treatment burden associated with current aVEGF therapy. Many novel agents and pathways are being explored and targeted for less burdensome treatment options, one of which is the ranibizumab port delivery system (PDS). The PDS is a surgically implanted, refillable device that allows for the sustained release of ranibizumab, a widely used aVEGF agent, into the vitreous cavity. Positive results non-inferior to monthly ranibizumab injections in both phase II and phase III clinical trials allowed for FDA approval of the device with refill intervals of 6 months, which represents the longest approved treatment interval to date for nAMD therapy. This article reviews the need for a durable nAMD treatment option in real-world practice, the clinical trial and extension study data for the PDS, the risk of adverse events and safety profile of the PDS and the potential clinical role of the PDS in answering the real-world needs of nAMD treatment. In addition, other pipeline sustained-treatment modalities are discussed in the context of ongoing clinical trials.
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Affiliation(s)
- David A Eichenbaum
- Retina Vitreous Associates of Florida, Saint Petersburg, Florida, USA .,Morsani College of Medicine at the Univeristy of South Florida, Tampa, Florida, USA
| | - Abrahim Ahmed
- Morsani College of Medicine at the Univeristy of South Florida, Tampa, Florida, USA
| | - Farhan Hiya
- Bascom Palmer Eye Institute Mary and Edward Norton Library of Ophthalmology, Miami, Florida, USA
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22
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Fabian-Jessing BK, Jakobsen TS, Jensen EG, Alsing S, Hansen S, Aagaard L, Askou AL, Bek T, Corydon TJ. Animal Models of Choroidal Neovascularization: A Systematic Review. Invest Ophthalmol Vis Sci 2022; 63:11. [PMID: 35943733 PMCID: PMC9379329 DOI: 10.1167/iovs.63.9.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose Animal models of choroidal neovascularization (CNV) are extensively used to characterize the pathophysiology of chorioretinal diseases with CNV formation and to evaluate novel treatment strategies. This systematic review aims to give a detailed overview of contemporary animal models of CNV. Methods A systematic search was performed in PubMed and EMBASE from November 20, 2015, to November 20, 2020, for mammalian animal models of CNV. Following inclusion by two investigators, data from the articles were extracted according to a predefined protocol. Results A total of 380 full articles, representing 409 independent animal models, were included. Mice were by far the most utilized animal (76%) followed by rats and non-human primates. The median age of rodents was 8 weeks but with a wide range. Male animals were used in 44% of the studies, but 32% did not report the sex. CNV was laser induced in 89% of the studies, but only 44% of these reported sufficiently on standard laser parameters. Surprisingly, 28% of the studies did not report a sample size for quantitative CNV evaluation. Less than half of the studies performed quantitative in vivo evaluation, and 73% evaluated CNV quantitatively ex vivo. Both in vivo and ex vivo evaluations were conducted primarily at day 7 and/or day 14. Conclusions The laser-induced mouse model is the predominant model for experimental CNV. The widespread use of young, healthy male animals may complicate clinical translation, and inadequate reporting challenges reproducibility. Definition and implementation of standardized methodologic and reporting guidelines are attractive.
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Affiliation(s)
- Bjørn K Fabian-Jessing
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Stax Jakobsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sidsel Alsing
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Silja Hansen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Lars Aagaard
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Anne Louise Askou
- Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
| | - Toke Bek
- Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas J Corydon
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
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23
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Mishra SK, Kumar P, Khullar S, Joshi A, Sati A, Kumar SV, Unni D, Kumar A. Efficacy and safety of brolucizumab versus aflibercept in patients with neovascular age-related macular degeneration: a randomized trial in Indian patients. Int J Retina Vitreous 2022; 8:51. [PMID: 35902887 PMCID: PMC9331073 DOI: 10.1186/s40942-022-00401-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The current standard treatment for neovascular age-related macular degeneration (nAMD) involves intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents. The aim of the present study was to compare the effectiveness and safety of two anti-VEGF drugs: brolucizumab and aflibercept, in treatment-naïve nAMD Indian patients over a period of 48 weeks. METHODS A prospective, randomized, single-centre, single-blinded, two-arm comparative study was conducted between March 2021 and February 2022. Of the 114 patients, 56 received intravitreal injections of brolucizumab (6 mg/50 µL) while 58 received aflibercept (2 mg/50 µL). The patients received 03 initial loading doses at 4-week intervals of both the agents and then respective therapies were given as individualized pro re nata (PRN) regimen based on the signs of active macular neovascularization. The functional and anatomical outcomes measured were mean change in best-corrected visual acuity (BCVA, logMAR), central macular thickness (CMT, µm), presence of intraretinal fluid, subretinal fluid or subretinal hyper-reflective material. Furthermore, the average number of additional injections required after the loading doses, the injection-free interval and safety of both the drugs were also assessed. RESULTS Brolucizumab was found to be non-inferior to aflibercept in terms of mean change in BCVA (-0.13 ± 0.21 logMAR vs. -0.10 ± 0.15 logMAR) and reduction in CMT (-112.59 ± 81.23 µm vs. -86.38 ± 71.82 µm). The percentage of eyes with IRF and SHRM was comparable between both the groups while fewer eyes treated with brolucizumab indicated SRF presence than aflibercept after the loading doses. These beneficial effects of brolucizumab were observed with significant (p < 0.0001) lesser number of injections (1.8 ± 1.1 vs. 3.8 ± 1.5) from week 12 to week 48. Moreover, the probability of no injections after the loading doses was significantly higher with brolucizumab compared to aflibercept indicating prolonged injection-free intervals. The average ocular side effects were comparable in the two groups. One adverse event of severe vitritis requiring treatment with oral steroids occurred in Brolucizumab group, while no such event occurred in Aflibercept group. CONCLUSION The results of the present study suggest non-inferiority of brolucizumab PRN regimen to aflibercept PRN regimen in treatment naïve nAMD Indian patients while achieving longer inter-injection intervals. Trial registration Clinical Trial Registration of India (CTRI/2021/06/034415). Registered 03 March, 2021, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=54328&EncHid=&userName = .
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Affiliation(s)
- Sanjay Kumar Mishra
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India
| | - Pradeep Kumar
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India.
| | - Srishti Khullar
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India
| | - Amrita Joshi
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India
| | - Alok Sati
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India
| | - Sonali Vinay Kumar
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India
| | - Deepesh Unni
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India
| | - Atul Kumar
- Department of Ophthalmology, Army Hospital Research Referral, Delhi Cantt, Delhi, 110010, New Delhi, India
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24
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Exudative versus Nonexudative Age-Related Macular Degeneration: Physiopathology and Treatment Options. Int J Mol Sci 2022; 23:ijms23052592. [PMID: 35269743 PMCID: PMC8910030 DOI: 10.3390/ijms23052592] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Age-related macular degeneration (AMD) is an eye disease typically associated with the aging and can be classified into two types—namely, the exudative and the nonexudative AMD. Currently available treatments for exudative AMD use intravitreal injections, which are associated with high risk of infection that can lead to endophthalmitis, while no successful treatments yet exist for the nonexudative form of AMD. In addition to the pharmacologic therapies administered by intravitreal injection already approved by the Food and Drug Administration (FDA) in exudative AMD, there are some laser treatments approved that can be used in combination with the pharmacological therapies. In this review, we discuss the latest developments of treatment options for AMD. Relevant literature available from 1993 was used, which included original articles and reviews available in PubMed database and also information collected from Clinical Trials Gov website using “age-related macular degeneration” and “antiangiogenic therapies” as keywords. The clinical trials search was limited to ongoing trials from 2015 to date.
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25
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Wolf AT, Harris A, Oddone F, Siesky B, Vercellin AV, Ciulla TA. Disease progression pathways of wet AMD: opportunities for new target discovery. Expert Opin Ther Targets 2022; 26:5-12. [PMID: 35060431 PMCID: PMC8915198 DOI: 10.1080/14728222.2022.2030706] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Age-related macular degeneration (AMD) is the leading cause of irreversible blindness among people age 60 years or older in developed countries. Current standard-of-care anti-vascular endothelial growth factor (VEGF) therapy, which inhibits angiogenesis and vascular permeability, has been shown to stabilize choroidal neovascularization and increase visual acuity in neovascular AMD. However, therapeutic limitations of anti-VEGF therapy include limited durability with consequent need for frequent intravitreal injections, and a ceiling of efficacy. Current strategies under investigation include targeting VEGF-C and VEGF-D, integrins, tyrosine kinase receptors, and the Tie2/angiopoietin-2 pathway. A literature search was conducted through November 30, 2021 on PubMed, Medline, Google Scholar, and associated digital platforms with the following keywords: wet macular degeneration, age-related macular degeneration, therapy, VEGF-A, VEGF-C, VEGF-D, integrins, Tie2/Ang2, and tyrosine kinase inhibitors. AREAS COVERED The authors provide a comprehensive review of AMD disease pathways and mechanisms involved in wet AMD as well as novel targets for future therapies. EXPERT OPINION With novel targets and advancements in drug delivery, there is potential to address treatment burden and to improve outcomes for patients afflicted with neovascular AMD.
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Affiliation(s)
- Amber T. Wolf
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Alon Harris
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | | | - Brent Siesky
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | | | - Thomas A. Ciulla
- Vitreoretinal Medicine and Surgery, Midwest Eye Institute, Indianapolis, IN, USA
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26
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Koistinen H, Künnapuu J, Jeltsch M. KLK3 in the Regulation of Angiogenesis-Tumorigenic or Not? Int J Mol Sci 2021; 22:ijms222413545. [PMID: 34948344 PMCID: PMC8704207 DOI: 10.3390/ijms222413545] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/07/2023] Open
Abstract
In this focused review, we address the role of the kallikrein-related peptidase 3 (KLK3), also known as prostate-specific antigen (PSA), in the regulation of angiogenesis. Early studies suggest that KLK3 is able to inhibit angiogenic processes, which is most likely dependent on its proteolytic activity. However, more recent evidence suggests that KLK3 may also have an opposite role, mediated by the ability of KLK3 to activate the (lymph)angiogenic vascular endothelial growth factors VEGF-C and VEGF-D, further discussed in the review.
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Affiliation(s)
- Hannu Koistinen
- Department of Clinical Chemistry, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland
- Correspondence: (H.K.); (M.J.)
| | - Jaana Künnapuu
- Drug Research Program, University of Helsinki, 00014 Helsinki, Finland;
| | - Michael Jeltsch
- Drug Research Program, University of Helsinki, 00014 Helsinki, Finland;
- Individualized Drug Therapy Research Program, University of Helsinki, 00014 Helsinki, Finland
- Wihuri Research Institute, 00290 Helsinki, Finland
- Correspondence: (H.K.); (M.J.)
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