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Rowe LW, Ciulla TA. Long-acting delivery and therapies for neovascular age-related macular degeneration. Expert Opin Biol Ther 2024:1-16. [PMID: 38953649 DOI: 10.1080/14712598.2024.2374869] [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: 03/17/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION Neovascular age-related macular degeneration (nAMD) represents a leading cause of severe visual impairment in individuals over 50 years of age in developed nations. Intravitreal anti-vascular endothelial growth factor (VEGF) injections have become the standard of care for treating nAMD; however, monthly or bimonthly dosing represents significant time and cost burden due to the disease's chronic nature and limited medication half-life. AREAS COVERED This review summarizes innovative therapeutics and delivery methods for nAMD. Emerging methods for extended drug delivery include high molar concentration anti-VEGF drugs, intravitreal sustained-release polymers and devices, reservoirs for intravitreal delivery, suprachoroidal delivery of small molecular suspensions and gene therapy biofactories. In addition to VEGF-A, therapies targeting inhibition of VEGF-C and D, the angiopoetin-2 (Ang-2)/Tie-2 pathway, tyrosine kinases, and integrins are reviewed. EXPERT OPINION The evolving therapeutic landscape of nAMD is rapidly expanding our toolkit for effective and durable treatment. Recent FDA approvals of faricimab (Vabysmo) and high-dose aflibercept (Eylea HD) for nAMD with potential extension of injection intervals up to four months have been promising developments for patients and providers alike. Further research and innovation, including novel delivery techniques and pharmacologic targets, is necessary to validate the efficacy of developing therapeutics and characterize real-world outcomes, demonstrating promise in expanding treatment durability.
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Affiliation(s)
- Lucas W Rowe
- Department of Ophthalmology, Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas A Ciulla
- Department of Ophthalmology, Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA
- Retina Service, Midwest Eye Institute, Indianapolis, IN, USA
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Zarbin MA, MacCumber MW, Karcher H, Adiguzel E, Mayhook A, LaPrise A, Bilano VL, Igwe F, Ip MS, Wykoff CC. Real-World Safety Outcomes with Brolucizumab in Neovascular Age-Related Macular Degeneration: Findings from the IRIS® Registry. Ophthalmol Ther 2024; 13:1357-1368. [PMID: 38520643 DOI: 10.1007/s40123-024-00920-3] [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: 01/17/2024] [Accepted: 02/27/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION To assess real-world safety outcomes for adults with neovascular age-related macular degeneration (nAMD) treated with brolucizumab from the US-based IRIS® (Intelligent Research in Sight) Registry. METHODS In this retrospective study, 18,312 eyes (15,998 patients) treated with ≥ 1 intravitreal brolucizumab injections between 8 October 2019 (US launch date for brolucizumab) and 7 October 2021 were followed up for ≤ 2 years after first injection (index date). The study assessed the predefined incident ocular adverse events of intraocular inflammation (IOI), retinal vasculitis (RV), and retinal vascular occlusion (RO). RESULTS Overall, 614/18,312 eyes (3.4%) experienced any IOI, RV, and/or RO event. Median (interquartile range [IQR]) time to an event was 84 (42-167) days; 77.4% of events (475/614) occurred within 6 months after index date. Median (IQR) number of brolucizumab injections before an event was 2 (1-4). For eyes with an adverse event and visual acuity (VA) data (n = 406), median (IQR) change in Early Treatment of Diabetic Retinopathy Study (ETDRS) letters from pre-event VA was 0 (- 7 to + 5) at the 6-month follow-up; 50 eyes (12.3%) had a VA loss of 10 or more ETDRS letters. Risk of an event (hazard ratio [95% confidence interval]) was decreased in eyes from male patients (0.61 [0.53-0.71]), from older patients (0.83 [0.76-0.90]), from treatment-naive patients (0.51 [0.38-0.69]), and from patients who started brolucizumab in the second year after launch (0.68 [0.53-0.86] vs. first year). CONCLUSION In this large real-world brolucizumab safety study, 3.4% of eyes experienced an IOI, RV, and/or RO event. Among eyes that experienced an adverse event for which VA data were available, median ETDRS vision change was 0 letters (IQR - 7 to + 5).
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Affiliation(s)
- Marco A Zarbin
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Rutgers University, 90 Bergen Street, Room 6155, Newark, NJ, 07103, USA.
| | - Mathew W MacCumber
- Department of Ophthalmology, Rush University Medical Center, Chicago, IL, USA
- Illinois Retina Associates, Chicago, IL, USA
| | | | - Eser Adiguzel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | | | | | - Michael S Ip
- Doheny Eye Institute, University of California, Los Angeles, CA, USA
| | - Charles C Wykoff
- Retina Consultants of Texas, Houston, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
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Kamao H, Mitsui E, Date Y, Goto K, Mizukawa K, Miki A. The Effect of a Loading Dose Regimen in the Switch to Brolucizumab for Patients with Aflibercept-Resistant nAMD. J Ophthalmol 2024; 2024:3673930. [PMID: 38322501 PMCID: PMC10846919 DOI: 10.1155/2024/3673930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/26/2023] [Accepted: 01/17/2024] [Indexed: 02/08/2024] Open
Abstract
Purpose To evaluate the one-year outcomes of switching to brolucizumab with and without a loading dose regimen (three monthly injections) in eyes with aflibercept-resistant neovascular age-related macular degeneration (nAMD). Methods We retrospectively studied nAMD patients who had retinal exudate under bimonthly injections of aflibercept and were switched to brolucizumab from aflibercept. Patients were grouped into intravitreal brolucizumab injection (IVBr) with a loading dose regimen (loading group) and without a loading dose regimen (nonloading group). We assessed the best-corrected visual acuity (BCVA), central retinal thickness (CRT) at the fovea, subfoveal choroidal thickness (SFCT), IVBr status (number of injections and last injection interval), and retinal exudate status on optical coherence tomography. Results Overall, 52 eyes received ≥1 IVBr; 26 eyes received ≥3 IVBr with 12-month follow-up. A total of 13 eyes in the loading group and 13 eyes in the nonloading group were reviewed. One year after switching, BCVA changed from 0.28 ± 0.25 to 0.19 ± 0.28 in the loading group (P=0.28) and from 0.25 ± 0.20 to 0.23 ± 0.25 in the nonloading group (P=0.92). The mean CRT decreased from 263.6 ± 40.7 µm to 221.7 ± 54.6 µm in the loading group (P=0.03), while it only changed from 244.9 ± 77.2 µm to 221.0 ± 78.7 µm in the nonloading group (P=0.26). Both the loading and nonloading groups achieved 69% dry macula. The number of injections received was significantly higher in the loading group (7.6 ± 0.6 vs. 6.8 ± 0.4, P < 0.001). Two patients (4.2%) developed intraocular inflammation. Conclusion Switching to brolucizumab from aflibercept for eyes with nAMD with resistance to bimonthly injections of aflibercept is a valuable treatment option with and without the loading regimen. This trial is registered with UMIN000023676.
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Affiliation(s)
- Hiroyuki Kamao
- Department of Ophthalmology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0114, Japan
| | - Erika Mitsui
- Department of Ophthalmology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0114, Japan
| | - Yuto Date
- Department of Ophthalmology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0114, Japan
| | - Katsutoshi Goto
- Department of Ophthalmology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0114, Japan
| | - Kenichi Mizukawa
- Shirai Eye Hospital, 1339 Takasecho Kamitakase, Mitoyo, Kagawa 767-0001, Japan
| | - Atsushi Miki
- Department of Ophthalmology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0114, Japan
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Coney JM, McCoy JE, Buxy Sinha S, Sonbolian N, Zhou L, Hull TP, Lewis SA, Miller DG, Novak MA, Pendergast SD, Pham H, Platt SM, Rao LJ, Schartman JP, Singerman LJ, Donkor R, Fink M, Zubricky R, Karcher H. One-Year and 18-Month Outcomes in nAMD Patient Eyes Switched to Brolucizumab Alone versus to Brolucizumab Alternating with Other Anti-VEGF Agents. Clin Ophthalmol 2023; 17:3601-3611. [PMID: 38026599 PMCID: PMC10680460 DOI: 10.2147/opth.s432957] [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: 09/27/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Retrospective, real-world study to evaluate visual acuity (VA), anti-vascular endothelial growth factor (anti-VEGF) injection intervals, and central macular thickness (CMT) in neovascular age-related macular degeneration (nAMD) eyes switched to brolucizumab only or to brolucizumab alternating with another anti-VEGF. Methods The overall study population comprised eyes that were given ≥1 brolucizumab injection between 1 October 2019 and 30 November 2021. The brolucizumab-only (BRO) cohort consisted of prior anti-VEGF-treated eyes treated exclusively with ≥3 brolucizumab injections over ≥12 or ≥18 months; the alternating brolucizumab (ALT) cohort comprised prior anti-VEGF-treated eyes treated with ≥2 brolucizumab injections and ≥1 other anti-VEGF over ≥12 or ≥18 months. Results A total of 482 eyes received ≥1 brolucizumab injection during the study period. Mean VA changes from baseline were -1.1±15.1 letters (BRO cohort; n = 174) and 1.3±13.0 letters (ALT cohort; n = 47) at Month 12, and 0.0±13.5 letters (BRO cohort; n = 95) and -7.3±17.2 letters (ALT cohort; n = 29) at Month 18. Mean changes in injection intervals were +26.9±48.1 days (BRO cohort) and +11.1±17.3 days (ALT cohort) at Month 12 and +36.3±52.3 days (BRO cohort) and +14.0±19.9 days (ALT cohort) at Month 18. Mean changes in CMT were -35.2±108.1 μm (BRO cohort) and -31.5±91.2 μm (ALT cohort) at Month 12 and -38.9±75.0 μm (BRO cohort) and -9.0±59.9 μm (ALT cohort) at Month 18. Intraocular inflammation-related adverse events were recorded in 22/482 (4.6%) eyes. Conclusion Treatment with either brolucizumab alone or brolucizumab alternating with another anti-VEGF can preserve vision, reduce CMT, and extend anti-VEGF injection intervals in patients with nAMD.
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Affiliation(s)
| | | | | | | | | | - Thomas P Hull
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | - Shawn A Lewis
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | | | | | | | - Hang Pham
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | - Sean M Platt
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | | | | | | | | | - Margaret Fink
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
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Saba NJ, Walter SD. Efficacy, Safety, and Durability of Brolucizumab: An 8-Month Post-Marketing Surveillance Analysis. Clin Ophthalmol 2023; 17:2791-2802. [PMID: 37753246 PMCID: PMC10518423 DOI: 10.2147/opth.s425709] [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: 06/29/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
Importance Brolucizumab (Beovu®) is an anti-vascular endothelial growth factor (anti-VEGF) agent approved for the treatment of neovascular age-related macular degeneration (nvAMD). Brolucizumab was marketed for its noninferiority to aflibercept and its potential for greater durability. However, post-marketing utilization has been tempered by safety concerns. Objective We evaluate the visual and anatomic efficacy of brolucizumab, examine changes in treatment intervals after switching to brolucizumab, and estimate the incidence of drug-related adverse events in the real world. Design Setting and Participants This was a retrospective consecutive case series of 626 eyes (543 patients) with nvAMD treated with 1438 brolucizumab injections at a single retina practice between 10/1/2019 and 5/15/2020. Main Outcomes and Measures Changes in visual acuity (VA); anatomic outcomes assessed by optical coherence tomography (OCT) including central subfield thickness (CST), macular volume (MV), presence of intraretinal fluid (IRF), subretinal fluid (SRF), and serous pigment epithelial detachment (sPED) on foveal line scans; treatment intervals before and after receiving brolucizumab; and the incidence of brolucizumab-related adverse events. Results The majority of eyes (N = 531, 89.7%) had received prior anti-VEGF therapy with aflibercept, ranibizumab, and/or bevacizumab. VA improved in treatment-naïve eyes (+3.7 letters, p = 0.04), and was maintained in previously treated eyes. There were significant improvements in all anatomic outcomes in both groups (p < 0.001). We observed a 4.8% incidence of intraocular inflammation (IOI) and a 0.6% incidence of retinal vasculitis. The average treatment interval increased from 6.3 to 6.8 weeks (p = 0.001). Conclusions and Relevance Brolucizumab treatment was associated with VA improvement in naïve eyes and maintenance of VA in previously treated eyes. Switching to brolucizumab was associated with improved anatomic outcomes and extended treatment intervals in most eyes. We observed a similar incidence of IOI and a lower incidence of retinal vasculitis compared to the Safety Review Committee's analysis of HAWK and HARRIER.
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Affiliation(s)
- Nicholas J Saba
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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MacCumber MW, Wykoff CC, Karcher H, Adiguzel E, Sinha SB, Vishwakarma S, LaPrise A, Igwe F, Freitas R, Ip MS, Zarbin MA. One-Year Brolucizumab Outcomes in Neovascular Age-Related Macular Degeneration from a Large United States Cohort in the IRIS® Registry. Ophthalmology 2023; 130:937-946. [PMID: 37086857 DOI: 10.1016/j.ophtha.2023.04.012] [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: 10/26/2022] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 04/24/2023] Open
Abstract
PURPOSE To evaluate visual acuity (VA) and injection intervals in patients with neovascular age-related macular degeneration (nAMD) after 12 months of brolucizumab therapy in clinical practice. DESIGN Retrospective cohort study. PARTICIPANTS Adults in the United States-based IRIS® Registry (Intelligent Research in Sight) with nAMD who received brolucizumab exclusively for 12 months (2308 eyes of 2079 patients). METHODS Observational study of eyes with a first injection of brolucizumab (index), followed by 2 or more brolucizumab injections over the following 12 months without switching to another anti-vascular endothelial growth factor (VEGF) agent. MAIN OUTCOME MEASURES Primary outcomes were change in best recorded VA and, for eyes receiving prior anti-VEGF therapy (treatment-experienced eyes), the difference between the brolucizumab injection interval at 12 months and the anti-VEGF injection interval before switching. The interval before switching was defined as the time between the prior anti-VEGF and index brolucizumab injections; brolucizumab interval was the time between the closest injection to day 365 and the preceding injection. Secondary outcomes included incident adverse events. RESULTS Overall VA at index was 61.6 ± 18.4 Early Treatment Diabetic Retinopathy Study letters; 83.7% of treatment-naive eyes (184/220) and 86.1% of treatment-experienced eyes (1797/2088) showed stable (< 10 letters gained or lost) or improved (≥ 10 letters gained) VA at 12 months. Among treatment-experienced eyes receiving a prior anti-VEGF injection within 365 days before index, 29.5% (594/2015) showed an interval before switching of 8 weeks or more (mean, 7.6 ± 5.5 weeks), whereas 83.1% (1734/2015) showed a brolucizumab injection interval at 12 months of 8 weeks or more (mean, 10.3 ± 4.0 weeks). In all, 77.1% of treatment-experienced eyes (1554/2015) showed an interval extension of 1 week or more; of these, 55.4% (861/1554) showed an extension of 4 weeks or more. CONCLUSIONS In this community-based study, at 12 months, brolucizumab treatment prolonged the interval between anti-VEGF injections for most treatment-experienced eyes, particularly those with shorter intervals before switching, while maintaining or improving VA. With careful balancing of the benefits and risks, switching to brolucizumab treatment may offer the advantage of extending the treatment interval for patients with a high anti-VEGF therapy burden. 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)
- Mathew W MacCumber
- Department of Ophthalmology, Rush University Medical Center, Chicago, and Illinois Retina Associates SC, Harvey, Illinois.
| | | | | | - Eser Adiguzel
- Novartis Pharmaceuticals Corp., East Hanover, New Jersey
| | | | | | | | | | - Rita Freitas
- Novartis Farma-Produtos Farmacêuticos S.A., Porto Salvo, Portugal
| | - Michael S Ip
- Doheny Eye Institute, University of California, Los Angeles, Los Angeles, California
| | - Marco A Zarbin
- Department of Ophthalmology and Visual Science, Rutgers-New Jersey Medical School, Newark, New Jersey
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MacCumber MW, Wykoff CC, Karcher H, Adiguzel E, Buxy Sinha S, Vishwakarma S, LaPrise A, Igwe F, Freitas R, Ip MS, Zarbin MA. Factors Linked to Injection Interval Extension in Eyes with Wet Age-Related Macular Degeneration Switched to Brolucizumab. Ophthalmology 2023:S0161-6420(23)00194-X. [PMID: 36990322 DOI: 10.1016/j.ophtha.2023.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
PURPOSE To evaluate factors associated with anti-VEGF injection interval extension in patients with neovascular age-related macular degeneration (nAMD) switched to brolucizumab. DESIGN Retrospective observational cohort study. PARTICIPANTS Adults in the US-based Intelligent Research in Sight (IRIS) Registry with nAMD who switched from another anti-VEGF agent (treatment-experienced) to brolucizumab-only treatment for at least 12 months in the time period of 10/08/2019 through 11/26/2021. METHODS Univariate and multivariable analyses were used to examine associations of demographic and clinical characteristics with the likelihood of interval extension following switch to brolucizumab therapy. MAIN OUTCOME MEASURES Eyes were classified as either "extenders" or "non-extenders" at 12 months. "Extenders" were eyes that achieved (i) an extension of ≥ 2 weeks in the brolucizumab injection interval at 12 months versus the pre-switch interval (time between the last known prior anti-VEGF injection and first ["index"] brolucizumab injection) and (ii) stable (< 10 letters gained or lost) or improved (≥ 10 letters gained) visual acuity (VA) at 12 months compared with VA at index. RESULTS Of the 2015 eyes among 1890 patients that switched to brolucizumab, 1186 eyes (58.9%) were "extenders". In univariate analyses, demographic and clinical characteristics were comparable between extenders and non-extenders, except that extenders had a shorter pre-switch interval compared with non-extenders (mean 5.9 ± 2.1 versus 10.1 ± 7.6 weeks, respectively). The multivariable logistic regression model showed that a shorter pre-switch interval was significantly and positively associated with interval extension with brolucizumab therapy (adjusted odds ratio 5.6 for pre-switch interval of <8 weeks compared with ≥8 weeks; 95% confidence interval 4.5-6.9; P <0.001), and that eyes with an index VA of 40-65 letters were significantly less likely to be extenders than eyes in the higher (better) index VA categories. CONCLUSIONS Length of the pre-switch treatment interval was the characteristic most strongly associated with successful interval extension with brolucizumab. Treatment-experienced patients who required more frequent injections (i.e., shorter pre-switch intervals) showed the greatest extensions when switching to brolucizumab. With careful consideration of the benefits/risks, brolucizumab may be a valuable treatment option for patients whose treatment burden is higher due to the need for frequent injections.
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