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Association of Systemic or Intravitreal Antivascular Endothelial Growth Factor (Anti-VEGF) and Impaired Wound Healing in Pediatric Patients: Collagen to the Rescue. J Wound Ostomy Continence Nurs 2021; 48:256-261. [PMID: 33951716 DOI: 10.1097/won.0000000000000764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bevacizumab is a humanized monoclonal antibody to vascular endothelial growth factor (VEGF) that has been used as a systemic chemotherapy treatment of various malignancies in adults since 2000. It has been used for pediatric patients over the last decade. In addition, bevacizumab is used for neonatal intravitreal administration for retinopathy of prematurity, a major complication of preterm birth, characterized by incomplete and abnormal vascularization of the retina that can lead to retinal detachment and blindness without treatment. CASES The objective of this multiple case series is to report impaired wound healing seen in 3 adolescents and 1 premature neonate receiving bevacizumab and to propose collagen-based dermal template as a choice for the management of such wounds. The 3 adolescents were undergoing treatment of malignancies and developed wound healing complication within weeks of receiving anti-VEGF. The premature neonate experienced an extravasation and had a slow wound healing trajectory after receiving intravitreal administration of bevacizumab for retinopathy of prematurity. All wounds achieved closure following topical treatment with a collagen dermal template. CONCLUSION Use of bevacizumab is increasing in the pediatric population. Clinicians should be aware of compromised wound healing and higher likelihood of wound dehiscence after bevacizumab administration. We recommend waiting for at least 4 to 6 weeks between anti-VEGF administration (either systemic or vitreous) and elective surgical procedures, consistent with adult literature recommendations. If patient has an existing wound, we assert that bevacizumab should not be administered until that wound is healed. If wound healing is stalled, we recommend dermal template as a safe and effective accelerator of wound healing.
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Ahn JW, Shalabi D, Correa-Selm LM, Dasgeb B, Nikbakht N, Cha J. Impaired wound healing secondary to bevacizumab. Int Wound J 2019; 16:1009-1012. [PMID: 31111622 DOI: 10.1111/iwj.13139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/28/2019] [Indexed: 01/16/2023] Open
Abstract
Bevacizumab is a monoclonal antibody that exerts its antitumor activity by inhibiting vascular endothelial growth factor. Consequently, it suppresses endothelial cell proliferation, vascular permeability, and angiogenesis. This inhibitory effect contributes to tumour size reduction but causes wound-healing delay, specifically during the proliferative phase, in patients receiving bevacizumab. Although surgical wound-healing complications (WHC) associated with bevacizumab have been extensively reported, there is limited literature on peripheral WHC. More importantly, the histopathology of bevacizumab-associated WHC has not been described. We present the histopathology findings of a non-healing ulcer in a patient receiving bevacizumab, providing insight into the possible aetiology of this drug's adverse reaction. Furthermore, our patient's positive response to hyperbaric oxygen suggests its possible use for treatment of bevacizumab-associated non-healing wounds.
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Affiliation(s)
- Ji W Ahn
- Department of Dermatology, University of Michigan Hospitals, Ann Arbor, Michigan
| | - Doaa Shalabi
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lilia M Correa-Selm
- Scully Welsh Cancer Center, Cleveland Clinic Indian River Hospital, Vero Beach, Florida
| | - Bahar Dasgeb
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Neda Nikbakht
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jisun Cha
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Michalska-Małecka K, Kabiesz A, Kimsa MW, Strzałka-Mrozik B, Formińska-Kapuścik M, Nita M, Mazurek U. Effects of intravitreal ranibizumab on the untreated eye and systemic gene expression profile in age-related macular degeneration. Clin Interv Aging 2016; 11:357-65. [PMID: 27069359 PMCID: PMC4818053 DOI: 10.2147/cia.s93820] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The purpose of this study was to evaluate the systemic effects of intravitreal ranibizumab (Lucentis) treatment in patients with neovascular age-related macular degeneration (AMD). The impact of intravitreal ranibizumab injections on central retinal thickness (CRT) of treated and contralateral untreated eyes, and differences in gene expression patterns in the peripheral blood mononuclear cells were analyzed. The study included 29 patients aged 50 years old and over with diagnosed neovascular AMD. The treatment was defined as 0.5 mg of ranibizumab injected intravitreally in the form of one injection every month during the period of 3 months. CRT was measured by optical coherence tomography. The gene expression profile was assigned using oligonucleotide microarrays of Affymetrix HG-U133A. Studies have shown that there was a change of CRT between treated and untreated eyes, and there were differences in CRT at baseline and after 1, 2, and 3 months of ranibizumab treatment. Three months after intravitreal injection, mean CRT was reduced in the treated eyes from 331.97±123.62 to 254.31±58.75 μm, while mean CRT in the untreated fellow eyes reduced from 251.07±40.29 to 235.45±36.21 μm at the same time. Furthermore, the research has shown that among all transcripts, 3,097 expresses change after the ranibizumab treatment in relation to controls. Among these transcripts, 1,339 were up-regulated, whereas 1,758 were down-regulated. Our results show the potential systemic effects of anti-VEGF therapy for AMD. Moreover, our study indicated different gene expression in peripheral blood mononuclear cells before and after intravitreal ranibizumab treatment.
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Affiliation(s)
- Katarzyna Michalska-Małecka
- Clinical Department of Ophthalmology, Medical University of Silesia, Katowice, Poland; University Center for Ophthalmology and Oncology, Independent Public Clinical Hospital, Medical University of Silesia, Katowice, Poland
| | - Adam Kabiesz
- University Center for Ophthalmology and Oncology, Independent Public Clinical Hospital, Medical University of Silesia, Katowice, Poland
| | - Malgorzata W Kimsa
- Department of Molecular Biology, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia, Katowice, Poland
| | - Barbara Strzałka-Mrozik
- Department of Molecular Biology, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia, Katowice, Poland
| | - Maria Formińska-Kapuścik
- University Center for Ophthalmology and Oncology, Independent Public Clinical Hospital, Medical University of Silesia, Katowice, Poland; Clinical Department of Children Ophthalmology, Medical University of Silesia, Katowice, Poland
| | - Malgorzata Nita
- Domestic and Specialized Medicine Centre "Dilmed", Katowice, Poland
| | - Urszula Mazurek
- Department of Molecular Biology, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia, Katowice, Poland
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Abstract
Intravitreal injections for the treatment of retinal disorders and intraocular infection have become a common ophthalmic procedure, and injections of anti-vascular endothelial growth factor agents or steroids are frequently performed for the treatment of diabetic macular edema or other diabetic vascular pathology. Diabetic patients may be at higher risk of adverse events than non-diabetic individuals given frequent systemic co-morbidities, such as cardiovascular and renal disease, susceptibility to infection, and unique ocular pathology that includes fibrovascular proliferation. Fortunately, many associated complications, including endophthalmitis, are related to the injection procedure and can therefore be circumvented by careful attention to injection techniques. This review highlights the safety profile of intravitreal injections in patients with diabetes. Although diabetic patients may theoretically be at higher risk than non-diabetic patients for complications, a comprehensive review of the literature does not demonstrate substantial increased risk of intravitreal injections in patients with diabetes.
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Affiliation(s)
- Hasanain Shikari
- Beetham Eye Institute, Joslin Diabetes Center , Boston, Massachusetts , USA and
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Zeaxanthin inhibits hypoxia-induced VEGF secretion by RPE cells through decreased protein levels of hypoxia-inducible factors-1α. BIOMED RESEARCH INTERNATIONAL 2015; 2015:687386. [PMID: 25688362 PMCID: PMC4320873 DOI: 10.1155/2015/687386] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 12/15/2014] [Indexed: 01/10/2023]
Abstract
Hypoxia is the most important stimulus leading to upregulation of VEGF in the retina and this is caused by accumulation of hypoxia-inducible factors-1α (HIF-1α) protein. The effects of zeaxanthin, a natural phytochemical, on the VEGF and HIF-1α expression in the primary culture of human retinal pigment epithelial (RPE) cells were studied. An in vitro RPE cell hypoxia model was established by placing cells under 1% oxygen pressure or by adding cobalt chloride (CoCl2) to the culture medium. RPE cells and conditioned media were collected from cultures treated with and without zeaxanthin under normoxic and hypoxic conditions. VEGF and HIF-1α protein and RNA levels were measured by ELISA kits and RT-PCR, respectively. Hypoxia caused a significant increase of VEGF expression and accumulation of HIF-1α in RPE cells. Zeaxanthin at 50-150 μM significantly inhibited the expression of VEGF and accumulation of HIF-1α protein caused by hypoxia but did not affect expression of VEGF and HIF-1α under normoxic conditions. This is the first report on the effect of zeaxanthin on VEGF and HIF-1α levels in cultured RPE cells and suggests that zeaxanthin may have potential value in the prevention and treatment of various retinal diseases associated with vascular leakage and neovascularization.
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Bodnar RJ. Anti-Angiogenic Drugs: Involvement in Cutaneous Side Effects and Wound-Healing Complication. Adv Wound Care (New Rochelle) 2014; 3:635-646. [PMID: 25302138 DOI: 10.1089/wound.2013.0496] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/14/2013] [Indexed: 02/06/2023] Open
Abstract
Significance: The uses of anti-angiogenic drugs have not only made an impact on the battle to eliminate cancer but are also responsible for a number of medical complications. The long-term use of these drugs has increased the spectrum and incidence of cutaneous side effects and wound-healing complications. It is, therefore, necessary to understand the overall impact that these drugs have on patient care. Recent Advances: This review highlights the role of vascular endothelial growth factor and fibroblast growth factor in angiogenesis and wound healing and looks at how angiogenic inhibitors promote wound-healing complications. Critical Issues: With an increased use of anti-angiogenic drugs for the treatment of various cancers and ocular diseases, there is an increased need for clinicians to define the risks and to optimize the usage of these drugs to reduce the incidence of cutaneous side effects and wound-healing complications. In addition, awareness is needed when treating patients on anti-angiogenic drugs so as not to exacerbate potential wound-healing complications when performing surgical procedures. Future Directions: Clinicians and surgeons will need to develop management guidelines to optimize patient care to reduce the risk of morbidity. When performing a surgical procedure, the impact of adverse effects from the use of anti-angiogenic drugs should be considered to ensure the welfare of the patient. In addition, the development of more specific inhibitors is necessary to reduce target effects to reduce the occurrence of adverse effects.
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Affiliation(s)
- Richard J. Bodnar
- Department of Pathology, University of Pittsbugh, Pittsburgh, Pennsylvania
- Pittsburgh Veterans Affairs Healthcare System, Pittsburgh, Pennsylvania
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Christoforidis JB, Xie Z, Jiang A, Wang J, Pratt C, Gemensky-Metzler A, Abdel-Rasoul M, Roy S, Liu Z. Serum levels of intravitreal bevacizumab after vitrectomy, lensectomy and non-surgical controls. Curr Eye Res 2013; 38:761-6. [PMID: 23548066 PMCID: PMC3886184 DOI: 10.3109/02713683.2013.763988] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To determine serum level differences of intravitreally-placed bevacizumab after vitrectomy and lensectomy-vitrectomy and to compare these with non-operated eyes in a rabbit model. METHODS Five Dutch-belted rabbits underwent pars plana vitrectomy (PPV), five rabbits underwent pars plana lensectomy (PPL) and five rabbits served as non-surgical controls. Twelve days following the surgical procedures, each operated eye underwent an intravitreal injection consisting of 1.25 mg/0.05 mL bevacizumab. Serum levels from each rabbit were drawn on days 2, 4, 7, 10, 14, 21, 28 and 35 and were measured with ELISA immunoassay. RESULTS The average peak serum concentration (Cmax) was highest for the PPL group (11.33 μg ± 3.48 mL), and was similar between the PPV (5.35 μg ± 2.69 mL) and non-surgical control groups (5.35 μg ± 0.69 mL). The average time to maximal plasma concentration (Tmax) in days was earliest for the PPL group (2.8 ± 0.47), followed by the PPV (5.6 ± 0.84) and non-surgical control groups (6.4 ± 0.71). The PPL group had higher serum levels than the other two groups until day 7 that was significant only at day 2 (p < 0.0001). After day 4, there were no significant differences or trends between any of the three groups. The half-life (T1/2) was fastest for the PPL group (1.41 ± 0.21 d) followed by the PPV (2.80 ± 3.35 d) and non-surgical control groups (6.69 ± 10.4 d). CONCLUSIONS Serum bevacizumab levels were initially elevated following lensectomy and vitrectomy compared to non-surgical eyes following intravitreal injection. The half-life of bevacizumab was prolonged in non-surgical eyes presumably due to a slower release from the vitreous cavity.
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Affiliation(s)
- John B Christoforidis
- Department of Ophthalmology & Visual Science, College of Medicine, The University of Arizona, Tucson, AZ, USA .
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Christoforidis JB, Wang J, Jiang A, Willard J, Pratt C, Abdel-Rasoul M, Roy S, Powell H. The effect of intravitreal bevacizumab and ranibizumab on cutaneous tensile strength during wound healing. Clin Ophthalmol 2013; 7:185-91. [PMID: 23378736 PMCID: PMC3559083 DOI: 10.2147/opth.s40537] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Purpose To investigate the effect of intravitreal bevacizumab and ranibizumab on wound tension and by histopathology during cutaneous wound healing in a rabbit model and to compare this effect to placebo intravitreal saline controls 1 and 2 weeks following intravitreal injection. Methods A total of 120 New Zealand white rabbits were randomly assigned to one of three treatment groups each consisting of 40 rabbits. Each group received intravitreal injections of bevacizumab, ranibizumab, or normal saline. Immediately afterwards, each rabbit underwent four 6 mm full-thickness dermatologic punch biopsies. Twenty rabbits from each agent group underwent wound harvesting on day 7 or day 14. The skin samples were stained for CD34 for vascular endothelial cells on day 7, and maximal wound tensile load was measured on days 7 and 14. Quantitative assessment of mean neovascularization (MNV) scores was obtained from 10 contiguous biopsy margin 400× fields of CD34-stained sections by two independent observers. Results Wound tension reading means (N) with standard error and adjusted P-values on day 7 were: saline placebos, 7.46 ± 0.87; bevacizumab, 4.50 ± 0.88 (P = 0.041); and ranibizumab, 4.67 ± 0.84 (P = 0.025). On day 14 these were: saline placebos, 7.34 ± 0.55; bevacizumab, 6.05 ± 0.54 (P = 0.18); and ranibizumab 7.99 ± 0.54 (P = 0.40). MNV scores in CD34 stained sections were: saline controls, 18.31 ± 0.43; bevacizumab, 11.02 ± 0.45 (P < 0.0001); and ranibizumab, 13.55 ± 0.43 (P < 0.0001). The interobserver correlation coefficient was 0.928. Conclusion At day 7, both anti–vascular endothelial growth factor (anti-VEGF) agents had significantly suppressed MNV scores and exerted a significant reduction of cutaneous wound tensile strength compared with saline controls. At day 14, neither agent produced a significant effect on tensile wound strength. Since angiogenesis is an integral component of the proliferative phase of wound healing, we encourage clinicians to be aware of their patients’ recent surgical history during intravitreal anti-VEGF therapy and to consider refraining from their use during the perioperative period.
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Affiliation(s)
- John B Christoforidis
- Department of Ophthalmology and Vision Science, College of Medicine, The University of Arizona, Tucson, AZ, USA
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