Randomized controlled double-blinded clinical trial of the effect of bevacizumab injection in the management of epistaxis in HHT patients undergoing surgical cauterization

INTRODUCTION

Given its role in the disease pathophysiology, inhibition of VEGF-mediated angiogenesis has received attention as a potential strategy to reduce epistaxis associated with hereditary hemorrhagic telangiectasia (HHT). This study evaluates the efficacy of a submucosal injection of bevacizumab, a VEGF-inhibitor, in reducing the severity of epistaxis and improving quality of life when given at the time of operative electrocautery.

METHODS

This randomized, double-blinded placebo-controlled trial was conducted at a single institution from 2014 to 2019. Patients scheduled to undergo operative bipolar electrocautery of nasal telangiectasias were randomized to receive a submucosal injection of saline or bevacizumab at time of surgery. Surveys to assess epistaxis severity and quality-of-life (QOL), including the Epistaxis Severity Score (ESS) and Short Form 12 (SF-12), were administered preoperatively and at 1, 2, 4, and 6 months postoperatively. The minimal clinically important difference (MCID) of the ESS instrument is reported to be 0.71.

RESULTS

Of 39 patients enrolled, 37 (94.9%) completed the study. The saline group demonstrated reduced ESS versus baseline at 1 (-1.2, p = 0.01) and 4 (-1.2, p = 0.05) months post-procedure. The bevacizumab group demonstrated reduced ESS versus baseline at 1 (-2.3, p<0.001), 2 (-2.3, p<0.001), 4 (-2.0, p = 0.003), and 6 (-1.3, p = 0.05) months post-procedure. The additive benefit of bevacizumab over saline exceeded the MCID at 1, 2, and 4 months but the difference was not statistically significant.

CONCLUSION

The addition of a single treatment of submucosal bevacizumab may be associated with additional clinically meaningful benefit for up to 4 months when compared to electrocautery alone. This article is protected by copyright. All rights reserved.

Topical Propranolol Improves Epistaxis Control in Hereditary Hemorrhagic Telangiectasia (HHT): A Randomized Double-Blind Placebo-Controlled Trial

Epistaxis is a common debilitating manifestation in hereditary hemorrhagic telangiectasia (HHT), due to mucocutaneous telangiectases. The epistaxis can be difficult to control despite available treatments. Dysregulated angiogenesis has been shown to be associated with telangiectases formation. Topical propranolol has demonstrated antiangiogenic properties. We performed a two-phase study, i.e., a double-blind placebo-controlled phase, followed by an open-label phase. The aim of the study was assessment of safety and efficacy of nasal propranolol gel in HHT-related epistaxis. Twenty participants with moderate-severe HHT-related epistaxis were randomized to eight weeks of propranolol gel 1.5%, or placebo 0.5 cc, applied to each nostril twice daily; and continued propranolol for eight weeks in an open-label study. For the propranolol group, the epistaxis severity score (ESS) improved significantly (-2.03 ± 1.7 as compared with -0.35 ± 0.68 for the placebo group, p = 0.009); hemoglobin levels improved significantly (10.5 ± 2.6 to 11.4 ± 2.02 g/dL, p = 0.009); and intravenous iron and blood transfusion requirement decreased. The change in nasal endoscopy findings was not significant. During the open-label period, the ESS score improved significantly in the former placebo group (-1.99 ± 1.41, p = 0.005). The most common adverse event was nasal mucosa burning sensation. No cardiovascular events were reported. Our results suggest that topical propranolol gel is safe and effective in HHT-related epistaxis.

Intranasal topical estrogen in the management of epistaxis in hereditary hemorrhagic telangiectasia

CONCLUSION

Application of topical estriol ointment is an effective treatment for hereditary hemorrhagic telangiectasia (HHT) epistaxis.

OBJECTIVE

HHT is an autosomal-dominant disease characterized by epistaxis in more than 96% of patients. Management of this major symptom, epistaxis, has not been standardized. This study reports experience with topical application of estriol in patients with HHT.

METHODS

Five patients with a confirmed diagnosis of HHT who first visited the hospital between 2012 and 2013 received 0.1% estriol ointment and were guided to apply the ointment twice daily to the anterior part of both nasal cavities. Severity of epistaxis was valued using epistaxis severity score (ESS) before and 3 months after initiating therapy.

RESULTS

Five patients (three males, two females) received treatment. After the initiation of treatment, intensity and frequency of epistaxis became moderate in all patients. ESS decreased significantly from pre- to post-treatment (p = 0.043). No adverse events were recorded during follow-up.