EyeWorld India December 2014 Issue

50 EWAP PHARMACEUTICALS December 2014 For anti-VEGFs to be effective, patients must return on a regular basis. To help bring awareness to what retinal disease can do to vision, Aditya Jyot Eye Hospital created the rst Amsler grid garden in the world. Source: S. Natarajan, MD by Maxine Lipner EyeWorld Senior Contributing Writer A wide view of anti-VEGF injections Preserving sight in a variety of patients F rom wet AMD to retinal vascular occlusions, diabetes and beyond, anti-VEGF injections help to preserve the sight of a variety of patients, according to David S. Boyer, MD , clinical professor of ophthalmology, University of Southern California, Los Angeles, Calif., U.S. “Some people use it as an adjunct to the treatment of proliferative diabetic retinopathy, or with proliferation or macular edema from virtually any condition,” Dr. Boyer said. “Others will use it to treat cystoid edema and rarer indications like idiopathic parafoveal telangiectasis.” Such anti-VEGF drugs have a two-pronged mechanism. “It’s an anti-permeability drug, so it stops leakage,” he explained. “It also stops neovascularization from forming and can actually cause temporary regression, when given intravitreally, for areas of neovascularization.” For conditions associated with fluid in the eye, from the start, the anti-VEGFs stave off leakage, Dr. Boyer noted, adding that as a result vision often improves very rapidly in most conditions. “Unfortunately, it’s a temporary fix,” he said. “The leakage will return in most cases unless the drugs are administered on a chronic basis.” Agents in action Currently, there are 3 anti- VEGF agents that are approved for AMD, said Keith A. Warren, MD , clinical professor of ophthalmology, University of Kansas, Overland Park, Kans., U.S. “These include Lucentis [ranibizumab, Genentech, South San Francisco], Eylea [aflibercept, Regeneron Pharmaceuticals, Tarrytown, NY, U.S.], and Macugen [pegaptanib sodium, OSI Pharmaceuticals, Melville, NY, U.S.],” he said. While Macugen was the first of these approved, it is now used sparingly because it is not as effective as the other drugs, Dr. Warren said. In addition, Avastin (bevacizumab, Genentech) is often used off-label. “I use Avastin most frequently, followed by Lucentis and then Eylea,” Dr. Warren said. “Avastin, as was demonstrated in the CATT study [Comparison of AMD Treatments Trials], is fairly effective in treating AMD and, for that matter, diabetic macular edema.” Dr. Warren also favors the drug because he has a wealth of experience with it, since it was the initial drug available for the treatment of diabetic macula edema. “Because of the CATT results and because of cost considerations, I prefer that drug as primary treatment,” he said. If a patient doesn’t respond, however, he switches to another agent. Most often he chooses Lucentis next, based on literature findings and his own experience. “We use Lucentis as primary treatment less frequently but find it very useful as rescue for unresponsive patients, as we do Eylea,” Dr. Warren said, adding that he likes Eylea in particular for patients who have a pigment epithelial detachment (PED). In addition, for patients who live farther away, Eylea may be more efficacious because it needs to be administered less frequently compared to once a month for Lucentis, he said. S. Natarajan, MD , professor of ophthalmology, and chairman and managing director, Aditya Jyot Eye Hospital, Mumbai, India, also tends to favor Lucentis. “In India, we only have Lucentis and Avastin,” he said. “I prefer to use Lucentis for those who can afford it.” Lucentis is made for the eye in particular, and the molecule is exactly right for the retina, unlike Avastin, which is bigger. In addition, Lucentis is given in a single-dose unit, while the Avastin vial must be distributed to more than 1 patient. Dr. Warren said that the anti-VEGF drugs are all highly effective, as found in the clinical trials. Likewise, clinical experience indicates that Avastin is effective as well. “Avastin has never been in the clinical trials similar to the others, but about 95% or more of patients will have no further progression of their disease,” he said. In addition, he finds that approximately 40% of patients on Avastin experience some improvement in their visual acuity. In Dr. Boyer’s experience, while all of the anti-VEGF medications work, some seem to dry the eye slightly better than others. “Based on a couple of studies, it appears that Eylea dries better than Lucentis and also than Avastin,” Dr. Boyer said. “However, as far as the visual acuity results associated with that, there doesn’t seem to be as much difference, even if some fluid is still left.” At least in the randomized clinical trials, visual acuity results for Eylea and Lucentis, administered monthly, seemed to be equal in ARMD patients, he said. He added that, at least in the AMD population, all the drugs seem to work well. As for the tolerability of the agents, they all appear to