Bevacizumab versus ranibizumab in the treatment of exudative age-related macular degeneration: A retrospective study of 58 patients

Managing Neovascular Age-Related Macular Degeneration in Clinical Practice: Systematic Review, Meta-Analysis, and Meta-Regression

The use of anti-vascular endothelial growth factor (VEGF) agents has profoundly changed the prognosis of neovascular age-related macular degeneration (nAMD). As clinical experiences have accumulated, it has become mandatory to summarize data to give information that can be useful in everyday practice. We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies that reported 12-month changes in best-corrected visual acuity (BCVA) in patients with nAMD on anti-VEGF monotherapy. Data were analyzed in a random-effects meta-analysis with BCVA change as the primary outcome. Meta-regression was conducted to evaluate the impact of multiple covariates. Four hundred and twelve heterogeneous study populations (109,666 eyes) were included. Anti-VEGFs induced an overall improvement of +5.37 ETDRS letters at 12 months. Meta-regression showed that mean BCVA change was statistically greater for RCTs (p = 0.0032) in comparison with observational studies. Populations following a proactive regimen had better outcomes than those following a reactive treatment regimen. Mean BCVA change was greater in younger populations, with lower baseline BCVA and treated with a higher number of injections (p < 0.001). Our results confirm that anti-VEGFs may produce a significant functional improvement at 12 months in patients with nAMD.

A comparison of responses to intravitreal bevacizumab, ranibizumab, or aflibercept injections for neovascular age-related macular degeneration

PURPOSE

To compare the responses of intravitreal injections of bevacizumab, ranibizumab, or aflibercept for the treatment of neovascular age-related macular degeneration (nAMD).

METHODS

This retrospective study examined 232 eyes of 232 patients who received intravitreal anti-vascular endothelial growth factor (VEGF) injections due to treatment-naïve nAMD. All patients, who were followed-up for at least 1 year, were treated with intravitreal injections monthly until 3 months, and then as needed. We evaluated the effects of intravitreal injections for treatment of nAMD using the central macular thickness (CMT), subretinal fluid (SRF), pigment epithelial detachment (PED) size, and best-corrected visual acuity (BCVA).

RESULTS

CMT, SRF, PED size, and BCVA (LogMAR) were significantly decreased after treatment with all three anti-VEGF agents. Overall, the bevacizumab, ranibizumab, and aflibercept treatments showed no significant differences in their responses. However, the aflibercept injections decreased PED size more quickly than bevacizumab injections (P = 0.034).

CONCLUSIONS

Bevacizumab, ranibizumab, and aflibercept injections are effective treatments for nAMD and have similar responses, although the number of injections of aflibercept was fewer than other anti-VEGF agents. In addition, aflibercept injections may be a better choice than other anti-VEGF agents for cases of severe increases in PED height.

Bevacizumab versus ranibizumab for neovascular age-related macular degeneration: a Meta-analysis

AIM

To systematically compare the efficacy and safety of off-label bevacizumab versus licensed ranibizumab intravitreal injections as well as monthly regimen versus pro re nata [PRN (as needed)] regimen in the treatment of neovascular age-related macular degeneration (nAMD).

METHODS

Relevant publications were identified through automatically retrieve of database and manually retrieving. The methodological quality of studies included was assessed using the Jadad score and the risk-of-bias assessment. The efficacy estimates were measured by the weight mean difference (WMD) for the improvement of best-corrected visual acuity (BCVA) and central retinal thickness (CRT) reduction. The safety estimates were measured by odds ratios (OR) for adverse events rates. Statistical analysis was conducted by Revman 5.2.7.

RESULTS

Seven studies were included in the Meta-analysis. There were no statistically significant differences between bevacizumab and ranibizumab in BCVA at 1 and 2y (P=0.37, P=0.18, respectively), However, both drugs has better BCVA given monthly than given as needed at 1 and 2y (P<0.05). The results demonstrated the mean decrease in CRT was less in bevacizumab group than ranibizumab group at 1y (P<0.05), while the difference was not significant at 2y (P=0.24). Treatment monthly gained much more decrease in CRT at 1 and 2y (P<0.005). There were no differences between drugs in the rates of death, arterial thrombotic events and venous thrombotic events (P=0.41, P=0.55, P=0.10, respectively), while the rates of medical dictionary for regulatory activities (MedDAR) system organ class events and ≥1 systemic serious adverse events were higher in bevacizumab group than ranibizumab group (P<0.05). But the incidences of death, arterial thrombotic events, venous thrombotic events, MedDAR system organ class events as well as ≥1 systemic serious adverse events were not statistically different between both treatment regimens of monthly and as needed (P=0.14, P=0.76, P=0.73, P=0.12, P=0.11, respectively).

CONCLUSION

Bevacizumab was equivalent to ranibizumab for BCVA, however bevacizumab tended to gain less decrease in CRT and had higher rates of serious adverse events. Compared with treatment as needed, treatment monthly showed superior efficacy in BCVA improvement and CRT reduction, while the rates of adverse events were similar in the two dosing regimens.

Intravitreal Aflibercept Outcomes in Patients with Persistent Macular Exudate Previously Treated with Bevacizumab and/or Ranibizumab for Neovascular Age-Related Macular Degeneration

Purpose. To assess whether intravitreal aflibercept (2.0 mg) can effectively reduce persistent macular exudate and enhance visual acuity in ranibizumab (0.5 mg) and/or bevacizumab (1.25 mg) treatment resistant patients with neovascular age-related macular degeneration. Methods. This retrospective study included 47 treatment resistant eyes from 47 patients switched to intravitreal aflibercept injections after receiving a minimum of 3 injections with either ranibizumab or bevacizumab. Snellen visual acuity and optical coherence tomography were assessed just prior to the first injection (baseline) and prior to the fourth injection (final). Additionally, anatomical regions of persistent macular exudate were tracked to determine if these areas yielded varying responses to aflibercept. Results. At baseline, patients had received an average of 11.3 injections with any prior anti-VEGF drug (SD 5.96). For whole group analysis, baseline and final central retinal thickness were 370.57 µm and 295.7 µm (P ≤ .001), respectively. Baseline and final retinal fluid volumes were 4.81 mm³ and 4.37 mm³ (P ≤ .001), respectively. Baseline and final logMAR were 0.56 and 0.53 (P = 0.301), respectively. Anatomic location of persistent exudate did not appreciably alter treatment outcome. Conclusion. Central retinal thickness and total retinal fluid volume were reduced in ranibizumab and/or bevacizumab treatment resistant patients following three aflibercept injections. No appreciable change in visual acuity was noted.

Results of intravitreal ranibizumab with a prn regimen in the treatment of extrafoveal and juxtafoveal neovascular membranes in age-related macular degeneration

PURPOSE

To evaluate the efficacy of intravitreal ranibizumab with a "pro re nata" regimen in the treatment of nonsubfoveal neovascular membranes secondary to age-related macular degeneration.

METHODS

Retrospective noncomparative case series. Thirty-one eyes with naive nonsubfoveal neovascularization secondary to age-related macular degeneration were consecutively enrolled and treated with ranibizumab intravitreal injections according to a pro re nata regimen. The follow-up was performed monthly up to 6 months and quarterly up to 2 years (25 patients). Early treatment diabetic retinopathy study best-corrected visual acuity and lesion size analysis with fluorescein angiography were recorded.

RESULTS

The mean baseline early treatment diabetic retinopathy study best-corrected visual acuity worsened from 20/40 (0.28 logMAR) at baseline to 20/50 (0.42 logMAR) at 1-year follow-up and 20/60 (0.53 logMAR) at 2-year follow-up. The mean lesions size nearly doubled from baseline at the 2-year follow up (1.19-2.47 mm). Twenty-two patients had one or more recurrences at 1-year follow-up. All 25 patients developed a recurrence at 2 years with 7 cases developing a recurrence by 12 months. Twelve cases progressed to subfoveal lesions by the 24-month visit.

CONCLUSION

Other regimens described in the literature might result in a more the satisfactory outcome using more frequent follow-up and more frequent intravitreal injections.

Comparison of bevacizumab and ranibizumab in age-related macular degeneration: a systematic review and meta-analysis

AIM

To compare the effectiveness and safety between bevacizumab and ranibizumab in the treatment of age-related macular degeneration (AMD) through a systematic review and meta-analysis.

METHODS

We performed a comprehensive search of randomized controlled trials (RCTs), non-RCTs, case-control and cohort studies that compared bevacizumab and ranibizumab using PubMed and the Cochrane Library. After the related data were extracted by two investigators independently, pooled weighted mean differences (WMDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using a random-effects or a fixed-effects model.

RESULTS

A total of four RCTs involving 1927 patients and eleven retrospective case series involving 2296 patients were included. For the primary outcomes, no significant differences were found between ranibizumab group and bevacizumab group in visual acuity (WMD: -0.04; 95%CI: -0.08 to 0.00; P=0.06), best corrected visual acuity (WMD: -0.05; 95%CI: -0.10 to 0.00; P=0.05), retina thickness (WMD: -4.69; 95%CI: -13.15 to 3.76; P=0.86) and foveal thickness (WMD: 10.91; 95%CI: -14.73 to 36.56; P=0.40). The pooled analyses in the evaluation of safety showed that compared to bevacizumab, ranibizumab was associated with decreased risks of ocular inflammation (RR: 0.45; 95% CI: 0.23 to 0.89; P=0.02) and venous thrombotic events (RR: 0.27; 95%CI: 0.08 to 0.89; P=0.03). However, there were no significant differences observed in deaths (P=0.69) and arterial thromboembolic events (P=0.71) between the two groups.

CONCLUSION

With equal clinical efficacy, ranibizumab was found to be associated with less adverse events compared to bevacizumab, indicating that ranibizumab might be a safer management.

Prognostic factors of eyes with naïve subfoveal myopic choroidal neovascularization after intravitreal bevacizumab

PURPOSE

To determine the efficacy of 1 intravitreal bevacizumab injection followed by pro re nata (1 + PRN) injection in cases of subfoveal myopic choroidal neovascularization (CNV) and to identify CNV-recurrence-related prognostic factors.

DESIGN

Retrospective observational case series.

METHODS

In total, 103 eyes of 89 consecutive naive patients who had subfoveal myopic CNV and had been followed-up for at least 2 years were included. Of those eyes, 24 had recurrences. The remaining eyes were stable after the initial treatment.

RESULTS

The average patient age was 51.1 ± 15.2 years. The average follow-up duration was 44.1 ± 12.7 months. At baseline and at the 1-year, 2-year, and final visits, the average best corrected visual acuities (BCVAs) were 0.57 ± 0.45, 0.38 ± 0.51, 0.40 ± 0.52, and 0.41 ± 0.41 logMAR, respectively. The recurrence rate during follow-up was 23.3%. The BCVA improved by 0.2 logMAR after 2.7 injections in the eyes without recurrence but by only 0.08 logMAR after 6.9 injections in the eyes with recurrence. In univariate analysis, recurrence was associated with older age, more myopic refraction, thinner choroid, larger CNV lesions, and subfoveal hemorrhage at baseline. In multivariate analysis, only baseline CNV lesion size associated significantly with CNV recurrence (P = 0.002). Recurrence, baseline BCVA, choroidal thickness, and CNV size associated significantly with final BCVA (P = 0.026, <0.0001, 0.007, and 0.002, respectively). Baseline choroidal thickness, CNV size, age, and presence of lacquer cracks associated significantly with injection number (P < 0.0001, <0.0001, 0.026, and 0.035, respectively).

CONCLUSIONS

1 + PRN intravitreal bevacizumab monotherapy effectively stabilized subfoveal myopic CNV. The CNV size, the baseline BCVA, and the choroidal thickness were the main prognostic factors of subfoveal myopic CNV after 1 + PRN injection of bevacizumab.