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Hristodorov D, Lohoff T, Luneborg N, Mulder GJ, Clark SJ. Investing in vision: Innovation in retinal therapeutics and the influence on venture capital investment. Prog Retin Eye Res 2024; 99:101243. [PMID: 38218527 DOI: 10.1016/j.preteyeres.2024.101243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
Since the groundbreaking approval of the first anti-VEGF therapy in 2004, the retinal therapeutics field has undergone a remarkable transformation, witnessing a surge in novel, disease-modifying therapeutics for a broad spectrum of retinal diseases, extending beyond exudative VEGF-driven conditions. The surge in scientific advancement and the pressing, unmet, medical need have captured the attention of venture capital investors, who have collectively invested close to $10 billion in research and development of new retinal therapeutics between 2004 and 2023. Notably, the field of exudative diseases has gradually shifted away from trying to outcompete anti-VEGF therapeutics towards lowering the overall treatment burden by reducing injection frequency. Simultaneously, a new era has emerged in the non-exudative field, targeting prevalent conditions like dry AMD and rare indications such as Retinitis pigmentosa. This has led to promising drug candidates in development, culminating in the landmark approval of Luxturna for a rare form of Retinitis pigmentosa. The validation of new mechanisms, such as the complement pathway in dry AMD has paved the way for the approvals of Syvovre (Apellis) and Izervay (Iveric/Astellas), marking the first two therapies for this condition. In this comprehensive review, we share our view on the cumulative lessons from the past two decades in developing retinal therapeutics, covering both positive achievements and challenges. We also contextualize the investments, strategic partnering deals, and acquisitions of biotech companies, pharmaceutical companies venture capital investors in retinal therapeutics, respectively. Finally, we provide an outlook and potentially a forward-looking roadmap on novel retinal therapeutics, highlighting the emergence of potential new intervention strategies, such as cell-based therapies, gene editing, and combination therapies. We conclude that upcoming developments have the potential to further stimulate venture capital investments, which ultimately could facilitate the development and delivery of new therapies to patients in need.
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Affiliation(s)
| | | | | | | | - Simon J Clark
- Institute for Ophthalmic Research, Department for Ophthalmology, University Medical Center, Eberhard Karls University of Tübingen, Tübingen, Germany; University Eye Clinic, University Hospital Tübingen, Tübingen, Germany; Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
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pH-responsive organic/inorganic hybrid nanocolloids for transcellular delivery of ribonucleolytic payloads toward targeted anti-glioma therapy. J Colloid Interface Sci 2023; 634:388-401. [PMID: 36542969 DOI: 10.1016/j.jcis.2022.12.018] [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: 07/26/2022] [Revised: 11/30/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
Proteins have been appreciated to be a superlative modality of therapeutics in view of their direct roles in regulating diverse sets of biological events, nonetheless, the clinical applications of the proteinic therapeutics have been strictly limited to act on the cell surface receptors owing to their inherent cell-impermeable character of the proteins. To this obstacle, we contrived carboxylation reaction upon the proteins (RNase A) into the overall negatively charged pro-RNase, followed by elaboration of intelligent pH-responsive pro-RNase delivery nanocolloids based on co-precipitation of pro-RNase and Arg-Gly-Asp (RGD)-functionalized poly(ethylene glycol) (PEG)-block-polyanion with aids of inorganic calcium phosphate (CaP). The resulting nanocolloids appeared to actively accumulate into glioma due to the specific binding affinities of RGD and glioma-enriched αVβ3 and αVβ5 integrins. Furthermore, the pH responsiveness to the acidic endolysosomal microenvironment of all compositions of nanocolloids (including: decarboxylation of pro-RNase composition to restore the native RNase A, ionization of CaP composition to elicit osmotic pressure, and charge reversal of PEG-block-polyanion into membrane-disruptive polycation) could stimulate not only efficient endolysosomal escape for translocation into the cytosol but also structural disassembly for ready liberation of the RNase A payloads, eventually exerting non-specific RNA degradation for apoptosis of the affected cells. Systemic dosage of the proposed nanocolloids demonstrated potent anti-tumor efficacies towards xenograft glioma due to massive RNA degradation. Therefore, our proposed RNase A prodrug nanocolloids could represent as a versatile platform for engineering transcellular protein delivery systems, which are expected to spur thriving emergence of a spectrum of proteins in precision intervention of intractable diseases.
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Montes Rodríguez P, Mateo Gabás J, Esteban Floría O, Honrubia Grijalbo A, Ascaso Puyuelo FJ. Cost-effectiveness of dexamethasone compared with aflibercept in naïve diabetic macular edema. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:61. [PMID: 36457024 PMCID: PMC9713987 DOI: 10.1186/s12962-022-00401-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 11/16/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND To assess the cost-effectiveness of the delayed-release device of dexamethasone compared with aflibercept in the treatment of patients with naïve diabetic macular edema (DME) from a societal perspective in the healthcare sector Zaragoza III in Spain. METHODS A Markov model with five states defined by visual acuity (VA) in the better-seeing eye (Snellen scale) and an additional death state were constructed. Two cohorts of patients were distributed along the VA states and treated during a year with either dexamethasone or aflibercept. One-year follow-up on each group was performed. Medical costs related to the DME treatment and follow-up, medical costs related to the DME comorbidities, and non-medical-related costs were taken into account. Costs (2020 €), health outcomes (Quality-Adjusted Life Years-QALYs), both discounted at a 3.5% annual rate, and incremental cost-effectiveness ratios (ICER: €/QALY) were determined for a lifetime horizon in the base case analysis. RESULTS Patients treated with dexamethasone were €77,349 more costly and provided 2.667 additional QALYs (€29,002/QALY) than those treated with aflibercept. The variable efficiency per patient was calculated dividing the improvement in quality of life (on the VFQ-25 scale) by the cost of the treatment. With the obtained results it can be concluded that the efficiency of treating the patients with dexamethasone is significantly superior than the efficiency of treating them with aflibercept. CONCLUSIONS The cost per QALY gained with the delayed-release device of dexamethasone compared with the one obtained by aflibercept in the naïve DME population is just below the €30,000 threshold, below which, new drugs are sometimes regarded as cost-effective strategies in Spain. In this model, the key variables with greater impact on the cost-effectiveness results were the selected time horizon, the chosen extrapolation method and the number of aflibercept and dexamethasone injections.
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Affiliation(s)
- Paula Montes Rodríguez
- grid.411050.10000 0004 1767 4212Department of Ophthalmology, Hospital Clínico Universitario “Lozano Blesa’’, Zaragoza, Spain ,grid.488737.70000000463436020Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - Javier Mateo Gabás
- grid.411050.10000 0004 1767 4212Department of Ophthalmology, Hospital Clínico Universitario “Lozano Blesa’’, Zaragoza, Spain ,grid.488737.70000000463436020Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - Olivia Esteban Floría
- grid.411050.10000 0004 1767 4212Department of Ophthalmology, Hospital Clínico Universitario “Lozano Blesa’’, Zaragoza, Spain ,grid.488737.70000000463436020Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - Ana Honrubia Grijalbo
- grid.411050.10000 0004 1767 4212Department of Ophthalmology, Hospital Clínico Universitario “Lozano Blesa’’, Zaragoza, Spain ,grid.488737.70000000463436020Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
| | - Francisco J. Ascaso Puyuelo
- grid.411050.10000 0004 1767 4212Department of Ophthalmology, Hospital Clínico Universitario “Lozano Blesa’’, Zaragoza, Spain ,grid.488737.70000000463436020Aragon Health Research Institute (IIS Aragon), Zaragoza, Spain
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Singh R, Chauhan R, Saxena A, Shah A, Mondal L, Bakhle D, Shah C, Shah A, Deoghare S, Krishnan N, Godse N. A prospective, randomized, parallel group, double blind, multicenter study to compare the efficacy, safety and immunogenicity of Lupin's Ranibizumab with Lucentis ® in patients with neovascular age-related macular degeneration. Indian J Ophthalmol 2022; 70:3008-3014. [PMID: 35918962 PMCID: PMC9672715 DOI: 10.4103/ijo.ijo_2118_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose: The present study compares the efficacy, safety, and immunogenicity of Lupin’s biosimilar ranibizumab with that of Lucentis® in patients with neovascular age-related macular degeneration. Methods: This prospective, double-blind, multi-centric phase-III study was conducted across 19 centers in India. A total of 202 patients with neovascular age-related macular degeneration were randomized (1:1) to receive either Lupin’s biosimilar ranibizumab or Lucentis®, 0.5 mg, as an intravitreous injection once every month for 3 months. The primary efficacy endpoint was the proportion of patients who lost fewer than 15 letters from baseline in best-corrected visual acuity. The safety profile included assessment of adverse events, ophthalmic examination, physical and systemic examination, and vital parameters. The immunogenicity assessment was based on evaluation of anti-drug antibodies. Results: Overall, 174 patients (87 [86.14%] in each group) completed the study. The demographics and baseline characteristics were comparable between the treatment groups. The proportion of patients losing fewer than 15 letters from baseline best corrected visual acuity score in the study eye was comparable between two groups. The difference between Lupin’s ranibizumab and Lucentis® for the proportion of patients who lost fewer than 15 letters was within the predefined equivalence margin (intention-to-treat population: 1.0%; 95% confidence interval [CI], −3.3% to 5.4% and per protocol population: 1.2%; 95% CI, −3.2% to 6.4%). The incidence of treatment-emergent adverse events was comparable, and 11 (10.89%) patients in Lupin’s ranibizumab and 19 (18.81%) patients in Lucentis® group had at least one treatment-emergent adverse event. The immunogenicity incidence as assessed by proportion of patients with positive anti-drug antibodies was numerically lower in Lupin’s ranibizumab (4.95%) than Lucentis® (12.87%). Conclusion: Lupin’s biosimilar ranibizumab demonstrated therapeutic equivalence, desirable safety, and favorable immunogenicity profile compared to Lucentis®.
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Affiliation(s)
- Ramandeep Singh
- Professor, Department of Ophthalmology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rohan Chauhan
- Vitreo Retinal Surgeon-Department of Ophthalmology, Rising Retina Clinic, Ahmedabad, Gujarat, India
| | - Ashish Saxena
- Consultant, Department of Ophthalmology, Kanoria Hospital and Research Center, Gandhinagar, Gujarat, India
| | - Anup Shah
- Consultant, Department of Ophthalmology, Dhadiwal Hospital, Nashik, Maharashtra, India
| | - Laxshmi Mondal
- Professor, Department of Ophthalmology, Regional institute of Opthalmology, Kolkata, West Bengal, India
| | - Dhananjay Bakhle
- Medical Research Department, Lupin Limited, Pune, Maharashtra, India
| | - Chirag Shah
- Medical Research Department, Lupin Limited, Pune, Maharashtra, India
| | - Arpit Shah
- Medical Research Department, Lupin Limited, Pune, Maharashtra, India
| | - Shashank Deoghare
- Medical Research Department, Lupin Limited, Pune, Maharashtra, India
| | | | - Neelima Godse
- Medical Research Department, Lupin Limited, Pune, Maharashtra, India
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Jones AV, MacGregor S, Han X, Francis J, Harris C, Kavanagh D, Lotery A, Waheed N. Evaluating a Causal Relationship between Complement Factor I Protein Level and Advanced Age-Related Macular Degeneration Using Mendelian Randomization. OPHTHALMOLOGY SCIENCE 2022; 2:100146. [PMID: 35693873 PMCID: PMC9186402 DOI: 10.1016/j.xops.2022.100146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 01/05/2023]
Abstract
Importance Risk of advanced age-related macular degeneration (AAMD) is associated with rare genetic variants in the gene encoding Complement factor I (CFI), which is associated with lower circulating CFI protein levels, but the nature of the relationship is unclear. Objective Can genetic factors be used to infer whether low circulating CFI is associated with AAMD risk? Design Two-sample inverse variance weighted Mendelian Randomisation (MR) was used to evaluate evidence for a relationship between CFI levels and AAMD risk, comparing CFI levels from genetically predefined subsets in AAMD and control cohorts. Setting Published genetic and proteomic data was combined with data from cohorts of Geographic Atrophy (GA) patients in a series of MR analyses. Participants We derived genetic instruments for systemic CFI level in 3,301 healthy European participants in the INTERVAL study. To evaluate a genetic causal odds ratio (OR) for the effect of CFI levels on AAMD risk, we used results from a genome-wide association study of 12,711 AAMD cases and 14,590 European controls from the International AMD Genomics Consortium (IAMDGC), and CFI levels from patients entered into the research studies SCOPE and SIGHT. Results We identified one common CFI variant rs7439493 which was strongly associated with low CFI level, explaining 4.8% of phenotypic variance. Using rs7439493 our MR analysis estimated that AAMD odds increased per standard deviation (SD) decrease in CFI level; OR 1.47 (95% confidence interval (CI) 1.30-1.65, P=2.1×10-10). We identified one rare variant (rs141853578 encoding p.Gly119Arg) which was genome-wide significantly associated with CFI levels after imputation; based on this, a 1 SD decrease in CFI leads to increased AAMD odds of 1.79 (95% CI 1.46-2.19, P=1.9×10-8). The rare variant rs141853578 explained a further 1.7% of phenotypic variance. To benchmark the effect of low CFI levels on AAMD odds using a CFI-specific proteomic assay, we estimated the effect using CFI levels from 24 rs141853578 positive GA patients; each 1 SD (3.5μg/mL) reduction in CFI was associated with 1.67 fold increased odds of AAMD (95% CI 1.40-2.00, P=1.85×10-8). Conclusion and relevance Excellent concordance in direction and effect size derived from rare and common variant calculations provide good genetic evidence for a potentially causal role of lower CFI level increasing AAMD risk.
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Affiliation(s)
- Amy V. Jones
- Gyroscope Therapeutics Ltd., London, United Kingdom
| | - Stuart MacGregor
- Statistical Genetics, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Xikun Han
- Statistical Genetics, QIMR Berghofer Medical Research Institute, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
| | | | - Claire Harris
- Gyroscope Therapeutics Ltd., London, United Kingdom
- Clinical & Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - David Kavanagh
- Clinical & Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Andrew Lotery
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Southampton Eye Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Nadia Waheed
- Gyroscope Therapeutics Ltd., London, United Kingdom
- Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts
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Hlávka JP, Yu JC, Goldman DP, Lakdawalla DN. The economics of alternative payment models for pharmaceuticals. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:559-569. [PMID: 33725260 PMCID: PMC8169601 DOI: 10.1007/s10198-021-01274-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/17/2021] [Indexed: 05/11/2023]
Abstract
Pharmaceuticals are priced uniformly by convention, but vary in their degree of effectiveness for different disease indications. As more high-cost therapies have launched, the demand for alternative payment models (APMs) has been increasing in many advanced markets, despite their well-documented limitations and challenges to implementation. Among policy justifications for such contracts is the maximization of value given scarce resources. We show that while uniform pricing rules can handle variable effectiveness in efficient markets, market inefficiencies of other kinds create a role for different value-based pricing structures. We first present a stylized theoretical model of efficient interaction among drug manufacturers, payers, and beneficiaries. In this stylized setting, uniform pricing works well, even when treatment effects are variable. We then use this framework to define market failures that result in obstacles to uniform pricing. The market failures we identify include: (1) uncertainty of patient distribution, (2) asymmetric beliefs, (3) agency imperfection by payer, (4) agency imperfection by provider, and (5) patient behavior and treatment adherence. We then apply our insights to real-world examples of alternative payment models, and highlight challenges related to contract implementation.
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Affiliation(s)
- Jakub P Hlávka
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA.
| | - Jeffrey C Yu
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
- USC School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Dana P Goldman
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
- USC School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Darius N Lakdawalla
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
- USC School of Pharmacy, University of Southern California, Los Angeles, CA, USA
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Martinez B, Peplow PV. MicroRNAs as diagnostic and prognostic biomarkers of age-related macular degeneration: advances and limitations. Neural Regen Res 2021; 16:440-447. [PMID: 32985463 PMCID: PMC7996036 DOI: 10.4103/1673-5374.293131] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 01/10/2023] Open
Abstract
A main cause of vision loss in the elderly is age-related macular degeneration (AMD). Among the cellular, biochemical, and molecular changes linked to this disease, inflammation and angiogenesis appear as being crucial in AMD pathogenesis and progression. There are two forms of the disease: dry AMD, accounting for 80-90% of cases, and wet AMD. The disease usually begins as dry AMD associated with retinal pigment epithelium and photoreceptor degeneration, whereas wet AMD is associated with choroidal neovascularization resulting in severe vision impairment. The new vessels are largely malformed, leading to blood and fluid leakage within the disrupted tissue, which provokes inflammation and scar formation and results in retinal damage and detachment. MicroRNAs are dysregulated in AMD and may facilitate the early detection of the disease and monitoring disease progression. Two recent reviews of microRNAs in AMD had indicated weaknesses or limitations in four earlier investigations. Studies in the last three years have shown considerable progress in overcoming some of these concerns and identifying specific microRNAs as biomarkers for AMD. Further large-scale studies are warranted using appropriate statistical methods to take into account gender and age disparity in the study populations and confounding factors such as smoking status.
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Affiliation(s)
- Bridget Martinez
- Physical Chemistry and Applied Spectroscopy, Chemistry Division, Los Alamos National Laboratory, Los Alamos, NM, USA
- Department of Medicine, St. George's University School of Medicine, Grenada
| | - Philip V. Peplow
- Department of Anatomy, University of Otago, Dunedin, New Zealand
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Krstić L, González-García MJ, Diebold Y. Ocular Delivery of Polyphenols: Meeting the Unmet Needs. Molecules 2021; 26:molecules26020370. [PMID: 33445725 PMCID: PMC7828190 DOI: 10.3390/molecules26020370] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 12/14/2022] Open
Abstract
Nature has become one of the main sources of exploration for researchers that search for new potential molecules to be used in therapy. Polyphenols are emerging as a class of compounds that have attracted the attention of pharmaceutical and biomedical scientists. Thanks to their structural peculiarities, polyphenolic compounds are characterized as good scavengers of free radical species. This, among other medicinal effects, permits them to interfere with different molecular pathways that are involved in the inflammatory process. Unfortunately, many compounds of this class possess low solubility in aqueous solvents and low stability. Ocular pathologies are spread worldwide. It is estimated that every individual at least once in their lifetime experiences some kind of eye disorder. Oxidative stress or inflammatory processes are the basic etiological mechanisms of many ocular pathologies. A variety of polyphenolic compounds have been proved to be efficient in suppressing some of the indicators of these pathologies in in vitro and in vivo models. Further application of polyphenolic compounds in ocular therapy lacks an adequate formulation approach. Therefore, more emphasis should be put in advanced delivery strategies that will overcome the limits of the delivery site as well as the ones related to the polyphenols in use. This review analyzes different drug delivery strategies that are employed for the formulation of polyphenolic compounds when used to treat ocular pathologies related to oxidative stress and inflammation.
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Affiliation(s)
- Luna Krstić
- Insituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, 47011 Valladolid, Spain; (L.K.); (M.J.G.-G.)
| | - María J. González-García
- Insituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, 47011 Valladolid, Spain; (L.K.); (M.J.G.-G.)
- Centro de Investigación Biomédica en Red Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Yolanda Diebold
- Insituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, 47011 Valladolid, Spain; (L.K.); (M.J.G.-G.)
- Centro de Investigación Biomédica en Red Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-883423274
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Singh RK, Nasonkin IO. Limitations and Promise of Retinal Tissue From Human Pluripotent Stem Cells for Developing Therapies of Blindness. Front Cell Neurosci 2020; 14:179. [PMID: 33132839 PMCID: PMC7513806 DOI: 10.3389/fncel.2020.00179] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/25/2020] [Indexed: 12/13/2022] Open
Abstract
The self-formation of retinal tissue from pluripotent stem cells generated a tremendous promise for developing new therapies of retinal degenerative diseases, which previously seemed unattainable. Together with use of induced pluripotent stem cells or/and CRISPR-based recombineering the retinal organoid technology provided an avenue for developing models of human retinal degenerative diseases "in a dish" for studying the pathology, delineating the mechanisms and also establishing a platform for large-scale drug screening. At the same time, retinal organoids, highly resembling developing human fetal retinal tissue, are viewed as source of multipotential retinal progenitors, young photoreceptors and just the whole retinal tissue, which may be transplanted into the subretinal space with a goal of replacing patient's degenerated retina with a new retinal "patch." Both approaches (transplantation and modeling/drug screening) were projected when Yoshiki Sasai demonstrated the feasibility of deriving mammalian retinal tissue from pluripotent stem cells, and generated a lot of excitement. With further work and testing of both approaches in vitro and in vivo, a major implicit limitation has become apparent pretty quickly: the absence of the uniform layer of Retinal Pigment Epithelium (RPE) cells, which is normally present in mammalian retina, surrounds photoreceptor layer and develops and matures first. The RPE layer polarize into apical and basal sides during development and establish microvilli on the apical side, interacting with photoreceptors, nurturing photoreceptor outer segments and participating in the visual cycle by recycling 11-trans retinal (bleached pigment) back to 11-cis retinal. Retinal organoids, however, either do not have RPE layer or carry patches of RPE mostly on one side, thus directly exposing most photoreceptors in the developing organoids to neural medium. Recreation of the critical retinal niche between the apical RPE and photoreceptors, where many retinal disease mechanisms originate, is so far unattainable, imposes clear limitations on both modeling/drug screening and transplantation approaches and is a focus of investigation in many labs. Here we dissect different retinal degenerative diseases and analyze how and where retinal organoid technology can contribute the most to developing therapies even with a current limitation and absence of long and functional outer segments, supported by RPE.
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Preclinical challenges for developing long acting intravitreal medicines. Eur J Pharm Biopharm 2020; 153:130-149. [DOI: 10.1016/j.ejpb.2020.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
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Ribeiro I, Batel Marques F, Mendes D, Alves C. A Systematic Review of Economic Studies Evaluating Ophthalmic Drugs: An Analysis of the Health-state Utilities. Ophthalmic Epidemiol 2020; 27:325-338. [PMID: 32691652 DOI: 10.1080/09286586.2020.1792938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To characterize the techniques used to derive health-state utilities (HSU) in the cost-utility studies (CUS) of ophthalmic drugs. METHODS A systematic review was conducted in Pubmed/Embase until October 2019. CUS evaluating ophthalmic drugs were included. Therapeutic area, technique to derive HSU and sources of HSU were extracted. It was assessed if the HSU and the other parameters of CUS were collected from the same population. The techniques to derive HSU used in the CUS were compared to the techniques recommended by the country-specific economic evaluation guidelines. RESULTS Seventy CUS were included. Forty-three (61.4%) used direct techniques to derive HSU, 19 (27.1%) used indirect, 1 (1.4%) used direct and indirect and the remaining (n = 7; 10.0%) used other or unknown techniques. Twelve (17.1%) CUS collected the HSU and the other parameters from the same population: nine (12.9%) retrieved utility data from experimental studies, two (2.9%) from observational and one (1.4%) from other sources. Forty-eight (68.6%) CUS collected the HSU and the other parameters from different populations: eight (11.4%) retrieved utility data from experimental studies, 33 (47.1%) from observational, one (1.4%) from both experimental and observational and six (8.6%) from other sources. It was not possible to identify the population from whom data were obtained in 10 (14.3%) CUS. Eleven (15.7%) CUS followed the recommendations of guidelines, 21 (30.0%) did not follow and for 38 (54.3%), it was not possible to assess. CONCLUSION Choosing different techniques to derive HSU may result in different results, which can preclude the comparison between cost-utility studies.
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Affiliation(s)
- Inês Ribeiro
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal.,Faculty of Pharmacy, University of Coimbra , Coimbra, Portugal
| | - Francisco Batel Marques
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal.,Laboratory of Social Pharmacy and Public Health, Faculty of Pharmacy, University of Coimbra , Coimbra, Portugal
| | - Diogo Mendes
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal
| | - Carlos Alves
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, CHAD - Centre for Health Technology Assessment and Drug Research , Coimbra, Portugal.,Laboratory of Social Pharmacy and Public Health, Faculty of Pharmacy, University of Coimbra , Coimbra, Portugal
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Dalvin LA, Starr MR, AbouChehade JE, Damento GM, Garcia M, Shah SM, Hodge DO, Meissner I, Bakri SJ, Iezzi R. Association of Intravitreal Anti-Vascular Endothelial Growth Factor Therapy With Risk of Stroke, Myocardial Infarction, and Death in Patients With Exudative Age-Related Macular Degeneration. JAMA Ophthalmol 2020; 137:483-490. [PMID: 30703203 DOI: 10.1001/jamaophthalmol.2018.6891] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Current studies assessing the risk of stroke, myocardial infarction (MI), and death in patients undergoing intravitreal anti-vascular endothelial growth factor (VEGF) therapy are inconclusive. To our knowledge, no population-based studies have been performed to examine these potential risks. Objective To examine whether patients with exudative age-related macular degeneration (AMD) receiving intravitreal anti-VEGF injections have a higher incidence of MI, stroke, or death compared with control populations. Design, Setting, and Participants This population-based, retrospective cohort study included 504 patients from Olmsted County, Minnesota, identified through the Rochester Epidemiology Project (REP) database as receiving at least 1 intravitreal anti-VEGF injection for exudative AMD from January 1, 2004, to December 31, 2013. Three age- and sex-matched control groups of individuals who did not receive anti-VEGF treatment and were derived from the REP database were also studied: control individuals with exudative AMD in the era before anti-VEGF (January 1, 1990, to December 31, 2003), controls with dry AMD, and controls without AMD. Data analysis was performed from September 1, 2016, to September 1, 2017. Main Outcomes and Measures Five-year risk of stroke, MI, and death were assessed in patients compared with controls using Kaplan-Meier and multivariate analysis with Cox proportional hazards regression models. Results The study included 504 patients (321 female [63.7%]; mean [SD] age, 76.5 [10.0] years) who received at least 1 intravitreal anti-VEGF injection for exudative AMD during the study period. Kaplan-Meier analysis revealed a 5-year risk of 7.2% for stroke, 6.1% for MI, and 30.0% for death. Patients who received anti-VEGF had no increased risk of stroke or MI compared with controls with dry AMD (n = 504), controls with exudative AMD (n = 473), or controls without AMD (n = 504). There was an increased risk of mortality compared with controls with exudative AMD in the era prior to anti-VEGF therapy but not the other control groups on multivariate analysis (hazard ratio, 1.63; 95% CI, 1.30-2.04; P < .001). Conclusions and Relevance This population-based study revealed that intravitreal anti-VEGF therapy for exudative AMD was not associated with consistent increases in the risk of stroke, MI, or death compared with no therapy in patients with or without AMD. It appears to be likely the cardiac events these patients experience are not attributable to their anti-VEGF therapy.
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Affiliation(s)
- Lauren A Dalvin
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Matthew R Starr
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Maria Garcia
- Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Saumya M Shah
- Mayo Clinic School of Medicine, Rochester, Minnesota
| | - David O Hodge
- Department of Health Sciences Research/Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - Irene Meissner
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Sophie J Bakri
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Raymond Iezzi
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
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Sodré SL, Barbosa IAF, Pacheco IE, Ferreira FDQT, David MA, Nascimento MA, Arieta CEL, Vasconcellos JPCD. Costs and benefits of bevacizumab vial sharing for the treatment of retinal diseases. BMC Public Health 2019; 19:1252. [PMID: 31510981 PMCID: PMC6740002 DOI: 10.1186/s12889-019-7562-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 08/28/2019] [Indexed: 11/23/2022] Open
Abstract
Background Antiangiogenic therapy has proved to be an important therapeutic tool for many retinal vascular diseases; however, its availability is limited in developing countries. This study sought to describe the bevacizumab vial sharing process and to evaluate the impact of this repackaging system on the costs incurred in a Brazilian public hospital. Method This retrospective study compared the number and costs of intravitreal antiangiogenic injections approved via court order in the first year of the study (2015) to the number and costs of the bevacizumab injections provided through the use of vial sharing in the second year of the study (2016). Vial sharing consists of the traditional process used to repackage bevacizumab; in this case, however, the drug samples used were the residual volume from the preparation of bevacizumab for oncology patients. The hospital adhered to the guidelines established by the Brazilian Health Surveillance Agency (ANVISA). Results In the first year of the study and using medication obtained through court orders, 550 intravitreal injections were performed in the ophthalmology ambulatory care center. Based on local pricing tables, the total cost of the medication was BRL$1,036,056.25 (USD$267,546.58), and the average cost of each application was BRL$1883.74 (USD$486.45). In the second year of the study, 1081 intravitreal applications were performed at the same hospital using doses obtained through bevacizumab vial sharing. The total cost was BRL$21,942.49 (USD$5663.30) and the per-unit cost was BRL$20.30, or USD$5.23 (a savings of 97.88%). Conclusion This study found that bevacizumab vial sharing led to a significant reduction in public health care costs associated with antiangiogenic treatment and increased the availability of the drug to public health care patients. These results can be extrapolated to other types of drugs and health care systems.
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Affiliation(s)
- Sávio Lima Sodré
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil.
| | - Italo Antunes França Barbosa
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | - Israel Emiliano Pacheco
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | | | - Milton Agrizzi David
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | - Mauricio Abujamra Nascimento
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
| | - Carlos Eduardo Leite Arieta
- Universidade Estadual De Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, SP, 13083-970, Brasil
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COMPLIANCE AND ADHERENCE OF PATIENTS WITH DIABETIC MACULAR EDEMA TO INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN DAILY PRACTICE. Retina 2019; 38:2293-2300. [PMID: 29068914 DOI: 10.1097/iae.0000000000001892] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We assessed differences in compliance and adherence (lateness of patients, visual acuity, reasons for abstaining) between patients with diabetic macular edema (DME) and patients with age-related macular degeneration (AMD), both under anti-vascular endothelial growth factor therapy. METHODS We included 136 patients with DME (36% women, 65 years, 22 visits, 13.9 injections, and 29.9 months of follow-up) and 109 patients with AMD (59% women, 76 years, 20 visits, 14.7 injections, and 22.3 months of follow-up) (minimum follow-up of 12 months and at least 5 injections). We assessed missed appointments (lateness >14 days) and therapy break-offs (lateness >100 days). All delayed patients were called and interviewed for abstaining reasons. RESULTS Forty-six percent of patients with DME and 22% of patients with AMD had at least one break-off. Thirty-five percent of patients with DME and 50% of patients with AMD were always on schedule. In patients with DME, there was significant correlation (P = 0.017) between the number of break-offs and change of visual acuity. In 60% DME and 38% AMD of break-off cases, visual acuity was worse than the before break-off. The most common reason for abstaining was comorbidities (33% AMD and 20% DME). CONCLUSION There are significant differences between patients with AMD and DME regarding compliance and adherence, which also affects outcome. Strategies to tie patients with DME to costly intravitreal therapy need to be developed to improve outcomes and efficacy.
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Barmas-Alamdari D, D’Souza HS, Kapoor KG, Wagner AL. Intravitreal Ziv-Aflibercept: A Comprehensive Review. Semin Ophthalmol 2019; 34:420-435. [DOI: 10.1080/08820538.2019.1641526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Haley S. D’Souza
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, USA
- Ophthalmology Research, Wagner Macula and Retina Center, Virginia Beach, Virginia, USA
| | - Kapil G. Kapoor
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, USA
- Ophthalmology Research, Wagner Macula and Retina Center, Virginia Beach, Virginia, USA
| | - Alan L. Wagner
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, USA
- Ophthalmology Research, Wagner Macula and Retina Center, Virginia Beach, Virginia, USA
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Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2019; 3:CD005139. [PMID: 30834517 PMCID: PMC6419319 DOI: 10.1002/14651858.cd005139.pub4] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the most common cause of uncorrectable severe vision loss in people aged 55 years and older in the developed world. Choroidal neovascularization (CNV) secondary to AMD accounts for most cases of AMD-related severe vision loss. Intravitreous injection of anti-vascular endothelial growth factor (anti-VEGF) agents aims to block the growth of abnormal blood vessels in the eye to prevent vision loss and, in some instances, to improve vision. OBJECTIVES • To investigate ocular and systemic effects of, and quality of life associated with, intravitreous injection of three anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) versus no anti-VEGF treatment for patients with neovascular AMD• To compare the relative effects of one of these anti-VEGF agents versus another when administered in comparable dosages and regimens SEARCH METHODS: To identify eligible studies for this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (searched January 31, 2018); MEDLINE Ovid (1946 to January 31, 2018); Embase Ovid (1947 to January 31, 2018); the Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to January 31, 2018); the International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com/editAdvancedSearch - searched January 31, 2018); ClinicalTrials.gov (www.clinicaltrials.gov - searched November 28, 2018); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en - searched January 31, 2018). We did not impose any date or language restrictions in electronic searches for trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated pegaptanib, ranibizumab, or bevacizumab versus each other or versus a control treatment (e.g. sham treatment, photodynamic therapy), in which participants were followed for at least one year. DATA COLLECTION AND ANALYSIS Two review authors independently screened records, extracted data, and assessed risks of bias. We contacted trial authors for additional data. We compared outcomes using risk ratios (RRs) or mean differences (MDs). We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 16 RCTs that had enrolled a total of 6347 participants with neovascular AMD (the number of participants per trial ranged from 23 to 1208) and identified one potentially relevant ongoing trial. Six trials compared anti-VEGF treatment (pegaptanib, ranibizumab, or bevacizumab) versus control, and 10 trials compared bevacizumab versus ranibizumab. Pharmaceutical companies conducted or sponsored four trials but funded none of the studies that evaluated bevacizumab. Researchers conducted these trials at various centers across five continents (North and South America, Europe, Asia, and Australia). The overall certainty of the evidence was moderate to high, and most trials had an overall low risk of bias. All but one trial had been registered prospectively.When compared with those who received control treatment, more participants who received intravitreous injection of any of the three anti-VEGF agents had gained 15 letters or more of visual acuity (risk ratio [RR] 4.19, 95% confidence interval [CI] 2.32 to 7.55; moderate-certainty evidence), had lost fewer than 15 letters of visual acuity (RR 1.40, 95% CI 1.27 to 1.55; high-certainty evidence), and showed mean improvement in visual acuity (mean difference 6.7 letters, 95% CI 4.4 to 9.0 in one pegaptanib trial; mean difference 17.8 letters, 95% CI 16.0 to 19.7 in three ranibizumab trials; moderate-certainty evidence) after one year of follow-up. Participants treated with anti-VEGF agents showed improvement in morphologic outcomes (e.g. size of CNV, central retinal thickness) compared with participants not treated with anti-VEGF agents (moderate-certainty evidence). No trial directly compared pegaptanib versus another anti-VEGF agent and followed participants for one year; however, when compared with control treatments, ranibizumab and bevacizumab each yielded larger improvements in visual acuity outcomes than pegaptanib.Visual acuity outcomes after bevacizumab and ranibizumab were similar when the same RCTs compared the same regimens with respect to gain of 15 or more letters of visual acuity (RR 0.95, 95% CI 0.81 to 1.12; high-certainty evidence) and loss of fewer than 15 letters of visual acuity (RR 1.00, 95% CI 0.98 to 1.02; high-certainty evidence); results showed similar mean improvement in visual acuity (mean difference [MD] -0.5 letters, 95% CI -1.5 to 0.5; high-certainty evidence) after one year of follow-up, despite the substantially lower cost of bevacizumab compared with ranibizumab. Reduction in central retinal thickness was less among bevacizumab-treated participants than among ranibizumab-treated participants after one year (MD -11.6 μm, 95% CI -21.6 to -1.7; high-certainty evidence); however, this difference is within the range of measurement error, and we did not interpret it to be clinically meaningful.Ocular inflammation and increased intraocular pressure (IOP) after intravitreal injection were the most frequently reported serious ocular adverse events. Researchers reported endophthalmitis in less than 1% of anti-VEGF-treated participants and in no cases among control groups. The occurrence of serious systemic adverse events was comparable across anti-VEGF-treated groups and control groups; however, the numbers of events and trial participants may have been insufficient to show a meaningful difference between groups (evidence of low- to moderate-certainty). Investigators rarely measured and reported data on visual function, quality of life, or economic outcomes. AUTHORS' CONCLUSIONS Results of this review show the effectiveness of anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) in terms of maintaining visual acuity; studies show that ranibizumab and bevacizumab improved visual acuity in some eyes that received these agents and were equally effective. Available information on the adverse effects of each medication does not suggest a higher incidence of potentially vision-threatening complications with intravitreous injection of anti-VEGF agents compared with control interventions; however, clinical trial sample sizes were not sufficient to estimate differences in rare safety outcomes. Future Cochrane Reviews should incorporate research evaluating variable dosing regimens of anti-VEGF agents, effects of long-term use, use of combination therapies (e.g. anti-VEGF treatment plus photodynamic therapy), and other methods of delivering these agents.
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Affiliation(s)
- Sharon D Solomon
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | | | - Magdalena G Krzystolik
- Mass Eye and Ear InfirmaryDepartment of Ophthalmology, Retina Service1 Randall Square, Suite 203ProvidenceRhode IslandUSA02904
| | - Barbara S Hawkins
- Johns Hopkins University School of MedicineWilmer Eye Institute600 North Wolfe StreetMaumenee 740BaltimoreMarylandUSA21287
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Amarakoon S, Martinez-Ciriano JP, van den Born LI, Baarsma S, Missotten T. Bevacizumab in age-related macular degeneration: a randomized controlled trial on the effect of on-demand therapy every 4 or 8 weeks. Acta Ophthalmol 2019; 97:107-112. [PMID: 30369062 DOI: 10.1111/aos.13774] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 03/04/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE Intravitreal anti-vascular endothelial growth factor (VEGF) injections are an effective treatment for neovascular age-related macular degeneration (nARMD). Bevacizumab appears to be a cost-effective off-label anti-VEGF alternative to ranibizumab, but an optimal injection schedule has not yet been determined. In this study, we investigate whether on-demand bevacizumab treatment every 8 weeks is non-inferior to on-demand bevacizumab every 4 weeks in treating nARMD. METHODS A total of 120 nARMD patients were randomly assigned to an on-demand regimen of intravitreal bevacizumab (IVB) every 4 (n = 60) or 8 weeks (n = 60). The primary outcome was visual acuity (VA) change after 1 year of treatment. RESULTS Visual acuity (VA) improved between baseline and 1 year in both treatment groups. The mean change in the VA score at 1 year was not significantly different between bevacizumab administration on-demand every 4 weeks [5.6 ± 10.2 Early Treatment Diabetic Retinopathy Study (ETDRS) letter] or 8 weeks (4.6 ± 12.0 ETDRS letters). A reduction in the central retinal thickness was observed in both groups. At 1 year, the mean decrease in central foveal thickness ranged from 61 ± 90 μm in the 4-week group to 91 ± 83 μm in the 8-week group (p = 0.07). The mean number of IVB treatments during the study period was 8.7 ± 2.3 in the 4-week group and 5.9 ± 1.0 in the 8-week group. CONCLUSION At 1 year, bevacizumab administration on-demand every 8 weeks was non-inferior to administration every 4 weeks. The results strongly suggest that bevacizumab acts longer than 4 weeks in ARMD, reducing the burden of injections for patients.
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Affiliation(s)
- Sankha Amarakoon
- Rotterdam Eye Hospital; Rotterdam the Netherlands
- Rotterdam Ophthalmic Institute; Rotterdam the Netherlands
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18
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Elshout M, Webers CA, van der Reis MI, Schouten JS. A systematic review on the quality, validity and usefulness of current cost-effectiveness studies for treatments of neovascular age-related macular degeneration. Acta Ophthalmol 2018; 96:770-778. [PMID: 29862641 DOI: 10.1111/aos.13824] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 04/13/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Ophthalmologists increasingly depend on new drugs to advance their treatment options. These options are limited by restraints on reimbursements for new and expensive drugs. These restraints are put in place through health policy decisions based on cost-effectiveness analyses (CEA). Cost-effectiveness analyses need to be valid and of good quality to support correct decisions to create new treatment opportunities. In this study, we report the quality, validity and usefulness of CEAs for therapies for nAMD. METHODS A systematic review in PubMed, EMBASE and Cochrane was performed to include CEAs. Quality and validity assessment was based on current general quality criteria and on elements that are specific to the field of ophthalmology. RESULTS Forty-eight CEAs were included in the review. Forty-four CEAs did not meet four basic model quality and validity criteria specific to CEAs in the field of ophthalmology (both eyes analysed instead of one; a time horizon extending beyond 4 years; extrapolating VA and treatment intervals beyond trial data realistically; and including the costs of low-vision). Four CEAs aligned with the quality and validity criteria. In two of these CEAs bevacizumab as-needed (PRN) was more cost-effective than bevacizumab monthly; aflibercept (VIEW); or ranibizumab monthly or PRN. In two CEAs, ranibizumab (PRN or treat and extent) was dominant over aflibercept. In two other CEAs, aflibercept was either more cost-effective or dominant over ranibizumab monthly or PRN. CONCLUSION Two of the CEAs of sufficient quality and validity show that bevacizumab PRN is the most cost-effective treatment. Comparing ranibizumab and aflibercept, either treatment can be more cost-effective depending on the assumptions used for drug prices and treatment frequencies. The majority of the published CEAs are of insufficient quality and validity. They wrongly inform decision-makers at the cost of opportunities for ophthalmologists to treat patients. As such, they may negatively influence overall patient outcomes and societal costs. For future ophthalmic treatments, CEAs need to be improved and only published when they are of sufficient quality and validity.
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Affiliation(s)
- Mari Elshout
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
| | - Carroll A.B. Webers
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
| | - Margriet I. van der Reis
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
| | - Jan S.A.G. Schouten
- Maastricht University Medical Center; University Eye Clinic Maastricht; Maastricht The Netherlands
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19
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Enhanced expression of soluble antibody fragments by low-temperature and overdosing with a nitrogen source. Enzyme Microb Technol 2018; 115:9-15. [DOI: 10.1016/j.enzmictec.2018.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 11/22/2022]
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20
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Maloca P, Hasler PW, Barthelmes D, Arnold P, Matthias M, Scholl HPN, Gerding H, Garweg J, Heeren T, Balaskas K, de Carvalho JER, Egan C, Tufail A, Zweifel SA. Safety and Feasibility of a Novel Sparse Optical Coherence Tomography Device for Patient-Delivered Retina Home Monitoring. Transl Vis Sci Technol 2018; 7:8. [PMID: 30050725 PMCID: PMC6058910 DOI: 10.1167/tvst.7.4.8] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/06/2018] [Indexed: 12/31/2022] Open
Abstract
Purpose To study a novel and fast optical coherence tomography (OCT) device for home-based monitoring in age-related macular degeneration (AMD) in a small sample yielding sparse OCT (spOCT) data and to compare the device to a commercially available reference device. Methods In this prospective study, both eyes of 31 participants with AMD were included. The subjects underwent scanning with an OCT prototype and a spectral-domain OCT to compare the accuracy of the central retinal thickness (CRT) measurements. Results Sixty-two eyes in 31 participants (21 females and 10 males) were included. The mean age was 79.6 years (age range, 69–92 years). The mean difference in the CRT measurements between the devices was 4.52 μm (SD ± 20.0 μm; range, −65.6 to 41.5 μm). The inter- and intrarater reliability coefficients of the OCT prototype were both >0.95. The laser power delivered was <0.54 mW for spOCT and <1.4 mW for SDOCT. No adverse events were reported, and the visual acuity before and after the measurements was stable. Conclusion This study demonstrated the safety and feasibility of this home-based OCT monitoring under real-life conditions, and it provided evidence for the potential clinical benefit of the device. Translational Relevance The newly developed spOCT is a valid and readily available retina scanner. It could be applied as a portable self-measuring OCT system. Its use may facilitate the sustainable monitoring of chronic retinal diseases by providing easily accessible and continuous retinal monitoring.
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Affiliation(s)
- Peter Maloca
- OCTlab, Department of Ophthalmology, University Hospital of Basel, Basel, Switzerland.,University of Basel, Department of Ophthalmology, Basel, Switzerland.,Moorfields Eye Hospital, London, UK
| | - Pascal W Hasler
- OCTlab, Department of Ophthalmology, University Hospital of Basel, Basel, Switzerland.,University of Basel, Department of Ophthalmology, Basel, Switzerland
| | - Daniel Barthelmes
- University of Zurich, Department of Ophthalmology, University Hospital, Zurich, Switzerland.,Save Sight Institute, The University of Sydney, Sydney, Australia
| | - Patrik Arnold
- University of Applied Sciences Engineering and Information Technology, Institute for Human Centered Engineering OptoLab, Biel/Berne, Switzerland
| | - Mooser Matthias
- University of Applied Sciences Engineering and Information Technology, Institute for Human Centered Engineering OptoLab, Biel/Berne, Switzerland
| | - Hendrik P N Scholl
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland.,University of Basel, Department of Ophthalmology, Basel, Switzerland.,Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Heinrich Gerding
- Pallas Kliniken AG, Olten, Switzerland.,Augenklinik der Universität Münster, Münster, Germany
| | - Justus Garweg
- Berner Augenklinik am Lindenhofspital and University of Bern, Bern, Switzerland
| | - Tjebo Heeren
- University College London, Institute of Ophthalmology, London, UK
| | - Konstantinos Balaskas
- Moorfields Ophthalmic Reading Centre, London, UK.,Moorfields Eye Hospital, London, UK
| | | | | | | | - Sandrine A Zweifel
- University of Zurich, Department of Ophthalmology, University Hospital, Zurich, Switzerland
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Schmid MK, Reich O, Blozik E, Faes L, Bodmer NS, Locher S, Thiel MA, Rapold R, Kuhn M, Bachmann LM. Outcomes and costs of Ranibizumab and Aflibercept treatment in a health-service research context. BMC Ophthalmol 2018; 18:64. [PMID: 29486762 PMCID: PMC5830340 DOI: 10.1186/s12886-018-0731-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/23/2018] [Indexed: 11/18/2022] Open
Abstract
Background To compare anti-VEGF treatments for macular disease in terms of costs and clinical outcomes. Methods We identified patients suffering from macular disease and treated either with aflibercept, ranibizumab or both at the largest public eye clinic in Switzerland between January 1st and December 31st 2016 who were insured in one of the two participating health insurance companies. Clinical data were extracted from the electronic health record system. The health insurers provided the health claim costs for the ophthalmologic care and the total health care costs of each patient in the observation period. Using multivariate regression models, we assessed the monthly ophthalmologic and the monthly total costs of patients with no history of switching (ranibizumab vs. aflibercept), patients with a history of switching from ranibizumab to aflibercept, patients switching during the observation period and a miscellaneous group. We examined baseline differences in age, proportion of males, visual acuity (letters), central retinal thickness (CRT) and treatment history before entering the study. We investigated treatment intensity and compared the changes in letters and CRT. Results The analysis involved 488 eyes (361 patients), 182 on ranibizumab treatment, and 63 on aflibercept treatment, 160 eyes with a history of switching from ranibizumab to aflibercept, and 45 switchers during follow-up and 38 eyes of the miscellaneous group. Compared to ranibizumab, monthly costs of ophthalmologic treatment were slightly higher for aflibercept treatment + 175.0 CHF (95%CI: 1.5 CHF to 348.3 CHF; p = 0.048) as were the total monthly costs + 581.0 CHF (95%CI: 159.5 CHF to 1002.4 CHF; p = 0.007). Compared to ranibizumab, the monthly treatment intensity with aflibercept was similar (+ 0.057 injections/month (95%CI -0.023 to 0.137; p = 0.162), corresponding to a projected annual number of 5.4 injections for ranibizumab vs. 6.1 injections for aflibercept. During follow-up, visus dropped by 0.7 letters with ranibizumab and increased by 0.6 letters with aflibercept (p = 0.243). CRT dropped by − 14.9 μm with ranibizumab and by − 19.5 μm with aflibercept (p = 0.708). The monthly costs of all other groups examined were higher. Conclusion These real-life data show that aflibercept treatment is equally expensive, and clinical outcomes between the two drugs are similar.
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Affiliation(s)
- Martin K Schmid
- University of Zurich, Zurich, Switzerland.,Eye Clinic, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Oliver Reich
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Livia Faes
- Eye Clinic, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Nicolas S Bodmer
- Medignition Inc. Research Consultants, Verena Conzett-Strasse 9, P.O. 9628, 8036, Zurich, CH, Switzerland
| | - Silvan Locher
- Eye Clinic, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Michael A Thiel
- University of Zurich, Zurich, Switzerland.,Eye Clinic, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Roland Rapold
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | | | - Lucas M Bachmann
- University of Zurich, Zurich, Switzerland. .,Medignition Inc. Research Consultants, Verena Conzett-Strasse 9, P.O. 9628, 8036, Zurich, CH, Switzerland.
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22
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Lau CML, Yu Y, Jahanmir G, Chau Y. Controlled release technology for anti-angiogenesis treatment of posterior eye diseases: Current status and challenges. Adv Drug Deliv Rev 2018; 126:145-161. [PMID: 29625138 DOI: 10.1016/j.addr.2018.03.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/25/2018] [Accepted: 03/27/2018] [Indexed: 12/27/2022]
Abstract
Antiangiogenic therapeutics, such as corticosteroids, VEGF targeting antibodies and aptamers have been demonstrated effective in controlling retinal and choroidal neovascularization related vision loss. However, to manage the chronic conditions, it requires long term and frequent intravitreal injections of these drugs, resulting in poor patient compliance and suboptimal treatment. In addition, emerging drugs such as tyrosine kinase inhibitors and siRNAs received much expectations, but the late stage clinical trials encountered various obstacles. Controlled release technology could improve the existing treatment regimen by extending therapeutic duration, reducing risks and burdens caused by frequent injections, and enabling new drugs to overcome the hurdles of translation. Here, we give qualitative and quantitative discussions about the principle mechanisms of polymeric reservoir, polymeric matrix and hydrogel systems. We also reveal the design rationales of the existing drug delivery and release systems in preclinical and clinical stages. Lastly, the animal models of ocular angiogenesis diseases are critically reviewed, which could help to facilitate the translation of controlled release technologies from bench to bedside.
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Affiliation(s)
- Chi Ming Laurence Lau
- Department of Chemical and Biological Engineering, The Hong Kong University of Science and Technology, Hong Kong
| | - Yu Yu
- Department of Chemical and Biological Engineering, The Hong Kong University of Science and Technology, Hong Kong; Pleryon Therapeutics Limited, Hong Kong
| | - Ghodsiehsadat Jahanmir
- Department of Chemical and Biological Engineering, The Hong Kong University of Science and Technology, Hong Kong
| | - Ying Chau
- Department of Chemical and Biological Engineering, The Hong Kong University of Science and Technology, Hong Kong; The Hong Kong University of Science and Technology Shenzhen Institute, Shenzhen 518057, China.
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23
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Vottonen P. Anti-vascular endothelial growth factors treatment of wet age-related macular degeneration: from neurophysiology to cost-effectiveness. Acta Ophthalmol 2018; 96 Suppl A109:1-46. [PMID: 29468838 DOI: 10.1111/aos.13706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Pasi Vottonen
- Department of Ophthalmology; Kuopio University Hospital; University of Eastern Finland; Kuopio Finland
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24
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Awwad S, Mohamed Ahmed AHA, Sharma G, Heng JS, Khaw PT, Brocchini S, Lockwood A. Principles of pharmacology in the eye. Br J Pharmacol 2017; 174:4205-4223. [PMID: 28865239 DOI: 10.1111/bph.14024] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/14/2017] [Accepted: 08/17/2017] [Indexed: 12/18/2022] Open
Abstract
The eye is a highly specialized organ that is subject to a huge range of pathology. Both local and systemic disease may affect different anatomical regions of the eye. The least invasive routes for ocular drug administration are topical (e.g. eye drops) and systemic (e.g. tablets) formulations. Barriers that subserve as protection against pathogen entry also restrict drug permeation. Topically administered drugs often display limited bioavailability due to many physical and biochemical barriers including the pre-corneal tear film, the structure and biophysiological properties of the cornea, the limited volume that can be accommodated by the cul-de-sac, the lacrimal drainage system and reflex tearing. The tissue layers of the cornea and conjunctiva are further key factors that act to restrict drug delivery. Using carriers that enhance viscosity or bind to the ocular surface increases bioavailability. Matching the pH and polarity of drug molecules to the tissue layers allows greater penetration. Drug delivery to the posterior segment is a greater challenge and, currently, the standard route is via intravitreal injection, notwithstanding the risks of endophthalmitis and retinal detachment with frequent injections. Intraocular implants that allow sustained drug release are at different stages of development. Novel exciting therapeutic approaches include methods for promoting transscleral delivery, sustained release devices, nanotechnology and gene therapy.
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Affiliation(s)
- Sahar Awwad
- UCL School of Pharmacy, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Abeer H A Mohamed Ahmed
- UCL School of Pharmacy, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Garima Sharma
- UCL School of Pharmacy, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Jacob S Heng
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Peng T Khaw
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Steve Brocchini
- UCL School of Pharmacy, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Alastair Lockwood
- Department of Ophthalmology, Queen Alexandra Hospital, Portsmouth, UK
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25
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HodjatJalali K, Mehravaran S, Faghihi H, Hashemi H, Kazemi P, Rastad H. Intravitreal injection of ziv-aflibercept in the treatment of choroidal and retinal vascular diseases. J Curr Ophthalmol 2017; 29:228-231. [PMID: 28913517 PMCID: PMC5587245 DOI: 10.1016/j.joco.2017.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 01/09/2017] [Accepted: 01/29/2017] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To investigate the short-term outcomes after intravitreal injection of ziv-aflibercept in the treatment of choroidal and retinal vascular diseases. METHODS Thirty-four eyes of 29 patients with age-related macular degeneration (AMD), diabetic retinopathy, and retinal vein occlusion (RVO) received a single dose intravitreal injection of 0.05 ml ziv-aflibercept (1.25 mg). Visual acuity, spectral domain optical coherence tomography (SD-OCT) activity, and possible side effects were assessed before and at 1 week and 1 month after the intervention. RESULTS At 1 month after treatment, mean central macular thickness (CMT) significantly decreased from 531.09 μm to 339.5 μm (P < 0.001), and no signs of side effects were observed in any subject. All patients responded to treatment in terms of reduction in CMT. The improvement in visual acuity was statistically non-significant. CONCLUSION Our findings suggest that a single dose intravitreal injection of ziv-aflibercept may have acceptable relative safety and efficacy in the treatment of patients with intraocular vascular disease. The trial was registered in the Iranian Registry of Clinical Trials (IRCT2015081723651N1).
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Affiliation(s)
| | - Shiva Mehravaran
- Department of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine, University of California in Los Angeles, Los Angeles, CA, USA
| | - Hooshang Faghihi
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Hassan Hashemi
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Pegah Kazemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Hadith Rastad
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
- Department of Epidemiology and Biostatics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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26
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Brown GC, Brown MM, Lieske HB, Turpcu A, Rajput Y. The comparative effectiveness and cost-effectiveness of ranibizumab for neovascular macular degeneration revisited. Int J Retina Vitreous 2017; 3:5. [PMID: 28289548 PMCID: PMC5304393 DOI: 10.1186/s40942-016-0058-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare a near decade of follow-up, newer control cohort data, use of both the societal and third party insurer cost perspectives, and integration of unilateral/bilateral therapy on the comparative effectiveness and cost-effectiveness of intravitreal ranibizumab therapy for neovascular, age-related macular degeneration (AMD). METHODS Value-Based Medicine®, 12-year, combined-eye model, cost-utility analysis employing MARINA and HORIZON clinical trial data. Preference-based comparative effectiveness outcomes were quantified in (1) QALY (quality-adjusted life-year) gain, and (2) percent improvement in quality-of-life, while cost-effectiveness outcomes were quantified in (3) the cost-utility ratio (CUR) and financial return-on-investment (ROI) to society. RESULTS Using MARINA and HORIZON trial data and a meta-analysis control cohort after 24 months, ranibizumab therapy conferred a combined-eye patient value (quality-of-life) gain of 16.3%, versus 10.4% found in 2006. The two-year direct ophthalmic medical cost for ranibizumab therapy was $46,450, a 33.8% real dollar decrease from 2006. The societal cost perspective CUR was -$242,920/QALY, indicating a $282,517 financial return-on-investment (ROI), or 12.3%/year to society for direct ophthalmic medical costs expended. The 3rd party insurer CUR ranged from $21,199/QALY utilizing all direct, medical costs, to $69,591/QALY using direct ophthalmic medical costs. CONCLUSIONS Ranibizumab therapy for neovascular AMD in 2015, considering treatment of both eyes, conferred greater patient value gain (comparative effectiveness) and improved cost-effectiveness than in 2006, as well as a large monetary return-on-investment to the Gross Domestic Product and nation's wealth. The model herein integrates important novel features for neovascular age-related macular degeneration, vitreoretinal cost effectiveness analyses, including: (1) treatment of both eyes, (2) a long-term, untreated control cohort, and (3) the use of societal costs.
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Affiliation(s)
- Gary C. Brown
- The Center for Value-Based Medicine®, Box 6181, Hilton Head, SC 29938 USA
- The Eye Research Institute, Philadelphia, PA USA
- The Retina Service, Wills Eye Institute, Jefferson Medical College, Philadelphia, PA USA
- The Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA USA
| | - Melissa M. Brown
- The Center for Value-Based Medicine®, Box 6181, Hilton Head, SC 29938 USA
- The Eye Research Institute, Philadelphia, PA USA
- The Research Department, Wills Eye Institute, Jefferson Medical College, Philadelphia, PA USA
- The Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA USA
| | - Heidi B. Lieske
- The Center for Value-Based Medicine®, Box 6181, Hilton Head, SC 29938 USA
| | - Adam Turpcu
- The Healthcare Economics Unit, Genentech, Inc., South San Francisco, CA USA
| | - Yamina Rajput
- The Healthcare Economics Unit, Genentech, Inc., South San Francisco, CA USA
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27
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Butt T, Tufail A, Rubin G. Health State Utility Values for Age-Related Macular Degeneration: Review and Advice. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:23-32. [PMID: 27637920 DOI: 10.1007/s40258-016-0275-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Health state utility values are a major source of uncertainty in economic evaluations of interventions for age-related macular degeneration (AMD). This review identifies and critiques published utility values and methods for eliciting de novo utility values in AMD. We describe how utility values have been used in healthcare decision making and provide guidance on the choice of utility values for future economic evaluations for AMD. Literature was searched using PubMed, and health technology assessments (HTA) were searched using HTA agency websites to identify articles reporting utility values or approaches to derive utility values in AMD and articles applying utilities for use in healthcare decision making relating to treatments for AMD. A total of 70 studies qualified for data extraction, 22 of which were classified as containing utility values and/or elicitation methods, and 48 were classified as using utility values in decision making. A large number of studies have elicited utility values for AMD, although those applied to decision making have focused on a few of these. There is an appreciation of the challenges in the measurement and valuation of health states, with recent studies addressing challenges such as the insensitivity of generic health-related quality of life (HRQoL) questionnaires and utility in the worse-seeing eye. We would encourage careful consideration when choosing utility values in decision making and an explicit critique of their applicability to the decision problem.
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Affiliation(s)
- Thomas Butt
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK.
| | - Adnan Tufail
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
- Moorfields Eye Hospital, London, UK
| | - Gary Rubin
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK
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28
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Teh BL, Megaw R, Borooah S, Dhillon B. Optimizing cataract surgery in patients with age-related macular degeneration. Surv Ophthalmol 2016; 62:346-356. [PMID: 28012877 DOI: 10.1016/j.survophthal.2016.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/12/2016] [Indexed: 10/20/2022]
Abstract
Age-related macular degeneration (AMD) is one of the leading causes of visual impairment. The development of cataract in AMD patients poses challenges in assessing timing of surgery, predicting potential benefit to the patient of surgery, and predicting short- and long-term effects of surgery on progression of their AMD. Although traditional cataract surgery remains the mainstay of treatment, recently several devices have been developed to address the specific needs of AMD patients with cataract. We look at the associations between cataract and AMD and outline the treatment approaches to cataract surgery in AMD, looking at the potential benefits and risks of both traditional approaches and newer devices. We provide clinicians treating patients with AMD and cataract with a framework for choosing the appropriate management.
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Affiliation(s)
| | - Roly Megaw
- Princess Alexandra Eye Pavilion, Edinburgh, UK
| | | | - Baljean Dhillon
- Princess Alexandra Eye Pavilion, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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29
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Vottonen P, Kankaanpää E. Cost-effectiveness of treating wet age-related macular degeneration at the Kuopio University Hospital in Finland based on a two-eye Markov transition model. Acta Ophthalmol 2016; 94:652-656. [PMID: 27481048 DOI: 10.1111/aos.13185] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/03/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Wet age-related macular degeneration (AMD) is the leading cause of blindness worldwide, which can be treated with regular intraocular anti-vascular endothelial growth factor (VEGF) injections. In this study, we wanted to evaluate whether less frequent injections of aflibercept would make it more cost-effective when compared with ranibizumab and low priced bevacizumab. METHODS We used a two-eye model to simulate the progression and the treatment of the disease. We selected an 8-year period, 3-month cycles and five health states based on the visual acuity of the better-seeing eye. The transition probabilities and utilities attached to the health states were gathered from previous studies. We conducted the analysis from the hospital perspective and we used the health care costs obtained from Kuopio University Hospital. The costs of intraocular adverse events were taken into account. RESULTS The incremental cost-effectiveness ratio (ICER) with 3% discount rate (€/QALY) for aflibercept compared with monthly bevacizumab was 1 801 228 and when compared with ranibizumab given as needed, the ICER was minus 3 716 943. The sensitivity analysis showed that a change of 20% of the estimated model parameters or a longer follow-up period did not influence these conclusions. CONCLUSION A two-eye Markov transition model was developed to analyse the cost-effectiveness of wet AMD treatment, as quality of life years (QALYs) are largely based on the visual acuity of the better-seeing eye. Monthly injected bevacizumab was the most cost-effective treatment and monthly ranibizumab the least effective.
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Affiliation(s)
- Pasi Vottonen
- Department of Ophthalmology; Kuopio University Hospital; Kuopio Finland
| | - Eila Kankaanpää
- Faculty of Social Sciences and Business Studies; Department of Health and Social Management; University of Eastern Finland; Kuopio Finland
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30
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Chakravarthy U, Harding SP, Rogers CA, Downes S, Lotery AJ, Dakin HA, Culliford L, Scott LJ, Nash RL, Taylor J, Muldrew A, Sahni J, Wordsworth S, Raftery J, Peto T, Reeves BC. A randomised controlled trial to assess the clinical effectiveness and cost-effectiveness of alternative treatments to Inhibit VEGF in Age-related choroidal Neovascularisation (IVAN). Health Technol Assess 2016; 19:1-298. [PMID: 26445075 DOI: 10.3310/hta19780] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Bevacizumab (Avastin®, Roche), which is used in cancer therapy, is the 'parent' molecule from which ranibizumab (Lucentis®, Novartis) was derived for the treatment of neovascular age-related macular degeneration (nAMD). There were reports in the literature on the effectiveness of bevacizumab in treating nAMD, but no trials. The cost per dose of bevacizumab is about 5-10% that of ranibizumab. This trial was a head-to-head comparison of these two drugs. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of ranibizumab and bevacizumab, and two treatment regimens, for nAMD. DESIGN Multicentre, factorial randomised controlled trial with within-trial cost-utility and cost-minimisation analyses from the perspective of the UK NHS. Participants, health professionals and researchers were masked to allocation of drug but not regimen. Computer-generated random allocations to combinations of ranibizumab or bevacizumab, and continuous or discontinuous regimen, were stratified by centre, blocked and concealed. SETTING Twenty-three ophthalmology departments in NHS hospitals. PARTICIPANTS Patients ≥ 50 years old with active nAMD in the study eye with best corrected distance visual acuity (BCVA) ≥ 25 letters measured on a Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. Previous treatment for nAMD, long-standing disease, lesion diameter > 6000 µm, thick blood at the fovea and any other confounding ocular disease were exclusion criteria. One eye per participant was studied; the fellow eye was treated according to usual care, if required. INTERVENTIONS Ranibizumab and bevacizumab were procured commercially. Doses were ranibizumab 0.5 mg or bevacizumab 1.25 mg. The repackaged bevacizumab was quality assured. All participants were treated at visits 0, 1 and 2. Participants randomised to the continuous regimen were treated monthly thereafter. Participants randomised to the discontinuous regimen were not retreated after visit 2 unless pre-specified criteria for active disease were met. If retreatment was needed, monthly injections over 3 months were mandated. MAIN OUTCOME MEASURES The primary outcome was BCVA. The non-inferiority margin was 3.5 letters. Secondary outcomes were contrast sensitivity; near visual acuity; reading index; neovascular lesion morphology; generic and disease-specific patient-reported outcomes, including macular disease-specific quality of life; survival free from treatment failure; resource use; quality-adjusted life-years (QALYs); and development of new geographic atrophy (GA) (outcome added during the trial). Results are reported for the study eye, except for patient-reported outcomes. RESULTS Between 27 March 2008 and 15 October 2010, 610 participants were allocated and treated (314 ranibizumab, 296 bevacizumab; at 3 months, 305 continuous, 300 discontinuous). After 2 years, bevacizumab was neither non-inferior nor inferior to ranibizumab [-1.37 letters, 95% confidence interval (CI) -3.75 to +1.01 letters] and discontinuous treatment was neither non-inferior nor inferior to continuous treatment (-1.63 letters, 95% CI -4.01 to +0.75 letters). Lesion thickness at the fovea was similar by drug [geometric mean ratio (GMR) 0.96, 95% CI 0.90 to 1.03; p = 0.24] but 9% less with continuous treatment (GMR 0.91, 95% CI 0.85 to 0.97; p = 0.004). Odds of developing new GA during the trial were similar by drug [odds ratio (OR) 0.87, 95% CI 0.61 to 1.25; p = 0.46] but significantly higher with continuous treatment (OR 1.47, 95% CI 1.03 to 2.11; p = 0.033). Safety outcomes did not differ by drug but mortality was lower with continuous treatment (OR 0.47, 95% CI 0.22 to 1.03; p = 0.05). Continuous ranibizumab cost £3.5M per QALY compared with continuous bevacizumab; continuous bevacizumab cost £30,220 per QALY compared with discontinuous bevacizumab. These results were robust in sensitivity analyses. CONCLUSIONS Ranibizumab and bevacizumab have similar efficacy. Discontinuing treatment and restarting when required results in slightly worse efficacy. Safety was worse with discontinuous treatment, although new GA developed more often with continuous treatment. Ranibizumab is not cost-effective, although it remains uncertain whether or not continuous bevacizumab is cost-effective compared with discontinuous bevacizumab at £20,000 per QALY threshold. Future studies should focus on the ocular safety of the two drugs, further optimisation of treatment regimens and criteria for stopping treatment. TRIAL REGISTRATION Current Controlled Trials ISRCTN92166560. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 78. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Usha Chakravarthy
- Centre for Experimental Medicine, Institute of Clinical Science, Queen's University Belfast, Belfast, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Susan Downes
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andrew J Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen A Dakin
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lauren J Scott
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachel L Nash
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Jodi Taylor
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Alyson Muldrew
- Centre for Experimental Medicine, Institute of Clinical Science, Queen's University Belfast, Belfast, UK
| | - Jayashree Sahni
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Sarah Wordsworth
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - James Raftery
- Wessex Institute, University of Southampton, Southampton, UK
| | - Tunde Peto
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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31
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Guthrie S, Bienkowska-Gibbs T, Manville C, Pollitt A, Kirtley A, Wooding S. The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation. Health Technol Assess 2016; 19:1-291. [PMID: 26307643 DOI: 10.3310/hta19670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact. METHODS Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research. RESULTS We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.
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32
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Lambert NG, ElShelmani H, Singh MK, Mansergh FC, Wride MA, Padilla M, Keegan D, Hogg RE, Ambati BK. Risk factors and biomarkers of age-related macular degeneration. Prog Retin Eye Res 2016; 54:64-102. [PMID: 27156982 DOI: 10.1016/j.preteyeres.2016.04.003] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 04/01/2016] [Accepted: 04/12/2016] [Indexed: 02/03/2023]
Abstract
A biomarker can be a substance or structure measured in body parts, fluids or products that can affect or predict disease incidence. As age-related macular degeneration (AMD) is the leading cause of blindness in the developed world, much research and effort has been invested in the identification of different biomarkers to predict disease incidence, identify at risk individuals, elucidate causative pathophysiological etiologies, guide screening, monitoring and treatment parameters, and predict disease outcomes. To date, a host of genetic, environmental, proteomic, and cellular targets have been identified as both risk factors and potential biomarkers for AMD. Despite this, their use has been confined to research settings and has not yet crossed into the clinical arena. A greater understanding of these factors and their use as potential biomarkers for AMD can guide future research and clinical practice. This article will discuss known risk factors and novel, potential biomarkers of AMD in addition to their application in both academic and clinical settings.
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Affiliation(s)
- Nathan G Lambert
- Ambati Lab, John A. Moran Eye Center, 65 Mario Capecchi Drive, Salt Lake City, UT, USA; Department of Ophthalmology & Visual Sciences, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT, USA.
| | - Hanan ElShelmani
- Ocular Development and Neurobiology Research Group, Zoology Department, School of Natural Sciences, University of Dublin, Trinity College, Dublin 2, Ireland.
| | - Malkit K Singh
- Ambati Lab, John A. Moran Eye Center, 65 Mario Capecchi Drive, Salt Lake City, UT, USA; Department of Ophthalmology & Visual Sciences, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT, USA.
| | - Fiona C Mansergh
- Smurfit Institute of Genetics, Trinity College Dublin, Dublin 2, Ireland.
| | - Michael A Wride
- Ocular Development and Neurobiology Research Group, Zoology Department, School of Natural Sciences, University of Dublin, Trinity College, Dublin 2, Ireland.
| | - Maximilian Padilla
- Ambati Lab, John A. Moran Eye Center, 65 Mario Capecchi Drive, Salt Lake City, UT, USA; Department of Ophthalmology & Visual Sciences, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT, USA.
| | - David Keegan
- Mater Misericordia Hospital, Eccles St, Dublin 7, Ireland.
| | - Ruth E Hogg
- Centre for Experimental Medicine, Institute of Clinical Science Block A, Grosvenor Road, Belfast, Co.Antrim, Northern Ireland, UK.
| | - Balamurali K Ambati
- Ambati Lab, John A. Moran Eye Center, 65 Mario Capecchi Drive, Salt Lake City, UT, USA; Department of Ophthalmology & Visual Sciences, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT, USA.
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Moreno TA, Kim SJ. Ranibizumab (Lucentis) versus Bevacizumab (Avastin) for the Treatment of Age-Related Macular Degeneration: An Economic Disparity of Eye Health. Semin Ophthalmol 2016; 31:378-84. [PMID: 27116030 DOI: 10.3109/08820538.2016.1154174] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Age-related macular degeneration (AMD) is the leading cause of blindness in the elderly, and the advent of anti-vascular endothelial growth factor agents (VEGF) has revolutionized treatment for neovascular AMD. Two of the most popular anti-VEGF agents, ranibizumab (Lucentis; Genentech/Roche) and bevacizumab (Avastin; Genentech/Roche), effectively treat neovascular AMD but have a substantial difference in price. Multiple level 1 trials have demonstrated that bevacizumab is noninferior to ranibizumab in the treatment of neovascular AMD and that both have similar safety profiles. The decision to use one drug over the other is multifactorial with influences from industry as well as individual physician biases. However, the additional billions spent on ranibizumab result in a large economic disparity that is not rationalized by cost effectiveness models.
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Affiliation(s)
- Tomas A Moreno
- a Department of Ophthalmology , Vanderbilt Eye Institute , Nashville , TN , USA
| | - Stephen J Kim
- a Department of Ophthalmology , Vanderbilt Eye Institute , Nashville , TN , USA
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Mansour AM, Chhablani J, Antonios RS, Yogi R, Younis MH, Dakroub R, Chahine H. Three-month outcome of ziv-aflibercept for exudative age-related macular degeneration. Br J Ophthalmol 2016; 100:1629-1633. [PMID: 27030277 DOI: 10.1136/bjophthalmol-2015-308319] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/15/2016] [Accepted: 03/05/2016] [Indexed: 11/04/2022]
Abstract
PURPOSE In vitro and in vivo studies did not detect toxicity to the retinal pigment epithelium cells using intravitreal ziv-aflibercept. Our purpose is to ascertain the 3-month safety and efficacy in wet age-related macular degeneration (AMD) treated with intravitreal ziv-aflibercept. METHODS Prospectively, consecutive patients with wet AMD underwent ziv-aflibercept intravitreal injection (1.25 mg/0.05 mL) from March 2015 to November 2015. Monitoring of best-corrected visual acuity, intraocular inflammation, cataract progression and by spectral domain optical coherence tomography were carried out at baseline day 1, 1 week, 1 month, 2 months and 3 months after injections. RESULTS 30 eyes were treated (22 Caucasians, 8 Indians; 16 men, 14 women; 14 right eyes and 16 left eyes) with mean age of 74.3 years with 11 treatment-naïve cases and 19 having had treatment-non-naïve. Best-corrected visual acuity improved from baseline logMAR 1.08-0.74 at 1 week, 0.72 at 1 month, 0.67 at 2 months and 0.71 at 3 months (p<0.001 for all time periods). Central macular thickness in microns decreased from 332.8 to 302.0 at 1 week, 244.8 at 1 month, 229.0 at 2 months and 208.2 at 3 months (p<0.001 for all time periods). There were no signs of intraocular inflammation, or change in lens status or increase in intraocular pressure throughout the study. CONCLUSIONS Off label use of ziv-aflibercept improves visual acuity, without detectable ocular toxicity and offers a cheaper alternative to the same molecule aflibercept, especially in low/middle-income countries and in countries where aflibercept (Eylea) is not available. TRIAL REGISTRATION NUMBER NCT02486484.
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Affiliation(s)
- Ahmad M Mansour
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon.,Department of Ophthalmology, Rafik Hariri University Hospital, Beirut, Lebanon
| | - Jay Chhablani
- Smt Kanuri Santhamma Centre for Vitreoretinal Diseases, LV Prasad Eye Institute, Hyderabad, Andhra Pradesh, India
| | - Rafic S Antonios
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon
| | - Rohit Yogi
- Smt Kanuri Santhamma Centre for Vitreoretinal Diseases, LV Prasad Eye Institute, Hyderabad, Andhra Pradesh, India
| | - Muhammad H Younis
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon.,Department of Ophthalmology, Rafik Hariri University Hospital, Beirut, Lebanon
| | - Rola Dakroub
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon.,Department of Ophthalmology, Rafik Hariri University Hospital, Beirut, Lebanon
| | - Hasan Chahine
- Department of Ophthalmology, American University of Beirut, Beirut, Lebanon
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Schmier JK, Hulme-Lowe CK. Cost-Effectiveness Models in Age-Related Macular Degeneration: Issues and Challenges. PHARMACOECONOMICS 2016; 34:259-272. [PMID: 26563248 DOI: 10.1007/s40273-015-0347-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Age-related macular degeneration (AMD) is a common ophthalmic condition that can have few symptoms in its early stage but can progress to major visual impairment. While there are no treatments for early-stage AMD, there are multiple modalities of treatment for advanced disease. Given the increasing prevalence of the disease, there are dozens of analyses of cost effectiveness of AMD treatments, but methods and approaches vary broadly. The goal of this review was to identify, characterize, and critique published models in AMD and provide guidance for their interpretation. After a literature review was performed to identify studies, and exclusion criteria applied to limit the review to studies comparing treatments for AMD, we compared methods across the 36 studies meeting the review criteria. To some extent, variation was related to targeting different audiences or acknowledging the most appropriate population for a given treatment. However, the review identified potential areas of uncertainty and difficulty in interpretation, particularly regarding duration of observation periods and the importance of visual acuity as an endpoint or a proxy for patient-reported utilities. We urge thoughtful consideration of these study characteristics when comparing results.
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Affiliation(s)
- Jordana K Schmier
- Exponent, Inc., 1800 Diagonal Road, Suite 500, Alexandria, VA, 22314, USA.
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Usui Y, Westenskow PD, Murinello S, Dorrell MI, Scheppke L, Bucher F, Sakimoto S, Paris LP, Aguilar E, Friedlander M. Angiogenesis and Eye Disease. Annu Rev Vis Sci 2015; 1:155-184. [DOI: 10.1146/annurev-vision-082114-035439] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshihiko Usui
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
| | - Peter D. Westenskow
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
- The Lowy Medical Research Institute, La Jolla, California 92037
| | - Salome Murinello
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
| | - Michael I. Dorrell
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
- The Lowy Medical Research Institute, La Jolla, California 92037
- Department of Biology, Point Loma Nazarene University, San Diego, California 92106
| | - Lea Scheppke
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
| | - Felicitas Bucher
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
| | - Susumu Sakimoto
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
| | - Liliana P. Paris
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
| | - Edith Aguilar
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
| | - Martin Friedlander
- Department of Cell and Molecular Biology, The Scripps Research Institute, La Jolla, California 92037; , , , , , , , , ,
- The Lowy Medical Research Institute, La Jolla, California 92037
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Hutton D, Newman-Casey PA, Tavag M, Zacks D, Stein J. Switching to less expensive blindness drug could save medicare part B $18 billion over a ten-year period. Health Aff (Millwood) 2015; 33:931-9. [PMID: 24889941 DOI: 10.1377/hlthaff.2013.0832] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The biologic drugs bevacizumab and ranibizumab have revolutionized treatment of diabetic macular edema and neovascular age-related macular degeneration, leading causes of blindness. Ophthalmologic use of these drugs has increased and now accounts for roughly one-sixth of the Medicare Part B drug budget. The two drugs have similar efficacy and potentially minor differences in adverse-event rates; however, at $2,023 per dose, ranibizumab costs forty times more than bevacizumab. Using modeling methods, we predict ten-year (2010-20) population-level costs and health benefits of using bevacizumab and ranibizumab. Our results show that if all patients were treated with the less expensive bevacizumab instead of current usage patterns, savings would amount to $18 billion for Medicare Part B and nearly $5 billion for patients. With an additional $6 billion savings in other health care expenses, the total savings would be almost $29 billion. Altering patterns of use with these therapies by encouraging bevacizumab use and hastening approval of biosimilar therapies would dramatically reduce spending without substantially affecting patient outcomes.
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Affiliation(s)
- David Hutton
- David Hutton is an assistant professor of Health Management and Policy at the University of Michigan, in Ann Arbor
| | - Paula Anne Newman-Casey
- Paula Anne Newman-Casey is an assistant professor in the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School
| | - Mrinalini Tavag
- Mrinalini Tavag is a graduate of the Department of Health Management and Policy at the University of Michigan
| | - David Zacks
- David Zacks is an associate professor in the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School
| | - Joshua Stein
- Joshua Stein is an assistant professor in the Department of Ophthalmology and Visual Sciences at the University of Michigan Medical School
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Solomon SD, Lindsley KB, Krzystolik MG, Vedula SS, Hawkins BS. Intravitreal Bevacizumab Versus Ranibizumab for Treatment of Neovascular Age-Related Macular Degeneration: Findings from a Cochrane Systematic Review. Ophthalmology 2015; 123:70-77.e1. [PMID: 26477843 DOI: 10.1016/j.ophtha.2015.09.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 08/26/2015] [Accepted: 09/02/2015] [Indexed: 12/31/2022] Open
Abstract
TOPIC To summarize the relative effects of bevacizumab (Avastin; Genentech, Inc, South San Francisco, CA) and ranibizumab (Lucentis; Genentech, Inc.), using findings from a Cochrane Eyes and Vision Group systematic review. CLINICAL RELEVANCE Neovascular age-related macular degeneration (NVAMD) is the most common cause of uncorrectable vision loss among the elderly in developed countries. Bevacizumab and ranibizumab are the most frequently used anti-vascular endothelial growth factor (VEGF) agents injected intravitreally to treat NVAMD. METHODS For this systematic review, we included only randomized controlled trials in which the 2 anti-VEGF agents had been compared directly. The primary outcome was 1-year gain in best-corrected visual acuity (BCVA) of ≥15 letters. We followed Cochrane methods for trial selection, data extraction, and data analyses. Relative effects of bevacizumab versus ranibizumab are presented as estimated risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). RESULTS We identified 6 eligible randomized controlled trials with 2809 participants. The proportion of eyes that gained ≥15 letters of BCVA by 1 year was similar for the 2 agents when the same regimens were compared (RR, 0.90; 95% CI, 0.73-1.11). The mean change in BCVA from baseline also was similar (MD, -0.5 letter; 95% CI, -1.6 to +0.6). Other BCVA and quality of life outcomes were similar for the 2 agents. One-year treatment cost with ranibizumab was 5.1 and 25.5 times the cost for bevacizumab in the 2 largest trials. Ocular adverse events were uncommon (<1%), and rates were similar for the 2 agents. CONCLUSIONS We found no important difference in effectiveness or safety between bevacizumab and ranibizumab for NVAMD treatment, but there was a large cost difference.
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Affiliation(s)
- Sharon D Solomon
- Wilmer Eye Institute, School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Kristina B Lindsley
- Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
| | | | | | - Barbara S Hawkins
- Wilmer Eye Institute, School of Medicine, The Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland.
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Wood EH, Karth PA, Moshfeghi DM, Leng T. Short-Term Outcomes of Aflibercept Therapy for Diabetic Macular Edema in Patients With Incomplete Response to Ranibizumab and/or Bevacizumab. Ophthalmic Surg Lasers Imaging Retina 2015; 46:950-4. [DOI: 10.3928/23258160-20151008-08] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 08/26/2015] [Indexed: 11/20/2022]
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Schmid MK, Reich O, Faes L, Boehni SC, Bittner M, Howell JP, Thiel MA, Signorell A, Bachmann LM. Comparison of Outcomes and Costs of Ranibizumab and Aflibercept Treatment in Real-Life. PLoS One 2015; 10:e0135050. [PMID: 26241852 PMCID: PMC4524713 DOI: 10.1371/journal.pone.0135050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/17/2015] [Indexed: 11/29/2022] Open
Abstract
Background Treatment efficacy and costs of anti-VEGF drugs have not been studied in clinical routine. Objective To compare treatment costs and clinical outcomes of the medications when adjusting for patients’ characteristics and clinical status. Design Comparative study. Setting The largest public ophthalmologic clinic in Switzerland. Patients Health care claims data of patients with age-related macular degeneration, diabetic macula edema and retinal vein occlusion were matched to clinical and outcome data. Measurements Patients’ underlying condition, gender, age, visual acuity and retinal thickness at baseline and after completing the loading phase, the total number of injections per treatment, the visual outcome and vital status was secured. Results We included 315 patients (19595 claims) with a follow-up time of 1 to 99 months (mean 32.7, SD 25.8) covering the years 2006–2014. Mean age was 78 years (SD 9.3) and 200 (63.5%) were female. At baseline, the mean number of letters was 55.6 (SD 16.3) and the central retinal thickness was 400.1 μm (SD 110.1). Patients received a mean number of 15.1 injections (SD 13.7; range 1 to 85). Compared to AMD, adjusted cost per month were significantly higher (+2174.88 CHF, 95%CI: 1094.50–3255.27; p<0.001) for patients with DME, while cost per month for RVO were slightly but not significantly higher. (+284.71 CHF, 95% CI: -866.73–1436.15; p = 0.627). Conclusions Patients with DME are almost twice as expensive as AMD and RVO patients. Cost excess occurs with non-ophthalmologic interventions. The currently licensed anti-VEGF medications did not differ in costs, injection frequency and clinical outcomes. Linking health care claims to clinical data is a useful tool to examine routine clinical care.
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Affiliation(s)
| | - Oliver Reich
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Livia Faes
- Eye Clinic, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | | | - Mario Bittner
- Eye Clinic, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | | | | | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
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Bevacizumab versus ranibizumab for neovascular age-related macular degeneration: a meta-analysis of randomized controlled trials. Retina 2015; 35:187-93. [PMID: 25105318 DOI: 10.1097/iae.0000000000000301] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE To evaluate the relative efficacy and safety of bevacizumab versus ranibizumab for the treatment of the neovascular form of age-related macular degeneration. METHODS A comprehensive literature search using the Cochrane Methodology Register to identify randomized controlled trials comparing bevacizumab with ranibizumab in patients with neovascular age-related macular degeneration. Efficacy estimates were determined by comparing weighted mean differences in the change of best-corrected visual acuity and central macular thickness from baseline. Safety estimates were determined by calculating the risk ratio for rates of death, arteriothrombotic events, venous thrombotic events, and at least 1 serious systemic adverse event. Statistical analysis was performed using the RevMan 5.1 software. RESULTS A total of 6 randomized controlled trials were selected for this meta-analysis, including 2,612 patients (1,292 patients in the bevacizumab group and 1,320 patients in the ranibizumab group). There were no significant differences between bevacizumab and ranibizumab in best-corrected visual acuity mean change at 1 year or 2 years (weighted mean difference = -0.40, 95% confidence interval [CI], -1.48 to 0.69, P = 0.47 and weighted mean difference = -1.16, 95% CI, -2.82 to 0.51, P = 0.17, respectively). Ranibizumab was found to be more efficacious in reducing central macular thickness at 1 year (weighted mean difference = 4.35, 95% CI, 0.92-7.78, P = 0.01). The pooled risk ratios comparing the rates of serious systemic adverse events at 1 year and 2 years were slightly in favor of ranibizumab (risk ratio = 1.24, 95% CI, 1.04-1.48, P = 0.02 and risk ratio = 1.20, 95% CI, 1.05-1.37, P = 0.008, respectively), whereas the rates of death, arteriothrombotic events, and venous thrombotic events did not differ statistically. CONCLUSION Bevacizumab and ranibizumab had equivalent efficacy for best-corrected visual acuity in the treatment of neovascular age-related macular degeneration. Ranibizumab tended to have a better anatomical outcome. There were no differences between drugs in rates of death, arteriothrombotic events or venous thrombotic events, and differences in rates of serious systemic adverse events that require further study.
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Selid PD, Jundt MC, Fortney AC, Beal JR. Intravitreal bevacizumab and aflibercept for the treatment of exudative age-related macular degeneration. Ophthalmic Surg Lasers Imaging Retina 2015; 45:275-81. [PMID: 25037009 DOI: 10.3928/23258160-20140709-03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 03/28/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To compare treatment of exudative age-related macular degeneration (AMD) with bevacizumab versus aflibercept in terms of central retinal thickness (CRT) and best corrected visual acuity (BCVA). PATIENTS AND METHODS A retrospective cohort study examining changes in CRT and BCVA over 12 months of follow-up in 111 patients treated with bevacizumab and 91 treated with aflibercept for exudative AMD. RESULTS Treatment with bevacizumab and aflibercept reduced CRT from baseline to 12 months. Aflibercept significantly reduced the mean change from baseline CRT at 12 months compared to bevacizumab. However, mean CRT at 12 months was not significantly different after aflibercept versus bevacizumab (271.6 ± 74.0 μm vs 257.9 ± 48.5 μm). BCVA was significantly better at 6 months in the aflibercept group. At baseline, 18.5% of bevacizumab and 26.4% of aflibercept patients had BCVA better than 20/40. At 12 months, 34.8% of bevacizumab and 38.9% of aflibercept patients had BCVA better than 20/40. CONCLUSION CRT decreased and BCVA improved after treatment with bevacizumab and aflibercept for exudative AMD.
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Mansour AM, Al-Ghadban SI, Yunis MH, El-Sabban ME. Ziv-aflibercept in macular disease. Br J Ophthalmol 2015; 99:1055-9. [PMID: 25677668 PMCID: PMC4518747 DOI: 10.1136/bjophthalmol-2014-306319] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 01/12/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS Aflibercept is an approved therapy for neovascular age-related macular degeneration (AMD) and diabetic macular oedema (DME). In vitro and in vivo studies did not detect toxicity to the retinal pigment epithelium cells using the approved cancer protein, ziv-aflibercept. Our purpose is to determine if ziv-aflibercept can be used in AMD and DME without ocular toxicity, to test the stability of ziv-aflibercept, and to do a cost analysis. METHODS Prospectively, consecutive patients with AMD or DME and poor vision underwent one intravitreal injection of 0.05 mL of fresh filtered ziv-aflibercept (1.25 mg). Monitoring of best-corrected visual acuity, intraocular inflammation, cataract progression, and retinal structure by spectral domain optical coherence tomography was done at 1 day and 1 week after injection. Ziv-aflibercept activity over 4 weeks was measured by capturing vascular endothelial growth factor by ELISA. RESULTS There were no signs of retinal toxicity, intraocular inflammation or change in lens status in four eyes with AMD and two eyes with DME. Visual acuity improved (p=0.05) and central foveal thickness decreased in all patients (p=0.05). Ziv-aflibercept had no loss of anti-VEGF activity when kept at 4°C in polycarbonate syringes over 4 weeks. Similar to bevacizumab, compounded ziv-aflibercept would yield a tremendous saving compared with aflibercept or ranibizumab. CONCLUSIONS Off-label use of ziv-aflibercept improves visual acuity without ocular toxicity and may offer a cheaper alternative to the same molecule aflibercept. TRIAL REGISTRATION NUMBER NCT02173873.
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Affiliation(s)
- Ahmad M Mansour
- Departments of Ophthalmology, American University of Beirut, and Rafic Hariri University Hospital, Beirut, Lebanon
| | - Sara I Al-Ghadban
- Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Muhammad H Yunis
- Departments of Ophthalmology, American University of Beirut, and Rafic Hariri University Hospital, Beirut, Lebanon
| | - Marwan E El-Sabban
- Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut, Beirut, Lebanon
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A randomized trial of intravitreal bevacizumab vs. ranibizumab for myopic CNV. Graefes Arch Clin Exp Ophthalmol 2014; 253:1867-72. [DOI: 10.1007/s00417-014-2886-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/24/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022] Open
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45
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Chalk D, Pitt M, Stein K. Cost-effectiveness of bevacizumab for diabetic macular oedema. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/bjhc.2014.20.12.585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Chalk
- Research Fellow in Applied Healthcare Modelling and Analysis, PenCHORD, PenCLAHRC, University of Exeter Medical School
| | - Martin Pitt
- Associate Professor of Healthcare Modelling and Simulation, PenCHORD, PenCLAHRC, University of Exeter Medical School
| | - Ken Stein
- Deputy Director of PenCLAHRC, University of Exeter Medical School
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46
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Current knowledge and trends in age-related macular degeneration: genetics, epidemiology, and prevention. Retina 2014; 34:423-41. [PMID: 24285245 DOI: 10.1097/iae.0000000000000036] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To address the most dynamic and current issues concerning human genetics, risk factors, pharmacoeconomics, and prevention regarding age-related macular degeneration. METHODS An online review of the database Pubmed and Ovid was performed, searching for the key words: age-related macular degeneration, AMD, pharmacoeconomics, risk factors, VEGF, prevention, genetics and their compound phrases. The search was limited to articles published since 1985 to date. All returned articles were carefully screened and their references were manually reviewed for additional relevant data. The webpage www.clinicaltrials.gov was also accessed in search of relevant research trials. RESULTS A total of 366 articles were reviewed, including 64 additional articles extracted from the references and 25 webpages and online databases from different institutions. At the end, only 244 references were included in this review. CONCLUSION Age-related macular degeneration is a complex multifactorial disease that has an uneven manifestation around the world but with one common denominator, it is increasing and spreading. The economic burden that this disease poses in developed nations will increase in the coming years. Effective preventive therapies need to be developed in the near future.
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47
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Kwong TQ, Mohamed M. Anti-vascular endothelial growth factor therapies in ophthalmology: current use, controversies and the future. Br J Clin Pharmacol 2014; 78:699-706. [PMID: 24602183 PMCID: PMC4239964 DOI: 10.1111/bcp.12371] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 02/26/2014] [Indexed: 12/14/2022] Open
Abstract
Use of anti-vascular endothelial growth factor (VEGF) therapies was introduced for the treatment of ocular disorders in 2005. In the UK, the current licensed and NICE approved indications are for the treatment of neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DMO), macular oedema secondary to a retinal vein occlusion (RVO) and choroidal neovascularization in pathological myopia. These diagnoses alone account for two-thirds of the main causes of legally registrable visual impairment and blindness. Ranibizumab (Lucentis®; Genentech/Novartis), a drug specifically designed for intraocular use, is the primary licensed medication. Controversially however, clinicians have been using an unlicensed cheaper drug, bevacizumab (Avastin®; Genentech/Roche), originally designed for systemic administration, with a similar mode of action and shown to have a similar efficacy. However, there are fears of greater side effects with bevacizumab though studies have not been sufficiently powered to show statistical difference. In the current global economic climate, anti-VEGF treatment places huge financial and logistical pressure on already strained health care systems. Bevacizumab is considerably more cost effective than ranibizumab, and thus using bevacizumab would widen access to treatment particularly in developing countries. This licensing issue also places clinicians in a difficult medico-legal position especially in Europe, where doctors are duty bound to use a licensed drug for a particular indication if this is available. As the indications of anti-VEGF therapies expand and the cost of health care provision becomes more expensive, the controversies surrounding their use will inevitably become more important.
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Affiliation(s)
- Tsong Qiang Kwong
- Department of Ophthalmology, Eastbourne District General Hospital, Eastbourne, East Sussex, BN21 2UD, UK
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Loutfi M, Siddiqui M, Dhedhi A, Kamal A. A systematic review and meta-analysis comparing intravitreal ranibizumab with bevacizumab for the treatment of myopic choroidal neovascularisation. Saudi J Ophthalmol 2014; 29:147-55. [PMID: 25892935 PMCID: PMC4398811 DOI: 10.1016/j.sjopt.2014.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 07/06/2014] [Accepted: 09/15/2014] [Indexed: 11/23/2022] Open
Abstract
Intravitreal injections of ranibizumab (IVR) and bevacizumab (IVB) have both been used as treatments for myopic choroidal neovascularisation. We aimed to produce a meta-analysis of published literature comparing IVR with IVB for the treatment of myopic choroidal neovascularisation, by searching electronic databases from January 1950 to March 2013. Our search produced three suitable studies that reported on 117 patients in total. The results of the meta-analysis demonstrated that the mean number of lines improvement after IVR appeared better compared with IVB [fixed effects model: SMD = 0.46, 95% CI (0.09, 0.83), z = 2.44, p = 0.01]. The number of patients who had a greater than 3 line improvement was similar between groups [fixed effects model: RR = 0.95, 95% CI (0.67, 1.32), z = 0.33, p = 0.74]. At follow up there was no difference in number of those who had an absence of leakage [fixed effects model: RR = 1.04, 95% CI (0.93, 1.16), z = 0.64, p = 0.52]. There was no statistical significance between the two groups in relation to the number of injections [random effects model: SMD = −0.25, 95% CI (−1.12, 0.61), z = 0.57, p = 0.57]. Early evidence therefore suggests that intravitreal injections of ranibizumab are comparable to intravitreal injections of bevacizumab in the treatment of myopic choroidal neovascularisation. Both treatments result in a statistically significant increase in visual acuity with high numbers of patients maintaining stable vision. Further studies are still needed to strengthen results.
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Affiliation(s)
- M. Loutfi
- University of Liverpool Medical School, Liverpool, UK
| | - M.R.S. Siddiqui
- Department of General Surgery, St Heliers Hospital, London, UK
| | - A. Dhedhi
- University of Liverpool Medical School, Liverpool, UK
| | - A. Kamal
- Ophthalmology Department, Aintree University Hospital, Liverpool, UK
- Corresponding author.
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Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2014; 8:CD005139. [PMID: 25170575 PMCID: PMC4270425 DOI: 10.1002/14651858.cd005139.pub3] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the most common cause of uncorrectable severe vision loss in people aged 55 years and older in the developed world. Choroidal neovascularization (CNV) secondary to neovascular AMD accounts for most AMD-related severe vision loss. Anti-vascular endothelial growth factor (anti-VEGF) agents, injected intravitreally, aim to block the growth of abnormal blood vessels in the eye to prevent vision loss and, in some instances, improve vision. OBJECTIVES To investigate: (1) the ocular and systemic effects of, and quality of life associated with, intravitreally injected anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) for the treatment of neovascular AMD compared with no anti-VEGF treatment; and (2) the relative effects of one anti-VEGF agent compared with another when administered in comparable dosages and regimens. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 3), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to March 2014), EMBASE (January 1980 to March 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to March 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 27 March 2014. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated pegaptanib, ranibizumab, or bevacizumab versus each other or a control treatment (e.g., sham treatment or photodynamic therapy). All trials followed participants for at least one year. DATA COLLECTION AND ANALYSIS Two review authors independently screened records, extracted data, and assessed risks of bias. We contacted trial authors for additional data. We analyzed outcomes as risk ratios (RRs) or mean differences (MDs). We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included 12 RCTs including a total of 5496 participants with neovascular AMD (the number of participants per trial ranged from 28 to 1208). One trial compared pegaptanib, three trials ranibizumab, and two trials bevacizumab versus controls; six trials compared bevacizumab with ranibizumab. Four trials were conducted by pharmaceutical companies; none of the eight studies which evaluated bevacizumab were funded by pharmaceutical companies. The trials were conducted at various centers across five continents (North and South America, Europe, Asia and Australia). The overall quality of the evidence was very good, with most trials having an overall low risk of bias.When compared with control treatments, participants who received any of the three anti-VEGF agents were more likely to have gained 15 letters or more of visual acuity, lost fewer than 15 letters of visual acuity, and had vision 20/200 or better after one year of follow up. Visual acuity outcomes after bevacizumab and ranibizumab were similar when the same regimens were compared in the same RCTs, despite the substantially lower cost for bevacizumab compared with ranibizumab. No trial directly compared pegaptanib with other anti-VEGF agents; however, when compared with controls, ranibizumab or bevacizumab yielded larger improvements in visual acuity outcomes than pegaptanib.Participants treated with anti-VEGFs showed improvements in morphologic outcomes (e.g., size of CNV or central retinal thickness) compared with participants not treated with anti-VEGF agents. There was less reduction in central retinal thickness among bevacizumab-treated participants than among ranibizumab-treated participants after one year (MD -13.97 μm; 95% confidence interval (CI) -26.52 to -1.41); however, this difference is within the range of measurement error and we did not interpret it as being clinically meaningful.Ocular inflammation and increased intraocular pressure after intravitreal injection were the most frequently reported serious ocular adverse events. Endophthalmitis was reported in fewer than 1% of anti-VEGF treated participants; no cases were reported in control groups. The occurrence of serious systemic adverse events was comparable across anti-VEGF-treated groups and control groups; however, the numbers of events and trial participants may have been insufficient to detect a meaningful difference between groups. Data for visual function, quality of life, and economic outcomes were sparsely measured and reported. AUTHORS' CONCLUSIONS The results of this review indicate the effectiveness of anti-VEGF agents (pegaptanib, ranibizumab, and bevacizumab) in terms of maintaining visual acuity; ranibizumab and bevacizumab were also shown to improve visual acuity. The information available on the adverse effects of each medication do not suggest a higher incidence of potentially vision-threatening complications with intravitreal injection compared with control interventions; however, clinical trial sample sizes may not have been sufficient to detect rare safety outcomes. Research evaluating variable dosing regimens with anti-VEGF agents, effects of long-term use, combination therapies (e.g., anti-VEGF treatment plus photodynamic therapy), and other methods of delivering the agents should be incorporated into future Cochrane reviews.
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Affiliation(s)
- Sharon D. Solomon
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristina Lindsley
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Barbara S. Hawkins
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Dakin HA, Wordsworth S, Rogers CA, Abangma G, Raftery J, Harding SP, Lotery AJ, Downes SM, Chakravarthy U, Reeves BC. Cost-effectiveness of ranibizumab and bevacizumab for age-related macular degeneration: 2-year findings from the IVAN randomised trial. BMJ Open 2014; 4:e005094. [PMID: 25079928 PMCID: PMC4120317 DOI: 10.1136/bmjopen-2014-005094] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the incremental cost and cost-effectiveness of continuous and discontinuous regimens of bevacizumab (Avastin) and ranibizumab (Lucentis) for neovascular age-related macular degeneration (nAMD) from a UK National Health Service (NHS) perspective. DESIGN A within-trial cost-utility analysis with a 2-year time horizon, based on a multicentre factorial, non-inferiority randomised controlled trial. SETTING 23 hospital ophthalmology clinics. PARTICIPANTS 610 patients aged ≥50 years with untreated nAMD in the study eye. INTERVENTIONS 0.5 mg ranibizumab or 1.25 mg bevacizumab given continuously (monthly) or discontinuously (as-needed) for 2 years. MAIN OUTCOME MEASURES Quality-adjusted life-years (QALYs). RESULTS Total 2-year costs ranged from £3002/patient ($4700; 95% CI £2601 to £3403) for discontinuous bevacizumab to £18 590/patient ($29 106; 95% CI £18 258 to £18 922) for continuous ranibizumab. Ranibizumab was significantly more costly than bevacizumab for both continuous (+£14 989/patient ($23 468); 95% CI £14 522 to £15 456; p<0.001) and discontinuous treatment (+£8498 ($13 305); 95% CI £7700 to £9295; p<0.001), with negligible difference in QALYs. Continuous ranibizumab would only be cost-effective compared with continuous bevacizumab if the NHS were willing to pay £3.5 million ($5.5 million) per additional QALY gained. Patients receiving continuous bevacizumab accrued higher total costs (+£599 ($938); 95% CI £91 to £1107; p=0.021) than those receiving discontinuous bevacizumab, but also accrued non-significantly more QALYs (+0.020; 95% CI -0.032 to 0.071; p=0.452). Continuous bevacizumab therefore cost £30 220 ($47 316) per QALY gained versus discontinuous bevacizumab. However, bootstrapping demonstrated that if the NHS is willing to pay £20 000/QALY gained, there is a 37% chance that continuous bevacizumab is cost-effective versus discontinuous bevacizumab. CONCLUSIONS Ranibizumab is not cost-effective compared with bevacizumab, being substantially more costly and producing little or no QALY gain. Discontinuous bevacizumab is likely to be the most cost-effective of the four treatment strategies evaluated in this UK trial, although there is a 37% chance that continuous bevacizumab is cost-effective. TRIAL REGISTRATION NUMBER ISRCTN92166560.
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Affiliation(s)
- Helen A Dakin
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - James Raftery
- Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Andrew J Lotery
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Susan M Downes
- Oxford Eye Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Usha Chakravarthy
- Centre for Experimental Medicine, The Queen's University of Belfast, Belfast, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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