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Xu C, Tan Y, Zhang LY, Luo XJ, Wu JF, Ma L, Deng F. The Application of Aptamer and Research Progress in Liver Disease. Mol Biotechnol 2024; 66:1000-1018. [PMID: 38305844 PMCID: PMC11087326 DOI: 10.1007/s12033-023-01030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/15/2023] [Indexed: 02/03/2024]
Abstract
Aptamers, as a kind of small-molecule nucleic acid, have attracted much attention since their discovery. Compared with biological reagents such as antibodies, aptamers have the advantages of small molecular weight, low immunogenicity, low cost, and easy modification. At present, aptamers are mainly used in disease biomarker discovery, disease diagnosis, treatment, and targeted drug delivery vectors. In the process of screening and optimizing aptamers, it is found that there are still many problems need to be solved such as the design of the library, optimization of screening conditions, the truncation of screened aptamer, and the stability and toxicity of the aptamer. In recent years, the incidence of liver-related diseases is increasing year by year and the treatment measures are relatively lacking, which has attracted the people's attention in the application of aptamers in liver diseases. This article mainly summarizes the research status of aptamers in disease diagnosis and treatment, especially focusing on the application of aptamers in liver diseases, showing the crucial significance of aptamers in the diagnosis and treatment of liver diseases, and the use of Discovery Studio software to find the binding target and sequence of aptamers, and explore their possible interaction sites.
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Affiliation(s)
- Cheng Xu
- Hubei Key Laboratory of Tumor Microenvironment and Immunotherapy, China Three Gorges University, Yichang, China
- College of Basic Medical Science, China Three Gorges University, Yichang, 443002, Hubei, China
- Institute of Organ Fibrosis and Targeted Drug Delivery, China Three Gorges University, Yichang, China
| | - Yong Tan
- Hubei Selenium and Human Health Institute, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei, China
| | - Li-Ye Zhang
- Hubei Key Laboratory of Tumor Microenvironment and Immunotherapy, China Three Gorges University, Yichang, China
- College of Basic Medical Science, China Three Gorges University, Yichang, 443002, Hubei, China
- Institute of Organ Fibrosis and Targeted Drug Delivery, China Three Gorges University, Yichang, China
| | - Xiao-Jie Luo
- Hubei Key Laboratory of Tumor Microenvironment and Immunotherapy, China Three Gorges University, Yichang, China
- College of Basic Medical Science, China Three Gorges University, Yichang, 443002, Hubei, China
- Institute of Organ Fibrosis and Targeted Drug Delivery, China Three Gorges University, Yichang, China
| | - Jiang-Feng Wu
- Hubei Key Laboratory of Tumor Microenvironment and Immunotherapy, China Three Gorges University, Yichang, China
- College of Basic Medical Science, China Three Gorges University, Yichang, 443002, Hubei, China
- Institute of Organ Fibrosis and Targeted Drug Delivery, China Three Gorges University, Yichang, China
| | - Lan Ma
- Hubei Key Laboratory of Tumor Microenvironment and Immunotherapy, China Three Gorges University, Yichang, China.
- College of Basic Medical Science, China Three Gorges University, Yichang, 443002, Hubei, China.
- Institute of Organ Fibrosis and Targeted Drug Delivery, China Three Gorges University, Yichang, China.
| | - Fei Deng
- Department of Oncology, The Second People's Hospital of China Three Gorges University, Yichang, 443000, China.
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Walton M, Bojke L, Simmonds M, Walker R, Llewellyn A, Fulbright H, Dias S, Stewart LA, Rush T, Steel DH, Lawrenson JG, Peto T, Hodgson R. Anti-Vascular Endothelial Growth Factor Drugs Compared With Panretinal Photocoagulation for the Treatment of Proliferative Diabetic Retinopathy: A Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)00122-0. [PMID: 38548182 DOI: 10.1016/j.jval.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/16/2024] [Accepted: 03/14/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES This study aimed to evaluate the cost-effectiveness of anti-vascular endothelial growth factor drugs (anti-VEGFs) compared with panretinal photocoagulation (PRP) for treating proliferative diabetic retinopathy (PDR) in the United Kingdom. METHODS A discrete event simulation model was developed, informed by individual participant data meta-analysis. The model captures treatment effects on best corrected visual acuity in both eyes, and the occurrence of diabetic macular edema and vitreous hemorrhage. The model also estimates the value of undertaking further research to resolve decision uncertainty. RESULTS Anti-VEGFs are unlikely to generate clinically meaningful benefits over PRP. The model predicted anti-VEGFs be more costly and similarly effective as PRP, generating 0.029 fewer quality-adjusted life-years at an additional cost of £3688, with a net health benefit of -0.214 at a £20 000 willingness-to-pay threshold. Scenario analysis results suggest that only under very select conditions may anti-VEGFs offer potential for cost-effective treatment of PDR. The consequences of loss to follow-up were an important driver of model outcomes. CONCLUSIONS Anti-VEGFs are unlikely to be a cost-effective treatment for early PDR compared with PRP. Anti-VEGFs are generally associated with higher costs and similar health outcomes across various scenarios. Although anti-VEGFs were associated with lower diabetic macular edema rates, the number of cases avoided is insufficient to offset the additional treatment costs. Key uncertainties relate to the long-term comparative effectiveness of anti-VEGFs, particularly considering the real-world rates and consequences of treatment nonadherence. Further research on long-term visual acuity and rates of vision-threatening complications may be beneficial in resolving uncertainties.
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Affiliation(s)
- Matthew Walton
- Centre for Reviews and Dissemination, University of York, UK.
| | - Laura Bojke
- Centre for Health Economics, University of York, UK
| | - Mark Simmonds
- Centre for Reviews and Dissemination, University of York, UK
| | - Ruth Walker
- Centre for Reviews and Dissemination, University of York, UK
| | | | - Helen Fulbright
- Centre for Reviews and Dissemination, University of York, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, UK
| | | | | | | | - John G Lawrenson
- Department of Optometry and Visual Sciences, City, University of London, UK
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, UK
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Jo SJ, Chae SU, Lee CB, Bae SK. Clinical Pharmacokinetics of Approved RNA Therapeutics. Int J Mol Sci 2023; 24:ijms24010746. [PMID: 36614189 PMCID: PMC9821128 DOI: 10.3390/ijms24010746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/18/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023] Open
Abstract
RNA-mediated drugs are a rapidly growing class of therapeutics. Over the last five years, the list of FDA-approved RNA therapeutics has expanded owing to their unique targets and prolonged pharmacological effects. Their absorption, distribution, metabolism, and excretion (ADME) have important clinical im-plications, but their pharmacokinetic properties have not been fully understood. Most RNA therapeutics have structural modifications to prevent rapid elimination from the plasma and are administered intravenously or subcutaneously, with some exceptions, for effective distribution to target organs. Distribution of drugs into tissues depends on the addition of a moiety that can be transported to the target and RNA therapeutics show a low volume of distribution because of their molecular size and negatively-charged backbone. Nucleases metabolize RNA therapeutics to a shortened chain, but their metabolic ratio is relatively low. Therefore, most RNA therapeutics are excreted in their intact form. This review covers not only ADME features but also clinical pharmacology data of the RNA therapeutics such as drug-drug interaction or population pharmacokinetic analyses. As the market of RNA therapeutics is expected to rapidly expand, comprehensive knowledge will contribute to interpreting and evaluating the pharmacological properties.
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Pennington B, Alshreef A, Flight L, Metry A, Poku E, Hykin P, Sivaprasad S, Prevost AT, Vasconcelos JC, Murphy C, Kelly J, Yang Y, Lotery A, Williams M, Brazier J. Cost Effectiveness of Ranibizumab vs Aflibercept vs Bevacizumab for the Treatment of Macular Oedema Due to Central Retinal Vein Occlusion: The LEAVO Study. PHARMACOECONOMICS 2021; 39:913-927. [PMID: 33900585 PMCID: PMC8298346 DOI: 10.1007/s40273-021-01026-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND We aimed to assess the cost effectiveness of intravitreal ranibizumab (Lucentis), aflibercept (Eylea) and bevacizumab (Avastin) for the treatment of macular oedema due to central retinal vein occlusion. METHODS We calculated costs and quality-adjusted life-years from the UK National Health Service and Personal Social Services perspective. We performed a within-trial analysis using the efficacy, safety, resource use and health utility data from a randomised controlled trial (LEAVO) over 100 weeks. We built a discrete event simulation to model long-term outcomes. We estimated utilities using the Visual-Functioning Questionnaire-Utility Index, EQ-5D and EQ-5D with an additional vision question. We used standard UK costs sources for 2018/19 and a cost of £28 per bevacizumab injection. We discounted costs and quality-adjusted life-years at 3.5% annually. RESULTS Bevacizumab was the least costly intervention followed by ranibizumab and aflibercept in both the within-trial analysis (bevacizumab: £6292, ranibizumab: £13,014, aflibercept: £14,328) and long-term model (bevacizumab: £18,353, ranibizumab: £30,226, aflibercept: £35,026). Although LEAVO did not demonstrate bevacizumab to be non-inferior for the visual acuity primary outcome, the three interventions generated similar quality-adjusted life-years in both analyses. Bevacizumab was always the most cost-effective intervention at a threshold of £30,000 per quality-adjusted life-year, even using the list price of £243 per injection. CONCLUSIONS Wider adoption of bevacizumab for the treatment of macular oedema due to central retinal vein occlusion could result in substantial savings to healthcare systems and deliver similar health-related quality of life. However, patients, funders and ophthalmologists should be fully aware that LEAVO could not demonstrate that bevacizumab is non-inferior to the licensed agents.
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Affiliation(s)
- Becky Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Philip Hykin
- NIHR Moorfields Biomedical Research Centre, London, UK
| | | | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Yit Yang
- Wolverhampton Eye Infirmary, Wolverhampton, UK
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Williams
- Centre for Medical Education, Queen's University of Belfast, Belfast, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Hykin P, Prevost AT, Sivaprasad S, Vasconcelos JC, Murphy C, Kelly J, Ramu J, Alshreef A, Flight L, Pennington R, Hounsome B, Lever E, Metry A, Poku E, Yang Y, Harding SP, Lotery A, Chakravarthy U, Brazier J. Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT. Health Technol Assess 2021; 25:1-196. [PMID: 34132192 PMCID: PMC8287375 DOI: 10.3310/hta25380] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period. OBJECTIVE The objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion. DESIGN This was a three-arm, double-masked, randomised controlled non-inferiority trial. SETTING The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018. PARTICIPANTS A total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial. INTERVENTIONS The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154). MAIN OUTCOME MEASURES The primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of -5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years. RESULTS The adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows - ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval -2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference -1.73 letters, 95% confidence interval -6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was -3.96 letters, 95% confidence interval -8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means -1.8, 95% confidence interval -2.9 to -0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model- and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000-30,000 per quality-adjusted life-year. LIMITATIONS The comparison of aflibercept and bevacizumab was a post hoc analysis. CONCLUSION The study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered. FUTURE WORK To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use. TRIAL REGISTRATION Current Controlled Trials ISRCTN13623634. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Philip Hykin
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Sobha Sivaprasad
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Jayashree Ramu
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rebekah Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Ellen Lever
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Yit Yang
- The Eye Infirmary, New Cross Hospital, Wolverhampton, UK
| | - Simon P Harding
- Eye and Vision Science, University of Liverpool, and St Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, UK
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Usha Chakravarthy
- Department of Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Human Pluripotent Stem-Cell-Derived Models as a Missing Link in Drug Discovery and Development. Pharmaceuticals (Basel) 2021; 14:ph14060525. [PMID: 34070895 PMCID: PMC8230131 DOI: 10.3390/ph14060525] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/11/2022] Open
Abstract
Human pluripotent stem cells (hPSCs), including human embryonic stem cells (hESCs) and human-induced pluripotent stem cells (hiPSCs), have the potential to accelerate the drug discovery and development process. In this review, by analyzing each stage of the drug discovery and development process, we identified the active role of hPSC-derived in vitro models in phenotypic screening, target-based screening, target validation, toxicology evaluation, precision medicine, clinical trial in a dish, and post-clinical studies. Patient-derived or genome-edited PSCs can generate valid in vitro models for dissecting disease mechanisms, discovering novel drug targets, screening drug candidates, and preclinically and post-clinically evaluating drug safety and efficacy. With the advances in modern biotechnologies and developmental biology, hPSC-derived in vitro models will hopefully improve the cost-effectiveness and the success rate of drug discovery and development.
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Abstract
PURPOSE To determine the dose-response characteristics of the antivascular endothelial growth factor agents ranibizumab and aflibercept in neovascular age-related macular degeneration using published randomized trials and observational series. METHODS Literature review of published series from 2006 to 2018 as determined from electronic searches of PubMed and the Cochrane Library. Data extracted included treatment strategy, frequency, and first year visual acuity response. Monthly or bimonthly treatment schedules were classified as Fixed, pro re nata studies as PRN, treat and extend as TE, and when no strategy was listed, as Variable. RESULTS Of 2062 citations retrieved, 96 were deemed eligible; these 96 citations provided 120 data points of dose frequency versus visual acuity change in Year 1 of treatment. The dose-response curve was nonlinear, but a log transform of the number of injections per year yielded a linear relationship defined by the expression, Letters of Improvement = -6.66 + 15.7*log (number of injections Year 1). After accounting for the number of injections neither the drug used (ranibizumab or aflibercept) nor the strategy used (Fixed, pro re nata, treat and extend, or Variable) were significant predictors of acuity change. As a group, studies using the pro re nata approach had the lowest number of injections and the worst acuity improvements as a treatment strategy. CONCLUSION There seems to be a predictable, mathematically defined relationship between dose frequency and visual acuity change at 1 year in neovascular age-related macular degeneration. The performance of current treatment efforts, as suggested by reported series and Medicare claims data, seems to be substandard.
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Nguyen T, Urrutia-Cabrera D, Liou RHC, Luu CD, Guymer R, Wong RCB. New Technologies to Study Functional Genomics of Age-Related Macular Degeneration. Front Cell Dev Biol 2021; 8:604220. [PMID: 33505962 PMCID: PMC7829507 DOI: 10.3389/fcell.2020.604220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/07/2020] [Indexed: 12/18/2022] Open
Abstract
Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss in people over 50 years old in developed countries. Currently, we still lack a comprehensive understanding of the genetic factors contributing to AMD, which is critical to identify effective therapeutic targets to improve treatment outcomes for AMD patients. Here we discuss the latest technologies that can facilitate the identification and functional study of putative genes in AMD pathology. We review improved genomic methods to identify novel AMD genes, advances in single cell transcriptomics to profile gene expression in specific retinal cell types, and summarize recent development of in vitro models for studying AMD using induced pluripotent stem cells, organoids and biomaterials, as well as new molecular technologies using CRISPR/Cas that could facilitate functional studies of AMD-associated genes.
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Affiliation(s)
- Tu Nguyen
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Daniel Urrutia-Cabrera
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Roxanne Hsiang-Chi Liou
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Chi D Luu
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Robyn Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Raymond Ching-Bong Wong
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
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Cerniauskas E, Kurzawa‐Akanbi M, Xie L, Hallam D, Moya‐Molina M, White K, Steel D, Doherty M, Whitfield P, Al‐Aama J, Armstrong L, Kavanagh D, Lambris JD, Korolchuk VI, Harris C, Lako M. Complement modulation reverses pathology in Y402H-retinal pigment epithelium cell model of age-related macular degeneration by restoring lysosomal function. Stem Cells Transl Med 2020; 9:1585-1603. [PMID: 32815311 PMCID: PMC7695639 DOI: 10.1002/sctm.20-0211] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/30/2020] [Accepted: 07/12/2020] [Indexed: 01/08/2023] Open
Abstract
Age-related macular degeneration (AMD) is a multifactorial disease, which is characterized by loss of central vision, affecting one in three people by the age of 75. The Y402H polymorphism in the complement factor H (CFH) gene significantly increases the risk of AMD. We show that Y402H-AMD-patient-specific retinal pigment epithelium (RPE) cells are characterized by a significant reduction in the number of melanosomes, an increased number of swollen lysosome-like-vesicles with fragile membranes, Cathepsin D leakage into drusen-like deposits and reduced lysosomal function. The turnover of C3 is increased significantly in high-risk RPE cells, resulting in higher internalization and deposition of the terminal complement complex C5b-9 at the lysosomes. Inhibition of C3 processing via the compstatin analogue Cp40 reverses the disease phenotypes by relieving the lysosomes of their overburden and restoring their function. These findings suggest that modulation of the complement system represents a useful therapeutic approach for AMD patients associated with complement dysregulation.
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Affiliation(s)
- Edvinas Cerniauskas
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Marzena Kurzawa‐Akanbi
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Long Xie
- Clinical & Translational Research Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Dean Hallam
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Marina Moya‐Molina
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Kathryn White
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - David Steel
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Mary Doherty
- University of the Highlands and IslandsInvernessUK
| | | | - Jumana Al‐Aama
- Department of Genetic Medicine and Princess Al‐Jawhara Center of Excellence in Research of Hereditary Disorders, Faculty of MedicineKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Lyle Armstrong
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - David Kavanagh
- Clinical & Translational Research Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
- National Renal Complement Therapeutics Centre, Royal Victoria InfirmaryNewcastle upon TyneUK
| | - John D. Lambris
- Department of Pathology and Laboratory MedicineUniversity of Pennsylvania School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Viktor I. Korolchuk
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Claire Harris
- Clinical & Translational Research Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
- National Renal Complement Therapeutics Centre, Royal Victoria InfirmaryNewcastle upon TyneUK
| | - Majlinda Lako
- Biosciences Institute, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
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Effect of the Duration of Intraretinal or Subretinal Fluid on the Response to Treatment in Undertreated Age-Related Macular Degeneration. J Ophthalmol 2020; 2020:5308597. [PMID: 32774905 PMCID: PMC7399753 DOI: 10.1155/2020/5308597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/19/2020] [Accepted: 06/26/2020] [Indexed: 01/26/2023] Open
Abstract
We investigated the association between the duration of intraretinal fluid (IRF) or subretinal fluid (SRF) and the response to antivascular endothelial growth factor injection in patients with undertreated age-related macular degeneration (ARMD). The Ethics Committee of Toho University Sakura Medical Center approved this study (no. S18030). Eighty eyes of ARMD patients with VA ≤20/100 were retrospectively assessed. Each injection's efficacy was classified, and the fluid accumulation prior to each injection was evaluated. The effect changes following to accumulated IRF, SRF, the longest persistent IRF period (≥10 months), and their determining factors were evaluated. Throughout observation, acquired refractoriness was rarely associated with increased accumulation of IRF or SRF. The injection span had a tendency to be short, and the polypoidal choroidal vasculopathy and occult choroidal neovasculopathy (CNV) proportions had a tendency to be higher among patients with diminished effects than among those with maintained effects. VA differed significantly with continuous IRF duration, but not with accumulated fluid. The diminishing effect of injections during long-standing IRF was rarely associated with undertreatment. The mechanism underlying acquired refractoriness remains unknown; the effect change demonstrated various patterns, including diminished and improved responses. The longest continuous IRF duration was associated with VA decline. Shortening the duration of continuous IRF may be necessary.
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11
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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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12
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Khanani AM, Dugel PU, Haller JA, Wagner AL, Lescrauwaet B, Schmidt R, Bennison C. Cost-effectiveness analysis of ocriplasmin versus watchful waiting for treatment of symptomatic vitreomacular adhesion in the US. J Comp Eff Res 2020; 9:287-305. [PMID: 31961196 DOI: 10.2217/cer-2019-0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Evaluate the cost-effectiveness of ocriplasmin in symptomatic vitreomacular adhesion (VMA) with or without full-thickness macular hole ≤400 μm versus standard of care. Methods: A state-transition model simulated a cohort through disease health states; assignment of utilities to health states reflected the distribution of visual acuity. Efficacy of ocriplasmin was derived from logistic regression models using Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole trial data. Model inputs were extracted from Phase III trials and published literature. The analysis was conducted from a US Medicare perspective. Results: Lifetime incremental cost-effectiveness ratio was US$4887 per quality-adjusted life year gained in the total population, US$4255 and US$10,167 in VMA subgroups without and with full-thickness macular hole, respectively. Conclusion: Ocriplasmin was cost effective compared with standard of care in symptomatic VMA.
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Affiliation(s)
- Arshad M Khanani
- Sierra Eye Associates, Reno, NV 89502, USA.,Reno School of Medicine, University of Nevada, Reno, NV 89557, USA
| | - Pravin U Dugel
- Retina Consultants of Arizona, Phoenix, AZ 85053, USA.,USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Julia A Haller
- Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Alan L Wagner
- Wagner Macula & Retina Center, Virginia Beach, VA 23454, USA.,Department of Ophthalmology, Eastern Virginia Medical School, Virginia Beach, VA 23456, USA
| | | | - Ralph Schmidt
- Department of Cognitive Science and Artificial Intelligence, Tilburg University, Tilburg, The Netherlands (Pharmerit International, Berlin, Germany at the time of project development & analysis)
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13
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Applications of microneedles in delivering drugs for various ocular diseases. Life Sci 2019; 237:116907. [PMID: 31606378 DOI: 10.1016/j.lfs.2019.116907] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 01/20/2023]
Abstract
Treatment of majority of eye diseases involve the use of eye drops or eye ointments, which have major drawbacks of needing frequent administration, lower bioavailability and inability to cross the various eye barriers. This necessitates the use of novel delivery systems. Microneedles (MNs) as an alternate novel delivery system facilitate drug delivery to various ocular diseases with promising approaches in healthcare. Advances in pharmaceutical technology have made MNs provide localized, effective, less invasive and targeted drug delivery in the eye. The purpose of this review is to provide an insight to efficacious therapeutic applications the MNs can bring in various ocular diseases. Out of which, glaucoma, age-related macular degeneration, uveitis, retinal vascular occlusion and retinitis pigmentosa are majorly discussed. Among the various types of MNs; solid coated, hollow and dissolving polymeric MNs are specifically focused for their applications in ocular diseases. In addition, MNs shows improvement in the visual acuity and decreases the progression of the different ocular diseases.
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14
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Parmeggiani F, Gallenga CE, Costagliola C, Semeraro F, Romano MR, Dell'Omo R, Russo A, De Nadai K, Gemmati D, D'Angelo S, Bolletta E, Sorrentino FS. Impact of methylenetetrahydrofolate reductase C677T polymorphism on the efficacy of photodynamic therapy in patients with neovascular age-related macular degeneration. Sci Rep 2019; 9:2614. [PMID: 30796269 PMCID: PMC6385217 DOI: 10.1038/s41598-019-38919-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/02/2019] [Indexed: 02/07/2023] Open
Abstract
The most severe visual impairments due to age-related macular degeneration (AMD) are frequently caused by the occurrence of choroidal neovascularization (CNV). Although photodynamic therapy with verteporfin (PDT-V) is currently a second-line treatment for neovascular AMD, it can be conveniently combined with drugs acting against vascular endothelial growth factor (anti-VEGF) to reduce the healthcare burden associated with the growing necessity of anti-VEGF intravitreal re-injection. Because the common 677 C > T polymorphism of the methylenetetrahydrofolate reductase gene (MTHFR-C677T; rs1801133) has been described as predictor of satisfactory short-term responsiveness of AMD-related CNV to PDT-V, we retrospectively examined the outcomes of 371 Caucasian patients treated with standardized, pro-re-nata, photodynamic regimen for 24 months. Responder (R) and non-responder (NR) patients were distinguished on the basis of the total number of scheduled PDT-V (TN-PDT-V) and change of best-corrected visual acuity (∆-BCVA). The risk for both TN-PDT-V and ∆-BCVA to pass from R to NR group was strongly correlated with CT and TT genotypes of MTHFR-C677T variant resulting, respectively, in odd ratios of 0.19 [95% CI, 0.12-0.32] and 0.09 [95% CI, 0.04-0.21] (P < 0.001), and odd ratios of 0.24 [95% CI, 0.15-0.39] and 0.03 [95% CI, 0.01-0.11] (P < 0.001). These pharmacogenetic findings indicate a rational basis to optimize the future clinical application of PDT-V during the combined treatments of AMD-related CNV, highlighting the role of thrombophilia to be aware of the efficacy profile of photodynamic therapy.
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Affiliation(s)
- Francesco Parmeggiani
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, 44121, Italy. .,Center for the Study of Inflammation of the University of Ferrara, Ferrara, 44121, Italy.
| | - Carla Enrica Gallenga
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, 44121, Italy
| | - Ciro Costagliola
- Department of Medicine and Health Sciences, University of Molise, Campobasso, 86100, Italy
| | - Francesco Semeraro
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, 25121, Italy
| | - Mario R Romano
- Department of Biomedical Sciences, Humanitas University, Milan, 20090, Italy
| | - Roberto Dell'Omo
- Department of Medicine and Health Sciences, University of Molise, Campobasso, 86100, Italy
| | - Andrea Russo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, 25121, Italy
| | - Katia De Nadai
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, 44121, Italy.,Center for Retinitis Pigmentosa of Veneto Region, Camposampiero Hospital, Azienda ULSS 6 Euganea, Padova, 35131, Italy
| | - Donato Gemmati
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, 44121, Italy
| | - Sergio D'Angelo
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, 44121, Italy
| | - Elena Bolletta
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, 44121, Italy
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15
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Squires H, Bermejo I, Poku EN, Cooper K, Stevens J, Hamilton J, Wong R, Denniston AK, Pearce I, Quhill FM. Dexamethasone implant for non-infectious uveitis: is it cost-effective? Br J Ophthalmol 2019; 103:1639-1644. [PMID: 30745307 DOI: 10.1136/bjophthalmol-2018-312765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/19/2018] [Accepted: 12/22/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Uveitis is inflammation inside the eye. The objective of this study is to assess the cost-effectiveness of a dexamethasone implant plus current practice (immunosuppressants and systemic corticosteroids) compared with current practice alone, in patients with non-infectious intermediate, posterior or pan-uveitis and to identify areas for future research. METHODS A Markov model was built to estimate the costs and benefits of dexamethasone. Systematic reviews were performed to identify available relevant evidence. Quality of life data from the key randomised-controlled trial (HURON) was used to estimate the interventions' effectiveness compared with the trial's comparator arm (placebo plus limited current practice (LCP)). The analysis took a National Health Service and Personal Social Services perspective. Costs were calculated based on standard UK sources. RESULTS The incremental cost-effectiveness ratio (ICER) of one dexamethasone implant compared with LCP is estimated as £19 509 per quality-adjusted life year (QALY) gained. The factors with the largest impact on the results were rate of blindness and relative proportion of blindness cases avoided by dexamethasone. Using plausible alternative assumptions, dexamethasone could be cost saving or it may be associated with an ICER of £56 329 per QALY gained compared with LCP. CONCLUSIONS Dexamethasone is estimated to be cost-effective using generally accepted UK thresholds. However, there is substantial uncertainty around these results due to scarcity of evidence. Future research on the following would help provide more reliable estimates: effectiveness of dexamethasone versus current practice (instead of LCP), with subgroup analyses for unilateral and bilateral uveitis, incidence of long-term blindness and effectiveness of dexamethasone in avoiding blindness.
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Affiliation(s)
- Hazel Squires
- Health Economics and Decision Sciences (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Iñigo Bermejo
- Health Economics and Decision Sciences (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith N Poku
- Health Economics and Decision Sciences (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katy Cooper
- Health Economics and Decision Sciences (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- Health Economics and Decision Sciences (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- Health Economics and Decision Sciences (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Sciences (HEDS), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alastair K Denniston
- Institute of Inflammation and Ageing, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Pearce
- Clinical Eye Research Centre, St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
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16
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Bermejo I, Squires H, Poku EN, Cooper K, Stevens JW, Hamilton J, Wong R, Pearce I, Quhill FM, Denniston AK. Adalimumab for non-infectious uveitis: is it cost-effective? Br J Ophthalmol 2019; 103:1633-1638. [PMID: 30728124 DOI: 10.1136/bjophthalmol-2018-312756] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/05/2018] [Accepted: 12/15/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS Uveitis is inflammation inside the eye. Our objective was to assess the cost-effectiveness of adalimumab compared with current practice (immunosuppressants and systemic corticosteroids) in patients with non-infectious intermediate, posterior or panuveitis and to identify areas for future research. METHODS A Markov model was built to estimate costs and benefits of the interventions. Systematic reviews were performed to identify the available relevant clinical and cost-effectiveness evidence. Data collected in two key randomised controlled trials (VISUAL I and VISUAL II) were used to estimate the interventions' effectiveness compared with the trials' comparator arms (placebo plus limited current practice (LCP)). The analysis was performed from the National Health Service and Personal Social Services perspective. Costs were calculated based on standard UK sources. RESULTS The estimated incremental cost-effectiveness ratios (ICERs) of adalimumab versus LCP for the base case are £92 600 and £318 075 per quality-adjusted life year (QALY) gained for active and inactive uveitis, respectively. In sensitivity analyses, the ICER varied from £15 579 to £120 653 and £35 642 to £800 775 per QALY for active and inactive uveitis. CONCLUSION The estimated ICERs of adalimumab versus LCP are above generally accepted thresholds for cost-effectiveness in the UK. Adalimumab may be more cost-effective in patients with active uveitis at greater risk of blindness. However, there is an unmet need for additional primary data to provide more reliable estimates in several important areas, including effectiveness of adalimumab versus current practice (instead of LCP), incidence of long-term blindness, adalimumab effectiveness in avoiding blindness, and rates and time to remission while on adalimumab.
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Affiliation(s)
| | | | | | - Katy Cooper
- ScHARR, University of Sheffield, Sheffield, UK
| | | | | | - Ruth Wong
- ScHARR, University of Sheffield, Sheffield, UK
| | - Ian Pearce
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Alastair K Denniston
- Department of Opthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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17
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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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18
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Downie LE, Makrai E, Bonggotgetsakul Y, Dirito LJ, Kristo K, Pham MAN, You M, Verspoor K, Pianta MJ. Appraising the Quality of Systematic Reviews for Age-Related Macular Degeneration Interventions: A Systematic Review. JAMA Ophthalmol 2018; 136:1051-1061. [PMID: 29978192 DOI: 10.1001/jamaophthalmol.2018.2620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Importance Age-related macular degeneration (AMD) is a leading cause of vision impairment. It is imperative that AMD care is timely, appropriate, and evidence-based. It is thus essential that AMD systematic reviews are robust; however, little is known about the quality of this literature. Objectives To investigate the methodological quality of systematic reviews of AMD intervention studies, and to evaluate their use for guiding evidence-based care. Evidence Review This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All studies that self-identified as a systematic review in their title or abstract or were categorized as a systematic review from a medical subject heading and investigated the safety, efficacy and/or effectiveness of an AMD intervention were included. Comprehensive electronic searches were performed in Ovid MEDLINE, Embase, and the Cochrane Library from inception to March 2017. Two reviewers independently assessed titles and abstracts, then full-texts for eligibility. Quality was assessed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool. Study characteristics (publication year, type of intervention, journal, citation rate, and funding source) were extracted. Findings Of 983 citations retrieved, 71 studies (7.6%) were deemed eligible. The first systematic review relating to an AMD intervention was published in 2003. More than half were published since 2014. Methodological quality was highly variable. The mean (SD) AMSTAR score was 5.8 (3.2) of 11.0, with no significant improvement over time (r = -0.03; 95% CI, -0.26 to 0.21; P = .83). Cochrane systematic reviews were overall of higher quality than reviews in other journals (mean [SD] AMSTAR score, 9.9 [1.2], n = 15 vs 4.7 [2.2], n = 56; P < .001). Overall, there was poor adherence to referring to an a priori design (22 articles [31%]) and reporting conflicts of interest in both the review and included studies (16 articles [23%]). Reviews funded by government grants and/or institutions were generally of higher quality than industry-sponsored reviews or where the funding source was not reported. Conclusions and Relevance There are gaps in the conduct of systematic reviews in the field of AMD. Enhanced endorsement of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement by refereed journals may improve review quality and improve the dissemination of reliable evidence relating to AMD interventions to clinicians.
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Affiliation(s)
- Laura E Downie
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Eve Makrai
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Yokim Bonggotgetsakul
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Lucy J Dirito
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Kresimir Kristo
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Minh-An N Pham
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Mina You
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Karin Verspoor
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - Michael J Pianta
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia
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19
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Squires H, Poku E, Bermejo I, Cooper K, Stevens J, Hamilton J, Wong R, Denniston A, Pearce I, Quhill F. A systematic review and economic evaluation of adalimumab and dexamethasone for treating non-infectious intermediate uveitis, posterior uveitis or panuveitis in adults. Health Technol Assess 2018; 21:1-170. [PMID: 29183563 DOI: 10.3310/hta21680] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Non-infectious intermediate uveitis, posterior uveitis and panuveitis are a heterogeneous group of inflammatory eye disorders. Management includes local and systemic corticosteroids, immunosuppressants and biological drugs. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of subcutaneous adalimumab (Humira®; AbbVie Ltd, Maidenhead, UK) and a dexamethasone intravitreal implant (Ozurdex®; Allergan Ltd, Marlow, UK) in adults with non-infectious intermediate uveitis, posterior uveitis or panuveitis. DATA SOURCES Electronic databases and clinical trials registries including MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the World Health Organization's International Clinical Trials Registry Platform were searched to June 2016, with an update search carried out in October 2016. REVIEW METHODS Review methods followed published guidelines. A Markov model was developed to assess the cost-effectiveness of dexamethasone and adalimumab, each compared with current practice, from a NHS and Personal Social Services (PSS) perspective over a lifetime horizon, parameterised with published evidence. Costs and benefits were discounted at 3.5%. Substantial sensitivity analyses were undertaken. RESULTS Of the 134 full-text articles screened, three studies (four articles) were included in the clinical effectiveness review. Two randomised controlled trials (RCTs) [VISUAL I (active uveitis) and VISUAL II (inactive uveitis)] compared adalimumab with placebo, with limited standard care also provided in both arms. Time to treatment failure (reduced visual acuity, intraocular inflammation, new vascular lesions) was longer in the adalimumab group than in the placebo group, with a hazard ratio of 0.50 [95% confidence interval (CI) 0.36 to 0.70; p < 0.001] in the VISUAL I trial and 0.57 (95% CI 0.39 to 0.84; p = 0.004) in the VISUAL II trial. The adalimumab group showed a significantly greater improvement than the placebo group in the 25-item Visual Function Questionnaire (VFQ-25) composite score in the VISUAL I trial (mean difference 4.20; p = 0.010) but not the VISUAL II trial (mean difference 2.12; p = 0.16). Some systemic adverse effects occurred more frequently with adalimumab than with placebo. One RCT [HURON (active uveitis)] compared a single 0.7-mg dexamethasone implant against a sham procedure, with limited standard care also provided in both arms. Dexamethasone provided significant benefits over the sham procedure at 8 and 26 weeks in the percentage of patients with a vitreous haze score of zero (p < 0.014), the mean best corrected visual acuity improvement (p ≤ 0.002) and the percentage of patients with a ≥ 5-point improvement in VFQ-25 score (p < 0.05). Raised intraocular pressure and cataracts occurred more frequently with dexamethasone than with the sham procedure. The incremental cost-effectiveness ratio (ICER) for one dexamethasone implant in one eye for a combination of patients with unilateral and bilateral uveitis compared with limited current practice, as per the HURON trial, was estimated to be £19,509 per quality-adjusted life-year (QALY) gained. The ICER of adalimumab for patients with mainly bilateral uveitis compared with limited current practice, as per the VISUAL trials, was estimated to be £94,523 and £317,547 per QALY gained in active and inactive uveitis respectively. Sensitivity analyses suggested that the rate of blindness has the biggest impact on the model results. The interventions may be more cost-effective in populations in which there is a greater risk of blindness. LIMITATIONS The clinical trials did not fully reflect clinical practice. Thirteen additional studies of clinically relevant comparator treatments were identified; however, network meta-analysis was not feasible. The model results are highly uncertain because of the limited evidence base. CONCLUSIONS Two RCTs of systemic adalimumab and one RCT of a unilateral, single dexamethasone implant showed significant benefits over placebo or a sham procedure. The ICERs for adalimumab were estimated to be above generally accepted thresholds for cost-effectiveness. The cost-effectiveness of dexamethasone was estimated to fall below standard thresholds. However, there is substantial uncertainty around the model assumptions. In future work, primary research should compare dexamethasone and adalimumab with current treatments over the long term and in important subgroups and consider how short-term improvements relate to long-term effects on vision. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041799. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hazel Squires
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Inigo Bermejo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Ian Pearce
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Fahd Quhill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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20
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Su Y, Wu J, Gu Y. Photodynamic therapy in combination with ranibizumab versus ranibizumab monotherapy for wet age-related macular degeneration: A systematic review and meta-analysis. Photodiagnosis Photodyn Ther 2018; 22:263-273. [PMID: 29753123 DOI: 10.1016/j.pdpdt.2018.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/08/2018] [Accepted: 05/04/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety between photodynamic therapy (PDT) combined with intravitreal ranibizumab (IVR) and ranibizumab monotherapy in treating wet age-related macular degeneration (AMD). METHODS A systematic search was performed in the PubMed, Embase, Web of Science and the Cochrane Library databases through December 31, 2017. The methodological quality of the references was evaluated according to the Cochrane quality assessment. RevMan 5.3 software was used to perform the meta-analysis. RESULTS Eight RCTs involving 817 participants were included. Wet AMD eyes in the mono-group achieved better best-corrected vision acuity (BCVA) than the combination group in month 12 (WMD = -0.19, 95% CI = -0.32 to -0.06, P = 0.004, I2 = 18%). The proportion of patients gaining more than 15 letters from baseline in the mono-group was larger than that in the combination group (RR = 0.70, 95% CI: 0.56 to 0.87, P = 0.001). However, the number of ranibizumab injections with combination therapy was smaller than that with mono-therapy (MD = -1.13, 95% CI: -2.11 to -0.15, P = 0.02, I2 = 85%). No significant differences were observed in the proportions of patients losing more than 15 letters, central retinal thickness (CRT), lesion size of choroidal neovascularization (CNV) and adverse events. CONCLUSIONS Combination therapy decreased the number of injections of ranibizumab, although its BCVA improvement was inferior to that of monotherapy over 12 months of follow-up. Given the inherent limitations of the included trials, more studies are needed to further validate and update the findings in this area.
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Affiliation(s)
- Yongxian Su
- The Second Affiliated Hospital of Southern Medical University, Guangzhou 510000, China.
| | - Jiawei Wu
- The Second Affiliated Hospital of Southern Medical University, Guangzhou 510000, China
| | - Yu Gu
- The Second Affiliated Hospital of Southern Medical University, Guangzhou 510000, China
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21
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Luqmani R, Lee E, Singh S, Gillett M, Schmidt WA, Bradburn M, Dasgupta B, Diamantopoulos AP, Forrester-Barker W, Hamilton W, Masters S, McDonald B, McNally E, Pease C, Piper J, Salmon J, Wailoo A, Wolfe K, Hutchings A. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess 2018; 20:1-238. [PMID: 27925577 DOI: 10.3310/hta20900] [Citation(s) in RCA: 251] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9-61% of true cases. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. DESIGN Prospective multicentre cohort study. SETTING Secondary care. PARTICIPANTS A total of 381 patients referred with newly suspected GCA. MAIN OUTCOME MEASURES Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. RESULTS We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician's assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). LIMITATIONS There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. CONCLUSION We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. FUTURE WORK Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Raashid Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ellen Lee
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Surjeet Singh
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mike Gillett
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
| | - Mike Bradburn
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital NHS Foundation Trust, Southend, UK
| | | | - Wulf Forrester-Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - William Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
| | - Shauna Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Brendan McDonald
- Department of Neuropathology and Ocular Pathology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eugene McNally
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Colin Pease
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jennifer Piper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - John Salmon
- Oxford Eye Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Allan Wailoo
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Konrad Wolfe
- Department of Pathology, Southend University Hospital NHS Foundation Trust, Southend, UK
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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22
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Hallam D, Collin J, Bojic S, Chichagova V, Buskin A, Xu Y, Lafage L, Otten EG, Anyfantis G, Mellough C, Przyborski S, Alharthi S, Korolchuk V, Lotery A, Saretzki G, McKibbin M, Armstrong L, Steel D, Kavanagh D, Lako M. An Induced Pluripotent Stem Cell Patient Specific Model of Complement Factor H (Y402H) Polymorphism Displays Characteristic Features of Age-Related Macular Degeneration and Indicates a Beneficial Role for UV Light Exposure. Stem Cells 2017; 35:2305-2320. [PMID: 28913923 PMCID: PMC5698780 DOI: 10.1002/stem.2708] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/21/2017] [Accepted: 09/07/2017] [Indexed: 11/11/2022]
Abstract
Age-related macular degeneration (AMD) is the most common cause of blindness, accounting for 8.7% of all blindness globally. Vision loss is caused ultimately by apoptosis of the retinal pigment epithelium (RPE) and overlying photoreceptors. Treatments are evolving for the wet form of the disease; however, these do not exist for the dry form. Complement factor H polymorphism in exon 9 (Y402H) has shown a strong association with susceptibility to AMD resulting in complement activation, recruitment of phagocytes, RPE damage, and visual decline. We have derived and characterized induced pluripotent stem cell (iPSC) lines from two subjects without AMD and low-risk genotype and two patients with advanced AMD and high-risk genotype and generated RPE cells that show local secretion of several proteins involved in the complement pathway including factor H, factor I, and factor H-like protein 1. The iPSC RPE cells derived from high-risk patients mimic several key features of AMD including increased inflammation and cellular stress, accumulation of lipid droplets, impaired autophagy, and deposition of "drüsen"-like deposits. The low- and high-risk RPE cells respond differently to intermittent exposure to UV light, which leads to an improvement in cellular and functional phenotype only in the high-risk AMD-RPE cells. Taken together, our data indicate that the patient specific iPSC model provides a robust platform for understanding the role of complement activation in AMD, evaluating new therapies based on complement modulation and drug testing. Stem Cells 2017;35:2305-2320.
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Affiliation(s)
- Dean Hallam
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Joseph Collin
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Sanja Bojic
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Valeria Chichagova
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Adriana Buskin
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Yaobo Xu
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Lucia Lafage
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Elsje G Otten
- Campus for Ageing and Vitality, Institute for Cell and Molecular Biosciences and Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - George Anyfantis
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Carla Mellough
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Stefan Przyborski
- Department of Biosciences, Durham University, Durham, United Kingdom
| | - Sameer Alharthi
- Princess Al Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, King Abdulaziz University, Saudi Arabia
| | - Viktor Korolchuk
- Campus for Ageing and Vitality, Institute for Cell and Molecular Biosciences and Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Gabriele Saretzki
- Campus for Ageing and Vitality, Institute for Cell and Molecular Biosciences and Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Lyle Armstrong
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - David Steel
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - David Kavanagh
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
| | - Majlinda Lako
- Institute of Genetic Medicine, International Centre for Life, United Kingdom
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23
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Brown G, Yoo J, Brown M, Turpcu A, Rajput Y, Benson W, Brown G, Fineman M, Fischer D, Garg S, Gupta O, Ho A, Hsu J, Kaiser R, Maguire J, Park C, Regillo C, Sivalingam A, Spirn M, Tasman W, Vander J. The Burden of Retinal Venous Occlusion: An Assessment of Fellow Eyes in 1000 Cases. ACTA ACUST UNITED AC 2017; 1:404-412. [DOI: 10.1016/j.oret.2017.01.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 01/26/2017] [Accepted: 01/27/2017] [Indexed: 12/15/2022]
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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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25
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Yanagi Y, Fukuda A, Barzey V, Adachi K. Cost-effectiveness of intravitreal aflibercept versus other treatments for wet age-related macular degeneration in Japan. J Med Econ 2017; 20:204-212. [PMID: 27701921 DOI: 10.1080/13696998.2016.1245196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This analysis estimated the cost-effectiveness of intravitreal aflibercept injection(s) (IAI) for wet age-related macular degeneration (wAMD) compared with other treatments in Japan. METHODS This was a cost-utility analysis based on published data. A state-transition cohort model was constructed with six health states based on best-corrected visual acuity in the better-seeing eye. The cycle time was 4 weeks, and the time horizon was 12 years. The model compared IAI 2 mg every 8 weeks (2q8) for 2 years after three initial monthly injections, ranibizumab as needed, ranibizumab 0.5 mg every 4 weeks (0.5q4), pegaptanib sodium 0.3 mg every 6 weeks, verteporfin photodynamic therapy (PDT), and best supportive care, assumed to include medical management and monitoring, but no active therapy. Costs (expressed as Japanese yen [JPY]) and quality-adjusted life years (QALYs) gained were estimated for each treatment and discounted at 2.0%. Input data were obtained from clinical studies, the Japanese drug tariff and social insurance reimbursement schedule, and expert opinion. The analysis was conducted from the societal perspective, including medical costs as well as costs of blindness. RESULTS IAI 2q8 was dominant (i.e. more effective in terms of QALYs and less costly) to all other comparators (ranibizumab as needed, ranibizumab 0.5q4, pegaptanib sodium, PDT, and best supportive care), as shown by the incremental cost-utility ratio (i.e. cost per QALY gained). LIMITATIONS The strengths of the analysis include the wide range of comparators evaluated and the use of Japanese-specific utility data. The limitations include the use of one eye, inclusion of published data up to 2 years only, and assumptions on disease course over 5 years. CONCLUSIONS IAI 2q8 was more effective in terms of QALYs and less costly compared with other treatments for wAMD in Japan.
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Affiliation(s)
- Yasuo Yanagi
- a Singapore National Eye Centre , Singapore
- b Singapore Eye Research Institute , Singapore
- c Duke-NUS (National Universityof Singapore) Graduate Medical School , Singapore
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26
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Different Strategies for the Treatment of Age-Related Macular Degeneration in China: An Economic Evaluation. J Ophthalmol 2016; 2016:7689862. [PMID: 27200183 PMCID: PMC4855017 DOI: 10.1155/2016/7689862] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose. To assess the cost-effectiveness of bevacizumab compared to ranibizumab, verteporfin photodynamic therapy (PDT), and usual care for the treatment of age-related macular degeneration (AMD) in China. Methods. A Markov model was developed according to patient visual acuity (VA) in the better-seeing eye (Snellen scale). Four cohorts of patients were treated with one of the following therapies: bevacizumab, ranibizumab, PDT, or usual care. Clinical data related to treatments were obtained from published randomized clinical trials. Direct medical costs and resource utilization in the Chinese health care setting were taken into account. Health and economic outcomes were evaluated over a lifetime horizon. Sensitivity analyses were performed. Results. Treatment with ranibizumab provided the greatest gains in quality-adjusted life-years (QALYs). The cost per marginal QALY gained with bevacizumab over usual care was $1,258, $3,803, and $2,066 for the predominantly classic, minimally classic, and occult lesions, respectively. One-way sensitivity analysis showed considerably influential factors, such as utility values and effectiveness data. Probabilistic sensitivity analysis indicated that, compared to usual care, PDT and ranibizumab most cases would be cost-effective in the bevacizumab arm at a threshold of $7,480/QALY. Conclusion. Bevacizumab can be a cost-effective option for the treatment of AMD in the Chinese setting.
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Abstract
The idea of treating disease in humans with genetic material was conceived over two decades ago and with that a promising journey involving development and efficacy studies in cells and animals of a large number of novel therapeutic reagents unfolded. In the footsteps of this process, successful gene therapy treatment of genetic conditions in humans has shown clear signs of efficacy. Notably, significant advancements using gene supplementation and silencing strategies have been made in the field of ocular gene therapy, thereby pinpointing ocular gene therapy as one of the compelling "actors" bringing gene therapy to the clinic. Most of all, this success has been facilitated because of (1) the fact that the eye is an effortlessly accessible, exceedingly compartmentalized, and immune-privileged organ offering a unique advantage as a gene therapy target, and (2) significant progress toward efficient, sustained transduction of cells within the retina having been achieved using nonintegrating vectors based on recombinant adeno-associated virus and nonintegrating lentivirus vectors. The results from in vivo experiments and trials suggest that treatment of inherited retinal dystrophies, ocular angiogenesis, and inflammation with gene therapy can be both safe and effective. Here, the progress of ocular gene therapy is examined with special emphasis on the potential use of RNAi- and protein-based antiangiogenic gene therapy to treat exudative age-related macular degeneration.
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Affiliation(s)
- Thomas J Corydon
- Department of Biomedicine, Aarhus University , Aarhus C, Denmark
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28
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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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Lindsley K, Li T, Ssemanda E, Virgili G, Dickersin K. Interventions for Age-Related Macular Degeneration: Are Practice Guidelines Based on Systematic Reviews? Ophthalmology 2016; 123:884-97. [PMID: 26804762 DOI: 10.1016/j.ophtha.2015.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/07/2015] [Accepted: 12/07/2015] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Are existing systematic reviews of interventions for age-related macular degeneration incorporated into clinical practice guidelines? DESIGN High-quality systematic reviews should be used to underpin evidence-based clinical practice guidelines and clinical care. We examined the reliability of systematic reviews of interventions for age-related macular degeneration (AMD) and described the main findings of reliable reviews in relation to clinical practice guidelines. METHODS Eligible publications were systematic reviews of the effectiveness of treatment interventions for AMD. We searched a database of systematic reviews in eyes and vision without language or date restrictions; the database was up to date as of May 6, 2014. Two authors independently screened records for eligibility and abstracted and assessed the characteristics and methods of each review. We classified reviews as reliable when they reported eligibility criteria, comprehensive searches, methodologic quality of included studies, appropriate statistical methods for meta-analysis, and conclusions based on results. We mapped treatment recommendations from the American Academy of Ophthalmology (AAO) Preferred Practice Patterns (PPPs) for AMD to systematic reviews and citations of reliable systematic reviews to support each treatment recommendation. RESULTS Of 1570 systematic reviews in our database, 47 met inclusion criteria; most targeted neovascular AMD and investigated anti-vascular endothelial growth factor (VEGF) interventions, dietary supplements, or photodynamic therapy. We classified 33 (70%) reviews as reliable. The quality of reporting varied, with criteria for reliable reporting met more often by Cochrane reviews and reviews whose authors disclosed conflicts of interest. Anti-VEGF agents and photodynamic therapy were the only interventions identified as effective by reliable reviews. Of 35 treatment recommendations extracted from the PPPs, 15 could have been supported with reliable systematic reviews; however, only 1 recommendation cited a reliable intervention systematic review. No reliable systematic review was identified for 20 treatment recommendations, highlighting areas of evidence gaps. CONCLUSIONS For AMD, reliable systematic reviews exist for many treatment recommendations in the AAO PPPs and should be cited to support these recommendations. We also identified areas where no high-level evidence exists. Mapping clinical practice guidelines to existing systematic reviews is one way to highlight areas where evidence generation or evidence synthesis is either available or needed.
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Affiliation(s)
- Kristina Lindsley
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Tianjing Li
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Ssemanda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gianni Virgili
- Department of Translational Surgery and Medicine, Eye Clinic, University of Florence, Florence, Italy
| | - Kay Dickersin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Cooper K, Shepherd J, Frampton G, Harris P, Lotery A. The cost-effectiveness of second-eye cataract surgery in the UK. Age Ageing 2015; 44:1026-31. [PMID: 26410365 DOI: 10.1093/ageing/afv126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 07/27/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Elective cataract surgery is the most commonly performed surgical procedure in developed countries. However, it is unclear whether cataract surgery on the second eye provides enough incremental benefit to be considered cost-effective. This study conducted a cost-effectiveness analysis of second-eye cataract surgery in the U.K. DESIGN A cost-effectiveness analysis. METHODS A decision-analytical model was developed to estimate the cost-effectiveness of second-eye cataract surgery, based on a comprehensive epidemiological and economic review to develop the parameters for the model. The model followed the clinical pathway of cohorts of patients receiving second-eye cataract surgery and included costs and health benefits associated with post-surgical complications. RESULTS In the model, second-eye surgery generated 0.68 additional quality-adjusted life years (QALY) with an incremental cost-effectiveness ratio of £1,964 per QALY gained. In sensitivity analyses, model results were most sensitive to changes in the health-related quality of life (HRQoL) gain associated with second-eye surgery, but otherwise robust to changes in parameter values. The probability that second-eye surgery is cost-effective at willingness to pay thresholds of £10,000 and £20,000 was 100%. CONCLUSION Second-eye cataract surgery is generally cost-effective based on the best available data and under most assumptions. However, there are only a small number of clinical trials for second-eye cataract surgery, and these have not been conducted in recent years.
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Affiliation(s)
- Keith Cooper
- SHTAC, University of Southampton, Southampton, Hampshire SO16 7NS, UK
| | - Jonathan Shepherd
- SHTAC, University of Southampton, Southampton, Hampshire SO16 7NS, UK
| | - Geoff Frampton
- SHTAC, University of Southampton, Southampton, Hampshire SO16 7NS, UK
| | - Petra Harris
- SHTAC, University of Southampton, Southampton, Hampshire SO16 7NS, UK
| | - Andrew Lotery
- Clinical and Experimental Sciences, University of Southampton, Southampton, Hampshire, UK
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Delplace V, Payne S, Shoichet M. Delivery strategies for treatment of age-related ocular diseases: From a biological understanding to biomaterial solutions. J Control Release 2015; 219:652-668. [PMID: 26435454 DOI: 10.1016/j.jconrel.2015.09.065] [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] [Received: 07/31/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 12/24/2022]
Abstract
Age-related ocular diseases, such as age-related macular degeneration (AMD), diabetic retinopathy, and glaucoma, result in life-long functional deficits and enormous global health care costs. As the worldwide population ages, vision loss has become a major concern for both economic and human health reasons. Due to recent research into biomaterials and nanotechnology major advances have been gained in the field of ocular delivery. This review provides a summary and discussion of the most recent strategies employed for the delivery of both drugs and cells to the eye to treat a variety of age-related diseases. It emphasizes the current challenges and limitations to ocular delivery and how the use of innovative materials can overcome these issues and ultimately provide treatment for age-related degeneration and regeneration of lost tissues. This review also provides critical considerations and an outlook for future studies in the field of ophthalmic delivery.
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Affiliation(s)
- Vianney Delplace
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, 200 College Street, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, 164 College Street, Toronto, ON M5S 3G9, Canada
| | - Samantha Payne
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, 200 College Street, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, 164 College Street, Toronto, ON M5S 3G9, Canada
| | - Molly Shoichet
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, 200 College Street, Toronto, ON M5S 3E5, Canada; Institute of Biomaterials and Biomedical Engineering, 164 College Street, Toronto, ON M5S 3G9, Canada.
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Szemraj M, Bielecka-Kowalska A, Oszajca K, Krajewska M, Goś R, Jurowski P, Kowalski M, Szemraj J. Serum MicroRNAs as Potential Biomarkers of AMD. Med Sci Monit 2015; 21:2734-42. [PMID: 26366973 PMCID: PMC4576928 DOI: 10.12659/msm.893697] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Age-related macular degeneration (AMD) is a major cause of blindness worldwide. Circulating microRNAs (miRNAs) in serum have emerged as novel candidate biomarkers for many diseases. The aim of the present study was to identify a serum microRNA (miRNA) expression profile specific for dry and wet forms of AMD. MATERIAL AND METHODS Serum miRNA expression was first screened using TaqMan® Human MicroRNA Array A (Applied Biosystems). An extensive, self-validated, individual, quantitative RT-PCR (qRT-PCR) study was then performed on a cohort of 300 AMD patients (150 wet form and 150 dry form) and 200 controls. The Mann-Whitney U test and nonparametric Spearman's rank correlation coefficient were used for statistical analysis. RESULTS miRNA expression analysis revealed increased expression of miR661 and miR3121 in serum of patients with dry AMD and miR4258, miR889, and Let7 in patients with wet form. Expression of analyzed miRNA was not observed or remained at low level in controls. CONCLUSIONS Differences in miRNA serum profile exist between patients with wet and dry form of AMD, which indicates miRNAs as potential biomarkers of AMD. Further studies should be performed to confirm its significance in clinical practice.
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Affiliation(s)
- Maciej Szemraj
- Department of Eye Diseases, Medical University of Łódź, Łódź, Poland
| | | | - Katarzyna Oszajca
- Departament of Medical Biochemistry, Medical University of Łódź, Łódź, Poland
| | - Marta Krajewska
- Department of Eye Diseases, Medical University of Łódź, Łódź, Poland
| | - Roman Goś
- Department of Eye Diseases, Medical University of Łódź, Łódź, Poland
| | - Piotr Jurowski
- Department of Eye Diseases, Medical University of Łódź, Łódź, Poland
| | | | - Janusz Szemraj
- Departament of Medical Biochemistry, Medical University of Łódź, Łódź, Poland
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Parmeggiani F, Costagliola C, Semeraro F, Romano MR, Rinaldi M, Gallenga CE, Serino ML, Incorvaia C, D’Angelo S, De Nadai K, Dell’Omo R, Russo A, Gemmati D, Perri P. Effect of Factor XIII-A G185T Polymorphism on Visual Prognosis after Photodynamic Therapy for Neovascular Macular Degeneration. Int J Mol Sci 2015; 16:19796-811. [PMID: 26307969 PMCID: PMC4581326 DOI: 10.3390/ijms160819796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/23/2015] [Accepted: 08/11/2015] [Indexed: 01/31/2023] Open
Abstract
Macular degenerations represent leading causes of central blindness or low vision in developed countries. Most of these severe visual disabilities are due to age-related macular degeneration (AMD) and pathologic myopia (PM), both of which are frequently complicated by subfoveal choroidal neovascularization (CNV). Photodynamic therapy with verteporfin (PDT-V) is still employed for CNV treatment in selected cases or in combined regimen. In Caucasian patients, the common polymorphism G185T of factor XIII-A gene (FXIII-A-G185T; rs5985) has been described as predictor of poor angiographic CNV responsiveness to PDT-V. Nevertheless, the prognostic implications of this pharmacogenetic determinant on long-term visual outcome after a PDT-V regimen have not been evaluated. We retrospectively selected Caucasian patients presenting with treatment-naive CNV and receiving standardized PDT-V protocol for two years. The study population included patients affected by subfoveal CNV secondary to AMD or PM. We assessed the correlations between the polymorphic allele T of FXIII-A-G185T and: (1) total number of photodynamic treatments; and (2) change in visual acuity from baseline to the end of the follow-up period. Considering a total study population of 412 patients with neovascular AMD or PM, the carriers of 185 T-allele of FXIII-A (GT or TT genotype) received a higher number of photodynamic treatments than patients without it (GG wild-type genotype) (p < 0.01; mean number of PDT-V: 5.51 vs. 3.76, respectively). Moreover, patients with 185 T-allele of FXIII-A had a more marked worsening of visual acuity at 24 months than those with the GG-185 wild genotype (p < 0.01; mean difference in logMAR visual acuity: 0.22 vs. 0.08, respectively). The present findings show that the G185T polymorphism of the FXIII-A gene is associated with significant differences in the long-term therapeutic outcomes of patients treated with standardized PDT-V protocol. The comprehensive appraisal of both anti-thrombophilic effects due to FXIII-A G185T variant and photo-thrombotic action of PDT-V toward CNV provides several clues about the rationale of this intriguing pharmacogenetic correlation. Further investigations are warranted to outline the appropriate paradigm for guiding PDT-V utilization in the course of the combined therapeutic protocol for neovascular macular degeneration.
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Affiliation(s)
- Francesco Parmeggiani
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Ciro Costagliola
- Eye Clinic, Department of Health Sciences, University of Molise, Via Francesco de Sanctis 1, 86100 Campobasso, Italy; E-Mails: (C.C.); (R.D.O.)
| | - Francesco Semeraro
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy; E-Mails: (F.S.); (A.R.)
| | - Mario R Romano
- Eye Clinic, Department of Neuroscience, Reproductive and Odonto-Stomatological Sciences, “Federico II” University of Naples, Via Pansini 5, 80131 Napoli, Italy; E-Mail:
| | - Michele Rinaldi
- Department of Ophthalmology, Second University of Naples, Via Pansini 5, 80131 Napoli, Italy; E-Mail:
| | - Carla Enrica Gallenga
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Maria Luisa Serino
- Center of Hemostasis and Thrombosis, Department of Medical Sciences, University of Ferrara, Corso Giovecca 203, 44121 Ferrara, Italy; E-Mails: (M.L.S.); (D.G.)
| | - Carlo Incorvaia
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Sergio D’Angelo
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Katia De Nadai
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Roberto Dell’Omo
- Eye Clinic, Department of Health Sciences, University of Molise, Via Francesco de Sanctis 1, 86100 Campobasso, Italy; E-Mails: (C.C.); (R.D.O.)
| | - Andrea Russo
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy; E-Mails: (F.S.); (A.R.)
| | - Donato Gemmati
- Center of Hemostasis and Thrombosis, Department of Medical Sciences, University of Ferrara, Corso Giovecca 203, 44121 Ferrara, Italy; E-Mails: (M.L.S.); (D.G.)
| | - Paolo Perri
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
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Nguyen TT, Guymer R. Conbercept (KH-902) for the treatment of neovascular age-related macular degeneration. Expert Rev Clin Pharmacol 2015; 8:541-8. [PMID: 26289225 DOI: 10.1586/17512433.2015.1075879] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Age-related macular degeneration (AMD) is a progressive, degenerative disease of the retina that occurs with increasing incidence with age and ranks third among the global causes of visual impairment. VEGF has been implicated in the development and progression of neovascular AMD. Drugs that block VEGF, leading to regression of the abnormal blood vessels, are the mainstay of treatment of neovascular AMD, particularly for subfoveal neovascular lesions. Anti-VEGF agents currently in use in neovascular AMD are pegaptanib (Macugen(®)), ranibizumab (Lucentis(®)), bevacizumab (Avastin(®)) and a soluble VEGF receptor decoy aflibercept (Eylea(®)). Recently, China Food and Drug Administration have approved conbercept for the treatment of neovascular AMD in China. Conbercept appears to offer yet another anti-VEGF drug for use in neovascular AMD. However, there is still a need for large, well-designed, randomized clinical trials to ensure its safety and efficacy.
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Affiliation(s)
- Thanh T Nguyen
- a Centre for Eye Research Australia, University of Melbourne, Melbourne, Victoria, Australia
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Mowatt G, Hernández R, Castillo M, Lois N, Elders A, Fraser C, Aremu O, Amoaku W, Burr J, Lotery A, Ramsay C, Azuara-Blanco A. Optical coherence tomography for the diagnosis, monitoring and guiding of treatment for neovascular age-related macular degeneration: a systematic review and economic evaluation. Health Technol Assess 2015; 18:1-254. [PMID: 25436855 DOI: 10.3310/hta18690] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Age-related macular degeneration is the most common cause of sight impairment in the UK. In neovascular age-related macular degeneration (nAMD), vision worsens rapidly (over weeks) due to abnormal blood vessels developing that leak fluid and blood at the macula. OBJECTIVES To determine the optimal role of optical coherence tomography (OCT) in diagnosing people newly presenting with suspected nAMD and monitoring those previously diagnosed with the disease. DATA SOURCES Databases searched: MEDLINE (1946 to March 2013), MEDLINE In-Process & Other Non-Indexed Citations (March 2013), EMBASE (1988 to March 2013), Biosciences Information Service (1995 to March 2013), Science Citation Index (1995 to March 2013), The Cochrane Library (Issue 2 2013), Database of Abstracts of Reviews of Effects (inception to March 2013), Medion (inception to March 2013), Health Technology Assessment database (inception to March 2013). REVIEW METHODS Types of studies: direct/indirect studies reporting diagnostic outcomes. INDEX TEST time domain optical coherence tomography (TD-OCT) or spectral domain optical coherence tomography (SD-OCT). COMPARATORS clinical evaluation, visual acuity, Amsler grid, colour fundus photographs, infrared reflectance, red-free images/blue reflectance, fundus autofluorescence imaging, indocyanine green angiography, preferential hyperacuity perimetry, microperimetry. Reference standard: fundus fluorescein angiography (FFA). Risk of bias was assessed using quality assessment of diagnostic accuracy studies, version 2. Meta-analysis models were fitted using hierarchical summary receiver operating characteristic curves. A Markov model was developed (65-year-old cohort, nAMD prevalence 70%), with nine strategies for diagnosis and/or monitoring, and cost-utility analysis conducted. NHS and Personal Social Services perspective was adopted. Costs (2011/12 prices) and quality-adjusted life-years (QALYs) were discounted (3.5%). Deterministic and probabilistic sensitivity analyses were performed. RESULTS In pooled estimates of diagnostic studies (all TD-OCT), sensitivity and specificity [95% confidence interval (CI)] was 88% (46% to 98%) and 78% (64% to 88%) respectively. For monitoring, the pooled sensitivity and specificity (95% CI) was 85% (72% to 93%) and 48% (30% to 67%) respectively. The FFA for diagnosis and nurse-technician-led monitoring strategy had the lowest cost (£ 39,769; QALYs 10.473) and dominated all others except FFA for diagnosis and ophthalmologist-led monitoring (£ 44,649; QALYs 10.575; incremental cost-effectiveness ratio £ 47,768). The least costly strategy had a 46.4% probability of being cost-effective at £ 30,000 willingness-to-pay threshold. LIMITATIONS Very few studies provided sufficient information for inclusion in meta-analyses. Only a few studies reported other tests; for some tests no studies were identified. The modelling was hampered by a lack of data on the diagnostic accuracy of strategies involving several tests. CONCLUSIONS Based on a small body of evidence of variable quality, OCT had high sensitivity and moderate specificity for diagnosis, and relatively high sensitivity but low specificity for monitoring. Strategies involving OCT alone for diagnosis and/or monitoring were unlikely to be cost-effective. Further research is required on (i) the performance of SD-OCT compared with FFA, especially for monitoring but also for diagnosis; (ii) the performance of strategies involving combinations/sequences of tests, for diagnosis and monitoring; (iii) the likelihood of active and inactive nAMD becoming inactive or active respectively; and (iv) assessment of treatment-associated utility weights (e.g. decrements), through a preference-based study. STUDY REGISTRATION This study is registered as PROSPERO CRD42012001930. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Graham Mowatt
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Mayret Castillo
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Noemi Lois
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Andrew Elders
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Olatunde Aremu
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Winfried Amoaku
- Department of Ophthalmology, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jennifer Burr
- Medical and Biosocial Sciences, School of Medicine, University of St Andrews, St Andrews, UK
| | - Andrew Lotery
- Clinical Neurosciences Research Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Frampton G, Harris P, Cooper K, Lotery A, Shepherd J. The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation. Health Technol Assess 2015; 18:1-205, v-vi. [PMID: 25405576 DOI: 10.3310/hta18680] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Elective cataract surgery is the most commonly performed surgical procedure in the NHS. In bilateral cataracts, the eye with greatest vision impairment from cataract is operated on first. First-eye surgery can improve vision and quality of life. However, it is unclear whether or not cataract surgery on the second eye provides enough incremental benefit to be considered clinically effective and cost-effective. OBJECTIVE To conduct a systematic review of clinical effectiveness and analysis of cost-effectiveness of second-eye cataract surgery in England and Wales, based on an economic model informed by systematic reviews of cost-effectiveness and quality of life. DATA SOURCES Twelve electronic bibliographic databases, including MEDLINE, EMBASE, Web of Science, The Cochrane Library and the Centre for Reviews and Dissemination databases were searched from database inception to April 2013, with searches updated in July 2013. Reference lists of relevant publications were also checked and experts consulted. REVIEW METHODS Two reviewers independently screened references, extracted and checked data from the included studies and appraised their risk of bias. Based on the review of cost-effectiveness, a de novo economic model was developed to estimate the cost-effectiveness of second-eye surgery in bilateral cataract patients. The model is based on changes in quality of life following second-eye surgery and includes post-surgical complications. RESULTS Three randomised controlled trials (RCTs) of clinical effectiveness, three studies of cost-effectiveness and 10 studies of health-related quality of life (HRQoL) met the inclusion criteria for the systematic reviews and, where possible, were used to inform the economic analysis. Heterogeneity of studies precluded meta-analyses, and instead data were synthesised narratively. The RCTs assessed visual acuity, contrast sensitivity, stereopsis and several measures of HRQoL. Improvements in binocular visual acuity and contrast sensitivity were small and unlikely to be of clinical significance, but stereopsis was improved to a clinically meaningful extent following second-eye surgery. Studies did not provide evidence that second-eye surgery significantly affected HRQoL, apart from an improvement in the mental health component of HRQoL in one RCT. In the model, second-eye surgery generated 0.68 incremental quality-adjusted life-years with an incremental cost-effectiveness ratio of £1964. Model results were most sensitive to changes in the utility gain associated with second-eye surgery, but otherwise robust to changes in parameter values. The probability that second-eye surgery is cost-effective at willingness-to-pay thresholds of £10,000 and £20,000 is 100%. LIMITATIONS Clinical effectiveness studies were all conducted more than 9 years ago. Patients had good vision pre surgery which may not represent all patients eligible for second-eye surgery. For some vision-related patient-reported outcomes and HRQoL measures, thresholds for determining important clinical effects are either unclear or have not been determined. CONCLUSIONS Second-eye cataract surgery is generally cost-effective based on the best available data and under most assumptions. However, more up-to-date data are needed. A well-conducted RCT that reflects current populations and enables the estimation of health state utility values would be appropriate. Guidance is required on which vision-related, patient-reported outcomes are suitable for assessing effects of cataract surgery in the NHS and how these measures should be interpreted clinically. STUDY REGISTRATION This project is registered as PROSPERO CRD42013004211. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Geoff Frampton
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Petra Harris
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Keith Cooper
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Andrew Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jonathan Shepherd
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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Claxton L, Malcolm B, Taylor M, Haig J, Leteneux C. Ranibizumab, verteporfin photodynamic therapy or observation for the treatment of myopic choroidal neovascularization: cost effectiveness in the UK. Drugs Aging 2015; 31:837-48. [PMID: 25300507 PMCID: PMC4210643 DOI: 10.1007/s40266-014-0216-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose The aim of this study was to evaluate the cost effectiveness of ranibizumab compared with verteporfin photodynamic therapy (vPDT) or no treatment (observation) in patients with visual impairment due to myopic choroidal neovascularization (CNV). Methods A Markov model with health states defined by best-corrected visual acuity and a 3-month cycle length was developed. It had a healthcare provider (UK National Health Service and personal social services) perspective, a lifetime time horizon, and was based on 2011 prices; future costs and health outcomes were discounted at 3.5 % per annum. Baseline characteristics were based on the phase III RADIANCE (Ranibizumab and vPDT Evaluation in Myopic CNV) study, and year 1 health-state transitions were based on this and the VIP (Verteporfin in Photodynamic Therapy) study. Extensive sensitivity analyses tested the robustness of the model. Results The lifetime cost of treating myopic CNV with ranibizumab was £12,866, whereas vPDT and observation were associated with total costs of £14,421 and £8,163, respectively. Ranibizumab treatment produced higher cumulative quality-adjusted life-years (QALYs; 12.99) than vPDT (12.60) or observation (12.45). Ranibizumab treatment was therefore dominant, with greater health gains and lower overall costs than vPDT. Ranibizumab was cost effective compared with observation, with an incremental cost-effectiveness ratio of £8,778/QALY. In the probabilistic sensitivity analysis, ranibizumab had a 100 % and 88 % probability of being cost effective compared with vPDT and observation, respectively, at a willingness-to-pay threshold of £20,000/QALY. Conclusion This study indicates that ranibizumab therapy is dominant over vPDT for the treatment of visual impairment due to CNV secondary to pathologic myopia in the UK healthcare setting and cost effective compared with observation. Electronic supplementary material The online version of this article (doi:10.1007/s40266-014-0216-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lindsay Claxton
- York Health Economics Consortium, University of York, York, YO10 5DD, UK,
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Bokinni Y, Shah N, Maguire O, Laidlaw DAH. Performance of a computerised visual acuity measurement device in subjects with age-related macular degeneration: comparison with gold standard ETDRS chart measurements. Eye (Lond) 2015; 29:1085-91. [PMID: 26043703 DOI: 10.1038/eye.2015.94] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 04/14/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The aim of the study was to compare the performance of two different COMPlog computerised, single letter scoring, visual acuity (VA) measurements against gold standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart measurements in patients with age-related macular degeneration (AMD). One computerised algorithm presented five and the other presented three letters per line; both computerised algorithms utilised half, rather than the full-letter width spacing standard on ETDRS charts that might induce crowding, fixation problems, increased test-retest variability (TRV), and bias. METHODS Fifty patients with AMD (mean age 83 years) underwent timed test and retest VA measurements using ETDRS charts and COMPlog five (C5) and three (C3) letters per line computerised VA measurement algorithms. All tests utilised single-letter scoring methodology. Bland and Altman methods were employed. Performance was measured in terms of bias, TRV, and test time. RESULTS The C5 and C3 scores showed no bias compared with the ETDRS chart measurements. C5 measurements had equal TRV to the ETDRS chart (±0.13 logMAR) with similar median test times (105 and 96 s, respectively). C3 measurements were slightly more variable (TRV ±0.17 logMAR), but 30 s quicker than ETDRS chart measurements. CONCLUSIONS The closer letter spacing employed in COMPlog testing algorithms appears to have no adverse effect on VA measurements compared with the gold standard ETDRS chart in patients with AMD. The three letter per line testing algorithm facilitates faster testing but with a two letter increase in TRV.
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Affiliation(s)
- Y Bokinni
- Addenbrookes's Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - N Shah
- Department of Ophthalmology, St Thomas' Hospital, London, UK
| | - O Maguire
- Department of Ophthalmology, St Thomas' Hospital, London, UK
| | - D A H Laidlaw
- Department of Ophthalmology, St Thomas' Hospital, London, UK
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Butt T, Crossland MD, West P, Orr SW, Rubin GS. Simulation contact lenses for AMD health state utility values in NICE appraisals: a different reality. Br J Ophthalmol 2015; 99:540-4. [PMID: 25351679 PMCID: PMC4392203 DOI: 10.1136/bjophthalmol-2014-305802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/23/2014] [Accepted: 09/26/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS The National Institute for Health and Care Excellence (NICE) has recommended the use of ranibizumab for neovascular age-related macular degeneration (AMD) and for diabetic macular oedema (DMO) as part of its health technology appraisal process. In the economic evaluations of both interventions, utility values were derived from members of the general public wearing contact lenses with a central opacity that was meant to simulate the blind spot experienced by many patients with advanced retinal disease. This paper tests the validity of the contact lens simulation, and finding it to be invalid, explores the impact on prior economic evaluations. METHODS Visual acuity, contrast sensitivity and visual fields were assessed with and without simulation lenses in five healthy subjects with normal vision. RESULTS We identified important differences between the contact lens simulation and vision loss experienced by patients with AMD. The contact lens simulator did not cause the central scotoma which is characteristic of late-stage AMD and which leads to severe difficulty with everyday activities such as reading or recognising faces and objects. The contact lens instead caused a reduction in retinal illumination experienced by the subjects as a general dimming across the retina. CONCLUSIONS A contact lens with a central opacity does not simulate a central scotoma. The clinical differences between simulated and actual AMD suggest there has been an underestimation of the severity of AMD health states. This brings into question the validity of the economic evaluations of treatments for AMD and DMO used by NICE.
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Affiliation(s)
| | - Michael D Crossland
- UCL Institute of Ophthalmology, London, UK
- Moorfields Eye Hospital, London, UK
| | - Peter West
- UCL Institute of Ophthalmology, London, UK
| | - Shepley W Orr
- UCL Department of Civil, Environmental and Geomatic Engineering, London, UK
| | - Gary S Rubin
- UCL Institute of Ophthalmology, London, UK
- NIHR Moorfields Biomedical Research Centre for Ophthalmology, London, UK
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Lozano López V, Serrano García M, Mantolán Sarmiento C, Pareja Ríos A, Losada Castillo MJ, Cordovés Dorta L, Quijada Fumero E, Virgós Aller T, Bullejos Molina M. [A cost-effectiveness study of dexamethasone implants in macular edema]. ACTA ACUST UNITED AC 2014; 90:14-21. [PMID: 25443181 DOI: 10.1016/j.oftal.2013.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 10/06/2013] [Accepted: 10/28/2013] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To analyze the cost-effectiveness and benefits of a dexamethasone intravitreal implant (Ozurdex®, Allergan, Irvine, CA, USA.) in its clinically relevant applications. MATERIAL AND METHODS A total of 88 eyes of 86 patients with macular edema of > 300 μm measured by optical coherence tomography (Cirrus Zeiss, Dublin, CA, USA) were included in this two-year retrospective study, with a minimum of 6 months follow-up. The patients were divide into 3 groups: group 1 with macular edema in retinal vein occlusion, group 2 with non-infectious posterior uveitis, and group 3 with diabetic macular edema. The treatment was off-label but supported by the literature. Before implantation, and on days 1, 30, 60, 90 and 180, corrected visual acuity (Snellen), central retinal thickness, intraocular pressure and biomicroscopy were evaluated. The cost-benefit analysis was tabulated by line of visual acuity gained, comparing the main therapeutic alternatives and assessment of the safety profile of the dexamethasone intravitreal implant (Ozurdex®, Allergan, Irvine, CA, USA). RESULTS The results of this study did not differ from the published studies, in terms of visual acuity improvement in 63.3% of cases, and with central macular thickness improvement in 97% of cases. There were relapses, which occurred after 120 days on average, and the need for retreatment was 40.9%. Increased intraocular pressure >23 mm Hg was among the side effects in 29.54%, and was controlled with topical treatment, except in 1.13% requiring surgical treatment. The development of cataract was 44.7%, and 10.6% required surgery. Treatment results showed less frequent use of Ozurdex® than other treatments for disease control, being a cost saving option. DISCUSSION Cost-effectiveness analyses are clinically relevant when applying treatment strategies in patients with macular edema. Dexamethasone intravitreal implant appears to be a safe and efficient therapy.
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Affiliation(s)
- V Lozano López
- Servicio de Oftalmología, Sección de Retina, Complejo Hospitalario Universitario de Canarias, Tenerife, España.
| | - M Serrano García
- Servicio de Oftalmología, Sección de Retina, Complejo Hospitalario Universitario de Canarias, Tenerife, España
| | - C Mantolán Sarmiento
- Servicio de Oftalmología, Sección de Retina, Complejo Hospitalario Universitario de Canarias, Tenerife, España
| | - A Pareja Ríos
- Servicio de Oftalmología, Sección de Retina, Complejo Hospitalario Universitario de Canarias, Tenerife, España
| | - M J Losada Castillo
- Servicio de Oftalmología, Sección de Retina, Complejo Hospitalario Universitario de Canarias, Tenerife, España
| | - L Cordovés Dorta
- Servicio de Oftalmología, Sección de Retina, Complejo Hospitalario Universitario de Canarias, Tenerife, España
| | - E Quijada Fumero
- Servicio de Oftalmología, Sección de Retina, Complejo Hospitalario Universitario de Canarias, Tenerife, España
| | - T Virgós Aller
- Servicio de Farmacia Hospitalaria, Complejo Hospitalario Universitario de Canarias, Tenerife, España
| | - M Bullejos Molina
- Servicio de Farmacia Hospitalaria, Complejo Hospitalario Universitario de Canarias, Tenerife, España
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Crabb DP, Russell RA, Malik R, Anand N, Baker H, Boodhna T, Bronze C, Fung SSM, Garway-Heath DF, Glen FC, Hernández R, Kirwan JF, Lemer C, McNaught AI, Viswanathan AC. Frequency of visual field testing when monitoring patients newly diagnosed with glaucoma: mixed methods and modelling. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02270] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundVisual field (VF) tests are the benchmark for detecting and monitoring the eye disease glaucoma. Measurements from VF tests are variable, which means that frequent monitoring, perhaps over a long period of time, is required to accurately detect true glaucomatous progression. In 2009, guidelines for the diagnosis and management of glaucoma issued by the National Institute for Health and Care Excellence revealed an absence of research evidence about the clinical effectiveness and cost-effectiveness of using different monitoring intervals to detect disease progression. However, the European Glaucoma Society (EGS) guidelines on patient examination recommend that newly diagnosed glaucoma patients should undergo VF testing three times per year in the first 2 years after initial diagnosis.ObjectivesThe primary objective of this project was to explore the clinical effectiveness and cost-effectiveness of using different monitoring intervals to detect VF progression in newly diagnosed glaucoma patients. Other objectives sought to (1) explore glaucoma patients’ views and experiences of monitoring using focus groups; and (2) establish glaucoma subspecialists’ attitudes regarding frequency of VF testing using a five-item questionnaire.DesignThese questions were investigated using a multicentre audit of current practice and existing NHS data (VF records from almost 90,000 patients). New research knowledge was provided through statistical and health economic modelling of these and additional published data.ResultsThe multicentre audit showed that VF monitoring is, on average, carried out annually. Patient focus groups indicated that, although patients do not like VF testing, they accept it as a critical part of their care. Patients raised concerns regarding distracting testing environments, quality of instructions, explanation of results and excessive waiting times. Questionnaires revealed that clinicians’ attitudes towards the frequency of VF testing varied considerably, and many glaucoma specialists believed that current recommendations are impractical. Statistical modelling suggested that EGS recommendations could be clinically effective as progression can be identified sooner than is possible with annual testing. Health economic modelling suggested that increased VF monitoring may also be cost-effective [incremental cost-effectiveness ratio (ICER) was equal to £21,679].ConclusionsStatistical modelling of VF data suggests there is strong rationale for following EGS recommendations with the primary benefit of providing better information about fast-progressing patients. Our health economic model suggested that increasing VF testingmaybe cost-effective (ICER was equal to £21,679), especially when accounting for gains to society. Nevertheless, many clinicians consider increased VF testing of patients impossible with current resources. In addition, patient focus groups raised concerns about the practicalities of delivery of VF tests.Future workResults from this study could inform the design of a prospective randomised comparative trial of different VF monitoring intervals in glaucoma linked to stratifying patients according to risk factors for progression. The statistical model for VF data can be further developed to be used as a practical tool for optimising individualised follow-up. The views of clinicians and patients indicate that service delivery of VF testing is an important issue and worthy of further investigation. Ensuring the confidence and co-operation of the patient should be at the centre of future research into the most efficient strategies for glaucoma monitoring.FundingThis work was funded by the National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- David P Crabb
- Division of Optometry and Visual Science, School of Health Sciences, City University London, London, UK
| | - Richard A Russell
- Division of Optometry and Visual Science, School of Health Sciences, City University London, London, UK
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Rizwan Malik
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Nitin Anand
- Department of Ophthalmology, Calderdale and Huddersfield NHS Trust, Calderdale and Huddersfield Royal Infirmaries, Halifax and Huddersfield, UK
| | - Helen Baker
- Division of Optometry and Visual Science, School of Health Sciences, City University London, London, UK
| | - Trishal Boodhna
- Division of Optometry and Visual Science, School of Health Sciences, City University London, London, UK
| | | | - Simon SM Fung
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - David F Garway-Heath
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Fiona C Glen
- Division of Optometry and Visual Science, School of Health Sciences, City University London, London, UK
| | - Rodolfo Hernández
- Health Services Research Unit, University of Aberdeen and Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - James F Kirwan
- Department of Ophthalmology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Andrew I McNaught
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, and Cranfield University, Bedford, UK
| | - Ananth C Viswanathan
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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Simcock P, Kingett B, Mann N, Reddy V, Park J. A safety audit of the first 10 000 intravitreal ranibizumab injections performed by nurse practitioners. Eye (Lond) 2014; 28:1161-4. [PMID: 25033899 DOI: 10.1038/eye.2014.153] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 05/22/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the safety of a nurse practitioner (NP)-delivered injection service for the treatment of wet age-related macular degeneration (wAMD) with ranibizumab. METHODS An evaluation of medical staffing resources for providing an injection service for wAMD highlighted difficulties covering lists. An alternative strategy of an NP-delivered injection service was evaluated. Two suitable NPs with previous extensive experience in minor surgical procedures were identified. The department's senior vitreo-retinal consultant supervised the NP's training programme. A prospective safety audit was conducted for the first 5.5 years of the service. RESULTS The NPs administered 10 006 injections in the first 5.5 years of the service (1 May 2008 to 8 October 2013). This represented 84.1% of the total injections performed during this period. Four patients developed presumed infectious endophthalmitis (1 was culture positive and 3 were culture negative). The incidence of post-injection endophthalmitis was 0.04%. There was no evidence of lens touch, retinal detachment, or systemic thrombo-embolic events. CONCLUSIONS Carefully selected and well-trained NPs are capable of delivering a safe and effective wAMD injection treatment service. This work demonstrates how such a service can be established and provides safety data that other units can use as a benchmark when evaluating their own practice.
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Affiliation(s)
- P Simcock
- West of England Eye Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - B Kingett
- West of England Eye Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - N Mann
- West of England Eye Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - V Reddy
- West of England Eye Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - J Park
- West of England Eye Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
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Kiss S, Liu Y, Brown J, Holekamp NM, Almony A, Campbell J, Kowalski JW. Clinical Monitoring of Patients With Age-Related Macular Degeneration Treated With Intravitreal Bevacizumab or Ranibizumab. Ophthalmic Surg Lasers Imaging Retina 2014; 45:285-91. [DOI: 10.3928/23258160-20140709-04] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 04/17/2014] [Indexed: 11/20/2022]
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Holekamp NM, Liu Y, Yeh WS, Chia Y, Kiss S, Almony A, Kowalski JW. Clinical utilization of anti-VEGF agents and disease monitoring in neovascular age-related macular degeneration. Am J Ophthalmol 2014; 157:825-833.e1. [PMID: 24388973 DOI: 10.1016/j.ajo.2013.12.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 12/20/2013] [Accepted: 12/23/2013] [Indexed: 11/15/2022]
Abstract
PURPOSE To examine bevacizumab and ranibizumab utilization and disease monitoring patterns in patients with neovascular age-related macular degeneration (neovascular AMD) in clinical practice. DESIGN Retrospective medical claims analysis. METHODS Patients receiving ≥1 ranibizumab or bevacizumab injection during the 12 months after initial neovascular AMD diagnosis were included. Annual bevacizumab and/or ranibizumab injection utilization was assessed by year of first injection cohorts: 2006 and 2007 (received either agent because of billing code overlap), 2008, 2009, and January-June 2010 (received each agent). Outcome measures were time to first injection relative to neovascular AMD diagnosis and mean numbers of intravitreal injections, ophthalmologist visits, and optical coherence tomography (OCT) and fluorescein angiography (FA) examinations in 12 months. RESULTS In the 2006 and 2007 cohorts (n = 8767), mean annual numbers of bevacizumab or ranibizumab injections were 4.7 and 5.0, respectively. Over 92% of patients in all cohorts received first treatment within 3 months of neovascular AMD diagnosis. In the 2008-2010 cohorts (n = 10 259), mean annual number of injections remained low (bevacizumab: 4.6, 5.1, and 5.5; ranibizumab: 6.1, 6.6, and 6.9), as did mean numbers of ophthalmologist visits (bevacizumab only) and OCT examinations (both agents), but there was no such trend in FA examinations. CONCLUSIONS Compared with treatment paradigms validated by clinical trials published at the time, in clinical practice, patients with neovascular AMD received fewer bevacizumab or ranibizumab injections and less-frequent monitoring from 2006 to mid-2011. Factors contributing to this lower injection frequency and visual outcomes associated with reduced utilization need to be researched.
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Affiliation(s)
- Nancy M Holekamp
- Pepose Vision Institute and Washington University School of Medicine, St Louis, Missouri.
| | - Ying Liu
- Allergan, Inc., Irvine, California
| | | | | | - Szilárd Kiss
- Weill Cornell Medical College, New York, New York
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Cost-effectiveness of bevacizumab and ranibizumab for newly diagnosed neovascular macular degeneration. Ophthalmology 2014; 121:936-45. [PMID: 24405740 DOI: 10.1016/j.ophtha.2013.10.037] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 10/07/2013] [Accepted: 10/25/2013] [Indexed: 11/24/2022] Open
Abstract
PURPOSE We sought to determine the most cost-effective treatment for patients with newly diagnosed neovascular macular degeneration: monthly or as-needed bevacizumab injections, or monthly or as-needed ranibizumab injections. DESIGN Cost-effectiveness analysis. PARTICIPANTS Hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration. METHODS Using a mathematical model with a 20-year time horizon, we compared the incremental cost-effectiveness of treating a hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration using monthly bevacizumab, as-needed bevacizumab, monthly ranibizumab, or as-needed ranibizumab. Data came from the Comparison of Age-related macular degeneration Treatment Trial (CATT), the Medicare Fee Schedule, and the medical literature. MAIN OUTCOME MEASURES Costs, quality-adjusted life-years (QALYs), and incremental costs per QALY gained. RESULTS Compared with as-needed bevacizumab, the incremental cost-effectiveness ratio of monthly bevacizumab is $24,2 357/QALY. Monthly ranibizumab gains an additional 0.02 QALYs versus monthly bevacizumab at an incremental cost-effectiveness ratio of >$10 million/QALY. As-needed ranibizumab was dominated by monthly bevacizumab, meaning it was more costly and less effective. In sensitivity analyses assuming a willingness to pay of $100,000/QALY, the annual risk of serious vascular events would have to be ≥2.5 times higher with bevacizumab than that observed in the CATT trial for as-needed ranibizumab to have an incremental cost-effectiveness ratio of <$100,000/QALY. In another sensitivity analysis, even if every patient receiving bevacizumab experienced declining vision by 1 category (e.g., from 20/25-20/40 to 20/50-20/80) after 2 years but every patient receiving ranibizumab retained their vision level, as-needed ranibizumab would have an incremental cost-effectiveness ratio of $97,340/QALY. CONCLUSIONS Even after considering the potential for differences in risks of serious adverse events and therapeutic effectiveness, bevacizumab confers considerably greater value than ranibizumab for the treatment of neovascular macular degeneration.
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Frampton JE. Ranibizumab: a review of its use in the treatment of neovascular age-related macular degeneration. Drugs Aging 2013; 30:331-58. [PMID: 23539234 DOI: 10.1007/s40266-013-0077-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Ranibizumab (Lucentis(®)), an inhibitor of all vascular endothelial growth factor (VEGF) A isoforms, is approved for the intravitreal treatment of neovascular age-related macular degeneration (AMD). In pivotal trials, monthly injections of ranibizumab were superior to verteporfin photodynamic therapy in the treatment of predominantly classic choroidal neovascularization (CNV) due to neovascular AMD (ANCHOR) and sham in the treatment of minimally classic or occult CNV due to neovascular AMD (MARINA). Monthly or less frequent injections of ranibizumab are generally well tolerated and associated with low rates of ocular and systemic serious adverse events (SAEs). Less frequent dosing has been evaluated with the aim of reducing the burden, risk and cost of monthly injections. In the landmark CATT trial, monthly monitoring and retreatment as-needed with ranibizumab was equivalent to monthly treatment in terms of the vision gain at 1 year, but reduced the number of injections (and the related cost) by approximately one-half. In head-to-head comparisons, aflibercept administered bimonthly was noninferior to ranibizumab administered monthly (VIEW 1 and 2), bevacizumab administered monthly was equivalent to ranibizumab administered monthly (CATT), and bevacizumab administered as-needed was equivalent to ranibizumab administered as-needed (CATT). Bevacizumab is widely used (off-label) for economic reasons; while it was less costly than ranibizumab, it was associated with more systemic SAEs. Notwithstanding the availability of other similarly effective anti-VEGF therapies that are approved (aflibercept) or unapproved (bevacizumab), ranibizumab continues to set the standard as regards the totality of evidence from randomized clinical trials demonstrating its efficacy and tolerability (particularly that of the monthly regimen) in the treatment of neovascular AMD.
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Affiliation(s)
- James E Frampton
- Adis, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore 0754, Auckland, New Zealand.
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Efficacy of Ethanol Extract of Fructus lycii and Its Constituents Lutein/Zeaxanthin in Protecting Retinal Pigment Epithelium Cells against Oxidative Stress: In Vivo and In Vitro Models of Age-Related Macular Degeneration. J Ophthalmol 2013; 2013:862806. [PMID: 24163760 PMCID: PMC3791792 DOI: 10.1155/2013/862806] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 07/27/2013] [Accepted: 07/29/2013] [Indexed: 11/24/2022] Open
Abstract
Age-related macular degeneration (AMD) is a major cause of blindness worldwide. Oxidative stress plays a large role in the pathogenesis of AMD. The present study was to evaluate the effects of Fructus lycii ethanol extract on AMD in mice and to investigate whether combination of lutein and zeaxanthin, two carotenoid pigments in Fructus lycii, could protect human retinal pigment epithelial ARPE-19 cells treated with hydrogen peroxide (H2O2) in vitro. We found that severe sediment beneath retinal pigment epithelium and thickened Bruch membrane occurred in AMD mice. However, Fructus lycii ethanol extract improved the histopathologic changes and decreased the thickness of Bruch membrane. Furthermore, the gene and protein expression of cathepsin B and cystatin C was upregulated in AMD mice but was eliminated by Fructus lycii ethanol extract. Investigations in vitro showed that ARPE-19 cell proliferation was suppressed by H2O2. However, lutein/zeaxanthin not only stimulated cell proliferation but also abrogated the enhanced expression of MMP-2 and TIMP-1 in H2O2-treated ARPE-19 cells. These data collectively suggested that Fructus lycii ethanol extract and its active components lutein/zeaxanthin had protective effects on AMD in vivo and in vitro, providing novel insights into the beneficial role of Fructus lycii for AMD therapy.
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Studnička J, Říhová B, Rencová E, Rozsíval P, Dubská Z, Chrapek O, Kolář P, Kandrnal V, Demlová R, Pitrová Š, Řehák J. Cost and effectiveness of therapy for wet age-related macular degeneration in routine clinical practice. Ophthalmologica 2013; 230:34-42. [PMID: 23751929 DOI: 10.1159/000350802] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 03/12/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE Evaluation of the cost and effectiveness of therapy for patients with the wet form of age-related macular degeneration (AMD) in routine clinical practice. METHODS A retrospective multicentre evaluation of changes in the best-corrected visual acuity in applied kinds of therapy and a comparison with the cost of individual therapeutic procedures. RESULTS An overall total of 788 eyes of 763 patients with an average age of 73.2 ± 8.6 years was evaluated for a 1-year minimum period. In the ranibizumab and pegaptanib therapy groups, a reduction of 1.3 letters (p = 0.303) and 1.4 letters (p = 0.197) was found, respectively. In the group of photodynamic therapy (PDT) with verteporfin, a reduction of 5.2 letters was achieved (p < 0.001). Under the conditions of routine practice in the Czech Republic, the annual cost is highest (EUR 5,467.63/patient) in patients with pegaptanib therapy. The annual cost in patients with ranibizumab therapy is lower by EUR 1,220.16. The cost is nearly half (EUR 2,783.65) in the group treated with PDT with verteporfin. CONCLUSION An initiation of AMD therapy by ranibizumab is cost-effective as compared to pegaptanib. Both ranibizumab and pegaptanib are significantly more efficient as compared to PDT with verteporfin. Therapy with ranibizumab and pegaptanib, as compared to PDT with verteporfin, prevents the loss of 1 line of vision on the ETDRS chart for EUR 1,225.98 and 2,286.18, respectively.
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Affiliation(s)
- Jan Studnička
- Department of Ophthalmology, Faculty of Medicine in Hradec Králové, Charles University in Prague, and University Hospital, Hradec Králové, Czech Republic
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Fong AHC, Lai TYY. Long-term effectiveness of ranibizumab for age-related macular degeneration and diabetic macular edema. Clin Interv Aging 2013; 8:467-83. [PMID: 23766636 PMCID: PMC3677930 DOI: 10.2147/cia.s36811] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Neovascular age-related macular degeneration (AMD) and diabetic macular edema (DME) are major causes of visual impairment in the elderly population worldwide. With the aging population, the prevalence of neovascular AMD and DME has increased substantially over the recent years. Vascular endothelial growth factor (VEGF) has been implicated as playing an important role in the pathogenesis of both neovascular AMD and DME. Since its introduction in 2006, ranibizumab, a recombinant, humanized, monoclonal antibody fragment against all isoforms of VEGF-A, has revolutionized the treatment of neovascular AMD and DME. The efficacy and safety of ranibizumab in neovascular AMD has been demonstrated in the ANCHOR and MARINA trials. Further studies including the PIER, PrONTO, and SUSTAIN trials have also evaluated the optimal dosing regimen of ranibizumab in neovascular AMD. The CATT and IVAN trials compared the safety and efficacy of ranibizumab with off-label use of bevacizumab. Studies such as SUSTAIN and HORIZON have shown that ranibizumab has a good safety profile and is well tolerated for over 4 years with very few serious ocular and systemic adverse events. For DME, Phase II RESOLVE study and Phase III RISE and RIDE studies have demonstrated superiority of ranibizumab treatment in improving vision over placebo controls. Phase II READ and Phase III RESOLVE and REVEAL studies have shown that ranibizumab is more effective both as monotherapy and in combination with laser compared with laser monotherapy. The 3-year results from the DRCRnet protocol I study found that ranibizumab with deferred laser resulted in better long-term visual outcome compared with ranibizumab with prompt laser. This review summarizes various important clinical trials on the long-term efficacy and safety of ranibizumab in the treatment of neovascular AMD and DME. The pharmacological properties of ranibizumab, its cost effectiveness, and impact on quality of life will also be discussed.
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Affiliation(s)
- Angie H C Fong
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Eye Hospital, Kowloon, Hong Kong
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