Eyeworld

EW RETINA 79 by Maxine Lipner EyeWorld Senior Contributing Writer A wide view of anti-VEGF injections macular edema." Dr. Warren also favors the drug because he has a wealth of experience with it, since it was the initial drug available for the treatment of diabetic macula edema. "Because of the CATT results and because of cost considerations, I prefer that drug as primary treat- ment," he said. If a patient doesn't respond, however, he switches to another agent. Most often he choos- es Lucentis next, based on literature findings and his own experience. "We use Lucentis as primary treat- ment less frequently but find it very useful as rescue for unresponsive patients, as we do Eylea," Dr. Warren said, adding that he likes Eylea in particular for patients who have a pigment epithelial detachment (PED). In addition, for patients who live farther away, Eylea may be more efficacious because it needs to be administered less frequently com- pared to once a month for Lucentis, he said. S. Natarajan, MD, professor of ophthalmology, and chairman and managing director, Aditya Jyot Eye Hospital, Mumbai, India, also tends to favor Lucentis. "In India, we only have Lucentis and Avastin," he said. "I prefer to use Lucentis for those who can afford it." Lucentis is made for the eye in particular, and the molecule is exactly right for the retina, unlike Avastin, which is big- ger. In addition, Lucentis is given in a single-dose unit, while the Avastin vial must be distributed to more than 1 patient. Dr. Warren said that the anti-VEGF drugs are all highly effective, as found in the clinical trials. Likewise, clinical experience indicates that Avastin is effective as well. "Avastin has never been in the clinical trials similar to the others, but about 95% or more of patients will have no further progression of their disease," he said. In addition, he finds that approximately 40% of patients on Avastin experience some improve- ment in their visual acuity. In Dr. Boyer's experience, while all of the anti-VEGF medications work, some seem to dry the eye slightly better than others. "Based on a couple of studies, it appears that Eylea dries better than Lucentis and also than Avastin," Dr. Boyer said. "However, as far as the visual acuity results associated with that, there doesn't seem to be as much difference, even if some fluid is still left." At least in the randomized clinical trials, visual acuity results for Eylea and Lucentis, administered monthly, seemed to be equal in ARMD patients, he said. He added that, at least in the AMD popula- tion, all the drugs seem to work well. As for the tolerability of the agents, they all appear to be rel- atively safe. "In the CATT study there were signals that bevacizumab had a higher incidence of adverse events," Dr. Boyer said. This may be a spurious finding, he said. "At this moment in time, I think that everyone would say they're all pretty safe," Dr. Boyer said. "The only cave- at now is that Avastin has to go to a compounding pharmacy to be made up and that adds one additional step where there could be contam- ination, and there have been a few outbreaks of endophthalmitis." Dr. Warren concurs that the compounding pharmacy issue may be problematic. "The FDA and CMS recently gave advice regarding compounding pharmacies," he said. "The current recommendation is that patients have to get an individ- ual prescription." Use of the anti-VEGFs does not necessarily only fall to retinal specialists. Dr. Boyer finds that a variety of practitioners are ad- ministering the anti-VEGF drugs, depending on where their practices are loacted. Patients in rural areas are less apt to travel to see a spe- cialist, he explained. However, the drugs administered may differ, with comprehensive ophthalmologists tending to offer the less costly Avastin, Dr. Boyer noted. "Rarely do I see them using the higher priced drugs because you have to have a lot of money tied up in inventory." F rom wet AMD to retinal vascular occlusions, diabetes and beyond, anti-VEGF in- jections help to preserve the sight of a variety of patients, according to David S. Boyer, MD, clinical professor of ophthalmology, University of Southern California, Los Angeles. "Some people use it as an adjunct to the treatment of proliferative diabetic retinopathy, or with proliferation or macular edema from virtually any condition," Dr. Boyer said. "Others will use it to treat cystoid edema and rarer indi- cations like idiopathic parafoveal telangiectasis." Such anti-VEGF drugs have a two-pronged mechanism. "It's an anti-permeability drug, so it stops leakage," he explained. "It also stops neovascularization from forming and can actually cause temporary regression, when given intravitreal- ly, for areas of neovascularization." For conditions associated with fluid in the eye, from the start, the anti- VEGFs stave off leakage, Dr. Boyer noted, adding that as a result vision often improves very rapidly in most conditions. "Unfortunately, it's a temporary fix," he said. "The leakage will return in most cases unless the drugs are administered on a chronic basis." Agents in action Currently, there are 3 anti-VEGF agents that are approved for AMD, said Keith A. Warren, MD, clinical professor of ophthalmology, Uni- versity of Kansas, Overland Park. "These include Lucentis [ranibizum- ab, Genentech, South San Francis- co], Eylea [aflibercept, Regeneron Pharmaceuticals, Tarrytown, N.Y.], and Macugen [pegaptanib sodi- um, OSI Pharmaceuticals, Melville, N.Y.]," he said. While Macugen was the first of these approved, it is now used sparingly because it is not as effective as the other drugs, Dr. Warren said. In addition, Avastin (bevacizumab, Genentech) is often used off-label. "I use Avastin most frequent- ly, followed by Lucentis and then Eylea," Dr. Warren said. "Avastin, as was demonstrated in the CATT study [Comparison of AMD Treatments Trials], is fairly effective in treating AMD and, for that matter, diabetic September 2014 Pharmaceutical focus For anti-VEGFs to be effective, patients must return on a regular basis. To help bring awareness to what retinal disease can do to vision, Aditya Jyot Eye Hospital created the first Amsler grid garden in the world. Source: S. Natarajan, MD continued on page 80

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