Haritoglou, Christos

Kampik, Anselm

Kook, Daniel

Strauss, R.

Wolf, Armin

English

Open Access LMU ( Ludwig-Maximilians-Univ. München)

How to treat recurrences afterAvastin treatment forneovascular AMD: stick toAvastin or switch to Lucentis?Before the recent approvement of ranibizu-mab (Lucentis) for the treatment of neovas-cular age-related macular degeneration(AMD), bevazicumab (Avastin) had beensuccessfully used as an off-label treatmentfor this condition.1 As a consequence, indaily practice we are confronted with a largenumber of patients having received Avastininjections in the past, now facing a recur-rence of the disease and therefore requiringadditional injections.2 This leaves theophthalmologist in a medical dilemma:should one continue with the off-label drugAvastin or switch to Lucentis? From aclinical point of view and disregarding thelegal aspects of continuing an off labeltreatment, this is not easy to answer, asthere are no comparative data available atpresent.3 Given this background, we com-pared the effect of Lucentis and Avastin in aretrospective analysis of a matched caseseries of patients with recurrent neovascularAMD who were initially treated withAvastin.Sixty-four patients who had finishedupload therapy were selected. Upload ther-apy existed of consecutive injections ofintravitreal Avastin every 4–6-week untillthe disapearance of macular oedema onOCT. All of these patients presented witha recurrence of neovascular AMD and hadundergone treatment of the recurrence withAvastin (group 1, n = 32) or Lucentis (group2, n = 32) thereafter. Comparing bothgroups, there was no significant differenceconcerning visual acuity (VA), central macu-lar oedema in OCT measurement and agebefore therapy; this also went for the gain ofVA and decrease in macular oedema follow-ing upload therapy, as well as the documen-ted decrease in VA and increase in retinalthickness measured as a result of therecurrence of the disease, indicating thatboth groups were very well matched(table 1). In both groups, therapy for therecurrence continued until a resolution ofthe macular oedema with sequential injec-tions at 4–6-week intervals was seen, num-ber of injections did not differ significantly(group 1: 2.5 injections, group 2: 2.7 injec-tions). Comparing patients having receivedLucentis and Avastin, no significant differ-ence concerning the development of VA (seefig 1) was seen, with both groups experien-cing an improvement of VA. In contrast,concerning the regression of macularoedema, the effect was more pronouncedin group 2 (p,0.028).However, using Lucentis or Avastin, themean VA did not reach the level measuredbefore the recurrence had occurred (p,0.05,Wilcoxon test for paired samples).Our results indicate a difference in theeffect of Lucentis and Avastin when used forthe treatment of a recurrence of neovascularAMD after initial Avastin treatment, withslightly better results seen for Lucentis (atTable 1 Histological profile of the cases reviewedAllcases Fatal outcome group Surviving groupx2 p ValueN = 19 N = 6 % N = 13 %Degree of differentiationWell differentiated 6 0 0.0 6 100.0 4.05 0.10Moderately differentiated 4 1 25.0 3 75.0 0.10 1.0Poorly differentiated 9 5 55.5 4 44.5 4.55 0.057*Presence and type of rosetteFlexner Wintersteiner 8 2 25.0 6 75.0 0.28 1.0Homer Wright 2 0 0 2 100 1.0 1.0Perivascular 8 6 75.0 2 25.0 12.06 0.001*Degenerative changesNecrosis 14 6 42.9 8 57.1 3.13 0.12Calcification 1 0 0 1 100 1.0 1.0Optic nerve involvementPostlaminar 11 6 54.5 5 45.5 6.38 0.018*Prelaminar 8 0 0 8 100 3.25 0.136p Value = two-tailed p value.*All cases with fatal outcomes had perivascular tumour cuffing, which when compared with the two cases among the surviving group withperivascular tumour cuffing was statistically significant (p = 0.001, x2 = 12.06).All cases with fatal outcomes exhibited significant tumour necrosis compared with the eight among the surviving group (p = 0.12;x2 = 3.13).Figure 1 Treatment of recurrent neovascularage-related macular degeneration afterintravitreal Avastin intravitreal therapy. Bothgroups showed an increase in visual acuity (VA)and a decrease in macular oedema. However,regarding the regression of macular oedema inour groups, there was more benefit for patientshaving been treated with Lucentis (p,0.028)ETDRS, Early Treatment Diabetic RetinopathyStudy; OCT, optical coherence tomography.PostScript1298 Br J Ophthalmol September 2008 Vol 92 No 9 group.bmj.com on April 24, 2013 - Published by bjo.bmj.comDownloaded from least concerning the regression of macularoedema). We are of course aware thatdefinite conclusions cannot be drawn, andrecommendations can not be given basedon our data due to the small number ofpatients and the retrospective nature of ouranalysis. Nevertheless, as both groups werecarefully matched as mentioned above, ourresults underline the need for a prospectivecomparative trial as mentioned by othergroups.3A Wolf, D Kook, R Strauss, A Kampik, C HaritoglouDepartment of Ophthalmology, Ludwig-Maximilians-University, Munich, GermanyCorrespondence to: Dr A Wolf, Department ofOphthalmology, Ludwig-Maximilians-University,Mathildenstr. 8, 80336 Mu¨nchen, Germany;armin.wolf@med.uni-muenchen.deCompeting interests: None.Accepted 4 March 2008Br J Ophthalmol 2008;92:1298–1299.doi:10.1136/bjo.2008.138396REFERENCES1. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Opticalcoherence tomography findings after an intravitrealinjection of bevacizumab (avastin) for neovascular age-related macular degeneration. Ophthalmic Surg LasersImaging 2005;36:331–5.2. Rosenfeld PJ, Rich RM, Lalwani GA. Ranibizumab:Phase III clinical trial results. Ophthalmol Clin North Am2006;19:361–72.3. Klein RM, Klein RB. Avastin versus Lucentis: ethicalissues in treatment of age-related maculardegeneration. Retina 2007;27:1163–5.Table 1 Characteristics of the two groupsGroup 1—Rescue treatment:Avastin Group 2—Rescue treatment: Lucentis p ValueBaselineAge (years) 76.9 77.2 0.54Sex (female) 75% 69% 0.32VA (before upload) 0.3 0.27 0.99Macular oedema (OCT) 332 mm 338 mm 0.5Upload with AvastinPretreatment (no. of Avastin injections during upload) 3 2.7 0.31OCT—after upload 242 mm 221 mm 0.2VA increase during upload (ETDRS letters) +5.9 +8.7 0.4RecurrenceRecurrence (weeks after last injection) 17.8 14.6 0.3Recurrence (ETDRS letters) 211.3 211.9 0.6Recurrence (OCT) +82 mm +98 mm 0.5In the mean, there was no difference between the groups before treatment of recurring neovascular AMD. This went for baseline characteristics before upload therapy, effects on visual acuity(VA) and retinal thickness during upload treatment and clinical parameters when presenting with the recurrence of neovascular AMD.ETDRS, Early Treatment Diabetic Retinopathy Study; OCT, optical coherence tomography.PostScriptBr J Ophthalmol September 2008 Vol 92 No 9 1299 group.bmj.com on April 24, 2013 - Published by bjo.bmj.comDownloaded from doi: 10.1136/bjo.2008.138396 2008 92: 1298-1299Br J Ophthalmol A Wolf, D Kook, R Strauss, et al. Avastin or switch to Lucentis?treatment for neovascular AMD: stick to How to treat recurrences after Avastin http://bjo.bmj.com/content/92/9/1298.full.htmlUpdated information and services can be found at: These include:References http://bjo.bmj.com/content/92/9/1298.full.html#ref-list-1This article cites 3 articlesserviceEmail alertingthe box at the top right corner of the online article.Receive free email alerts when new articles cite this article. 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How to treat recurrences after Avastin treatment for neovascular AMD: stick to Avastin or switch to Lucentis?

A Wolf

D Kook

R Strauss

A Kampik

C Haritoglou

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https://epub.ub.uni-muenchen.de/14973/1/How_to_treat_recurrences_after_avastin.pdf

How to treat recurrences after Avastin treatment for neovascular AMD: stick to Avastin or switch to Lucentis?

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