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Safety concerns may speak to need for judicious anti-VEGF use, speaker says
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CHICAGO — The optimal dosing paradigm for anti-VEGF therapy remains elusive, but there still may be rationale for judicious use of VEGF blockade, according to a speaker here.
From a biologic perspective, VEGF is produced by Müller and photoreceptor cells, and VEGF blockade may lead to apoptosis of those critical cells in the back of the eye, Elias Reichel, MD, said at Retina Subspecialty day prior to the joint meeting of the American Academy of Ophthalmology and the Middle East Africa Council of Ophthalmology.
Additionally, anti-VEGF injection can detrimentally affect IOP, especially after multiple injections. Tachyphylaxis is also a concern after multiple injections, Dr. Reichel said. The agents also appear to reduce ocular perfusion pressure at the time of injection, he said.
How individual patients respond to anti-VEGF therapy may also suggest that physicians should carefully consider how anti-VEGF therapy is applied. Subtle clinical presentations and masquerade pathologies may lead to inappropriate or unnecessary anti-VEGF use. On the other hand, certain patients are prone to hyper-response to therapy due to genotypic or phenotypic facts that are not currently well understood.
Dr. Reichel brings up several potentially important drawbacks to continuous VEGF blockade in the eye when attempting to manage wet AMD or other retinal conditions. The good news is that a detrimental effect on the retina in humans with pan-VEGF blockade has yet to be seen with agents that have been in use for more than 4 years. Furthermore, both tachyphylaxis and persistently elevated IOP are rare in patients undergoing anti-VEGF therapy. Although there are studies with as-needed regimens that fall short of the results seen in the pivotal trials with ranibizumab, there are others that demonstrate adequate control of exudation in AMD with individualized, non-continuous treatment. Therefore, at this time, it appears prudent in practice to attempt to keep the macula dry with the least number of anti-VEGF treatments possible when managing wet AMD.
– Carl D. Regillo, MD
Philadelphia