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Which drug do you prefer for the treatment of wet AMD, ranibizumab or bevacizumab?
Ranibizumab has edge over bevacizumab
 Steve Charles |
I use Lucentis to treat age-related macular degeneration, unless a patient cannot afford the co-pay. Genentech scientist Napoleone Ferrara, MD, PhD, and his team of researchers developed Lucentis (ranibizumab, Genentech) and Avastin (bevacizumab, Genentech) with corporate funds. I do not understand why some physicians are indignant about the cost of Lucentis; not a single taxpayer dollar paid for product development, which has ultimately helped millions of patients avoid or reverse vision loss. The use of Avastin for wet AMD, meanwhile, was pioneered by Dr. Phil Rosenfeld and has helped millions of patients.
While CATT was well designed and well executed, classifying better optical coherence tomography results for Lucentis as an “outlier” is unjustified. Subretinal fluid has not been shown to be beneficial. This raises the question of whether NEI grantees have a conflict of interest when doing cost-effectiveness studies on drugs that affect Medicare payments. Furthermore, it is important to note that the CATT results do not apply to diabetic macular edema (DME) or retinal vein occlusion (RVO), for which VEGF levels have been shown to be more than 1,000 times higher. Lucentis has a 25 times greater affinity for VEGF than Avastin. The BRAVO and CRUISE studies demonstrated excellent outcomes for Lucentis as treatment for RVO, just as the DRCR.net study demonstrated superb outcomes for DME. VEGF Trap-Eye (aflibercept ophthalmic solution, Regeneron Pharmaceuticals), once it is FDA approved, will probably replace Lucentis for AMD, DME and RVO, if priced responsibly, because its durability is more than twice as long as that for Lucentis or Avastin, and its molecular affinity for VEGF is even higher than that of Lucentis.
Steve Charles, MD, FACS, FICS, is a clinical professor of ophthalmology at the University of Tennessee. Disclosure: Dr. Charles has never been a consultant for Genentech or Regeneron, but he participated briefly in a Genentech DME study and a Regeneron AMD trial.
Bevacizumab gives bigger bang for the buck
 Philip J. Rosenfeld |
I use Avastin and Lucentis, and my major determining factors are patient preference, cost and insurance coverage. Based on my clinical experience, the CATT results and the totality of published data on this subject, I see no difference between Avastin and Lucentis when dosed monthly or when dosed using a strict as-needed schedule or a treat-and-extend schedule. If patients leave the decision up to me, I choose Avastin; I can always switch to Lucentis if fluid persists. I have a few patients who respond better to Lucentis and a few who respond better to Avastin, but these patients are rare. I also have patients who require re-treatment every 4 to 8 weeks with both drugs. If I can achieve less frequent dosing using VEGF Trap-Eye, then all these patients will get VEGF Trap-Eye.
I am not surprised that visual acuity outcomes were slightly lower for the as-needed arms in CATT compared with the monthly arms because compliance with re-treatment guidelines will always be difficult to enforce in a multicenter trial. In fact, I was pleasantly surprised by the results. Due to our own early success in the PrONTO study, which used an as-needed regimen, I am confident in my ability to treat based on the OCT appearance of lesions using a strict monthly follow-up schedule. However, I have also learned that monthly visits are impractical, so I have incorporated a hybrid strategy using monthly doses to initially dry the macula, followed by a slow treat-and-extend strategy to maintain a dry macula. Once the macula is dry, I give patients a choice between getting an injection and extending the treatment interval by 2 weeks or skipping the injection and returning in 4 weeks. Almost all patients elect to get the injection and extend the interval. Even though the treat-and-extend strategy was not tested in CATT, I am confident that the premise of maintaining a dry macula was supported in CATT, and the treat-and-extend strategy should yield a per-year injection rate somewhere between that of an as-needed regimen and a monthly regimen.
Philip J. Rosenfeld, MD, PhD, is a professor of ophthalmology at the Bascom Palmer Eye Institute of the University of Miami Miller School of Medicine. Disclosure: Dr. Rosenfeld has no financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.