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New drug treatment for Neovascular ARMD: some notes David Kinshuck 2008 |
Lucentis, Macugen, Avastin |
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These drugs which are given as injections into the vitreous cavity of the eye see. They are very effective treating most types of wet ARMD. They are anti-growth factor drugs, and work by preventing the growth factor VEGF from working. VEGF stimulates the growth of the 'new blood vessels' involved in neovascular ARMD, so when its effect is blocked the vessels close and the leakage stops. The VEGF is released from damaged retina. NICE have announced in provisional guidleines that Lucentis will be funded in the next few months. This is for both classic and occult wet-armd. Research suggests Lucentis is the most effective. Macugen is less effective, and both have been approved by the FDA. Macugen . These drugs may be more effective if used in combination with PDT. Many ophthalmologisst believe that Avastin (Moorfields) is just as effective as Lucentis, either but it has to be given 'off label' in the UK; both are now approved in the US, but only Lucentis is licensed for use in the UK.Avastin is much cheaper than Lucentis, and is made by the same company. All the research has been carried out with Lucentis, not Avastin. It is likely that this is because the company has a conflict of interests, and there is much less profit to be made from Avastin. The company is withdrawing cheap Avastin from the US making it difficult for ophthalmologists to use. Avastin is safe studies of avastin for a RAP CNV ARMD more studies The benefits of Lucentis
(Ranibizumab) are described in October 2006's NEJM in
minimally classic/occult ARMD, and in classic .
The financial aspects, and the debate as to whether
ranibizumab (Lucentis) and bevacizumab (Avastin)
are
most effective, is discussed here .
An audio
interview is here. Although these drugs are effective, 'dry' macula' changes still progress after treatment and sight can slowly deteriorate over years. |
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Current protocols |
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Anchor study |
| This is is the main Lucentis and classic CNV study. | ![]() |
Marina study |
This is is the main Lucentis and occult CNV study. Aisenbrey's study. |
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Anecortave acetate |
| This is a modified steroid that can be injected behind the eye. See See It does help to prevent progression of CNV, but is probably not as effective as the 3 drugs above. |
A flow chart |
A very simplified ARMD treatment pathway (2008) |
IVT: intravitreal triamcinolone |
| IVT is a steroid and can help reduce the size of CNV membranes. The procedure and risks are discussed here. With ARMD or CNV it is usually given in addition to PDT. and here . Concerning macular oedema in diabetes, Triamcinolone may reduce macular oedema more effectively. |
Lucentis, Avastin, Macugen intravitreal injections |
The procedure is discussed here. (Triamcinolone has extra risks and is discussed here.) In ARMD or CNV they are usually given in addition to PDT. These drugs are not yet available for general NHS use. Avastin, Macugen , infection..preventing These drugs are given as an injection into the vitreous cavity of your eye. They are given in a clean room or an operating theatre. The injection procedure itself takes seconds and is usually feels like a tiny prick. You can go home later that day...this is a 'day case' procedure'. |
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Macular degeneration shown in green by the arrow. Macular degeneration affects the centre of the retina which is responsible for sharp vision. The front of the eye is on the left, and the retina is shown in red. |
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The eye is cleaned. Anaesthetic drops are instilled, and a few minutes later the nearly painless injection is given. The eye pressure may go up for a few hours, and extra treatment may be needed. You may see the drug floating around your eye for the next few weeks. |
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After the injection |
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After the injection you usually notice black swirls in the vision, which start to disperse gradually, but are a nuisance for a few weeks. By one month the drug should be working. |
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Risks etc |
| Triamcolone | Triamcinolone has extra risks in addition to those on this page and is discussed here. |
| Hours | The injection will put the eye pressure up for a few hours. It is therefore riskier is you have glaucoma, but this is generally not a major problem. The eye must have a normal pressure before the patient goes home. |
| Days | About 1/1000 people will develop a serious eye infection. The day after the injection your eye should be comfortable. If your
eye starts to get red, with misty vision (there
may be no pain), perhaps 2-5 days after the injection, you should
suspect an infection and attend your eye department urgently. In Birmingham
this is the Birmingham
and Midland Eye Centre Casualty at the Birmingham & Midland
Eye Centre, City Hospital, Dudley Road, Birmingham B18 7QH |
| Risks are summarised | See this summary. There is a small chance these drugs will cause other serious problems. As these drugs have not yet passed clinical trials, the exact risks are not known. |
| Pregnancy | Please tell your doctor is you are pregnant, and try and avoid getting pregnant for the 6 weeks following the injection. These drugs should not be given during pregnancy. |
| Anticoagulants ...extra precautions | I have no detailed advice as yet, but generally your anticoagulant dose should be reduced or carefully checked, and you should remind your ophthalmic team you use anticoagulants and ask for specific advice. |
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