Bevacizumab Injection in Patients with Neovascular Age-Related Macular Degeneration Increases Angiogenic Biomarkers

doi:10.1016/j.oret.2017.04.004

Ophthalmology Retina

Volume 2, Issue 1, January 2018, Pages 31-37

https://doi.org/10.1016/j.oret.2017.04.004 Get rights and content

Purpose

To evaluate the expression of 19 angiogenic biomarkers in the aqueous humor before and after intravitreal bevacizumab injection (IVB) in eyes with neovascular age-related macular degeneration (AMD).

Design

Prospective, noncomparative, interventional case series.

Participants

Twenty-three eyes of 23 treatment-naïve patients with choroidal neovascularization (CNV) secondary to neovascular AMD.

Methods

Eyes were diagnosed with CNV secondary to neovascular AMD and were treated with 3 monthly IVBs. Aqueous humor samples were obtained by anterior chamber paracentesis at baseline and immediately before each intravitreal bevacizumab injection.

Main Outcome Measures

Aqueous humor levels of 19 angiogenic biomarkers (angiopoietin 2, bone morphogenetic protein 9 [BMP-9], epidermal growth factor [EGF], endoglin, endothelin 1, fibroblast growth factor [FGF]-1 and FGF-2, follistatin, granulocyte colony-stimulating factor [GCSF], heparin-binding EGF-like growth factor [HB-EGF], hepatocyte growth factor [HGF], interleukin 8, leptin, placental growth factor [PLGF], vascular endothelial growth factor [VEGF]-A, VEGF-C, VEGF-D, and tissue inhibitor of metalloproteinases [TIMP]-1 and TIMP-2) were measured. Best-corrected visual acuity (BCVA), spectral-domain OCT parameters, and intraocular pressure also were evaluated.

Results

Baseline aqueous VEGF-A expression was elevated in all study eyes before treatment initiation. A statistically significant decrease of VEGF-A was observed at the 1- and 2-month follow-ups. A statistically significant increased concentration was observed in 7 biomarkers: VEGF-C, angiopoietin 2, endothelin 1, follistatin, HB-EGF, HGF, and interleukin 8. The other 11 study biomarker levels (VEGF-D, BMP-9, EGF, endoglin, FGF-1, FGF-2, GCSF, leptin, PLGF, TIMP-1, and TIMP-2) did not show any significant difference during follow-up. The BCVA statistically improved significantly at 2 months. Spectral-domain OCT parameters improved significantly at all follow-ups. Mean intraocular pressure values were not statistically different during the study period.

Conclusions

Despite a decrease in VEGF-A, the aqueous levels of VEGF-C, angiopoietin 2, endothelin 1, follistatin, HB-EGF, HGF, and interleukin 8 increased significantly after intravitreal injection of bevacizumab. These upregulated angiogenic biomarkers may represent new therapeutic targets in exudative AMD.

Section snippets

Methods

In this prospective study, the aqueous levels of 19 angiogenic biomarkers were measured in eyes with neovascular AMD treated with IVB at the Retina Department of Public Service Hospital of São Paulo (IAMSPE), São Paulo, Brazil. The institutional review board of the Federal University of São Paulo (reference number, 215195) and the Public Service Hospital of São Paulo (reference number, 0115/10) approved the off-label use of bevacizumab and collection of aqueous humor in the current study. All

Results

In total, 69 anterior chamber biopsies were collected from 23 eyes, and there were no complications, such as uveitis, lens opacification, or endophthalmitis. At baseline, before the first intravitreal injection of bevacizumab, the VEGF-A concentration was increased in all patients, and a significant decrease in its levels was observed at the 1- and 2-month follow-ups (Fig 1A). The mean±standard deviation aqueous concentration of VEGF-A was 79.91±48.17 pg/ml at baseline and was reduced

Discussion

Approximately 30 years ago, angiogenesis was first proposed to have a key role in the survival of cancer cells and in local tumor growth.¹⁸ In this setting, the development of new blood vessels is critical for affording appropriate oxygen and nutrient amounts to the growing tumor tissue. Such blood vessel formation within the neoplastic mass is controlled by the production of various growth factors and growth inhibitors.¹⁹ Similar to tumor growth, the formation of new blood vessels in

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Neovascular (wet) age-related macular degeneration (nAMD) is driven by VEGFs A, C, and D, which promote angiogenesis and vascular permeability. Intravitreal injections of anti–VEGF-A drugs are the standard of care, but these do not inhibit VEGF-C and D, which may explain why many patients fail to respond fully. This trial aimed to test the safety and efficacy of OPT-302, a biologic inhibitor of VEGF-C and D, in combination with the anti–VEGF-A inhibitor ranibizumab.
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Of 366 participants recruited from December 1, 2017, to November 30, 2018, 122, 123, and 121 were randomized to 0.5 mg OPT-302, 2.0 mg OPT-302, and sham, respectively. Mean (± standard deviation) visual acuity gain in the 2.0 mg OPT-302 group was significantly superior to sham (+14.2 ± 11.61 vs. +10.8 ± 11.52 letters; P = 0.01). The 0.5 mg OPT-302 group was not significantly different than the sham group (+9.44 ± 11.32 letters; P = 0.83). Compared with sham, the secondary BCVA outcomes favored the 2.0 mg OPT-302 group, with structural outcomes favoring both OPT-302 dosage groups. Adverse events (AEs) were similar across groups, with 16 (13.3%), 7 (5.6%), and 10 (8.3%) participants in the lower-dose, higher-dose, and sham groups, respectively, developing at least 1 serious AE. Two unrelated deaths both occurred in the sham arm.
Significantly superior vision gain was observed with OPT-302 2.0 mg combination therapy, versus standard of care, with favorable safety (ClinicalTrials.gov identifier: NCT03345082).
Proprietary or commercial disclosure may be found after the references.
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The eye is one of the most important organs in the human body providing critical information on the environment. Many corneal diseases can lead to vision loss affecting the lives of people around the world. Ophthalmic drug delivery has always been a major challenge in the medical sciences. Since traditional methods are less efficient (∼5%) at delivering drugs to ocular tissues, contact lenses have generated growing interest in ocular drug delivery due to their potential to enhance drug bioavailability in ocular tissues. The main techniques used to achieve sustained release are discussed in this review, including soaking in drug solutions, incorporating drug into multilayered contact lenses, use of vitamin E barriers, molecular imprinting, nanoparticles, micelles and liposomes. The most clinically relevant results on different eye pathologies are presented. In addition, this review summarizes the benefits of contact lenses over eye drops, strategies for incorporating drugs into lenses to achieve sustained release, results of in vitro and in vivo studies, and recent advances in the commercialization of therapeutic contact lenses for allergic conjunctivitis.
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The drug initially approved by the US FDA for the treatment of colorectal cancer found its use in treating ocular diseases after the pioneering work by Rosenfeld et al. [9]. Though bevacizumab injection in patients with neovascular AMD inhibits the VEGF-A, frequent dosing due to the short retention time of the drug and high clearance rates from the ocular humor results in the expression of other angiogenic biomarkers such as VEGF-C, angiopoietin 2, endothelin 1, interleukin 8, etc [5,10]. Moreover, fractionation of the drug is important to avoid contamination and the associated endophthalmitis [11,12].
Intraocular angiogenesis mediated by vascular endothelial growth factor (VEGF) and the related ocular disease, age-related macular degeneration (AMD), is the leading cause of loss of vision worldwide. Though anti-VEGF antibodies are used to control AMD, administration of high doses or frequent dosing, and poor ocular retention of the drug adversely affect the patient outcomes. Herein, we report the synthesis of anti-angiogenic carbon nanovesicles (CNVs) through one-step mild carbonization of Brij L76 for loading and sustained release of anti-VEGF antibody [bevacizumab (Avastin)] to treat VEGF-induced angiogenesis. Compared to liposomes and polymersomes, the preparation of CNVs is relatively quick, straightforward, and cost-effective. The bevacizumab loading efficiency of the CNVs is 24.4%, with an encapsulation efficiency of 56.4%. With negligible cytotoxicity toward human umbilical vein endothelial cells and retinal pigment epithelial cells, the bevacizumab-loaded CNVs (BVZ@CNVs) effectively inhibit VEGF-induced cell proliferation and suppress HUVEC migration. In vivo studies show that BVZ@CNVs has superior efficacy to bevacizumab in treating pathological angiogenesis of rabbit eyes as a result of increased bioavailability of the drug through sustained release combined with the anti-angiogenic effect of CNVs. Our findings indicate that BVZ@CNVs hold great potential as a therapeutic anti-angiogenic agent for clinical AMD treatment.
Incomplete response to Anti-VEGF therapy in neovascular AMD: Exploring disease mechanisms and therapeutic opportunities
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For instance, it has been shown that repeated exposure to bevacizumab can be associated with increased levels of VEGF-C and VEGF-D in the aqueous humor of eyes of NVAMD patients. Increased expression of these other mediators could mediate leakage in spite of adequate levels of functional drug targeting VEGF-A, producing an apparent loss of drug effect upon continued exposure to that anti-VEGF drug of interest (Cabral et al., 2018). Based on these data and general rationale, efforts are underway to develop a novel VEGF-C/D “Trap” fusion protein drug (OPT-302, Opthea), to be administered in combination with anti-VEGF(-A) drugs, to reduce PDA and improve vision response (Dugel et al., 2020b).
Intravitreal anti-vascular endothelial growth factor (VEGF) drugs have revolutionized the treatment of neovascular age-related macular degeneration (NVAMD). However, many patients suffer from incomplete response to anti-VEGF therapy (IRT), which is defined as (1) persistent (plasma) fluid exudation; (2) unresolved or new hemorrhage; (3) progressive lesion fibrosis; and/or (4) suboptimal vision recovery. The first three of these collectively comprise the problem of persistent disease activity (PDA) in spite of anti-VEGF therapy. Meanwhile, the problem of suboptimal vision recovery (SVR) is defined as a failure to achieve excellent functional visual acuity of 20/40 or better in spite of sufficient anti-VEGF treatment. Thus, incomplete response to anti-VEGF therapy, and specifically PDA and SVR, represent significant clinical unmet needs.
In this review, we will explore PDA and SVR in NVAMD, characterizing the clinical manifestations and exploring the pathobiology of each. We will demonstrate that PDA occurs most frequently in NVAMD patients who develop high-flow CNV lesions with arteriolarization, in contrast to patients with capillary CNV who are highly responsive to anti-VEGF therapy. We will review investigations of experimental CNV and demonstrate that both types of CNV can be modeled in mice. We will present and consider a provocative hypothesis: formation of arteriolar CNV occurs via a distinct pathobiology, termed neovascular remodeling (NVR), wherein blood-derived macrophages infiltrate the incipient CNV lesion, recruit bone marrow-derived mesenchymal precursor cells (MPCs) from the circulation, and activate MPCs to become vascular smooth muscle cells (VSMCs) and myofibroblasts, driving the development of high-flow CNV with arteriolarization and perivascular fibrosis. In considering SVR, we will discuss the concept that limited or poor vision in spite of anti-VEGF may not be caused simply by photoreceptor degeneration but instead may be associated with photoreceptor synaptic dysfunction in the neurosensory retina overlying CNV, triggered by infiltrating blood-derived macrophages and mediated by Müller cell activation Finally, for each of PDA and SVR, we will discuss current approaches to disease management and treatment and consider novel avenues for potential future therapies.
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: Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

: Supported by the National Institutes of Health, Bethesda, Maryland (grant nos.: K08EY020530, R01EY024665, R01EY025225, R01EY024698, and R21AG050437 [V.B.M.]).

: Author Contributions:

: Conception and design: Cabral, Polido, Oshima, Serracarbassa, Regatieri, Belfort Jr.

: Analysis and interpretation: Cabral, Lima, Mello, Duong, Regatieri, Mahajan, Belfort Jr.

: Data collection: Cabral, Polido, Correa

: Overall responsibility: Cabral, Lima, Mello, Mahajan, Belfort Jr.

: Human Subjects: This study includes human subject/tissues. Study protocol was approved by IRB. Informed consent was obtained from all human subjects. All tenets of the Declaration of Helsinki were followed.

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Original articleBevacizumab Injection in Patients with Neovascular Age-Related Macular Degeneration Increases Angiogenic Biomarkers

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Methods

Results

Discussion

Ophthalmology

Cancer Lett

Biochimie

Ophthalmology

Microvasc Res

Ophthalmology

Ophthalmology

Angiogenesis in health and disease

Nat Med

Immunological factors in the pathogenesis and treatment of age-related macular degeneration

Ocul Immunol Inflamm

Causes and prevalence of visual impairment among adults in the United States

Arch Ophthalmol

Transdifferentiated retinal pigment epithelial cells are immunoreactive for vascular endothelial growth factor in surgically excised age-related macular degeneration-related choroidal neovascular membranes

Invest Ophthalmol Vis Sci

Metastatic squamous cell carcinoma cells that overexpress c-Met exhibit enhanced angiogenesis factor expression, scattering and metastasis in response to hepatocyte growth factor

Oncogene

Comparison of VEGF, VEGF-B, VEGF-C and Ang-1 mRNA regulation by serum, growth factors, oncoproteins and hypoxia

Oncogene

c-Src-dependent EGF receptor transactivation contributes to ET-1-induced COX-2 expression in brain microvascular endothelial cells

J Neuroinflam

Tumor-derived vascular endothelial growth factor up-regulates angiopoietin-2 in host endothelium and destabilizes host vasculature, supporting angiogenesis in ovarian cancer

Cancer Res

The activin binding proteins follistatin and follistatin-related protein are differentially regulated in vitro and during cutaneous wound repair

J Endocrinol

Upregulated stromal EGFR and vascular remodeling in mouse xenograft models of angiogenesis inhibitor-resistant human lung adenocarcinoma

J Clin Invest

Angiopoietin-2 may be involved in the resistance to bevacizumab in recurrent glioblastoma

Cancer Invest

Effect of intravitreal triamcinolone in diabetic macular edema unresponsive to intravitreal bevacizumab

Retina

Original article
Bevacizumab Injection in Patients with Neovascular Age-Related Macular Degeneration Increases Angiogenic Biomarkers