What medications are used to treat wet AMD?
Unlike the dry type of age-related macular degeneration (AMD), wet AMD can be effectively treated using medication. There are a number of different drugs that can help to improve vision at least temporarily or to keep it from getting worse for quite a long time.
In wet AMD, new blood vessels grow underneath the retina. They grow into the retina and may lift it up. The new blood vessels may also become “leaky,” allowing blood and fluid to seep into the retina, where it damages the area we need for central vision.
Wet AMD is usually treated using the following medications, which belong to a group of drugs known as anti-vascular endothelial growth factor (anti-VEGF) drugs:
- Ranibizumab (trade name: Lucentis)
- Aflibercept (Eylea)
The drug bevacizumab (Avastin) is also used. But it has been approved for cancer treatment, and not for the treatment of AMD. If doctors prescribe it for AMD, they have to prescribe it “off-label” (see final section below).
All three medications work based on a similar principle: They block specific growth factors that are responsible for the growth of abnormal blood vessels into the eye. The aim of treatment with medication is to slow down the progression of wet AMD, or to at least temporarily stop it.
How is the medication used?
These medicines are injected into the eyeball in a day-surgery procedure. Anesthetic eye drops are used first to numb the eye. Then the doctor uses a thin needle to inject the actual drug into the eye.
The drug is first injected once a month for three months. For Lucentis, the number of injections needed and the amount of time between injections will depend on how the AMD progresses. Regular eye exams and eye tests are done to check up on this. Eylea is injected every two months after the first three months of treatment. After one year, the treatment will also be continued depending on how the condition develops.
How well have the medications been tested?
To assess the benefits of Lucentis and Avastin, researchers analyzed the results of 16 studies involving a total of 6,500 participants:
- Three studies compared Lucentis with a placebo (fake drug).
- Six studies compared Lucentis with Avastin.
- Two studies compared Avastin with a placebo.
Most of these studies were of high quality, so their results provide a solid foundation for assessing the pros and cons of these drugs.
Eylea has been approved for the treatment of AMD since 2012. Although it was compared with Lucentis in the studies, it is still not clear whether Eylea has any advantages or disadvantages compared to Lucentis.
How effective are the medications?
These drugs are able to temporarily stop or at least delay loss of vision in many people who have wet AMD. Sometimes vision even improves again during treatment. They don't cure the disease, though.
The research on Lucentis shows what may be expected from treating wet AMD with this drug:
- Without treatment: About 60 out of 100 people who used a placebo experienced only slight worsening of vision or had no change in vision over a period of one year.
- With treatment: About 95 out of 100 people who used Lucentis experienced only slight worsening of vision or had no change in vision over the same time period.
In other words, Lucentis noticeably delayed the worsening of vision in about 35 out of 100 people.
Vision had even improved in around 16 out of 100 people after one year. The research also suggests that treatment improved the participants’ quality of life. There is not yet enough research to know how the medications affect the progression of AMD over the long term.
What are the possible side effects?
The injections may cause temporary (usually only mild) eye pain. Injecting fluid into the eyeball can raise the pressure inside of the eye. Another common side effect is seeing spots or dots that follow the eye’s movements. These are caused by small air bubbles getting into the eye through the injections. These bubbles are not dangerous and go away on their own after one or two days.
Rare but serious side effects of this treatment may include inflammation of the inside of the eye (endophthalmitis) or the middle layer of the eye (uveitis), cataracts or retinal damage. In total, these types of side effects occur in less than 1 out of 100 people.
Studies suggest that the regular use of these drugs may slightly increase the risk of developing conditions affecting the blood vessels in the brain, such as circulation problems, bleeding or strokes. About 1 out of every 100 participants who used Lucentis had one of these side effects.
Off-label: Avastin for treating age-related macular degeneration
As mentioned above, Lucentis and Eylea have been approved for the treatment of macular degeneration, but Avastin has only been approved for cancer treatment. The active ingredients in Avastin und Lucentis are very similar, though. Several studies have shown that Avastin is just as effective as Lucentis in treating wet AMD.
Severe side effects were more common in people who had treatment with Avastin: at least one severe side effect occurred within two years in about 36 out of 100 people who received Avastin, compared to about 30 out of 100 people who used Lucentis. Gastrointestinal (stomach and bowel) problems are somewhat more common with Avastin too: 4 out of 100 study participants who used Avastin had these side effects, compared to 2 out of 100 who used Lucentis. Other side effects were equally common with both medications.
Because Avastin costs quite a bit less than Lucentis but is just as effective, some doctors prescribe it "off-label" for the treatment of AMD. A doctor who prescribes a drug for off-label use is required to provide additional information and instructions on this type of use. Statutory health insurers in Germany don't have to cover the costs of off-label treatment, so it is important to check with your insurer beforehand.
Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Aflibercept (Eylea): Benefit assessment according to § 35a Social Code Book V; Dossier assessment; Commission A12-19. March 13, 2013. (IQWiG reports; Volume 156).
Moja L, Lucenteforte E, Kwag KH, Bertele V, Campomori A, Chakravarthy U et al. Systemic safety of bevacizumab versus ranibizumab for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2014; (9): CD011230.
Sarwar S, Clearfield E, Soliman MK, Sadiq MA, Baldwin AJ, Hanout M et al. Aflibercept for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2016; (2): CD011346.
Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age-related macular degeneration. Cochrane Database Syst Rev 2014; (8): CD005139.
Ueta T, Noda Y, Toyama T, Yamaguchi T, Amano S. Systemic vascular safety of ranibizumab for age-related macular degeneration: Systematic review and meta-analysis of randomized trials. Ophthalmology 2014; 121(11): 2193-2203.
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