Age-related macular degeneration: anti-vascular endothelial growth factor treatment

Overview

General background | Focus of the review | Comments on evidence | Search and appraisal summary | Substantive changes at this update | Abstract | Cite as

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General background

Age-related macular degeneration (AMD) is common and has a major public health impact, with cost to both society and the individual through visual impairment and loss of quality of life. Loss of central vision occurs in the late stages of the disease, due to both atrophy (dry AMD) and exudation and scarring from choroidal neovascularisation (wet AMD). Management for dry AMD is limited to the provision of low vision aids and other disability services.

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Focus of the review

Although visual loss in untreated wet AMD is generally rapid and more profound, the outlook for and management of people with choroidal neovascularisation (CNV) in AMD has been revolutionised following introduction of anti-vascular endothelial growth factor (VEGF) therapy into clinical practice. Previous therapies attempted showed only borderline benefit, chiefly limitation of visual loss, and were limited to a small subset of people with wet AMD. However anti-VEGF therapy has demonstrated that visual improvement over the first 1 to 2 years is possible.

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Comments on evidence

We found RCT evidence for all our interventions of interest. They were all medium to large studies; however, there were weaknesses in the methods and/or analysis used. Most studies did not report quality of life as an outcome.

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Search and appraisal summary

The update literature search for this overview was carried out from the date of the last search, March 2006, to January 2014. A back search from 1966 was performed for the new options added to the scope at this update. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 901 studies. After deduplication and removal of conference abstracts, 597 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 423 studies and the further review of 174 full publications. Of the 174 full articles evaluated, two systematic reviews, 10 RCTs, and four further reports were added at this update.

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Additional information

Further phase I, II, and III RCTs of alternate therapies are under way, which may bring added benefit by targeting a broader range of growth factors and by less intense treatment regimens.

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Substantive changes at this update

Anti-angiogenesis treatment using ranibizumab Two systematic reviews,[10][11] one RCT,[13] and three further RCTs (reported in four publications).[15][16][17][18] and three further reports.[19][14][23] Categorisation unchanged (beneficial).

Anti-angiogenesis treatment using aflibercept New option. Three RCTs added,[27][29] and one further report.[28] Categorised as 'beneficial'.

Anti-angiogenesis treatment using bevacizumab New option. Two systematic reviews[10][11], one RCT,[15] and one further report added.[19] Categorised as 'beneficial'.

Ranibizumab plus photodynamic treatment with verteporfin New option. One systematic review[10] and three RCTs added.[32][33][34] Categorised as 'unknown effectiveness'.

Abstract

INTRODUCTION: Sight-threatening (late) age-related macular degeneration (AMD) is found in about 1.4% of people of European ancestry aged 70 years, with prevalence increasing with age. Early-stage disease is marked by normal vision but retinal changes (drusen and pigment changes). Disease progression leads to worsening central vision, but peripheral vision is generally preserved. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments for exudative age-related macular degeneration? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2014 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 901 studies. After deduplication and removal of conference abstracts, 597 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 423 studies and the further review of 174 full publications. Of the 174 full articles evaluated, two systematic reviews, 10 RCTs, and four further reports were added at this update. We performed a GRADE evaluation of the quality of evidence for nine PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for four interventions, based on information relating to the effectiveness and safety of anti-angiogenesis (using aflibercept, bevazicumab, and ranibizumab) and ranibizumab plus photodynamic therapy with verteporfin.

Cite as

Arnold JJ. Age-related macular degeneration: anti-vascular endothelial growth factor treatment. Systematic review 701. BMJ Clinical Evidence. . 2016 February. Accessed [date].

Latest citations

Anti–vascular endothelial growth factor drugs for the treatment of retinal conditions. ( 19 August 2016 )

Aflibercept for neovascular age-related macular degeneration. ( 24 March 2016 )