How to treat recurrences after Avastin treatment for neovascular AMD: stick to Avastin or switch to Lucentis?

Before the recent approvement of ranibizumab (Lucentis) for the treatment of neovascular age-related macular degeneration (AMD), bevazicumab (Avastin) had been successfully used as an off-label treatment for this condition. As a consequence, in daily practice we are confronted with a large number of patients having received Avastin injections in the past, now facing a recurrence of the disease and therefore requiring additional injections. This leaves the ophthalmologist in a medical dilemma: should one continue with the off-label drug Avastin or switch to Lucentis? From a clinical point of view and disregarding the legal aspects of continuing an off label treatment, this is not easy to answer, as there are no comparative data available at present. Given this background, we compared the effect of Lucentis and Avastin in a retrospective analysis of a matched case series of patients with recurrent neovascular AMD who were initially treated with Avastin. Sixty-four patients who had finished upload therapy were selected. Upload therapy existed of consecutive injections of intravitreal Avastin every 4–6-week untill the disapearance of macular oedema on OCT. All of these patients presented with a recurrence of neovascular AMD and had undergone treatment of the recurrence with Avastin (group 1, n = 32) or Lucentis (group 2, n = 32) thereafter. Comparing both groups, there was no significant difference concerning visual acuity (VA), central macular oedema in OCT measurement and age before therapy; this also went for the gain of VA and decrease in macular oedema following upload therapy, as well as the documented decrease in VA and increase in retinal thickness measured as a result of the recurrence of the disease, indicating that both groups were very well matched (table 1). In both groups, therapy for the recurrence continued until a resolution of the macular oedema with sequential injections at 4–6-week intervals was seen, number of injections did not differ significantly (group 1: 2.5 injections, group 2: 2.7 injections). Comparing patients having received Lucentis and Avastin, no significant difference concerning the development of VA (see fig 1) was seen, with both groups experiencing an improvement of VA. In contrast, concerning the regression of macular oedema, the effect was more pronounced in group 2 (p,0.028). However, using Lucentis or Avastin, the mean VA did not reach the level measured before the recurrence had occurred (p,0.05, Wilcoxon test for paired samples). Our results indicate a difference in the effect of Lucentis and Avastin when used for the treatment of a recurrence of neovascular AMD after initial Avastin treatment, with slightly better results seen for Lucentis (at Table 1 Histological profile of the cases reviewed