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In the news: Nutrition Support May Work Synergistically with Anti-VEGF for Wet AMD

Anti-VEGF Plus Nutrition Support May Be Beneficial in Wet AMD

Although evidence has clearly shown that monthly or bi-monthly intravitreal injection of anti-vascular endothelial growth factor (VEGF) can prevent vision loss and may even improve visual acuity in wet AMD, about 5-10% of patients continue to lose visual acuity. Further, monthly injections are an economic burden. Against this backdrop, university researchers in Italy conducted a pilot study (1) to see whether complementary therapies could improve treatment success of anti-VEGF injections.

Methods

This prospective, randomized, 12 month-long pilot study included 60 patients with new-onset neovascular AMD and no prior intravitreal treatment. Patients were randomized to one of three groups: 1) aflibercept (IVA) therapy alone, 2) aflibercept combined with the non-steroidal anti-inflammatory 0.1% pranoprofen eye drops 3 times daily, or 3) aflibercept plus an AREDS2 formula (modified) with 325 mg EPA + DHA daily. All participants received an initial injection of 2 mg IVA followed by two additional monthly injections. A blinded examiner prescribed further IVA injections as per designated retreatment criteria. Primary outcomes were the changes in best-corrected visual acuity (BCVA in the enrolled eye and in central retinal thickness (CRT). The secondary outcome was a comparison of the required IVA retreatments over the 12-month period among the treatment arms.

Results

At 12 months, all groups showed significant improvement in BCVA, with no between group differences.

The mean CRT change from baseline to 12 months was -76.9 ± 10.9 μm, -129 ± 19.9 μm, and -105 ± 11.6 μm in groups 1, 2 and 3, respectively. A small but significant difference in central retinal thickness was observed with pranoprofen co-treatment (Group 2) vs. anti-VEGF treatment alone (p = 0.001).

Co-therapy with nutritional support (Group 3) yielded a significant difference of one less aflibercept injection in the 12-month period compared with anti-VEGF treatment alone (p < 0.001).

Comments

These findings suggest that nutritional support and topical anti-inflammatory drops may complement anti-VEGF therapy, the first line of treatment in exudative AMD. The results of this pilot study, however, need to be validated in larger and longer trials,

Previous clinical trials (2) found that topical NSAIDS augmented the activity of intravitreal anti-VEGF in reducing central retinal thickness – findings that agree with those for co-treatment with pranoprofen in the current study.

A previous study (3) also reported that omega-3 supplementation combined with anti-VEGF treatment was associated with decreased vitreal VEGF-A levels in wet AMD patients – a finding that might explain the reduced need for aflibercept injection seen in the present study.

Although inflammation is not central to AMD as it is in uveitis for example, it has been reported to play a role in AMD development and progression. Nutritional support or NSAIDS could contribute by influencing the inflammatory cascades and angiogenesis involved in AMD pathogenesis.

References

1. Semeraro F, et al. Treatment of exudative age-related macular degeneration with aflibercept combined with pranoprofen eye drops or nutraceutical support with omega-3: A randomized trial. Br J Clin Pharmacol. Epub Jan. 24, 1019.
2. Russo A, et al. A randomized controlled trial of ranibizumab with and without ketorolac eyedrops for exudative age-related macular degeneration. Br J Ophthalmol 97:1273-6, 2013.
3. Rezende FA, et al. Omega-3 supplementation combined with anti-vascular endothelial growth factor lowers vitreal levels of vascular endothelial growth factor in wet age-related macular degeneration. Am J Ophthalmol. 158:1071-78, 2014.