Age-related macular degeneration (AMD) has two major forms: dry or non-neovascular (~90% of patients) and wet or neovascular (~10% of patients).

The FDA has approved Susvimo (Genentech), a refillable permanent ocular implant containing the vascular endothelial growth factor (VEGF) inhibitor ranibizumab, for treatment of neovascular (wet) age-related macular degeneration (nAMD) in patients who have previously responded to at least two intravitreal injections of a VEGF inhibitor. Ranibizumab intravitreal injection (Lucentis) has been available since 2006 for monthly treatment of nAMD. The FDA has approved ranibizumab-nuna (Byooviz), a biosimilar of Lucentis and the first ophthalmologic biosimilar; it will be available in June 2022.

Faricimab-svoa (Vabysmo – Genentech), an inhibitor of both vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2), has been approved by the FDA for intravitreal treatment of neovascular (wet) age-related macular degeneration (nAMD) and diabetic macular edema (DME). It is the first drug to become available in the US that targets two pathways involved in maintaining vascular homeostasis. Several VEGF inhibitors are available for treatment of nAMD and DME (see Table 2).

Brolucizumab-dbll (Beovu — Novartis), a vascular endothelial growth factor (VEGF) inhibitor, has been approved by the FDA as an intravitreal injection for treatment of neovascular (wet) age-related macular degeneration (AMD). It is the fourth VEGF inhibitor to be approved in the US for this indication; bevacizumab (Avastin, and others), a VEGF inhibitor FDA-approved for treatment of breast cancer and other malignancies, has been used off-label for this indication for years.

This issue includes reviews of drugs for glaucoma, age-related macular degeneration (AMD), bacterial conjunctivitis, and dry eye disease. Allergic conjunctivitis is reviewed in a separate issue.

The FDA has approved the oral tyrosine kinase inhibitor cabozantinib (Cabometyx – Exelixis) for treatment of patients with advanced renal cell carcinoma previously treated with antiangiogenic therapy. Cabozantinib was first approved in 2012 as Cometriq for treatment of progressive, metastatic medullary thyroid cancer.

Anti-VEGF antibodies, tyrosine kinase inhibitors, and mTOR kinase inhibitors have become the standard of care for treatment of unresectable or metastatic renal cell cancer.1

FDA approval was based on the results of a randomized open-label trial (METEOR) comparing cabozantinib to everolimus in 658 patients with advanced or metastatic renal cell carcinoma that had progressed on antivascular endothelial growth factor receptor (VEGFR) therapy. In patients treated with cabozantinib, median progression-free survival was significantly longer (7.4 vs 3.8 months with everolimus) and the objective response rate was significantly higher (21% vs 5% with everolimus).2Median overall survival was 21.4 months with cabozantinib and 16.5 months with everolimus.3

Common adverse effects of cabozantinib include diarrhea, fatigue, nausea, vomiting, weight loss, palmar-plantar erythrodysesthesia, and hypertension. Serious adverse effects, including GI perforation, hemorrhage, and arterial thromboembolic events, occurred in >60% of patients treated with cabozantinib in the clinical trial.

The recommended dosage of cabozantinib is 60 mg taken once daily without food. Dosage adjustments are required for patients taking strong CYP3A4 inhibitors or inducers concomitantly.4 In patients who experience severe or intolerable adverse effects, reducing the dosage or withholding the drug until improvement occurs is recommended.

1. Axitinib (Inlyta) for advanced renal cell carcinoma. Med Lett Drugs Ther 2012; 54:47.
2. TK Choueiri et al. Cabozantinib versus everolimus in advanced renal-cell carcinoma. N Engl J Med 2015; 373:1814.
3. TK Choueiri et al. Cabozantinib versus everolimus in advanced renal cell carcinoma (METEOR): final results from a randomised, open-label, phase 3 trial. Lancet Oncol 2016 June 3 (epub).
4. Inhibitors and inducers of CYP enzymes and P-glycoprotein. Med Lett Drugs Ther 2016; 58:e46.

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The FDA has approved Lonsurf (Taiho Oncology), a combination of the thymidine-based nucleoside analog trifluridine and the thymidine phosphorylase inhibitor tipiracil, for oral treatment of metastatic colorectal cancer. Trifluridine is incorporated into DNA, interfering with DNA synthesis and inhibiting cell proliferation. Tipiracil inhibits the metabolism of trifluridine. The combination is only approved for use in patients who were previously treated with a fluoropyrimidine (fluorouracil or capecitabine), oxaliplatin, irinotecan, an anti-VEGF biological such as bevacizumab, and, if the tumor is RAS wild-type, an anti-EGFR agent (cetuximab or panitumumab). The median survival of patients with metastatic colorectal cancer treated with these drugs is about 30 months.

FDA approval of trifluridine/tipiracil was based on the results of a randomized, double-blind, placebo-controlled trial in 800 patients with metastatic colorectal cancer who had previously been treated with chemotherapy and biological therapy. Median overall survival, the primary endpoint, was significantly longer with trifluridine/tipiracil compared to placebo (7.1 months vs 5.3 months). Median progression-free survival, a secondary endpoint, was 1.7 months with placebo and 2.0 months with trifluridine/tipiracil. The most common adverse effects of the combination included nausea, vomiting, diarrhea, fatigue, neutropenia, anemia, and leukopenia. Among 533 patients treated with the combination, only one treatment-related death occurred (from septic shock).1

Lonsurf is available in tablets containing 15 mg of trifluridine and 6.14 mg of tipiracil or 20 mg of trifluridine and 8.19 mg of tipiracil. The recommended dosage is 35 mg/m² (based on the trifluridine component) orally twice daily on days 1-5 and 8-12 of each 28-day cycle until disease progression or unacceptable toxicity occurs. Lonsurf should be taken within one hour after meals. The cost of one treatment cycle (sixty 20 mg/8.19 mg tablets) is $10,947.70.2

1. RJ Mayer et al. Randomized trial of TAS-102 for refractory metastatic colorectal cancer. N Engl J Med 2015; 372:1909.
2. Approximate WAC for a patient with a 1.7 m² surface area. WAC = wholesaler acquisition cost or manufacturer's published price to wholesalers; WAC represents a published catalogue or list price and may not represent an actual transactional price. Source: AnalySource® Monthly. May 5, 2016. Reprinted with permission by First Databank, Inc. All rights reserved. ©2016. www.fdbhealth. com/policies/drug-pricing-policy.

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Vascular endothelial growth factor (VEGF) is a principal mediator of neovascularization in wet age-related macular degeneration (AMD) and diabetic macular edema. It induces angiogenesis and increases vascular permeability and inflammation. VEGF inhibitors reduce leakage from blood vessels, prevent proliferation of new abnormal vessels, decrease swelling of the retina, and improve visual acuity in patients with neovascular (wet) AMD and diabetic macular edema. These drugs are given as periodic intravitreal injections with topical anesthesia.

Ziv-aflibercept (Zaltrap – Sanofi/Regeneron), a vascular endothelial growth factor (VEGF) inhibitor, has been approved by the FDA for use in combination with 5-fluorouracil, leucovorin and irinotecan (FOLFIRI) for treatment of metastatic colorectal cancer that is resistant to or has progressed following an oxaliplatin-containing regimen. It is the same drug as aflibercept, which was approved last year as an intravitreal injection (Eylea) for treatment of neovascular (wet) agerelated macular degeneration (AMD). Ziv-aflibercept is the second VEGF inhibitor approved for treatment of metastatic colorectal cancer; bevacizumab (Avastin), given in addition to chemotherapy, is a standard firstand second-line therapy.

Drugs for glaucoma, age-related macular degeneration, bacterial conjunctivitis, and dry eyes are reviewed here. Drugs for the treatment of allergic conjunctivitis will be reviewed in a future issue of Treatment Guidelines on Drugs for Allergic Disorders.

Axitinib (Inlyta – Pfizer), an oral tyrosine kinase inhibitor, has been approved by the FDA for treatment of advanced renal cell carcinoma after failure of one prior systemic therapy. It is the fourth oral tyrosine kinase inhibitor to be approved for treatment of advanced renal cell carcinoma.

Drugs for glaucoma, age-related macular degeneration, bacterial conjunctivitis, and dry eyes are reviewed here. Ophthalmic drugs can have local and systemic adverse effects. In addition, for some elderly patients, the complexity of self-administering numerous ophthalmic drugs may be the limiting factor in their ability to care for themselves. Drugs for the treatment of allergic conjunctivitis will be reviewed in a future issue of Treatment Guidelines on Drugs for Allergic Disorders.

Bevacizumab (Avastin - Genentech) is a recombinant humanized monoclonal antibody that binds to vascular endothelial growth factor and prevents it from binding to receptors on endothelial cells, inhibiting formation of new blood vessels. Previously approved by the FDA for use in combination regimens for first-line treatment of metastatic colon cancer and metastatic non-small cell lung cancer, and used off-label for treatment of agerelated macular degeneration, it has now also been approved by the FDA for use in combination with paclitaxel (Taxol, and others) for first-line treatment of HER2-negative metastatic breast cancer.

Temsirolimus (Torisel - Wyeth), an mTOR (mammalian target of rapamycin) kinase inhibitor that is metabolized to sirolimus (rapamycin), has been approved by the FDA for intravenous treatment of advanced renal cell carcinoma.

Drugs for glaucoma, age-related macular degeneration, bacterial and allergic conjunctivitis, and dry eyes are reviewed here. Ophthalmic drugs can have local and systemic adverse effects. In addition, for some elderly patients, the complexity of self-administering numerous ophthalmic drugs may be the limiting factor in their ability to care for themselves.

The FDA has approved ranibizumab (Lucentis - Genentech) as an intravitreal injection for treatment of neovascular (wet) age-related macular degeneration (AMD). Ranibizumab is a derivative of bevacizumab (Avastin), which is FDA-approved for intravenous treatment of metastatic colorectal cancer and nonsmall cell lung cancer, but has also been used off label for intravitreal treatment of neovascular AMD.

A variety of cancer chemotherapy drugs are used, mostly in combination, for treatment of locally advanced and metastatic esophageal, gastric and colorectal cancers. The mechanism of action, indications and adverse effects of some of these drugs are discussed in thei article.

The FDA has approved pegaptanib sodium (Macugen - Pfizer/Eyetech) as an intravitreous injection for treatment of all subtypes of neovascular (wet) age-related macular degeneration (AMD). The only other approved treatment for this condition is photodynamic therapy with intravenous verteporfin (Visudyne), which is recommended only for patients with one subtype (predominantly classic) of neovascular AMD.

Cetuximab (Erbitux - ImClone Systems/Bristol-Myers Squibb), an epidermal growth factor receptor (EGFR) inhibitor, and bevacizumab (Avastin - Genentech), the first vascular endothelial growth factor angiogenesis inhibitor, have recently been approved by the FDA for treatment of patients with metastatic colorectal cancer. Cetuximab is approved for treatment of patients with EGFR-expressing tumors, either in combination regimens with irinotecan (Camptosar)when the cancer has progressed on irinotecan-based therapy, or as monotherapy for those who cannot tolerate irinotecan. Bevacizumab is approved for first-line therapy in combination with a fluorouracil-based regimen.