• Users Online: 84448
  • Home
  • Print this page
  • Email this page

   Table of Contents      
COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1102

Commentary: Single-use bevacizumab: The final solution?


Director, Suven Clinical Research Centre; Hon. Gen. Secretary, VRSI. L.V. Prasad Eye Institute, Banjara Hills, Hyderabad, Telangana, India

Date of Web Publication25-May-2020

Correspondence Address:
Dr. Raja Narayanan
Director, Suven Clinical Research Centre; Hon. Gen. Secretary, VRSI. L.V. Prasad Eye Institute, Banjara Hills, Hyderabad, Telangana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_24_20

Rights and Permissions

How to cite this article:
Narayanan R. Commentary: Single-use bevacizumab: The final solution?. Indian J Ophthalmol 2020;68:1102

How to cite this URL:
Narayanan R. Commentary: Single-use bevacizumab: The final solution?. Indian J Ophthalmol [serial online] 2020 [cited 2024 Mar 29];68:1102. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?2020/68/6/1102/284840



The All India Ophthalmological Society (AIOS) has conducted an important survey on the use of multi-dose bevacizumab among retina specialists in India,[1] and is of valuable importance for modifying Practice Guidelines for intravitreal injections (IVI) in the future. The relatively high response rate in this survey is a welcome change from many surveys where the response rate is typically less than 50%. The survey results confirm the inherent nature of practicing abundance of caution among retina specialists in India. Most of the injections in India are performed in the main operating room, although Western practice recommends that clinic-based injections are equally safe. While this increases the cost and time involved for the injection, doctors are unwilling to take the additional marginal risk of infection post-IVI in the clinic. The significant usage of antibiotics before and after IVI by practitioners is again an additional safety measure of prophylaxis against infection, but this must be evaluated against the risk of increasing antibiotic resistance among the conjunctival flora of patients undergoing multiple IVI.[2] Instillation of topical povidone iodine is equally effective,[3],[4] but requires a change in mindset of the feel-good factor of prescribing antibiotics. I am optimistic that the data of 2% of practitioners not wearing gloves during injection in this survey is a response error rather than the actual practice.

This survey brings out the challenges in aliquoting injections, and the practice of storing them in refrigerators for prolonged duration. While the last decade has been essentially the decade of anti-vascular endothelial growth factor (VEGF), most of the intellectual energy has been spent on debating the safety and off-label use of bevacizumab compared to other anti-VEGF molecules. It was also blemished by numerous episodes of cluster endophthalmitis following IVI bevacizumab,[5] followed by the spread of ignorance rather than knowledge about off-label use of medicines. One bright spot in this heated debate was the coming together of leaders from AIOS, Vitreo-Retinal Society of India (VRSI) and respected experts to bring about a consensus and present a unified response to the Central Drugs Standard Control Organisation (CDSCO), Govt. of India. The CDSCO acted in a very mature manner, putting patient safety first. Based on the inputs of AIOS and VRSI, CDSCO restored status quo ante, and placed evidence above label in defining doctor–patient relationship.[6] The onus is now completely on doctors to follow the guidelines based on the highest level of evidence.[4] Many doctors have now shied away from taking the additional risk of liability of using bevacizumab, and have completely switched to biosimilars which provide a cost-effective alternative to the more expensive innovator drugs. It would have been good to know from the survey about the number of practitioners who have stopped using bevacizumab and switched to biosimilars. There are other off-label drugs such as triamcinolone, ringer lactate, and antibiotics which are used by retina specialists without as much apprehension as compared to bevacizumab. The results of such differences in perception could have been brought out by the survey.

This survey highlights the need for safety measures against contamination of bevacizumab while aliquoting. Regulatory restrictions prevent any pharmaceutical company to directly manufacture and market single use bevacizumab, without going through the rigors of a large clinical trial. The need for protective measures against spurious drugs still remains unanswered. Spurious drugs can cause mass outbreaks of endophthalmitis, and one could protect against such events by using the Kezzler code, or by performing a microbiology testing of a sample before using a batch of bevacizumab in patients.

While the industry, academia, and hospitals have their voices heard in health care, the patient's voice seems to be completely missing. As doctors, we are most privileged to listen to our patient's voice. It is time we started to listen to them, more than the voices of the industry or our managers in hospitals, to regain the ground which we lost in the last decade. This survey by AIOS has added more responsibility on retina specialists.



 
  References Top

1.
Sundar D, Das T, Chhablani J, kumar A, Sharma N. All India Ophthalmological Society members' survey: Practice pattern of intravitreal anti-vascular endothelial growth factor injection. Indian J Ophthalmol 2020;68:1095-8.  Back to cited text no. 1
  [Full text]  
2.
Milder E, Vander J, Shah C, Garg S. Changes in antibiotic resistance patterns of conjunctival flora due to repeated use of topical antibiotics after intravitreal injection. Ophthalmology 2012;119:1420-4.  Back to cited text no. 2
    
3.
Available from: https://www.aao.org/eyenet/article/how-to-give -intravitreal-injections. [Last accessed on 2020 Jan 17].  Back to cited text no. 3
    
4.
Available from: https://vrsi.in/wp-content/uploads/2018/02/Avastin_Guidelines. [Last accessed on 2020 Jan 17].  Back to cited text no. 4
    
5.
Stewart MJ, Narayanan R, Gupta V, Rosenfeld PJ, Martin DF, Chakravarthy U. Counterfeit avastin in India: Punish the criminals, not the patients. Am J Ophthalmol 2016;170:228-31.  Back to cited text no. 5
    
6.
Narayanan R, Honavar SG. A tale of two drugs: Off and on-label. Indian J Ophthalmol 2017;65:549-50.  Back to cited text no. 6
[PUBMED]  [Full text]  




 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
References

 Article Access Statistics
    Viewed1062    
    Printed50    
    Emailed0    
    PDF Downloaded125    
    Comments [Add]    

Recommend this journal