title: Anti vascular endothelial growth factor sequential therapy for neovascular age-related macular degeneration: is this the new deal?
abstract: OBJECTIVE
  To review clinical data on the sequential use of the non-selective vascular endothelial growth factor (VEGF) inhibitors (ranibizumab and bevacizumab) and the selective VEGF inhibitor (pegaptanib) in the treatment of neovascular age related macular degeneration (n-AMD).
  
  
  METHODS
  This is a selective review of the literature based on a PubMed search using the terms 'age-related macular degeneration', 'selective anti-VEGF', 'non-selective anti-VEGF' and 'combination therapy' from 2000 to date in the English language. Studies on the management of n-AMD reporting adherence, patient-reported outcomes, costs, side effects, resource use and cost effectiveness were also included.
  
  
  RESULTS
  The trial data suggest that pan-VEGF inhibition provides improved treatment outcomes in patients with n-AMD with selective anti-VEGF agents offering better tolerability on long-term treatment. A pilot trial and a large-scale, multicentre study confirmed the long-term efficacy of a selective VEGF inhibitor when used as maintenance therapy. Importantly, there is evidence that selective VEGF inhibition also reduces the risks associated with pan-VEGF blockade in patients with n-AMD.
  
  
  CONCLUSIONS
  Anti-VEGF agents play a principal role in the management of n-AMD. The most potent are the pan-VEGF agents although there is some discussion regarding their long-term tolerability. The sequential use of non-selective VEGF inhibitors as booster therapy with a selective VEGF inhibitor as maintenance therapy seems to offer a promising safety/efficacy profile, as well as improved cost/effectiveness.
authors.affiliation: The Eye Clinic, Polytechnic University of Marche, Ancona, Italy. p.neri@univpm.it
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Neri
authors.forename: Cesare
authors.initials: C
authors.lastname: Mariotti
authors.forename: Ilir
authors.initials: I
authors.lastname: Arapi
authors.forename: Elisa
authors.initials: E
authors.lastname: Bambini
authors.forename: Alfonso
authors.initials: A
authors.lastname: Giovannini
mesh_terms: D020533:Angiogenesis Inhibitors / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D000068258:Bevacizumab; D006801:Humans; D008268:Macular Degeneration / Q000188:drug therapy; D000069579:Ranibizumab; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors*; D057135:Wet Macular Degeneration / Q000188:drug therapy*
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; D042461:Vascular Endothelial Growth Factor A; D000068258:Bevacizumab; D000069579:Ranibizumab