Avaliação e desenvolvimento de novas drogas antiangiogênicas para o tratamento de neovascularização de coroide
Data
2023-03-02
Autores
Kniggendorf, Vinicius Ferreira 
Orientadores
Regatieri, Caio Vinicius Saito
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Objetivos: Avaliação e desenvolvimento de novas drogas antiangiogênicas para o tratamento de membrana neovascular sub-retiniana secundária à degeneração macular relacionada à idade (DMRI). Métodos: Revisão de literatura foi realizada para avaliação dos tratamentos existentes, em desenvolvimento e para reconhecimento de alvos terapêuticos para DMRI exsudativa. No estudo in vitro, utilizamos uma heparina quimicamente modificada (N-dessulfatada Re-N-acetilada [N-DRN]) que não possui efeito anticoagulante, mas mantém seus efeitos anti-angiogênicos. A N-DRN foi testada para avaliação de citotoxicidade, formação de estruturas capilares, proliferação e migração celular nas concentrações de 10 ng/mL, 100 ng/mL e 1.000 ng/mL, comparada com a solução salina. Posteriormente, foram avaliados os efeitos in vivo na neovascularização de coroide induzida por laser, em ratos pigmentados do tipo Zucker, através das medidas de área e perímetro da membrana neovascular no grupo controle e nos grupos da heparina (100 ng/mL, 1.000 ng/mL e 10.000 ng/mL). No estudo de Fase 1, realizou-se injeção intravítrea de ziv-aflibercepte (1,25 mg) para tratamento de pacientes com DMRI exsudativa, os quais foram acompanhados com exames de acuidade visual, eletrorretinograma e tomografia de coerência óptica para avaliação de segurança e eficácia. Resultados: Os tratamentos existentes de DMRI possuem bom perfil de segurança e eficácia, porém a busca por novas alternativas e alvos terapêuticos está em andamento com inúmeros estudos em fase 2 e 3, com objetivo de melhorar a eficácia e o intervalo de tratamento. No estudo in vitro, a heparina N-dessulfatada Re-N-acetilada apresentou diminuição estatisticamente significativa na proliferação e migração celular, associada à diminuição na formação de estruturas do tipo capilar e sem alteração da viabilidade celular. No estudo in vivo, a heparina foi capaz de reduzir estatisticamente a área e o perímetro da neovascularização em comparação com o grupo controle. No estudo do ziv-aflibercepte, a aplicação intravítrea demonstrou melhora da acuidade visual e espessura retiniana após 52 semanas de tratamento, com perfil de segurança demonstrado pelo eletrorretinograma. Conclusão: A procura por novas drogas para tratamento de DMRI exsudativa é necessária para melhorar eficácia, aumentar intervalos de aplicações e diminuir o fardo para o paciente de consultas, exames e injeções constantes. A heparina N-DRN apresentou efeitos antiangiogênicos, antiproliferativos e antimigratórios nos estudos in vitro com redução da membrana neovascular na avaliação in vivo, comprovando ser uma droga em potencial para tratamento de membranas neovasculares. O ziv-aflibercepte é uma nova opção de tratamento, com perfil de segurança e eficácia similar ao de drogas já utilizadas, porém com vantagem em relação ao preço, o que poderia facilitar o acesso a tratamento e aumentar o número de pacientes beneficiados.
Purpose: To analyze and to evaluate new antiangiogenic drugs for the treatment of subretinal neovascular membrane secondary to age-related macular degeneration (AMD). Methods: A literature review was performed to evaluate existing treatments, drugs under development and to recognize therapeutic targets for wet AMD. In the in vitro study, we used a chemically modified heparin (N-desulfated Re-N-acetylated [N-DRN}) that has no effects on homeostasis but maintains its antiangiogenic effects. N-DRN was tested to evaluate cytotoxicity, cell tube formation, proliferation and migration in the concentration of 10 n/mL, 100 ng/mL and 1.000 ng /mL, compared to saline. Subsequently, the in vivo effects on laser-induced choroidal neovascularization in pigmented rats (Zucker) were evaluated by measuring the area and perimeter of the neovascular membrane in the control group compared to heparin groups (100 ng/mL, 1.000 ng/mL and 10.000 ng/ml). In the phase 1 study, intravitreal injection of ziv-aflibercept (1.25 mg) was performed to treat neovascular AMD and patients were followed up with visual acuity test, electroretinogram and optical coherence tomography to evaluate safety and efficacy. Results: Existing AMD treatments have a safe and efficient profile, but the search for new alternatives and therapeutic targets is ongoing with numerous studies in phase 2 and 3, with the aim of improving efficacy and treatment interval. In the in vitro study, N-desulfated Re-N-acetylated significantly reduced cell proliferation, migration and cell tube formation with no effect on cell viability. The in vivo study showed that heparin was able to reduce the area and limits of neovascularization compared to the control group. In the ziv-aflibercept study, intravitreal injection demonstrated improvement in visual acuity and retinal thickness after 52 weeks of treatment, with a safety profile demonstrated by electroretinogram. Conclusion: The search for new drugs to treat wet AMD is necessary to improve efficacy, increase application intervals and reduce patient’s burden of frequent medical appointments, exams and injections. N-DRN heparin showed antiangiogenic, antiproliferative and antimigratory effects in vitro, with reduction of the neovascular membrane in animal models, proving to be a potential drug for the treatment of neovascular membranes. Ziv-aflibercept is a new treatment option, with a safety and efficacy profile similar to existing drugs, but with cost advantage, which could facilitate access to treatment and increase the number of patients benefited.
Purpose: To analyze and to evaluate new antiangiogenic drugs for the treatment of subretinal neovascular membrane secondary to age-related macular degeneration (AMD). Methods: A literature review was performed to evaluate existing treatments, drugs under development and to recognize therapeutic targets for wet AMD. In the in vitro study, we used a chemically modified heparin (N-desulfated Re-N-acetylated [N-DRN}) that has no effects on homeostasis but maintains its antiangiogenic effects. N-DRN was tested to evaluate cytotoxicity, cell tube formation, proliferation and migration in the concentration of 10 n/mL, 100 ng/mL and 1.000 ng /mL, compared to saline. Subsequently, the in vivo effects on laser-induced choroidal neovascularization in pigmented rats (Zucker) were evaluated by measuring the area and perimeter of the neovascular membrane in the control group compared to heparin groups (100 ng/mL, 1.000 ng/mL and 10.000 ng/ml). In the phase 1 study, intravitreal injection of ziv-aflibercept (1.25 mg) was performed to treat neovascular AMD and patients were followed up with visual acuity test, electroretinogram and optical coherence tomography to evaluate safety and efficacy. Results: Existing AMD treatments have a safe and efficient profile, but the search for new alternatives and therapeutic targets is ongoing with numerous studies in phase 2 and 3, with the aim of improving efficacy and treatment interval. In the in vitro study, N-desulfated Re-N-acetylated significantly reduced cell proliferation, migration and cell tube formation with no effect on cell viability. The in vivo study showed that heparin was able to reduce the area and limits of neovascularization compared to the control group. In the ziv-aflibercept study, intravitreal injection demonstrated improvement in visual acuity and retinal thickness after 52 weeks of treatment, with a safety profile demonstrated by electroretinogram. Conclusion: The search for new drugs to treat wet AMD is necessary to improve efficacy, increase application intervals and reduce patient’s burden of frequent medical appointments, exams and injections. N-DRN heparin showed antiangiogenic, antiproliferative and antimigratory effects in vitro, with reduction of the neovascular membrane in animal models, proving to be a potential drug for the treatment of neovascular membranes. Ziv-aflibercept is a new treatment option, with a safety and efficacy profile similar to existing drugs, but with cost advantage, which could facilitate access to treatment and increase the number of patients benefited.