RU2758662C1 - Method for determining indications for antiangiogenic therapy in case of suspicion of wet form of age-related macular degeneration - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to ophthalmology, and can be used to determine the indications for antiangiogenic therapy in case of suspicion of a wet form of age-related macular degeneration (AMD). In the blood serum, the concentration of the cytokines HGF and IL-1RA is determined. At a concentration of HGF above 226 pg/ml and/or IL-1RA above 293 pg/ml, the wet form of AMD is confirmed and indications for antiangiogenic therapy are determined.EFFECT: method provides an opportunity to confirm the presence of AMD and determine the criterion of indications for antiangiogenic therapy in wet AMD by determining the cytokines IL-1RA and/or HGF in the patient's blood serum, which allows adequate therapy in accordance with the diagnosis and provides a therapeutic effect in AMD.1 cl, 3 ex

Description

The proposed invention relates to ophthalmology and is intended to improve the efficiency of diagnosis and determine the indications for antiangiogenic therapy in the wet form of age-related macular degeneration (AMD).

AMD is the leading cause of blindness in the elderly, and the prevalence of the disease increases exponentially every decade after age 50. It is a multifactorial disease involving a complex interaction of genetic, environmental, metabolic factors. A growing body of evidence indicates that inflammation and the immune system may play a key role in the development of disease. AMD can go from an early form to an intermediate, and then to a late form, where there are two subtypes: dry form (GA) and wet form [Cheung L.K., Eaton A. Age-related macular degeneration. Pharmacotherapy. 2013; 33 (8): 838-55]. A distinctive feature of the wet form is the development of choroidal neovascularization (CNV) under the retinal pigment epithelium (latent type), which can also grow through defects in Bruch's membrane into the subretinal space (classic type), causing exudative and / or hemorrhagic complications [Solomon SD, Lindsley K. , Vedula SS, Krzystolik MG, Hawkins BS Anti-vascular endothelial growth factor for neovascuiar age-related macular degeneration. Cochrane Database Syst Rev. 2019; 3 (3): CD005139].

Despite numerous studies, the mechanisms of pathogenesis and factors of progression of the wet form of AMD remain poorly understood.

Vascular endothelial growth factor (VEGF-A) is a key modulator of angiogenesis, promoting the growth of new vessels of the retina and choroid and is considered critical for the formation of CNV in neovascular AMD of the eye [Patel M, Chan CC Immunopathological aspects of age-related macular degeneration. Semin Immunopathol. 2008; 30 (2): 97-10]. However, in addition to VEGF-A, a number of vasoactive compounds are currently classified as positive factors regulating angiogenesis: hepatocyte growth factor (HGF), interleukin 8 (IL-8), transforming growth factors α and β (TGF α, β), growth factor connective tissue (CTGF), epidermal growth factor (EGF) [Jonas JB, Tao Y., Neumaier M., Findeisen P. Cytokine concentration in aqueous humor of eyes with exudative age-related macular degeneration. Acta Ophthalmol. 2012; 90 (5): e381-8]. In particular, it has been shown that HGF and HB-EGF, which have mitogenic activity against the endothelium of blood vessels, are direct regulators of VEGF-A and, in synergy with the latter, exert their vasoproliferative effect [T. Cabral, L.H. Lima, L.G.M. Mello, J.Polido, E.P. Correa, A. Oshima, J. Duong, P. Serracarbassa, C.V. Regatieri, V.B. Mahajan, R. Belfort Bevacizumab Injection in Patients with Neovascular Age-Related Macular Degeneration Increases Angiogenic Biomarkers // Ophthalmol Retina. 2018 Jan; 2 (1): 31-37].

Timely diagnosis and treatment improves the prognosis for the treatment of wet AMD [Holz F.G., Schmitz-Valckenberg S., Fleckenstein M. Recent developments the treatment of age-related macular degeneration. J Clin Invest. 2014; 124 (4): 1430-8].

Wet AMD can affect one eye or both eyes at the same time or sequentially. Symptoms of this form of AMD include metamorphopsias, scotomas, and blurred vision. CNV is diagnosed using clinical and instrumental examination methods such as optical coherence tomography (OCT), OCT in angio mode, fluorescence angiography (FA) and indocyanine angiography (IAG). However, difficulties in diagnosis can arise when these research methods are not informative due to opaque optical media and impaired fixation in the patient, as well as in the absence of appropriate equipment and misinterpretation of the data obtained. In such cases, the lack of adequate treatment of wet AMD with angiogenesis inhibitors can lead to irreversible loss of visual functions, social maladjustment and disability.

There is a method for differential diagnosis of CNV types in wet form of AMD, proposed by Bikbov et al, in which the concentration of vascular endothelial growth factor is determined, after which the result is assessed according to the level of these indicators. If the concentration is more than 650 pg / ml, classical CNV is diagnosed; at a value of 300-400 pg / ml, mixed CNV is diagnosed; less than 160 pg / ml is diagnosed with active fibrovascular CNV. The disadvantage of this method is the invasiveness and laboriousness of the procedure, in which it is necessary to take the moisture in the anterior chamber of the eye.

The closest analogue of the present invention is a method for determining indications for antiangiogenic therapy in wet AMD, developed by R. Mori et al, which is based on performing OCT of the macular zone with the calculation of the thickness of the retina and choroid of the affected eye. But this method requires appropriate equipment and transparency of optical media [Mori R., Tanaka K., Haruyama M., et al. Comparison of pro re nata versus Bimonthly Injection of Intravitreal Aflibercept for Typical Neovascular Age-Related Macular Degeneration. Ophthalmologica. 2017; 238 (1-2): 17-22].

The objective of the present invention is to develop an accessible and simple method for confirming the presence of AMD and determining the criterion for an indication for antiangiogenic therapy in wet AMD.

The technical result of the proposed method is the ability to conduct adequate therapy in accordance with the diagnosis, and provide a therapeutic effect in AMD.

The technical result is achieved by determining the cytokines IL-1RA and / or HGF in the patient's blood serum (SC).

Timely initiation of treatment for this form of AMD has a positive effect on the functional result. In some cases, in the absence of appropriate equipment or if it is impossible to carry out instrumental research methods due to the opacity of the optical media and the lack of visual fixation to confirm the alleged diagnosis, timely diagnosis and treatment of the wet form of AMD is difficult. In this connection, the relevance of the search for alternative methods for diagnosing the wet form of AMD is noted.

The basis for the development of the proposed method was the data obtained in the course of multiplex analysis of 45 cytokines in the SC of 23 patients with a wet form of AMD, who had not previously received treatment.

The control group consisted of 25 apparently healthy individuals. A comparative analysis of the data of the wet AMD group and the control group revealed significant shifts in the concentration of cytokines EGF, HGF and IL-1RA in 100% of the test samples studied (p <0.05). As a result of the study, it was found that in the UK in patients with CNV, on average, local levels of EGF were 45.4 ± 4.7 pg / ml, HGF - 319.5 ± 27.8 pg / ml, IL-1RA - 805, 3 ± 122.4 pg / ml, which statistically significantly differed from those in the SC of practically healthy individuals 35.7 ± 5.9 pg / ml, 214.5 ± 13.3 pg / ml, 466.1 ± 95.4 pg / ml, respectively. To determine the diagnostic value of EGF, HGF and IL-1RA, ROC analysis was performed with the construction of a curve and an estimate of the area under it for these cytokines. The diagnostic significance of the cytokines HGF and IL-1RA was confirmed by calculating the area under the AUC curve (0.603 for EGF, 0.732 for IL-1RA, 0.763 for HGF). The cut-off thresholds for HGF are 226 pg / ml, for IL-1RA - 293 pg / ml. It was concluded that it is possible to use two specific cytokines at a certain concentration in the blood serum to determine the indications for antiangiogenic therapy in patients with a confirmed diagnosis of wet AMD.

The method is carried out as follows.

In the UK of a patient with suspected wet AMD, the concentration of cytokines HGF and / or IL-1RA is determined. With an increase in the concentration of HGF above 226 pg / ml and / or IL-1RA above 293 pg / ml, the presence of a wet form of AMD is confirmed and indications for antiangiogenic therapy are determined.

Blood is collected from the cubital vein into sterile vacuum tubes without a coagulation activator. Storage of the collected biomaterial at a temperature of -70 ° C is allowed. The concentration of these cytokines can be determined using enzyme-linked immunosorbent assay (ELISA: semi- or automatic) or by multiplex analysis, for example, on the xMAP platform (MAGPIX device, Luminex Corporation, USA). The results obtained are expressed in pg / ml.

Example 1.

Patient, 75 years old, with a preliminary diagnosis: OU - mature cataract, AMD. The patient complained of decreased visual acuity within 1 month and a dark spot in front of the right eye. Family history is not burdened.

Objectively at the time of examination: Vis OD = 0.15 ecc with cor. Vis OS = 0.3 s cor .; IOP OU = 16 mm Hg. Art.

Biomicroscopy OD: the cornea is transparent, the anterior chamber is of medium depth, the moisture of the anterior chamber is transparent, the iris is subatrophic, the reaction to light is weakened, pronounced opacities in the nucleus and cortical layers of the lens. Destruction of the vitreous body. Details of the fundus (behind the veil): optic nerve disc pale pink, vessels of uneven caliber. Details of the macular zone and periphery are not visualized.

Biomicroscopy OS: the cornea is transparent, the anterior chamber is of medium depth, the moisture of the anterior chamber is transparent, the iris is subatrophic, the reaction to light is weakened, moderate opacities in the nucleus and cortical layers of the lens. Destruction of the vitreous body. Details of the fundus (behind the veil): optic nerve disc pale pink, vessels of uneven caliber. In the macular zone, there are multiple confluent drusen, dyspigmentation and detachment of the pigment epithelium. Periphery details are not rendered.

Taking into account the lack of fixation in the patient and cataracts, which make it difficult to perform instrumental research methods, it was necessary to conduct an additional study that would make it possible to objectively diagnose this disease and resolve the issue of antiangiogenic therapy.

The concentration of HGF in SC was determined in the framework of multiplex analysis on a MAGPIX analyzer ("Luminex Corporation", USA) in the Luminex xPONENT 3.1 program, using kits (Procarta Plex "eBioscience", Austria). The study showed a high level of HGF (1835.91 pg / ml) in the UK. The diagnosis of wet AMD at OD was confirmed.

In the department of the Federal State Budgetary Institution “NMITs im. Helmholtz ”, the patient received anti-angiogenic therapy. During the dispensary observation, the patient had a positive result.

Example 2.

Patient, 65 years old, with a preliminary diagnosis: OU - AMD, cataract, OS - corneal leucorrhoea. The patient complained of decreased visual acuity within 2 months, a dark spot and curved lines in front of the left eye. Family history is not burdened.

Objectively at the time of examination: Vis OD = 0.5 s cor. Vis OS = 0.15 ecc with short; IOP OU = 13 mm Hg. Art.

Biomicroscopy OD: the cornea is transparent, the anterior chamber is of medium depth, the moisture of the anterior chamber is transparent, the iris is embossed, the reaction to light is preserved, moderate opacities in the nucleus and cortical layers of the lens. Destruction of the vitreous body. Details of the fundus (behind the veil): optic nerve disc pale pink, vessels of uneven caliber. In the macular zone, single drusen, dyspigmentation. On the visible periphery without focal pathology.

Biomicroscopy OS: corneal leucorrhoea in the optical zone, the anterior chamber of medium depth, the moisture of the anterior chamber is transparent, the iris is embossed, the reaction to light is preserved, pronounced opacities in the nucleus and cortical layers of the lens. Deeper structures are not rendered.

Considering the lack of fixation in the patient, cataract and corneal leucorrhoea, which make it difficult to perform instrumental research methods, it was necessary to conduct an additional study to objectively confirm the diagnosis of the disease and reasonably prescribe antiangiogenic therapy.

The concentration of IL-1RA in SC was determined in the framework of multiplex analysis on a MAGPIX analyzer (Luminex Corporation, USA) in the Luminex xPONENT 3.1 program, using kits (Procarta Plex "eBioscience", Austria). The study showed a high IL-1RA level of 335.5 pg / ml in the UK. Confirmed diagnosis of wet AMD on OS.

In the department of the Federal State Budgetary Institution “NMITs im. Helmholtz ”the patient received anti-angiogenic therapy. During the dispensary observation, the patient had a positive result.

Example 3.

Patient, 87 years old, with a preliminary diagnosis: OU - AMD, cataract, OD - wet form. The patient complained of a decrease in visual acuity within 1 month, a dark spot and curvature of the lines in front of the right eye. Family history is not burdened.

Objectively at the time of examination: Vis OD = 0.2 ecc with cor. Vis OS = 0.5 s cor .; IOP OU = 14 mm Hg. Art.

Biomicroscopy OD: the cornea is transparent, the anterior chamber is of medium depth, the moisture of the anterior chamber is transparent, the iris is embossed, the reaction to light is preserved, moderate opacities in the nucleus and cortical layers of the lens. Destruction of the vitreous body. Details of the fundus (behind the veil): optic nerve disc pale pink, vessels of uneven caliber. In the macular zone, there are single drusen, dyspigmentation, detachment of the pigment epithelium. On the visible periphery without focal pathology.

Biomicroscopy OS: the cornea is transparent, the anterior chamber is of medium depth, the moisture of the anterior chamber is transparent, the iris is embossed, the reaction to light is preserved, moderate opacities in the nucleus and cortical layers of the lens. Destruction of the vitreous body. Details of the fundus (behind the veil): optic nerve disc pale pink, vessels of uneven caliber. In the macular zone and on the visible periphery without focal pathology.

On OCT: OD - the contour of the fovea is changed, the detachment of the pigment epithelium, the wavy contour of the pigment epithelium, corresponding to the druses, OS - the contour of the fovea and the structure of the retina are preserved.

Given the lack of fixation in the patient, which makes it difficult to perform OCT-A to confirm the presence of the disease, it was necessary to conduct an additional study to objectively confirm the presence of a wet form of AMD for an adequate treatment strategy.

The concentration of HGF and IL-1RA in SC was determined in the framework of multiplex analysis on a MAGPIX analyzer (Luminex Corporation, USA) in the Luminex xPONENT 3.1 program, using kits (Procarta Plex "eBioscience", Austria). The study showed a high level of HGF (307.1 pg / ml) and IL-1RA (428.9 pg / ml) in the UK. Diagnosed with wet form of VIC on OD.

In the department of the Federal State Budgetary Institution “NMITs im. Helmholtz ”, the patient received anti-angiogenic therapy. During the dispensary observation, the patient had a positive result.

Thus, the proposed method makes it possible to confirm the diagnosis of the wet form of AMD in patients with suspicion of this disease and, accordingly, to carry out adequate treatment with anti-angiogenic drugs.

Claims (1)

A method for determining indications for antiangiogenic therapy in case of suspicion of a wet form of age-related macular degeneration (AMD), characterized in that the concentration of cytokines HGF and IL-1RA is determined in the blood serum and at a concentration of HGF above 226 pg / ml and / or IL-1RA above 293 pg / ml confirm the wet form of AMD and determine the indications for antiangiogenic therapy.