4. AVASTIN
INDICATIONS
AND USAGE-
• Metastatic colorectal cancer, in combination with intravenous
fluorouracil-based chemotherapy for first- or second-line treatment.
• Metastatic colorectal cancer, in combination with fluoropyrimidine-
irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for
second-line treatment in patients who have progressed on a first-
line bevacizumab product-containing regimen
• Unresectable, locally advanced, recurrent or metastatic non-
squamous non-small cell lung cancer, in combination with
carboplatin and paclitaxel for first-line treatment.
• Recurrent glioblastoma in adults.
• Metastatic renal cell carcinoma in combination with interferon-alfa.
• Persistent, recurrent, or metastatic cervical cancer, in combination
with paclitaxel and cisplatin, or paclitaxel and topotecan.
• Epithelial ovarian, fallopian tube, or primary peritoneal cancer:
5.
6. ROLE OF VEGF IN HEALING PROCESS
• Vascular endothelial growth factor (VEGF) is functions as an
endothelial cell mitogen , chemotactic agent , and inducer of vascular
permeability Other angiogenic growth factors such as basic fibroblast
growth factor (bFGF) and transforming growth factor β (TGF-β) have
been described, but VEGF is unique for its effects on multiple
components of the wound healing cascade, including angiogenesis
and recently shown epithelization and collagen deposition.
9. precution
• Gastrointestinal Perforations and Fistula: Discontinue for gastrointestinal perforations, tracheoesophageal fistula,
or fistula formation involving any organ.
• Surgery and Wound Healing Complications: In patients who experience wound healing complications during MVASI
treatment, withhold MVASI until adequate wound healing. Withhold for at least 28 days prior to elective surgery.
Do not administer MVASI for at least 28 days following a major surgery, and until adequate wound healing. The
safety of resumption of bevacizumab products after resolution of wound healing complication has not been
established. Discontinue for wound healing complication of necrotizing fasciitis.
• Hemorrhage: Severe or fatal hemorrhages have occurred. Do not administer for recent hemoptysis. Discontinue for
Grade 3-4 hemorrhage.
• Arterial Thromboembolic Events (ATE): Discontinue for severe ATE.
• Venous Thromboembolic Events (VTE): Discontinue for Grade 4 VTE.
• Hypertension: Monitor blood pressure and treat hypertension. Withhold if not medically controlled; resume once
controlled. Discontinue for hypertensive crisis or hypertensive encephalopathy.
11. mechanism
• TNF is made intracellularly, mainly by activated macrophages. The precursor TNF is converted to
soluble TNF after proteolysis by the TNF-converting enzyme. This soluble TNF then oligomerizes
and forms the biologically active homotrimer TNF. There are two types of TNF, which are very
closely related, TNF-alpha and TNF-beta. The activities of both TNFs are mediated through
binding to the TNF receptors I and II (TNFRI and TNFRII), which are present on almost all cell types
(except erythrocytes).
• The binding of TNF to TNFRI and TNFRII activates several signaling pathways, including
transcription factor activation (nuclear factor-κB), proteases (caspases), and protein kinases (c-Jun
N-terminal kinase, MAP kinase). This signaling leads to activation of the target cell leading to the
inflammatory and immune response by releasing several cytokines and apoptotic pathway
initiation. Thus, the biological effects of TNF include activation of other cells (macrophages, T-
cells, B-cells), proinflammatory cytokine production (IL-1, IL-6), chemokine production (IL-8,
RANTES), expression of adhesion molecule (ICAM-1, E-selectin), inhibition of regulatory T-cells,
RANK-ligand expression upregulation, matrix metalloproteinase production and induction of
apoptosis.
12.
13.
14. Infections
• Serious infections are a significant and concerning adverse effect of anti-TNF agents and may
include bacterial, fungal, viral, or atypical infections. These infections may be fatal. Infections are
more common in patients receiving multiple immunosuppressive agents such as methotrexate or
corticosteroids combined with anti-TNF agents. Reports exist of the reactivation of tuberculosis
and viral hepatitis B and C, and it is a recommendation to screen individuals for these before
initiating an anti-TNF agent. In cases of reactivated latent tuberculosis, the reactivation occurs
within the first few months of treatment with TNF-alpha inhibitors. Patients with latent
tuberculosis should receive treatment with isoniazid or combination anti-tuberculosis agents
before initiating anti-TNF agents. Patients living in areas with a higher incidence of certain fungal
infections such as blastomycosis, coccidioidomycosis, or histoplasmosis should have screening for
these conditions before initiating anti-TNF agents. Lastly, clinicians should hold anti-TNF therapy
in patients who develop a serious infection, and they can consider resuming treatment after
complete recovery from the infection, provided the benefits of restarting the anti-TNF therapy
outweighs the risk of recurrent infections in the particular patient.
15. Cont…
• Anti-TNF agents may be associated with a higher risk in patients undergoing major
surgeries such as hip or knee replacement. The recommendation is to hold these
medications one week and one dosing cycle before the surgery. They can be resumed
two weeks after the surgery, provided there is no infection and incisions are healing
well.
16.
17.
18. REFERENCES
• MVASI® (bevacizumab-awwb) injection, for intravenous use
Initial U.S. Approval: 2017
MVASI (bevacizumab-awwb) is biosimilar* to AVASTIN®
(bevacizumab)
• Sun BK, Siprashvili Z, Khavari PA. Advances in skin grafting and
treatment of cutaneous wounds. Science 2014; 346:941.
Dosing intervals obtained from prescribing information provided online by pharmaceutical companies.
DMARDs = disease-modifying antirheumatic drugs; SQ = subcutaneous; IV = intravenous; SLE = systemic lupus erythematosus; PO = oral.
*2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Anti-rheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty Shading with Bold italics indicates recommendation that has changed since 2017.
† Drug added for 2022 update.
†† Severe SLE indicates organ threatening disease.
** Recommendation pertains to infection risk and does not account for risk of cardiac events or venous thromboembolism.
***For patients with RA, AS, PsA, or all SLE for whom anti-rheumatic therapy was held prior to undergoing TJA, restarting the anti-rheumatic therapy once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema or drainage, and there is no ongoing non-surgical site infection, which is typically about 14 days.
