Bevacizumab as Treatment for Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Literature Review

Abstract

Background: Severe, recurring epistaxis is the most common symptom of hereditary hemorrhagic telangiectasias (HHT). Current treatment modalities range from noninvasive treatments that frequently fail to achieve even short-term control to surgeries and systemic therapies that carry significant risk of complications. Recently, bevacizumab, a VEGF inhibitor, has been proposed as an alternative option to alleviate epistaxis symptoms in HHT. Objective: To review the current literature regarding the use of bevacizumab for the treatment of epistaxis in patients with HHT and provide guidance on its usage for this indication. Methods: A narrative literature review was performed to analyze various methods and dosages of bevacizumab administration for the treatment of HHT-related epistaxis, along with a review of current treatment modalities and their drawbacks. Results: The current standard of care for HHT-related epistaxis consists of treatments that are largely ineffective or invasive with significant potential complications. Submucosal bevacizumab has demonstrated efficacy in reducing frequency, duration, and severity of epistaxis in those with HHT. Conclusion: Given the inadequacies and potential drawbacks of current treatments for epistaxis in HHT, there is a need for new therapeutic options. Submucosal bevacizumab has been effective with a limited risk profile in a number of studies and should now be considered as a treatment option for refractory epistaxis. Controlled studies are recommended to quantify optimal dosing, treatment schedule, and specific subpopulations that will respond best to this treatment.

Upregulated GRB7 promotes proliferation and tumorigenesis of Bladder Cancer via Phospho-AKT Pathway

“…Urinary elevated human chorionic gonadotropin (HCG) in patients with malignant teratoma is associated with prognosis [22]. A variety of drugs that target abnormal genes in tumors, such as vascular endothelial growth factor receptor inhibitors Bevacizumab, anti-HER2 monoclonal antibodies Trastuzumab, Bcr-abl tyrosine kinase inhibitors Imatinib and the like have been clinically applied and have achieved good therapeutic effects [23][24][25]. Many studies have been devoted to the search for new molecular targets for bladder cancer.…”

Randomized, controlled, double‐blinded clinical trial of effect of bevacizumab injection in management of epistaxis in hereditary hemorrhagic telangiectasia patients undergoing surgical cauterization

“…First-line treatment of HHTrelated epistaxis typically consists of prophylaxis with humidification and hydration, with laser photocoagulation, radiofrequency ablation, sclerotherapy, and electrocautery recommended in refractory cases. 2,3,18 The proangiogenic factors transforming growth factor-beta and VEGF have been found to be upregulated in patients with HHT, making the case for the utility of VEGF inhibitors such as bevacizumab. 4 Although systemic bevacizumab has been used with some success for the treatment of HHT-associated epistaxis, local injection may have the advantage of avoiding systemic side effects-such as venous thrombosis, hypertension, headache, diarrhea, muscle pain, and gastrointestinal perforation-while still offering the promise of local control through rebalancing pro-and anti-angiogenic factors in the nasal mucosa.…”

“…HHT is a debilitating disease with significant morbidity and detriment to QOL. First‐line treatment of HHT‐related epistaxis typically consists of prophylaxis with humidification and hydration, with laser photocoagulation, radiofrequency ablation, sclerotherapy, and electrocautery recommended in refractory cases 2,3,18 . The pro‐angiogenic factors transforming growth factor‐beta and VEGF have been found to be upregulated in patients with HHT, making the case for the utility of VEGF inhibitors such as bevacizumab 4 .…”

Sclerotherapy Versus Cautery/Laser Treatment for Epistaxis in Hereditary Hemorrhagic Telangiectasia

“…Several of these procedures including septal dermoplasty and the Young's procedure are quite effective but fraught with disadvantages 11 . The advent of antiangiogenic medical therapies, delivered either topically or systemically, has shown promising results in improving blood counts and transfusion needs in HHT 23 . To build upon the results of these data, studies assessing a multi‐modality combination of medical therapies and STS on impacting hemorrhagic end‐points in HHT‐related recurrent epistaxis need to be conducted.…”