Can the vascular endothelial growth factor (VEGF) inhibitor bevacizumab (Avastin) treat hereditary hemorrhagic telangiectasia (HHT) epistaxis?
Background: HHT is an autosomal dominant disorder involving abnormal blood vessel development. An estimated 90 percent of HHT patients have epistaxis which can lead to significant blood loss requiring IV iron, emergency room visits and blood transfusions. Surgical outcomes are generally poor. VEGF has recently been found to be elevated in HHT patients. Bevacizumab (Avastin) is a recombinant, humanized, monoclonal antibody that binds to and inhibits the activity of VEGF.
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February 2010Study design: Case report of a 45-year-old male with HHT and frequent epistaxis.
Setting: The patient’s epistaxis began prior to 10 years of age. With frequent nosebleeds, anemia and varying hemoglobin levels, he sought treatment at the University of California, San Diego nasal dysfunction clinic.
Synopsis: After local anesthesia, the patient was injected submucosally with 100 mg of bevacizumab into both anterior nasal cavities without injection into the cartilaginous septum. The patient had no difficulties and within a week all nasal bleeding stopped. At the end of four months, however, the bleeding resumed.
A total of 50 mg of bevacizumab was diluted in 5 mL of normal saline. For two consecutive weeks following nasal irrigation with hypertonic saline, 0.1 mL of the spray was delivered into each nostril twice a day. After four days, the epistaxis ceased. Following seven days, bleeding was reduced to less than once a week. Between three and four months, the epistaxis resumed.
The patient elected to pursue a second course of topical treatment. Bleeding once again ceased and has remained minimal for 2.5 months.
Bottom line: If VEGF plays a role in the development of the telangiectasias that occur in HHT patients, bevacizumab may be useful in their treatment.
Citation: Davidson TM, Olitsky SE, Wei JL. Hereditary hemorrhagic telangiectasia/Avastin. The Laryngoscope. 2009;120(2):432-435.