II. Indications
-
Colorectal Cancer (metastatic, advanced or unresectable)
- Bevacizumab
- Ramucirumab
-
Non-Small Cell Lung Cancer
- Bevacizumab
- Ramucirumab
- Glioblastoma (recurrent)
- Bevacizumab
-
Renal Cell Carcinoma (metastatic)
- Bevacizumab
-
Cervical Cancer (advanced, recurrent)
- Bevacizumab
-
Ovarian Cancer, Fallopian Tube Cancer or Primary Peritoneal Cancer (resistant)
- Bevacizumab
-
Hepatocellular Carcinoma
- Bevacizumab
- Ramucirumab
-
Gastric Cancer (advanced)
- Ramucirumab
- Soft-Tissue Sarcoma
- Bevacizumab (off-label)
-
Age-Related Macular Degeneration
- See VEGF Inhibitor Intravitreal Injection
- Bevacizumab (off-label)
III. Mechanism
-
Vascular Endothelial Growth Factor Receptor (VEGF, VEGFR)
- See Tyrosine Kinase
- Angiogenesis signaling Protein
- Vascular Endothelial Growth Factors (VEGF) are pro-angiogenic Cytokines
- Bind to VEGF receptors on Tyrosine Kinases to initiate Angiogenesis
- Target in some Targeted Cancer Therapy (as below)
- Other functions
- Monocyte activation and differentiation (VEGFR 1)
- Also used in Age-Related Macular Degeneration as a VEGF Inhibitor Intravitreal Injection
-
VEGFR Inhibitors
- VEGF Inhibitors suppress Angiogenesis
- Recombinant Monoclonal Antibody against Vascular Endothelial Growth Factor (VEGF)
- Inhibit VEGF receptor binding, interfering with the growth and maintenance of neoplastic vessels
- Other Inhibitors of VEGFR
IV. Medications
- Bevacizumab (Avastin) IV Infusion
- Risk of CV events, VTE, bleeding, MAHA, GI perforation, Proteinuria, Hypertension, poor Wound Healing
- Ramucirumab (Cyramza) IV Infusion
V. Dosing
- See other references for disease specific dosing protocols
VI. Adverse Effects
-
General
- Infusion Reaction (Bevacizumab, Ramucirumab)
- Poor Wound Healing and wound dehiscence (Bevacizumab, Ramucirumab)
- Avoid Bevacizumab for 28 days before elective surgery and at least 28 days after surgery
- Cardiovascular
- Arterial Thrombosis including TIA/CVA, MI (Bevacizumab, Ramucirumab)
- Severe Hypertension including PRES (Bevacizumab, Ramucirumab)
- Congestive Heart Failure (Bevacizumab)
- Hematologic
- Venous Thromboembolism (Bevacizumab)
- Microangiopathic Hemolytic Anemia or MAHA (Bevacizumab, Ramucirumab)
- Hemorrhage (Bevacizumab, Ramucirumab)
- Gastrointestinal
- Gastrointestinal perforation or fistula (Bevacizumab, Ramucirumab)
- Exacerbation of hepatic Impairment in patients with cirrhosis Child-Pugh B or C (Ramucirumab)
- Renal
- Proteinuria including Nephrotic Syndrome (Bevacizumab, Ramucirumab)
- Endocrine
- Premature Ovarian Failure with Impaired future fertility (Bevacizumab)
- Thyroid dysfunction (Ramucirumab)
- Other common reported adverse effects
VII. Safety
- Avoid in Lactation
- Avoid in pregnancy (all trimesters, Pregnancy category X)
- Use reliable Contraception
- Monitoring
- Blood Pressure
- Urinalysis
- Thyroid Function Tests (Ramucirumab)
VIII. Drug Interactions
-
Anticoagulation
- Higher risk of bleeding and thrombosis while on Venous Thromboembolism treatment (Bevacizumab)
-
Sunitinib
- Avoid in combination with Bevacizumab