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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2018-022031 on 28 May 2019. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay- per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 24, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-022031 on 28 May 2019. Downloaded from Anti–Vascular Endothelial Growth Factor Treatment for Retinal Conditions: A Systematic Review and Meta-analysis Journal: BMJ Open ManuscriptFor ID peerbmjopen-2018-022031 review only Article Type: Research Date Submitted by the Author: 29-Jan-2018 Complete List of Authors: Pham, Ba; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program Thomas, Sonia; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program Lillie, Erin; Li Ka Shing Knowledge Institute, St Michael's Hospital, Knowledge Translation Program Lee, Taehoon; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program Hamid, Jemila; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program; McMaster University, Department of Clinical Epidemiology and Biostatistics Richter, Trevor; Canadian Agency for Drugs and Technologies in Health, http://bmjopen.bmj.com/ Janoudi, Ghayath; Canadian Agency for Drugs and Technologies in Health Agarwal, Arnav; McMaster University, Department of Clinical Epidemiology and Biostatistics; University of Toronto, Faculty of Medicine Sharpe, Jane ; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program Scott, Alistair; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program Warren, Rachel; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program on September 24, 2021 by guest. Protected copyright. Brahmbhatt, Ronak; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program Macdonald, Erin; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program; University of Toronto, Institute of Health Policy, Management and Evaluation Straus, Sharon; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program; University of Toronto, Department of Geriatric Medicine Tricco, Andrea; Li Ka Shing Knowledge Institute, St Michael's Hospital; University of Toronto, Epidemiology Division, Dalla Lana School of Public Health ranibizumab, bevacizumab, aflibercept, anti-vascular endothelial growth Keywords: factor, age-related macular degeneration, diabetic macular edema For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 88 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-022031 on 28 May 2019. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 http://bmjopen.bmj.com/ 31 32 33 34 35 36 37 38 on September 24, 2021 by guest. Protected copyright. 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2BMJ Open: first published as 10.1136/bmjopen-2018-022031 on 28 May 2019. Downloaded from of 88 1 2 3 1 Anti–Vascular Endothelial Growth Factor Treatment for Retinal Conditions: A Systematic 4 5 6 2 Review and Meta-analysis 7 8 9 1 10 3 Ba’ Pham PhD, MSc Email: [email protected] 11 12 4 Sonia M. Thomas MSc1 Email: [email protected] 13 14 5 Erin Lillie MSc1 Email: [email protected] 15 16 For1 peer review only 17 6 Taehoon Lee MD, MPH Email: [email protected] 18 19 7 Jemila S. Hamid PhD, MSc1,2 Email: [email protected] 20 21 8 Trevor Richter PhD, MSc3 Email: [email protected] 22 23 3 24 9 Ghayath Janoudi MD, MSc Email: [email protected] 25 26 10 Arnav Agarwal HBSc2,4 Email: [email protected] 27 28 11 Jane P. Sharpe BSc1 Email: [email protected] 29 30 1 http://bmjopen.bmj.com/ 31 12 Alistair Scott BSc Email: [email protected] 32 1 33 13 Rachel Warren MA Email: [email protected] 34 35 14 Ronak Brahmbhatt MBBS, MPH1 Email: [email protected] 36 37 15 Erin Macdonald MSc, HBSc1,5 Email: [email protected] 38 on September 24, 2021 by guest. Protected copyright. 39 1,6 40 16 Sharon E. Straus MD, MSc Email: [email protected] 41 42 17 Andrea C. Tricco PhD, MSc1,7,* Email: [email protected] 43 44 45 46 18 1 Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, East Building, 47 48 49 19 Toronto, Ontario, M5B 1W8, Canada 50 51 20 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main 52 53 21 Street West, Hamilton, Ontario, L8S 4K1, Canada 54 55 1 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 88 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-022031 on 28 May 2019. Downloaded from 1 2 3 22 3 Canadian Agency for Drugs and Technologies in Health (CADTH), 865 Carling Avenue, 4 5 6 23 Ottawa, Ontario, K1S 5S8, Canada 7 4 8 24 Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, M5S 9 10 25 1A8, Canada 11 12 26 5 Institute of Health Policy, Management and Evaluation, University of Toronto, 6th floor, 155 13 14 15 27 College Street, Toronto, Ontario, M5T 3M7, Canada 16 For peer review only 17 28 6 Department of Geriatric Medicine, University of Toronto, 27 King’s College Circle, Toronto, 18 19 29 Ontario, M5S 1A1, Canada 20 21 7 22 30 Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 6th Floor, 23 24 31 155 College Street, Toronto, Ontario, M5T 3M7, Canada 25 26 27 28 32 * Corresponding Author 29 30 http://bmjopen.bmj.com/ 31 33 Dr. Andrea C. Tricco 32 33 34 Scientist, Knowledge Translation program 34 35 35 Li Ka Shing Knowledge Institute, St. Michael’s Hospital 36 37 36 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada 38 on September 24, 2021 by guest. Protected copyright. 39 40 37 Phone: 416-864-6060 ext. 77521, e-mail: [email protected] 41 42 43 44 38 Word count: 285/300 (Abstract), 3397/4000 (Main text), 1 figure, 4 tables, 2 supplementary 45 46 39 files 47 48 49 50 51 52 53 54 55 2 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4BMJ Open: first published as 10.1136/bmjopen-2018-022031 on 28 May 2019. Downloaded from of 88 1 2 3 4 40 ABSTRACT 5 6 7 8 41 Objectives: To evaluate the comparative effectiveness and safety of intravitreal bevacizumab, 9 10 42 ranibizumab, and aflibercept for patients with choroidal neovascular age-related macular 11 12 43 degeneration (cn-AMD), diabetic macular edema (DME), macular edema due to retinal vein 13 14 44 occlusion (RVO-ME) and myopic choroidal neovascularization (m-CNV). 15 16 For peer review only 17 45 Design: Systematic review and random effects meta-analysis. 18 19 46 Methods: Multiple databases were searched from inception to August 17th, 2017 (MEDLINE, 20 21 47 Embase, Cochrane Central). Eligible head-to-head randomized controlled trials (RCTs) 22 23 24 48 comparing the anti-VEGF drugs in patients aged ≥18 years with the retinal conditions of interest. 25 26 49 Two reviewers independently extracted data and assessed risk of bias using the Cochrane risk-of- 27 28 50 bias tool. 29 30 http://bmjopen.bmj.com/ 31 51 Results: Nineteen RCTs involving 7459 patients with: cn-AMD (n=12), DME (n=3), RVO-ME 32 33 52 (n=2), and m-CNV (n=2) were included. Vision gain was not significantly different in patients 34 35 53 with cn-AMD, DME, RVO-ME, and m-CNV treated with bevacizumab versus ranibizumab. 36 37 54 Similarly, vision gain was not significantly different between cn-AMD patients treated with 38 on September 24, 2021 by guest. Protected copyright. 39 40 55 aflibercept versus ranibizumab. In DME patients treated for 2 years, vision gain was as likely to 41 42 56 be attained with aflibercept as with ranibizumab or bevacizumab; however, in the first year of 43 44 57 treatment, patients treated with aflibercept were more likely to attain vision gain than patients 45 46 47 58 with ranibizumab or bevacizumab. Rates of systemic serious harms were similar among 48 49 59 bevacizumab, ranibizumab, and aflibercept. For cn-AMD patients, compared to monthly 50 51 60 treatment, an as-needed treatment regimen (6-9 injections per year) was associated with a 52 53 54 61 mortality increase of 1.8% (RR: 2.0, [1.2, 3.5], 2 RCTs, 1795 patients) in a post-hoc analysis.
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