NSC- HHT – a systematic review of intranasal Bevacizumab
Reviewed by Suki Ahluwalia

This systematic review of 13 studies concerning the use of an anti-angiogenic nasal treatment in the management of epistaxis in HHT patients finds no significant effect. This paper looked at four RCTs, three prospective studies, three retrospective, one case series and two case reports involving 357 patients. In HHT, mutations in two genes on chromosomes 9 and 12 result in elevated levels of transforming growth factor and vascular endothelial growth factor, which have been linked to abnormal, immature and disorganised vascular growth prone to constant remodelling and rupture. Hence anti-angiogenic agents such as Bevacizumab (Avastin) which have been used in management of liver AVMs very successfully were thought to be of use in epistaxis. This paper looks at the available evidence for use in the nose to prevent epistaxis, one of the most debilitating symptoms of this condition. Therapy can be given via submucosal injections or via nasal spray which can also be nebulised. There is no standardisation across treatment regimes in terms of dose or frequency. Effectiveness was judged on epistaxis duration, frequency, severity and impact on quality of life. Severity was measured by mean duration and frequency and no studies were able to show a significant benefit when compared to either placebo or other known treatments. The Epistaxis severity score, epistaxis VAS and other scores, again showed no significant difference with Bevacizumab over placebo or other known regimes. It would seem that this treatment may not be as promising as first expected, although the available research is hampered by low power studies and inconsistent dosing and treatment regimes. 

Intranasal bevacizumab in the treatment of HHT-related epistaxis: a systematic review.
Stokes P, Rimmer J.
RHINOLOGY
2018;56:3-10.