Lancet 21 Jul 2007 Vol 370

A useful short reminder piece about new treatments for age-related macular degeneration. The story is much as was told in the New England Journal last October, under the apt heading “The Price of Sight”:  A drug developed for use in bowel cancer – bevacizumab – had already earned its manufacturer Genetech billions of dollars, but they wanted more billions from a drug for macular degeneration costing $1950 monthly, called ranibizumab. Fortunately, a retinal specialist in the USA realised that the two drugs are very similar, and started using an appropriate molar dilution of bevacizumab, costing one hundred times less. Thousands of ophthalmologists have followed. Naturally enough, Genetech are sulking, and won’t fund a comparative trial that might stop them getting rich at the expense of elderly people who are going blind.

If you ever give a lecture involving the renin-angiotensin-aldosterone system, you can easily dumbfound your audience by asking them what the initial substrate is called. It is angiotensinogen, converted to angiotensin 1 by the action of renin. Until recently, we could block every stage of the RAAS except this first one, but now we have direct renin inhibitors like aliskiren. They have no effect on blood pressure in normotensive subjects but reduce it if inappropriately elevated. This study shows that aliskiren combines very well with a drug which works at the other end of the system, the angiotensin receptor blocker valsartan. But quite how it will fit in to the overall range of blood pressure lowering drugs is something that only time and further studies will tell (see commentary on p.195).

Chronic lymphocytic leukaemia is a common malignancy with a range of familiar chemotherapies: this trial establishes which is the best. It is fludarabine plus cyclophosphamide. Even ordinary doctors may be able to remember that.

I badly needed to update my knowledge of psoriasis, so I read this and the following paper from beginning to end. I think I now know a little more about the clinical features, but as for the pathogenesis, I’m not so sure. I like things to have a cause, not lots of genetic predispositions and pathways.

And then there are the current and future treatments of psoriasis. The current ones are comprehensively explained, with narrow-band ultraviolet light taking a star role; the emerging ones are mostly anti-TNF? drugs with unknown long-term effects.