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Aflibercept is a biopharmaceutical drug invented by Regeneron Pharmaceuticals, approved in the United States and Europe for the treatment of wet macular degeneration under the trade name Eylea, and for metastatic colorectal cancer as Zaltrap. As the active ingredient of Zaltrap, the substance is called ziv-aflibercept in the US.

Clinical data
Trade namesEylea, Zaltrap
License data
  • US: C (Risk not ruled out)
Routes of
ATC code
Legal status
Legal status
CAS Number
  • none
Chemical and physical data
Molar mass96.90 kg/mol g·mol−1
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It is an inhibitor of vascular endothelial growth factor (VEGF).[1][2]

Aflibercept is being co-developed for cancer treatment by Sanofi and Regeneron under a deal signed in 2003, and is being co-developed for eye diseases by Bayer HealthCare and Regeneron under a deal signed in 2006.[3]



Aflibercept is a recombinant fusion protein consisting of vascular endothelial growth factor (VEGF)-binding portions from the extracellular domains of human VEGF receptors 1 and 2, that are fused to the Fc portion of the human IgG1 immunoglobulin.[4]

Indications and administrationEdit

Eylea, the formulation for the treatment of wet macular degeneration, is administered as an intravitreal injection, that is, into the eye.[5] Zaltrap, for cancer treatment, is given intravenously in combination with the other cancer drugs 5-fluorouracil and irinotecan and the adjuvant folinic acid.[6] In August 27, 2014, Eylea was also indicated for the treatment of patients with visual impairment due to diabetic macular oedema, according to the updated summary of product characteristics.[7] In May 2019 FDA expanded the indication for Eylea (aflibercept) to include all stages of diabetic retinopathy.[8] Conclusion: Eylea (aflibercept) Injection 2 mg (0.05 mL) is indicated for the treatment of patients with Neovascular (Wet) Age-related Macular Degeneration (AMD), Macular Edema following Retinal Vein Occlusion (RVO), Diabetic Macular Edema (DME), and Diabetic Retinopathy (DR).[9]


Eylea is contraindicated in patients with infections or active inflammations of or near the eye,[5] while Zaltrap has no contraindications.[6]

Adverse effectsEdit

Common adverse effects of the eye formulation include conjunctival hemorrhage, eye pain, cataract, vitreous detachment, floaters, and ocular hypertension.[5]

Zaltrap has adverse effects typical of anti-cancer drugs, such as reduced blood cell count (leukopenia, neutropenia, thrombocytopenia), gastrointestinal disorders like diarrhoea and abdominal pain, and fatigue. Another common effect is hypertension (increased blood pressure).[6]


No interactions are described for either formulation.[5][6]

Mechanism of actionEdit

In wet macular degeneration, abnormal blood vessels grow in the choriocapillaris, a layer of capillaries in the eye, leading to blood and protein leakage below the macula.

Tumours need blood vessels sprouting into them when they become larger than a few millimetres, in order to get access to oxygen and nutritive substances to facilitate further growth.

Aflibercept binds to circulating VEGFs and acts like a "VEGF trap".[10] It thereby inhibits the activity of the vascular endothelial growth factor subtypes VEGF-A and VEGF-B, as well as to placental growth factor (PGF), inhibiting the growth of new blood vessels in the choriocapillaris or the tumour, respectively.[11] The aim of the cancer treatment, so to speak, is to starve the tumour.


Regeneron commenced clinical testing of aflibercept in cancer in 2001.[12] In 2003, Regeneon signed a major deal with Aventis to develop aflibercept in the field of cancer.[13] In 2004 Regeneron started testing the compound, locally delivered, in proliferative eye diseases,[12] and in 2006 Regeneron and Bayer signed an agreement to develop the eye indications.[14]

Clinical trialsEdit

In March 2011 Regeneron reported that aflibercept failed its primary endpoint of overall survival in the Vital phase III trial for second-line treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC), although it improved the secondary endpoint of progression-free survival.[11][15]

In April 2011 Regeneron reported that aflibercept improved its primary endpoint of overall survival in the Velour phase III clinical trial for second-line treatment for metastatic colorectal cancer (mCRC).[11]

Aflibercept was also in a phase III trial for hormone-refractory metastatic prostate cancer as of April 2011.[11]

A 2016 Cochrane Review examined outcomes comparing aflibercept versus ranibizumab injections in over 2400 patients with neovascular AMD, from two randomized controlled trials. Both treatment options yielded similar improvements in visual acuity and morphological outcomes in patients, though the authors note that the aflibercept treatment regimen has the potential to reduce treatment burden other risks from injections.[16]

A 2017 review update studying the effects of anti-VEGF drugs on diabetic macular edema found that while all three studied treatments have advantages over laser therapy, there was moderate evidence that aflibercept is significantly favored in all measured efficacy outcomes over ranibizumab and bevacizumab, after one year.[17]


In November 2011 the United States Food and Drug Administration (FDA) approved aflibercept (Eylea) for the treatment of wet macular degeneration.[18]

On August 3, 2012 the FDA approved aflibercept (Zaltrap) for use in combination with 5-fluorouracil, folinic acid and irinotecan to treat adults with metastatic colorectal cancer that is resistant to or has progressed following an oxaliplatin‑containing regimen.[4] To avoid confusion with Eylea, the FDA assigned a new name, ziv-aflibercept, to the active ingredient.[19]

In November 2012 the European Medicines Agency (EMA) approved aflibercept for the treatment of wet macular degeneration.[20]

On February 1, 2013 the European Commission granted a marketing authorisation valid throughout the European Union for treatment of adults with metastatic colorectal cancer for whom treatment based on oxaliplatin has not worked or the cancer got worse, in combination with the other drugs mentioned above.[21]


On 12 March 2015, aflibercept was one of a group of drugs delisted from the UK Cancer Drugs Fund.[22] In 2017, injections of aflibercept (HCPCS code J0178) were responsible for the most billing to Medicare Part B, at $2.36 billion.[23]


  1. ^ Fraser HM, Wilson H, Silvestri A, Morris KD, Wiegand SJ (September 2008). "The role of vascular endothelial growth factor and estradiol in the regulation of endometrial angiogenesis and cell proliferation in the marmoset". Endocrinology. 149 (9): 4413–20. doi:10.1210/en.2008-0325. PMID 18499749.
  2. ^ Duncan WC, van den Driesche S, Fraser HM (July 2008). "Inhibition of vascular endothelial growth factor in the primate ovary up-regulates hypoxia-inducible factor-1alpha in the follicle and corpus luteum". Endocrinology. 149 (7): 3313–20. doi:10.1210/en.2007-1649. PMID 18388198.
  3. ^ The Vault. Regeneron Pharmaceuticals, Inc. Archived 2014-04-14 at the Wayback Machine Page accessed April 14, 2014
  4. ^ a b "Ziv-Aflibercept". FDA Drug Approvals Database. Food and Drug Administration. August 3, 2012. Archived from the original on October 16, 2013. Retrieved 2013-10-16.
  5. ^ a b c d FDA Professional Drug Information for Eylea
  6. ^ a b c d FDA Professional Drug Information for Zaltrap
  7. ^ "New indication for Eylea". The Pharmaceutical Journal (7826). Royal Pharmaceutical Society. 27 Aug 2014. Archived from the original on 20 June 2015. Retrieved 20 September 2014.
  8. ^ FDA Approves Eylea (aflibercept) Injection for Diabetic Retinopathy, PM Regeneron May 13, 2019 - retrieved May 14, 2019
  9. ^ "Indications". Retrieved 2019-05-14.
  10. ^ "Aflibercept Approved for Colorectal Cancer in Europe". 7 Feb 2013. Archived from the original on 2013-02-10.
  11. ^ a b c d "Regeneron and Sanofi-Aventis Report Positive Phase III mCRC Trial Data". 27 Apr 2011. Archived from the original on 2012-02-02.
  12. ^ a b "Our History - A 25 year commitment to repeated innovation". Archived from the original on 17 May 2017. Retrieved 7 May 2018.
  13. ^ Candace Hoffmann for First Word Pharma. September 8th, 2003 Aventis inks deal with Regeneron for collaboration on cancer therapy Archived 2014-04-14 at the Wayback Machine
  14. ^ Genetic Engineering and Biotechnology News. Oct 19, 2006 Bayer HealthCare Signs On to Help Develop Regeneron’s VEGF Trap-Eye Archived 2014-04-14 at the Wayback Machine
  15. ^ "Regeneron and Sanofi-Aventis Cancer Drug Misses Phase III Primary Endpoint but Meets Secondary Targets". 11 Mar 2011. Archived from the original on 2012-04-06.
  16. ^ Sarwar S, Clearfield E, Soliman MK, Sadiq MA, Baldwin AJ, Hanout M, Agarwal A, Sepah YJ, Do DV, Nguyen QD (February 2016). "Aflibercept for neovascular age-related macular degeneration". The Cochrane Database of Systematic Reviews. 2: CD011346. doi:10.1002/14651858.CD011346.pub2. PMC 5030844. PMID 26857947.
  17. ^ Virgili G, Parravano M, Evans JR, Gordon I, Lucenteforte E (October 2018). "Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis". The Cochrane Database of Systematic Reviews. 10: CD007419. doi:10.1002/14651858.CD007419.pub6. PMC 6517135. PMID 30325017.
  18. ^ Gever, John (November 19, 2011). "FDA Approves Eylea for Macular Degeneration". Archived from the original on May 28, 2013. Retrieved 2013-10-16.
  19. ^ BioWorld: GPhA: Common Name is Key to Biosimilar Competition Archived 2013-12-13 at the Wayback Machine
  20. ^ "Aflibercept Injection Approved for the Treatment of Wet Age-Related Macular Degeneration in Europe". Archived from the original on 2013-11-25. Retrieved 2013-10-16.
  21. ^ "Archived copy" (PDF). Archived (PDF) from the original on 2013-10-16. Retrieved 2013-07-01.CS1 maint: Archived copy as title (link)
  22. ^ "Cancer: Drugs:Written question - HL3340". UK Parliament. 19 November 2015. Archived from the original on 2 April 2018.
  23. ^ "Physician/Supplier National Data" (PDF). Retrieved 2019-06-11.