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In reference to Hereditary Hemorrhagic Telangiectasia/Avastin

It was with great interest that we read the article from Davidson et al. titled ‘‘Hereditary Hemorrhagic Telangiectasia/Avastin,’’ which described for the first time that bevacizumab might have a fascinating effect on patients with moderate epistaxis due to hereditary hemorrhagic telangiectasia (HHT). This is exciting because it describes for the first time that bevacizumab might have an effect by topical and noninvasive application. No one can explain how that works. The antibody bevacizumab is a protein with a molecular weight comparable to immunoglobulins. Theoretically, one would expect that bevacizumab would not pass a cell membrane and would not be absorbed in the gastrointestinal tract. Is there an active transport into the cell? Is there any systemic absorption? It is therefore challenging to find out how bevacizumab works when applied topically by a nasal spray. The HHT Foundation’s Epistaxis Severity Scoring (ESS) tool for hereditary hemorrhagic telangiectasia was used in a clinical report for the first time. The system was presented at the 8th International Hereditary Hemorrhagic Telangiectasia Conference in Santander, Spain, May 27–31, 2009, and the discussion paved the way for scientific controversy. The grading system observes symptoms that had occurred since the last treatment for nose bleeding. The period, which is observed for the grading, will therefore vary from patient to patient. Furthermore, it is difficult for a patient to find out what is meant by a typical frequency of nose bleeding (question 1), a typical duration of nose bleeding (question 2), or a typical nose bleeding intensity (question 3). Most patients with HHT do not remember a typical situation but suffer from epistaxis, which typically varies both in frequency, intensity, and periods of occurrence. Finally, the grading is based on the question of whether the patient had sought medical attention or not (question 4). The availability of medical attention varies greatly from nation to nation. In addition, it depends on the social status of the patient. Question 4 is multiplied by the second highest factor, a bias that will give significantly different results when comparing populations from different countries. We feel that the ESS is not an ideal tool for the grading of epistaxis in patients with HHT. We would like to emphasize that the observation period for the grading of epistaxis should focus on a defined period of time, and an international grading system should be suitable for most countries in the world independent of the development of the healthcare system in each nation. However, we thank the authors for the report, and we look forward to further studies on this promising new treatment option.