Practical ways to extend anti-VEGF control in RVO, AMD, and DME

How far can newer anti-VEGF agents extend treatment intervals, and how should retina specialists choose among them? Those were the questions at the center of a recent virtual Modern Retina Clinical Forum, “Optimizing Anti-VEGF Therapy for RVO, AMD, and DME: Practical Strategies to Achieve Durable Disease Control.”

Jordana G. Fein, MD, MS, of the Retina Group of Washington in Fairfax and Manassas, Virginia, and assistant clinical professor of ophthalmology at Georgetown University School of Medicine in Washington, DC, moderated the discussion, which centered on 3 patient cases.

Extending high-dose therapy in new-onset wet AMD

The first case involved a patient with new-onset neovascular age-related macular degeneration (AMD) who started treatment with aflibercept 8 mg (Eylea HD; Regeneron) from the outset. After the loading dose, Fein said, the patient could be extended “very far out between intervals.” Imaging at almost 16 weeks was reviewed, and the patient has since been extended to a 20- to 24-week interval. “What was impressive about this was just seeing the real-life durability of the high-dose aflibercept in a patient with new-onset wet AMD,” Fein said. Participants also wondered whether getting a patient dry immediately is what allows them to extend. In contrast, a patient who is switched to a newer agent later in treatment, or who is more of a nonresponder, may not show the same effect, she said. Fein said a patient with new-onset disease has the opportunity to use a newer agent much more immediately, which may be part of the difference.

Choosing an agent in treatment-naive DME

The second case was a treatment-naive patient with diabetic macular edema (DME) who was set to start faricimab-svoa (Vabysmo; Genentech). The discussion turned to how clinicians make that choice, whether by optical coherence tomography (OCT) biomarkers, vision, or patient characteristics. Fein said some participants feel faricimab may offer more benefit than other anti-VEGF agents when significant hard exudates are present, whereas others use their preferred agent regardless of OCT biomarkers or presenting vision. “There was sort of a wide variety of opinions on this,” she said. Fein also asked participants which agent they would choose if the decision were entirely theirs.

Fein added that the decision is not always made by the physician and patient alone. Payer requirements and step therapy can drive it, she said. From her own experience, she has seen good improvement in hard exudates with faricimab and with aflibercept 8 mg.

Fein described the patient as a very real-world example of DME. The patient had not yet returned for a first injection, which Fein called “not an uncommon phenomenon” among working-age patients with diabetes who have complex medical histories and many visits. Patients with DME whose vision is still decent may not be very symptomatic, she said. That reality leads many specialists to favor a newer-generation anti-VEGF agent when possible, in the hope that patients can go longer between treatments after their loading doses.

Setting interval expectations after a switch

The third case featured a patient with retinal vein occlusion (RVO) and macular edema who began on bevacizumab (Avastin; Genentech) to meet step therapy requirements and was later transitioned to aflibercept 8 mg. The patient responded well to bevacizumab but needed tighter intervals to control the edema. After the switch, the patient reached roughly 14 to 16 weeks with aflibercept 8 mg, although the macular edema recurred when the interval was pushed past 17 weeks. Fein said the case illustrated how a patient who responds to an older agent can still gain durability from a switch.

The group discussed how much additional time to expect when moving patients from an older agent, such as bevacizumab or aflibercept 2 mg (Eylea; Regeneron), to aflibercept 8 mg. “The consensus was 2 to 3 weeks maybe would be on average what we quote patients,” Fein said, describing it as a reasonable amount to expect.

Fewer steroids since newer anti-VEGF agents

Asked whether anything new came out of the conversation, Fein said she was struck by how strongly some participants favor one anti-VEGF agent for every indication. One participant, she said, described reviewing their practice’s overall use of intravitreal steroids, including dexamethasone implants, and finding a significant decline since newer-generation anti-VEGF agents became available. Fein did not have specific figures and called it a really interesting point to emerge from the discussion.

In the past, patients who did not respond adequately to bevacizumab might have been moved to a steroid, she said. With faricimab and aflibercept 8 mg, many of those patients “don’t end up becoming anti-VEGF failures,” Fein said.