When to switch anti-VEGF therapy: Lessons from three retina cases

Treatment switches and extension intervals were central themes throughout a recent Modern Retina Case-Based Roundtable® focused on retinal vein occlusion (RVO), age-related macular degeneration (AMD), and diabetic retinopathy (DR). Anu Patel, MD, of the Retina Institute of Michigan in Bingham Farms, Michigan, moderated the discussion, presenting 3 cases from practice to guide a conversation on how retina specialists define treatment failure in daily practice. The cases prompted discussion among attendees drawn from different practice settings and states.

Case 1. The first case centered on a patient with branch retinal vein occlusion who started with reasonably good vision on bevacizumab before eventually switching to aflibercept 8 mg. Patel called it one of the roundtable’s best discussions, noting that the conversation centered on “what is your preferred treat and extend protocol, and how would you handle these patients that have failures at extensions,” Patel said.

The case was notable because the patient appeared to be doing well on imaging, yet remained unhappy with his progress, prompting a broader discussion of patient expectations. The patient later missed a follow-up visit and returned with recurrent macular edema, shifting the conversation toward appropriate treatment intervals. “It was a great discussion of what treatment intervals we’re seeing with our patients, and there were some differences of opinions,” Patel said.

Case 2. The second case involved a patient with AMD who was initially treated with bevacizumab for insurance reasons before switching to faricimab. Discussion centered on how much residual fluid physicians are willing to tolerate and how quickly to extend treatment intervals.

“I think the biggest takeaway is that there is actually still some debate on whether you are willing to tolerate fluid, and whether we look at just fluid or fluid and vision as the marker of failure, and what do we do—how do we put that together in a clinical setting,” Patel said.

Case 3. The third case featured a patient with DR and an extensive treatment history. The discussion focused on defining treatment goals for patients with advanced disease and the outcomes achievable when a physician’s preferred agent is used from the outset.

“Another great lively discussion, with actually some surprising imaging where a patient did very, very well when they were treated the way the physician wanted to treat them from the beginning,” Patel said.

Following the case discussions, the group reviewed recent data on extension intervals for both aflibercept 8 mg and faricimab, noting that a large percentage of patients are getting out past 12 weeks and 16 weeks, and in some cases up to 20 and 24 weeks.

Range of options

Patel noted that bringing together specialists from different practice settings and states naturally surfaced a range of opinions. “Everyone takes really, really good data and interprets it and applies it to their patients within the context of what they’re allowed to do,” she said.

One area of discussion was the potential for IOP increases associated with aflibercept 8 mg. “Some attendees felt like it was no big deal at all… and then some attendees and some discussants felt that it was a significant factor,” Patel said. She added that having physicians who treat patients every day engage in that kind of active discussion was the best part of the roundtable.

The value of case-based discussion

Asked about the broader value of case-based roundtables, Patel described them as one of the best ways for physicians to continue to learn, share, and practice together.

“A lot of this comes down to what do you do every day, especially in these situations. There is no case report or something I can look up to tell me what I should do in this particular patient example,” she said. “Those kinds of opinions are the most valuable, and really you can only get them in these kinds of settings.”