Optimizing nAMD and DME Treatment: Real-World Durability, and Fluid Outcomes with Second Generation Anti-VEGF Agents - Episode 6
Real-World Treatment Strategies Using Next-Generation Therapies for Neovascular AMD and DME
Ehsan Rahimy, MD; David G. Miller, MD; and Michael Klufas, MD, discuss how real-world treatment strategies for neovascular age-related macular degeneration (AMD) and diabetic macular edema (DME) with next-generation anti-VEGF therapies differ from clinical trials, including individualized loading dose approaches, extension interval considerations, and the challenges of balancing durability with appropriate monitoring.
Summary of "Real World Treatment Strategies Using Next Generation Therapies for Neovascular AMD and DME"
This discussion among Dr Ehsan Rahimy, Dr David Miller, and Dr Michael Klufas covers practical strategies for managing neovascular AMD and DME with newer, more durable anti-VEGF therapies.
Key Points:
Value of Real-World Data
- Real-world data supplements clinical trials by providing safety insights from larger patient populations
- Clinical trials typically involve treatment-naive patients while physicians often use new agents in previously treated patients
- Real-world practice often differs from trial protocols, especially regarding loading doses and switching therapies
Loading Dose Strategies
- For treatment-naive patients, physicians generally follow recommended loading doses to maximize vision gains
- For previously treated patients switching to newer agents (faricimab, aflibercept 8 mg), complete reloading may not be necessary
- Disease-specific considerations: AMD typically requires more strict adherence to loading protocols than DME
Extension Intervals
- Both physicians have become more comfortable with 4-week extensions for DME patients
- For neovascular AMD, especially in monocular patients, 1- to 2-week extensions remain standard practice due to risk of hemorrhage
- Physicians note a sweet spot of 3- to 4-month intervals for most patients, as compliance drops significantly beyond this timeframe
Maximum Extension Limits
- Traditional 12-week caps are being reconsidered with newer agents
- Some physicians now feel comfortable extending to 16 weeks in appropriate patients
- For DME, extensions to 20 weeks may be appropriate, particularly when hemoglobin A1c is controlled
- For neovascular AMD, most remain cautious about extending beyond 16 weeks due to monitoring concerns
Patient Perspectives
- Some patients prefer more frequent visits as a “security blanket” despite drug durability
- Patient preferences and vision dependence should factor into treatment decisions
- Physicians should balance optimal disease control with patient convenience
Monitoring Challenges
- Extended intervals create challenges in monitoring fellow eyes for conversion
- Home monitoring technologies (OCT) show promise but reimbursement and workflow concerns exist
- Patient compliance decreases significantly with intervals beyond 4 months
Real-World Benefits of Newer Agents
- When switching from aflibercept 2 mg to 8 mg, physicians typically see a 2- to 4-week extension in treatment intervals
- Benefits of extension often improve over time rather than immediately after switching
Future Directions
- Gene therapy shows promise, particularly subretinal injection approaches
- Better geographic atrophy treatments remain an unmet need
- Tyrosine kinase inhibitors may offer a balance between efficacy and delivery convenience
- Suprachoroidal delivery for DME shows potential
This summary provides key clinical insights on treatment strategies using newer anti-VEGF agents, balancing protocol adherence with real-world considerations to optimize patient outcomes.
