Optimizing Anti-VEGF Treatment Outcomes in Neovascular AMD and DME - Episode 12
Experts discuss their experience using the treat and extend strategy with aflibercept and their clinical advice when administering treatment.
Ehsan Rahimy, MD: On label, aflibercept can be given every month, every 8 weeks, and every 12 weeks after a year of therapy. Ali, what’s your experience with using treat-and-extend regimen with it?
Ali Khan, MD, FACS, FASRS: It’s been positive. It’s 1 of the drugs that’s most commonly switched to if [the patient is] a suboptimal responder to bevacizumab or ranibizumab. I’ve had good experiences extending patients on aflibercept. I usually get the longest interval with that drug in my own practice. With the higher-dosing aflibercept potentially becoming available, we’ll see if that will even further increase that durability.
But the treat-and-extend protocol with aflibercept has worked very well for me, and that came about while we were fellows. I remember…1 of our co-fellows who first looked at treat-and-extend with aflibercept. It’s my go-to strategy for patients who either had a suboptimal response with a previous agent, or who are already on aflibercept, to continue to extend by 1 to 2 weeks. Most of my patients get to that 6- to 8-week mark, for the most part. Can you get to 12 to 16? That [happens] less often, but that’s simply their disease process, not necessarily the drug itself. You’d probably get similar outcomes regardless of the drug you used. But the safety profile and the experience with treat-and-extend is robust with aflibercept and has worked well for me.
Ehsan Rahimy, MD: Do you guys find that a higher proportion of your patients are able to get to that 12-week mark on aflibercept? What’s the breakdown when you look across your practice, Veeral?
Veeral Sheth, MD, MBA, FASRS, FACS: We’ve looked at it in the past. It looks like a bell-shaped curve. It peaks between 7 and 8 weeks, but we have equal amounts of 4- and 12-week patients. Those are the smaller groups, but if you were to look at the middle 50%, it’s between 6 and 8 weeks.
Ehsan Rahimy, MD: Matt McCumber did some of the real-world IRIS registry analysis on this and found that, in general, patients are going to somewhere around that 6- to 8-week mark. Is that the same for you, Jon?
Jonathan Jonisch, MD: Yes, we had software that could analyze 15 of our doctors [responses], and most of us average between 49 and 56 days. You’re right: about 7 to 8 weeks exactly. That takes all comers. We definitely all have a bunch of 4- or 5-week patients. On the other side of the curve, we have patients who could extend up to 12 or 16 weeks, which makes sense. CATT [Comparison of Age-Related Macular Degeneration Treatment Trials] taught us that a lot of patients in that prn [as-needed dosing] arm never needed treatment beyond the original load. That’s a built-in 7% or 8% for whom, no matter what anti-VEGF therapy use, you’re going to be able to extend out pretty rapidly.
Transcript edited for clarity.