Treat-and-Extend for Anti-VEGF May Provide More Optimal Dosing and Fewer Clinic Visits

November 13, 2021
Kevin Kunzmann

A meta-analysis comparison of dosing regimens for patients with nAMD show little difference in efficacy, but differences in patient involvement in care.

Treat-and-extend (T&E) dosing strategies for anti-VEGF therapy was not associated with significantly improved or decreased efficacy and safety comparing to other regimens in patients with neovascular age-related macular degeneration (AMD), according to a new study.

In data presented at the American Academy of Ophthalmology (AAO) 2021 Meeting in New Orleans this week, a team of Toronto-based investigators showed T&E was associated with less treatment burden in patients with wet AMD receiving intravitreal injections, versus monthly and pro re nata dosing strategies.

Led by Prem A. H. Nichani, MD, MSc, of the Department of Ophthalmology and Vision Sciences at the University of Toronto, investigators sought to systematically review and compare measures of injection burden, efficacy, and safety of the 3 most prevalent dosing regimens for anti-VEGF in patients with neovascular AMD.

“Intravitreal anti-VEGF injection therapy is a mainstay in AMD treatment, improving visual acuity and retinal thickness” Nichani said. “However, the optimal interval of anti-VEGF administration remains unclear.”

Their meta-analysis included 5 databases that sought English-language randomized controlled trials of eyes with nAMD that compared the efficacy and safety of T&E versus ≥1 other dosing strategy. Nichani and colleagues sought outcomes of best corrected visual acuity (BCVA), mean number of patient clinic visits and injections, presence of retinal fluid, length of follow-up, and any observed adverse events in treated patients.

Their assessment included 1697 baseline eyes from 6 randomized controlled trials and 41 full-text reviews. Mean patient age was 77.3 years, with 56.9% of patients identified as female. Baseline BCVA score was 59.1 ETDRS letters, and baseline central subfield thickness (CST) was 422.3 mcm.

All patients were treated with either ranibizumab (97.5%) or aflibercept (2.5%). Observed dosing regimens included T&E (n = 781), monthly (n = 663), pro re nata (n = 130), and bi-monthly (n = 123).

Investigators observed no significant differences in mean BCVA nor CST changes from baseline associated with any of the anti-VEGF treatment regimens (P > .05). Intravitreal injections were less frequent for patients on T&E regimens versus those on monthly regimens but more than patients on pro re nata regiments (P <.001). However, patients on T&E had fewer clinic visits than patients on pro re nata.

The trial’s limitations included limited available randomized controlled trial data, inconsistent reporting, high heterogeneity and a high risk of bias with conflicts of interest. Additionally, investigators had no data on T&E patient satisfaction, adherence to treatment, or their cost savings.

That said, Nichani and colleagues concluded that assessment of patient satisfaction, treatment adherence, and cost savings with T&E regimens are recommended to continue to interpret the value of anti-VEGF treatment dose regimens.

“For patients, treat-and-extend may decrease work absenteeism and anxiety associated with injections, as patients know when they’re receiving injections, versus pro re nata, and have fewer injections overall versus monthly,” Nichani said.

The study, “Treat-and-Extend Dosing of Intravitreal Anti-VEGF Agents in Neovascular Age-Related Macular Degeneration: A Meta-Analysis of 1697 Eyes,” was presented at AAO 2021.


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