Current Treatment Options for nAMD


Experts offer clinical advice on identifying and managing suboptimal responders on anti-vascular endothelial growth factor (Anti-VEGF) treatment.


Ehsan Rahimy, MD: So Jon, give us a brief overview [of] currently available treatments for neovascular AMD [age-related macular degeneration]? What’s the track record been for improving visual outcomes thus far?

Jonathan Jonisch, MD: For the past decade plus we’ve really had a choice of 3 options. Two FDA approved treatments, aflibercept and ranibizumab, and one off-label treatment, bevacizumab, which has the benefit of significantly reduced cost to the overall health system. If you speak to different physicians, obviously, there’s different references along that between those 3. Over the next decade, and in the recent past, we’ve had an explosion where we’ve gone from 3 to now probably within a year or 2 we’re going to have over 10. So it’s really exponentially growing.

Fortunately, in terms of treatment options, we have longer duration treatments now. So we have newer treatments now that have the benefit of increased durability like faricimab where there’s a dual mechanism. So we’re stepping away somewhat from anti-VEGF monotherapy, having dual pathway that increase the durability. In the future we may have some higher doses of medications like aflibercept come to the market. Then we have biosimilar, ranibizumab, and we expect in the next couple of years to have biosimilar aflibercept medications.

So our refrigerators are getting really packed. There’s a lot more choices. It’s really become a real nuanced. Treatment algorithms vary differently between physician preferences. Obviously, when you have 10 choices, there’s going to be a lot more algorithms than 3, but it’s great for our patients. They’re getting a lot more technology in the drugs and, you know, we look forward to better and better outcomes.

Ehsan Rahimy, MD: I was going to ask you, but you already mentioned, there’s only so much space. There’s just resource constraints, refrigerators. Is it the reality that a practice should carry all of these medications and we’re tailoring based on an individual patient? How do you guys reconcile that? Are you going to pick and choose the ones you think you have the best experience with and have your own algorithm? What’s it like for you guys?

Jonathan Jonisch, MD: If we look at the experience with the oncology world, it seems like you kind of pick 1 of the biosimilars that you feel comfortable with and you go with that. Maybe you’ll switch to another biosimilar. It doesn’t really make sense to be stocking 4 or 5 different biosimilar medicines of the same molecule. I don’t think that makes a lot of sense. But when you have these other drugs, such as faricimab, aflibercept, ranibizumab, some of the higher doses that may come out, I think those are still going to be stocked, especially the newer ones.

Ali Khan, MD, FACS, FASRS: I think it’s tough because a lot of these choices are no longer just based on efficacy. It’s cost. And so your reasoning for choosing a biosimilar vs the original registration drug. Why would you change for any other reason [except for] cost in some of these scenarios? I think as more and more biosimilars come out by different manufacturers, I think we as retina specialists have been fortunate to have options, but we’ve had relatively few that gives us a good feeling or a good experience with each of the available current drugs.

When you introduce maybe up to 10 within a 2-year period, it’s going to be hard, at least for me, to feel comfortable with a bunch of different agents without purposefully trying it just for the sake of trying it. Because our current drugs work very well. So again, I think we’re kind of moving past just efficacy alone and 1, trying to get more efficacy with durability, but also, especially with the biosimilars, it’s really a question of cost. So I think that’s going to be a bigger discussion amongst retina specialists and is probably going to vary [between] practice settings, which adds to the complexity.

Veeral Sheth, MD, MBA, FASRS, FACS: To add a couple of quick things as someone in private practice. There’s just the practical aspects of this. To Ali’s point, there’s going to be 10 of these drugs, and I can’t necessarily stock all 10. Fridge space is one thing, but then there’s a process for each of these drugs, right? There’s a vendor that you have to deal with. There’s all these other things that you’ve got to deal with. If you’re not doing significant volume in an otherwise high-volume practice, it’s not necessarily something that you can do efficiently. And so I think these are all considerations, and I think the assumption here is if they are interchangeable, right? We can certainly make the argument if you think a drug is superior, obviously, that’s a different story. But in these, in this world of biosimilars, and all these other potentially interchangeable drugs, I think these are the things that separate what you end up using at the end.

Jonathan Jonisch, MD: Yeah, and I think one strength of the retina community is kind of our ability to rapidly do post-marketing analysis, surveillance, and safety. I think as a community, we have a really good track record of being able to flag issues and I think that protocol with the ASRS [American Society of Retina Specialists] is going to become more and more important as we get flooded with new medications. The clinical trials for the biosimilars are not as rigorous as they are with the originators so they’re not powered to detect complications that occur at a very low rate. We’re going to really have to continue to be vigilant as a community to report some of these findings on some drugs. In some of the cases, [they] aren’t even being manufactured here in the United States.

Ali Khan, MD, FACS, FASRS: Jon, to your point, nobody wants issues. At this point our current drugs work well and we feel comfortable with the safety profile, whether it’s a biosimilar or even a new registration trial drug. If there are concerns with inflammation in particular, especially inflammatory vasculitis, that’s a hard no. If there’s even a chance of that, there’s no real reason to use that medication. So, again, our refrigerators are bigger, but also our reasons are sort of diversifying as to why we’re choosing [a medication]. So, that’s something that I think the retina community is going to figure out on its own. It might be regional, it might be practice setting to practice setting, but I think we can all agree that safety is going to be number 1 because what we have right now is working quite well.

Transcript edited for clarity.

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