Selecting Therapies for Individual Patients in nAMD and DME

Opinion
Video

Retina specialists discuss factors to consider when selecting a therapy for patients with neovascular AMD and DME as well as loading-dose recommendations for select patients.

Rishi P. Singh, MD: When you talk about some of the therapies, and we have so many available now, we talk about off-label bevacizumab, we’ve got unlabeled drugs with anti-VEGF, we’ve got the combined bispecific, we’ve got combined, we’ve got high-dose aflibercept. How do you work your patients through these therapies and determine what the right option is based on their presenting findings or something else that you may consider?

M. Ali Khan, MD, FACS, FASRS: That’s a great question, because if we’re looking at similar duration intervals, that is taken out of the equation of both drugs and achieves that 12- to 16-week interval in a large percentage of patients. That was the initial thing most patients would be interested in, [which] is how long you can go, but if you have 2 drugs that could do the same, it’s a little more of a discussion. So I bring up the fact that 1 molecule is inhibiting 2 different proteins. Some patients get into that aspect of type 2 inhibition, especially in the patients [with diabetes], because of the anatomic changes we saw in the [diabetes] faricimab trials showing some improved drying effect of the drug compared with aflibercept 2 mg. There is some anatomic consideration there that patients can understand. On the other side, if patients are already on aflibercept, many are comfortable with that drug. So the switch to the higher doses [is] conceptually very easy for them to understand while switching to a completely different drug; sometimes patients are a little hesitant or have more questions. So there’s a combination of things to consider, but particularly in patients [with diabetes] and patients with more of the anatomic findings on their OCT [optical coherence tomography] [scan] that I’m concerned with, that might push me toward including the type 2 inhibition with faricimab. However, both drugs, based on the durability, are going to be good options.

Rishi P. Singh, MD: I agree with you. The big driver for a lot of our decisions tends to be insurance first and foremost and then patient outlay of cost. And sometimes they will determine their therapies based on that. And for those who at least have that covered, then the more durable agents, and by that I mean the agents that are the newer agents, are the ones we try to migrate to over time because we know…how often we treat these patients, how much we get to give them medications, and how long we expect to treat them over time. It makes sense to pick the most durable agent possible for all these activities as well.

Dr Khan, one of the things [that] has been a controversy in our field has been loading doses. Many studies have used loading doses as part of the initial ramp-up, some as many as 5 or 6 in the diabetic macular edema [DME] studies and at least 3 or 4 in the neovascular AMD [age-related macular degeneration] trials. Talk to me a little about your approach and thoughts on loading doses.

M. Ali Khan, MD, FACS, FASRS: The loading doses [for our prior agents] were easy to remember; it was always 3 monthly injections. With faricimab and the high-dose aflibercept, it’s been anywhere from 3 to 6, depending on the arm of the trial. For treatment-naive patients, I am following the loading-dose suggestions based on the trials. I’m still doing 3 to start, and if I’m seeing good effect, then I don’t necessarily continue beyond 3 loading doses and instead go immediately into the treat-and-extend [regimen]. [As] I said before, the trial’s treat-and-extend [regimen] started at 4-week intervals. I’m going [with] a little less than that initially, maybe at 2 weeks, in between the loading dose and the treat-and-extend [regimen] in a way if you consider the trial design. But for patients who are already on an agent, I have not reverted to a full loading-dose strategy. I’ve typically kept the patients at the same interval that they were on [with] the previous agent and adjusted from there, perhaps keeping them at that same interval for 2 to 3 injections, perhaps not extending immediately, but not going all the way back to a Q4 week loading-dose strategy. It’s that distinction between a treatment-naive [patient] and a patient [with] currently controlled or refractory [disease]. There’s a bit of a distinction there, at least in my practice.

Rishi P. Singh, MD: I would agree with you. Most of us do loading without calling it loading; we treat till dry. And inevitably, we get anywhere from 3 to 4 to 5 injections in any way. But there’s been a lot of literature out there that show that loading doses matter in these patients because there is a disconnect between the OCT and vision. So giving the patients those 3 injections does make a difference in the final visual outcome in some of these patients over time. There is value in doing so. It simplifies the regimen, but we don’t tend to do them because we tend to follow the OCT, which is a reasonable parameter to follow and make sure we do that over time. So that’s another option to consider, [which] is treat till dry and then continue thereafter. You probably have the same effect [with] regard to loading overall.

Transcript is AI generated and edited for clarity and readability.

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