Apr 16, 2024

Treatment challenges in patients with nAMD

by: Lynda Charters

David Eichenbaum, MD, discusses his experiences with aflibercept, faricimab.

Reviewed by David Eichenbaum, MD

David Eichenbaum, MD, from Retina Vitreous Associates of Florida and the Morsani College of Medicine at the University of South Florida, Tampa, discussed challenging cases of neovascular age-related macular degeneration (nAMD) recently at a case-based roundtable exchange.

Case 1

Case 1 was that of a typical patient with exudative AMD who presented with acute vision loss to 20/63, a pigment epithelial detachment (PED), and subretinal fluid. Eichenbaum generally starts such patients on aflibercept (Eylea; Regeneron) or faricimab (Vabysmo; Genentech), based on insurance coverage.

In this case, he started the patient on aflibercept 8 mg with the goal of flattening the PED. Aflibercept has good drying ability and durability with treatment intervals tested out to every 16 weeks in the first year of treatment.

The second injection was scheduled for 4 weeks after the first, at which time the patient had a substantial improvement in vision and anatomy, with complete flattening of the PED. Generally, Eichenbaum uses a loading dose series of about 3 injections for almost all treatment-naive patients.

After the third injection, the patient was extended out to 8 weeks. Eight weeks after the third injection, the patient looked “fantastic” with no subretinal fluid. The patient then was extended to 12 weeks.

Eichenbaum’s goal is to abolish all intraretinal and subretinal fluid. He explained that intraretinal fluid is probably the most detrimental for long-term anatomy, and select patients can tolerate some subretinal fluid and maintain good vision. He advised that if patients are not dry after the loading dose to treat more aggressively early in their course of disease, which is a window of time when vision can be restored. Once they are dry, he tries to extend the treatment intervals.

If patients are not dry after the loading dose, he switches to another treatment. He also switches agents if the patients do not obtain good durability. “I will try to use a second-generation agent as in this patient. I like to have them on 1 of those 2 second-generation agents when I’m trying to extend their treatment interval, especially if I can’t do that using bevacizumab [Avastin; Genentech], ranibizumab [Lucentis; Genentech], or aflibercept 2 mg,” he explained.

Eichenbaum’s volume of experience commercially with faricimab and aflibercept 8 mg differs. Faricimab has been available for 2 years and aflibercept 8 mg for several months, so he has had more experience with faricimab. He uses both drugs and believes both are superior to the first-generation agents, including ranibizumab and aflibercept 2 mg. “The anatomic response, potency, and durability are greater with the second-generation drugs,” he said.

Case 2

This 88-year-old man started treatment in 2015 for bilateral nAMD. He started on bevacizumab and currently has been on aflibercept 2 mg for an extended period. He is treated every 5 to 6 weeks in his better right eye with 20/63 vision and has some chronic intraretinal fluid. Eichenbaum does not want to extend the treatment interval because of the low-level activity in this better eye…..

Read more: https://rb.gy/nqgb7u

Source: Ophthalmology Times

Dr. David Eichenbaum, MD serves on the Macular Degeneration Associations medical board

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