Work

Modified observe‐and‐plan regimen using aflibercept for neovascular age‐related macular degeneration

Year: 2021

Type: article

Abstract: Several treatment strategies with anti-vascular endothelial growth factor are available for patients with neovascular age-related macular degeneration (nAMD). The treat-and-extend (TAE) regimen reduces the burden of injections, compared to a monthly dosing regimen (Abedi et al. 2014). However, the possibility of over-treatment is inherent in patients with little or no recurrence. The regularity of the retreatment rhythm in nAMD has already been reported (Mantel et al. 2013). A modified TAE method has been suggested that determines the treatment interval based on the initial recurrence interval (Ohnaka et al. 2017). However, patients with little recurrence showed higher variation during the intervals, so predictability was poor. This modified method still has the potential risk of over-treatment. Here, we suggest a modified observe-and-plan regimen. Data of 48 eyes (48 patients) with treatment-naïve nAMD, who were administered aflibercept and completed the 1-year follow-up, were collected retrospectively. The Medical Ethics Committee of the Yeungnam University Hospital approved this study. All patients were administered monthly intravitreal aflibercept for 3 months (total of 3) as a loading dose. They were monitored monthly during the subsequent observation phase (at least 3 months) to determine whether a dry macula was attained. The patients who showed exudative activity within 3 months were allocated to the early-recurrence group. The other patients were allocated to the late-recurrence group. The early-recurrence group was treated with the TAE regimen, under the assumption of frequent recurrences. If there were no exudative signs, the treatment interval was extended by 2 weeks at each visit up to a maximum of 12 weeks. The minimum interval covered by the Korean National Health Insurance is 8 weeks. If there was a recurrence, the next treatment was shortened by 2 weeks. Patients in the late-recurrence group were treated as needed (Fig. 1A). Twenty patients were allocated to the early-recurrence and 28 patients were allocated to the late-recurrence group. No significant differences in the baseline characteristics, including age, sex, best-corrected visual acuity (BCVA), central macular thickness (CMT) or type of neovascular lesion, were observed between the two groups. We observed improvements in mean BCVA and CMT in the early- and late-recurrence group (Fig. 1B,C). The mean number of injections was 6.6 ± 0.5 in the early-recurrence, and 3.7 ± 0.8 in the late-recurrence group with a mean number of recurrences of 0.7 (Fig. 1D). One-half of the patients in the late-recurrence group did not experience recurrence. The treatment interval in the early-recurrence group was extended in seven (35%), maintained in 10 (50%) and shortened in three eyes (15%) at month 12, compared with initial recurrence interval. The mean extended interval was 9.9 ± 1.5 weeks at 12 months. In six eyes (30%), initial 8-week treatment interval was not extended due to persistent exudation during 12 months (Fig. 1E). Despite the frequent recurrence in the early-recurrence group, treatment interval could be extended using our TAE regimen. The number of injections (6.6 over 12 months) was slightly lower than that of conventional TAE. The PRN regimen, which is known to be associated with worse outcomes, could control exudation with far fewer injections in the late-recurrence group. The visual outcomes of both groups were comparable at 12 months (by 8-9 ETDRS letters) with those of previous strategies including the fixed dosing (Heier et al. 2012), standard TAE (Wai & Singh 2018) and the modified TAE (Ohnaka et al. 2017). Overall, our protocol, which selects the TAE or PRN regimen according to the initial recurrence interval, showed good visual outcomes. Potential limitations are the retrospective design, small sample size and short-term follow-up period. A modified observe-and-plan strategy according to the individual recurrence interval could be an effective alternative strategy for treating nAMD patients.

Source: Acta Ophthalmologica

DOI: 10.1111/aos.14803

Authors: Seongyong Jeong, Gahyung Ryu, Min Sagong

Institutions: Yeungnam University Medical Center, Yeungnam University College, Yeungnam University

Language: English

Topic: Retinal Diseases and Treatments

Subfield: Ophthalmology

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: bronze

Funder: Yeungnam University