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28 June 2020 | Issue #2
risks. We are considering the treatment for patients who cannot be extended and who cannot come more frequently, and whose fellow eyes have reasonably good vision,” he continued.
Assessing the Options in nAMD Treatment
by Brooke Herron
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nti–vascular endothelial growth factor (anti-VEGF) therapies dramatically changed the prognosis of neovascular age-related macular degeneration (nAMD), when before we only had photodynamic therapy (PDT), began Dr. Patricia Udaondo from the Hospital Universitario y Politécnico de La Fe in Valencia, Spain. Today, nAMD is often managed with intravitreal anti-VEGF injections. And as ground-breaking as these agents are, the treatment burden can be high for both patients and physicians — especially for those on fixed monthly dosing. Thanks to the high burden, regimens like treat-and-extend (T&E) are gaining steam: “T&E strikes a balance between the benefits of a fixed regimen and the desire for physicians to individualize based on specific response,” said Dr. Udaondo. “This reduces the cost of treatment and gets vision outcomes closer to that in clinical trials.” In addition, new treatments, like longerlasting anti-VEGFs and gene therapy are making waves. These updates and more were discussed during the Subspecialty Day: Management of Age-related Macular Degeneration session on the second day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).
Bevacizumab isn’t going anywhere “Will bevacizumab still be used for management of wet AMD five years from now?” asked Dr. Baruch Kuppermann from the Gavin Herbert Eye Institute, University of California Irvine, USA. The answer is yes.
Although bevacizumab is off-label, it’s often used over approved anti-VEGFs due to its low cost and non-inferiority to other agents. According to Dr. Kuppermann, in 2018, the average wholesale cost for ranibizumab was $1950; aflibercept was $1850. Meanwhile, bevacizumab sits at $50 per dose. Also, Dr. Kupperman noted that biosimilars (in development for ranibizumab) won’t be able to compete with bevacizumab either, when it comes to cost and cost effectiveness. “We will continue to have bevacizumab as a strong weapon in our armamentarium in the fight against wet AMD for the foreseeable future,” he concluded.
Safety concerns rock the boat for brolucizumab Brolucizumab entered the market buoyed by results of efficacy and reduced injection frequency. Then the American Society of Retina Specialists (ASRS) alerted the ophthalmic community of 14 cases of retinal vasculitis. However, as serious these side effects are, physicians aren’t quite jumping ship yet. “Before the new safety concern, we had contemplated moving to brolucizumab as a first-line therapy,” said Dr. Srinivas Sadda, from the Doheny Eye Institute UCLA, California. He detailed several patient cases where brolucizumab resulted in better outcomes than other agents. “It appears to have superior drying and consequently, superior durability over other currently available agents. “Now in view of those concerns, we’re having extensive discussions with our patients so that they understand those
“If we’re able to predict who is going to get the inflammation, or if we’re able to get insight into why the inflammation is occurring and can manage it or prevent it, then that will obviously impact our utilization,” explained Dr. Sadda.
It’s all in the genes Gene therapy is showing promise for treating nAMD, said Dr. Allen Ho from Wills Eye Hospital, Pennsylvania, USA. During his presentation, Dr. Ho discussed phase I/II trial results for a new therapy from Regenxbio using subretinal delivery, dubbed as RGX-314. Results showed that RGX-314 was well-tolerated at all dose levels, reported Dr. Ho. In cohort 3, there was a longterm, durable treatment effect for over two years, resulting in improved VA and stable retinal thickness. It also significantly reduced the treatment burden. In cohort 5, 73% of patients remained anti-VEGF injection-free at 9 months. Could gene therapy rally to the frontline of nAMD treatment soon? We can’t predict the outcomes, but it certainly looks promising.
“T&E strikes a balance between the benefits of a fixed regimen and the desire for physicians to individualize based on specific response. This reduces the cost of treatment and gets vision outcomes closer to that in clinical trials.” Dr. Patricia Udaondo Hospital Universitario y Politécnico de La Fe Valencia, Spain
