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Anti-VEGF Update: When is Switching Patients Acceptable and Preferable?

By: David Eichenbaum, MD-Moderator; Caroline Baumal, MD; Victor Gonzalez, MD; Rahul N. Khurana, MD; Carl D. Regillo, MD

This course has expired. You can still review the content but course credit is no longer available.

Supplement Credits: 1

Expiration Date: Friday, September 30, 2016
Release Date: September 2015

Learning Objectives

Upon completion of this activity participants should be able to:

• Understand the most recent monotherapy and combination therapy clinical study evidence using available treatment therapies for common retinal diseases, including AMD and DME

• Discuss the benefits of anti-VEGF therapies over other potential therapies and how to educate patients on appropriate expectations

• Develop plans to initiate treatment for conditions such as AMD and DME, as well as better understand when to change therapeutic strategies and/or therapeutic classes of treatment

Statement of Need

The introduction of anti-vascular endothelial growth factor (anti-VEGF) therapies for the treatment of retinal vascular disorders has been revolutionary, and the class of drugs is now considered standard of care for the treatment of diabetic macular edema that involves the fovea.1-4 With two approved intravitreal drugs (aflibercept and ranibizumab)5,6 and one used off-label (bevacizumab), clinicians have a host of potential treatments. Yet there remains a limited consensus on best practices, from which drug to begin therapy in treatment-naïve patients, to when to treat patients [monthly, PRN, or treat-and-extend (TAE)], to when to switch patients and how to assess or quantify “treatment failure.” In the DME patient, a decreased response or failure to respond is typically determined by optical coherence tomography (OCT) central thickness and volume. Laser photocoagulation is still a viable option, especially for those patients in whom a complete response (ie., complete resolution with improvement in vision) is lacking.7 A complicating factor in treating these patients is a lack of a universally accepted nomenclature that would describe the different types of non-response.8 Certain ethnicities have a higher prevalence of developing DME,9 leaving the question about when and with which therapies to intervene debatable. Corticosteroid treatments are limited in the US–the most recent product to be approved (dexamethasone) was limited to pseudophakic patients or those scheduled to undergo cataract surgery as a result of the high incidence of cataract in phakic patients.9 While the cost of these steroids is considerably lower than the anti-VEGF treatments due to the former’s infrequent dosing, the latter remains a more effective treatment for maintaining and providing visual gains. Leading retina specialists are unlikely to switch patients to a steroid before opting for a different anti-VEGF in phakic patients.10 Pseudophakic nonresponders are much more likely to be switched to a corticosteroid. Still others will discontinue intravitreal injections altogether and treat with vitrectomy if the patient does not respond.11 A full knowledge of the dynamics of treatment options for DME will be beneficial for eye care specialists who use these treatments. An understanding of when to treat, coupled with when to switch to an alternative treatment in nonresponders, would provide these specialists with a more complete understanding when counseling patients. It is expected that providing this education would remove a potential barrier to greater acceptance in this area of disease management. Diabetes is a systemic disease, and the primary treatment involves optimal glycemic and blood pressure control. By providing detailed insights into management strategies in this chronic and often bilateral disease, clinicians will be able to reduce treatment complications and further loss of vision.

1.  Ford JA, Lois N, Royle P, et al. Current treatments in diabetic macular oedema: Systematic review and metaanalysis. BMJ Open. 2013;3(3).

2.  Stewart MW. Critical appraisal of ranibizumab in the treatment of diabetic macular edema. Clin Ophthalmol. 2013;7:1257-67.

3.  Kent C. Treating DME: Laser, anti-VEGF or steroids? Review of Ophthalmology: Jobson, 2013.

4.  Gupta N, Mansoor S, Sharma A, et al. Diabetic retinopathy and VEGF. Open Ophthalmol J. 2013;7:4-10

5.  Eylea [package insert]. Tarrytown, NY: Regeneron, 2014.

6.  Lucentis [package insert]. South San Francisco, CA: Genentech Inc., 2014.

7.  Jampol LM, Bressler NM, Glassman AR. Revolution to a new standard treatment of diabetic macular edema. JAMA. 2014;311(22):2269-70.

8.  Weiner G. When anti-VEGF fails in AMD patients: 3 treatment approaches. EyeNet: American Academy of Ophthalmology, 2012.

9.  Ozurdex [package insert]. Irvine, CA: Allergan Inc., 2014.

10. Kaiser PK, Duker JS, Ho AC, Martin DF. Clinical trial updates: Putting research into practice for retinal diseases. Retinal Physician. Ambler, PA: PentaVision, 2014.

11. Boyer DS, Humayun MS, Staurenghi G, Yeh S. New modalities for treating diseases of the choroid and retina. Retina Today. Bryn Mawr, PA: Bryn Mawr Communications, 2014;Suppl: July-Aug.

Disclaimer

The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of The Dulaney Foundation and Retina Today.

Anti-VEGF Switching Update: When is Switching Patients Acceptable and Preferable?

David Eichenbaum, MD-Moderator; Caroline Baumal, MD; Victor Gonzalez, MD; Rahul N. Khurana, MD; Carl D. Regillo, MD

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