Fundamental principles of an anti-VEGF treatment regimen: optimal application of intravitreal anti-vascular endothelial growth factor therapy of macular diseases

Abstract

Background: Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is now considered the gold standard for the treatment of various retinal disorders. As therapy has evolved, so too have the treatment regimens employed by physicians in clinical practice; however, visual outcomes observed in the real world have typically not reflected those reported in clinical trials. Possible reasons for this include a lack of consensus on treatment regimens and a lack of clarity about what the aims of treatment should be.

Methods: The Vision Academy Steering Committee met to discuss the principles of an ideal treatment regimen, using evidence from the literature to substantiate each point. Literature searches were performed using the MEDLINE/PubMed database (cut-off date: March 2016) and restricted to English-language publications. Studies with fewer than ten patients were excluded from this review.

Results: The Steering Committee identified the following four key principles for the ideal treatment regimen for anti-VEGF management of retinal diseases: 1. Maximize and maintain visual acuity (VA) benefits for all patients 2. Decide when to treat next, rather than whether to treat now 3. Titrate the treatment intervals to match patients' needs 4. Treat at each monitoring visit.

Conclusions: It is proposed that the adoption of a proactive and more personalized approach in the clinic such as a treat-and-extend regimen will lead to benefits for both the patient and the physician, through a reduction in the associated treatment burden and better utilization of clinic resources. Implementation of the four principles should also lead to better VA outcomes for each patient, with a minimized risk of vision loss.

Keywords: Aflibercept; Anti–vascular endothelial growth factor; Retinal disease; Treat-and-extend; Treatment regimens; Visual acuity.

Fig. 1

Illustrative example of how a treat-and-extend regimen might be implemented in the clinic

Fig. 2

Outcomes from AURA: changes in VA from baseline per country over 2 years (only countries enrolling >400 participants have been displayed) [55]. LOCF, last observation carried forward

Fig. 3

Distribution of individual VEGF suppression times of patients with nAMD treated with ranibizumab, as reported in Muether et al. [89]

Fig. 4

Distribution of treatment intervals in patients receiving intravitreal aflibercept in the ATLAS study [89]

Fig. 5

PRN treatment with monthly monitoring leaves patients at risk of disease resurgence