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. 2020 Oct;34(10):1825-1834.
doi: 10.1038/s41433-019-0747-x. Epub 2020 Jan 3.

Recommendations by a UK expert panel on an aflibercept treat-and-extend pathway for the treatment of neovascular age-related macular degeneration

Adam H Ross  1 , Louise Downey  2 , Helen Devonport  3 , Richard P Gale  4 , Ajay Kotagiri  5 , Sajjad Mahmood  6 , Hemal Mehta  7 , Niro Narendran  8 , Praveen J Patel  9 , Nina Parmar  10 , Nitin Jain  10
Affiliations

Recommendations by a UK expert panel on an aflibercept treat-and-extend pathway for the treatment of neovascular age-related macular degeneration

Adam H Ross et al. Eye (Lond). 2020 Oct.

Abstract

Objectives: This report aims to provide clear recommendations and practical guidance from a panel of UK retinal experts on an aflibercept treat-and-extend (T&E) pathway that can be implemented in clinical practice. These recommendations may help service providers across the NHS intending to implement a T&E approach, with the aim of effectively addressing the capacity and resource issues putting strain on UK neovascular age-related macular degeneration (nAMD) services while promoting patients' best interests throughout.

Methods: Two structured roundtable meetings of retinal specialists were held in London, UK on 7 December 2018 and 1 March 2019. These meetings were organised and funded by Bayer.

Results: The panel provided recommendations for an aflibercept T&E pathway and developed specific criteria based on visual acuity, retinal morphology and optical coherence tomography imaging to guide reduction, maintenance and extension of injection intervals. They also discussed the extension of treatment intervals by 2- or 4-week adjustments to a maximum treatment interval of 16 weeks, the management of retinal fluid and the stopping of treatment.

Conclusions: The long-term benefits of implementing a T&E pathway may include superior visual outcomes compared with a pro re nata (PRN; as needed) protocol, and a lower treatment burden compared with a fixed protocol, which is likely to improve service capacity. Furthermore, the predictable nature of a T&E approach compared with a PRN service may aid capacity planning for the future nAMD treatment demand.

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Conflict of interest statement

All authors except NJ and NP received honoraria from Bayer plc UK. AR: Consulting fees from Bayer and Allergan; lecture fees from Bayer and Allergan. LD: Consulting and lecture fees from Bayer, Novartis, Alimera Sciences, Bausch + Lomb; grant support (travel) from Bayer, Novartis and Allergan; research funding from Bayer, Novartis, Allergan, Alimera Sciences and Roche. HD: Consulting fees from Bayer; lecture fees from Bayer; grant support (travel) from Bayer. RG: Consulting fees from Bayer and Novartis; research funding and educational grants from Bayer and Novartis. SM: Consulting fees from Bayer and Novartis; lecture fees from Bayer and Novartis; grant support (travel) from Bayer and Novartis; research funding from Roche. HM: Consulting fees from Bayer, Novartis, Roche and Allergan; research funding from Bayer, Novartis, Roche and Allergan. NN: Consulting fees from Bayer and Novartis; lecture fees from Bayer and Novartis; grant support (travel) from Bayer and Novartis. PJP: Consulting fees from Bayer and Novartis; research funding and educational grants from Bayer. NP: Owns Bayer shares and is employed by Bayer plc UK serving as a Medical Science Liaison. NJ: Owns Bayer shares and is employed by Bayer plc UK serving as a Senior Medical Advisor and MSL manager (Specialty Medicine – Ophthalmology).

Figures

Fig. 1
Fig. 1. The recommended aflibercept T&E pathway for the treatment of patients with nAMD.
Notes: Additional signs of disease activity may include new or worsening subretinal hyperreflective material (SHRM) and changing PED. *Treatment at less than 8-week intervals in the first year is off-label and at the discretion of the treating clinician. †Extension should not be attempted if vision is deteriorating without any other causative pathology in the presence of stable fluid. The decision to extend the treatment interval by 2- or 4-week adjustments is at the discretion of the treating clinician. ETDRS Early Treatment Diabetic Retinopathy Study, IVT intravitreal injection therapy, nAMD neovascular age-related macular degeneration, OCT optical coherence tomography, PED pigment epithelial detachment, T&E treat-and-extend, VA, visual acuity.
Fig. 2
Fig. 2
The following OCT images demonstrate different signs of nAMD disease activity, including PED (a), SHRM (a) and SRF (b). nAMD neovascular age-related macular degeneration, OCT optical coherence tomography, PED pigment epithelial detachment, SHRM subretinal hyperreflective material, SRF subretinal fluid.
Fig. 3
Fig. 3
The following OCT images demonstrate cases of minor disease reactivation due to new IRF (a) or recurrence of SRF (b), which should be treated with a reduction of the treatment interval. IRF intraretinal fluid, OCT optical coherence tomography, SRF subretinal fluid.
Fig. 4
Fig. 4. This OCT image shows stable fibrovascular PED with no evidence of disease activity after a period of treatment and successful interval extensions.
This patient should be considered for discharge from the AMD service. AMD age-related macular degeneration, OCT optical coherence tomography, PED pigment epithelial detachment.
See this image and copyright information in PMC

References

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