Age Related Macular Degeneration (AMD) is a progressive eye condition that gradually affects the central portion of your vision, leading to permanent blindness if untreated.

Anti-VEGF injections such as Aflibercept, Ranibizumab and Eylea can help patients suffering from wet macular degeneration to enjoy improved vision by inhibiting abnormal blood vessel growth that leak fluid under their retinas. As such, patients will see improved visual clarity.

Anti-VEGF Therapy

Long-term anti-vascular endothelial growth factor (anti-VEGF) therapy has been proven to significantly enhance visual outcomes in patients suffering from neovascular age-related macular degeneration. But for it to work successfully, patients must adhere and persist with their treatment plans, which typically consist of monthly or bi-monthly injections. Recently, researchers published a systematic review that explored levels and reasons behind patient non-adherence or non-persistence with intravitreal anti-VEGF injections.

The findings revealed that patient factors, including personality traits, health status and social circumstances have an enormous impact on adherence or persistence with therapy. Furthermore, this research identified interventions as necessary to overcome barriers that impede such commitment to therapy.

Aflibercept is one of the most frequently prescribed anti-VEGF agents in the US and researchers found that its use significantly slowed progression of proliferative diabetic retinopathy among those treated with it, while improving vision in advanced diabetic macular edema cases even with non-treated maculae present.

One strategy for improving outcomes involves identifying whether an excess fluid in a patient’s retina is caused by hemiretinal vein occlusion (HRVO) or central retinal vein occlusion (CRVO). They found that patients with CRVO experienced worse vision and macular edema more frequently than those with HRVO; however, resolution of excess retinal thickness and improvement of best corrected visual acuity was similar between groups.

Monitoring patients with neovascular macular degeneration to determine whether they are responding adequately to anti-VEGF therapy is another strategy, as researchers studied results of several clinical trials that compared performance of those achieving complete regression with that of those not doing so, finding that more eyes with complete regression experienced visual acuity improvement and had CST reduction of at least 10 percent than in non-complete regression patients.

Dr. Arshad Khanani provides insight into his approach to treating wet age related macular degeneration with real world evidence and long term data, such as when to start faricimab (a bispecific antibody targeting two distinct pathways). He details how patients who could go on treatment pauses between anti-VEGF injections performed better than those requiring monthly injections for maintaining vision; his team is investigating Apolipoprotein B100, an important protein which inhibits abnormal blood vessel growth as a biomarker that may predict patient response to anti-VEGF drugs.

Anti-VEGF Injections

Anti-VEGF injections have proven highly successful at slowing vision loss in many patients suffering from wet AMD, and may even allow some to gain back some vision that they would have lost without treatment.

At first, ranibizumab (now available under its brand name of Lucentis) was approved by the FDA for treating neovascular AMD; however, shortly thereafter ophthalmologists began using bevacizumab (Avastin), originally intended for treating cancer, to treat patients suffering from neovascular AMD with similar results as seen during clinical trials that led to its approval. These “off-label” injections achieved similar success as did ranibizumab’s approval.

Since 2010, more than a dozen anti-VEGF medications have been approved for treating neovascular AMD. These include Aflibercept solution for injection, Adalimumab (Humira), and Brolucizumab (Brilumetumab). Additional experimental medicines are currently undergoing early phase clinical trials to potentially replace or complement these treatments.

One of the challenges in treating neovascular AMD lies in needing regular visits to an eye doctor for injections. Unfortunately, many patients struggle to make time for these appointments and therefore miss treatments which may worsen vision over time.

Long-term use of anti-VEGF medications increases a patient’s risk of glaucoma, necessitating surgical interventions to lower eye pressure. According to one recent study, those receiving seven or more bevacizumab injections each year had 2.5 times greater likelihood of needing glaucoma surgery compared with those who received three or less injections annually.

Researchers from Johns Hopkins University are conducting a study on whether some patients receiving anti-VEGF injections can enter into a period known as “treatment pause.” For this, they looked at 106 wet AMD patients treated at Wilmer Eye Institute in Baltimore with ranibizumab or aflibercept injections; eligible patients included those who achieved best corrected visual acuities between 6/12 and 6/96 with no permanent structural damage to central fovea or evidence of presumed progression on either slit lamp photos or optical coherence tomography scans.

Anti-VEGF Tablets

Age related macular degeneration (AMD) is an eye condition that leads to progressive vision loss in those over 50 years of age. It develops when deposits buildup on and around retinal pigment epithelial (RPE) cells of the macula, leading to its degradation and eventual vision loss. With early diagnosis and treatment however, this progression may be stopped while some even retain some central vision with effective results.

Treatment for wet age related macular degeneration generally entails inhibiting abnormal blood vessel growth, such as via anti-VEGF drugs such as ranibizumab (Lucentis) or bevacizumab (Avastin).

These drugs prevent leakage of fluid from newly formed blood vessels, thus relieving macular edema and stopping further vision loss. Patients may even benefit from receiving injections; once all fluid has been cleared away, periodic shots must be given in order to prevent its return and further vision loss.

Faricimab-svoab from Vabysmo-Gentech works similarly to intravitreal injections by decreasing how often medication needs to be injected into the eye, providing another means of dosing anti-VEGF. Recently approved by the FDA.

Anti-VEGF therapy can now be taken more conveniently by taking daily pills in pill form, which can be taken at home rather than having to visit their ophthalmologist every month for injections.

Studies have demonstrated that taking high doses of antioxidants and zinc, as recommended by the Age-Related Macular Degeneration Study Research Group (AREDS), are significantly more likely to lower their risk of wet macular degeneration than those not taking supplements. Furthermore, a recent Retina publication suggests that diabetes medication metformin may offer some measure of protection from neovascular AMD.

Faricimab

Faricimab is a new bispecific antibody targeting both VEGF and the Ang-Tie pathway, recently approved by both FDA and EMA for treating wet age related macular degeneration and diabetic macular edema. Clinical trials such as TENAYA and LUCERNE as well as RHINE and YOSEMITE have demonstrated its safety and efficacy for extended treatment intervals than previous standard of care such as Aflibercept + Ranibizumab (3-4 weeks).

Faricimab works differently from aflibercept and ranibizumab in targeting both pathways simultaneously to prevent further fluid build-up by targeting both pathways simultaneously. Genentech developed this breakthrough drug which is expected to significantly reduce injection frequency for those suffering with DME/neovascular AMD.

Studies published in The Lancet have demonstrated that high-dose faricimab therapy combined with intravitreal ranibizumab can effectively stabilize and prevent further vision loss among those living with neovascular age-related macular degeneration, or DME. The treatment was safe, well tolerated, and did not cause serious side effects in treated eyes; research conducted within an ongoing registry of participants who received regular eye exams from eye doctors as prescribed, including receiving anti-VEGF therapy to stabilize vision or treat DME.

This study demonstrated the safety and effectiveness of using faricimab and ranibizumab together in treating DME, making this treatment approach safe and effective. If instructed by your physician to follow a particular treatment regimen for evaluation of vision and anatomic status. Likewise it is wise to refrain from taking beta blockers or steroids while receiving either Aflibercept or Ranibizumab to minimize interactions. For any further queries on their interactions consult with either your physician or pharmacist.

These guidelines do not alter existing NHS funding arrangements for treatment with Aflibercept or Ranibizumab that began prior to publication of these guidelines. Therefore, individuals currently receiving this treatment should continue as planned without changes to their funding arrangements until either themselves or their NHS clinician deem it appropriate to discontinue it.