Treat-and-extend regimens with anti-vascular endothelial growth factor agents in age-related macular degeneration

ABSTRACT

Introduction: Individualized treatment regimen using currently available/approved anti-vascular endothelial growth factor (VEGF) agents for the therapy of neovascular age-related macular degeneration (nAMD) has been developed to achieve optimal visual outcome while reducing the treatment burden. The so-called treat-and-extend regimens (TERs) are the most recent ones and are nowadays widely used.

Areas covered: The article provides a systematic review of the patterns of different TER approaches with anti-VEGF agents in nAMD treatment including the keywords: loading phase, disease inactivity criteria, extension phase, exit strategy, and predictive biomarkers of treatment responses.

Expert opinion: TER is an individualized treatment approach, which aims to optimize treatment burden, real-world long-term outcome, and health-care costs in the real-world clinical setting. Baseline biomarkers and early treatment responses may have a predictive value of long-term treatment outcome with a TER and therefore need to be taken into account to personalize and adapt the therapy.

KEYWORDS:

• Neovascular age-related macular degeneration (nAMD)
• anti-vascular endothelial growth factor (anti-VEGF)
• treat-and-extend regimen (TER)
• individualized treatment
• optical coherence tomography (OCT)

Article highlights

• The article provides a comprehensive review of TER treatment patterns using currently approved anti-VEGF drugs to treat nAMD including the keywords loading phase, disease inactivity criteria, extension phase, exit strategy, and predictive biomarkers of treatment responses.

• Strict adherence to monthly doses until achieving inactive disease is recommended for the pre-extension/loading phase of a TER. Elimination of IRF is compulsory for disease inactivity. A more tolerant approach toward SRF seems not to worsen visual outcome but to control the risk of atrophy development.

• Treatment intervals can be extended stepwise from an initial 4-weekly by 1–4 weeks to a maximal interval of 12–16 weeks. More careful extension is necessary after disease reactivation to avoid repeated recurrences. A rigorous exit strategy may reduce health-care burden after the maximal treatment interval is achieved in good responders.

• Some biomarkers indicate patient’s responses and can be taken into account to personalize a TER. Patients who have both SRF and PVD at baseline and show a good response during the loading phase may profit from extension to longer treatment intervals. Rapid responders who were extended to the maximal treatment interval with minimal injections may be suited for a subsequent exit strategy with a (temporarily) stop of the treatments. On the other hand, patients presenting with pigment epithelium detachment and VMA at treatment cessation have a higher chance of disease recurrence and need closer follow-ups after treatment exit.

Declaration of interest

R Rückert is an employee of Eyegnos consulting and consultants for Bayer. Dr Rückert also owns stocks in Bayer, Novartis, and Roche. MR Munk received lecturer fees from Novartis and travel support from Bayer and is a consultant for Allergan. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.