Treat and extend paradigm in management of neovascular age-related macular degeneration: current practice and future directions

ABSTRACT

Introduction: With neovascular age-related macular degeneration (nAMD) being a leading cause of irreversible vision loss and its implications as a major health care burden, treatment regimens that offer practicable and sustainable approaches in the real-world setting are being explored for their efficacy. The treat and extend (TREX) approach to nAMD management allows for personalization of treatment based on patient variability of response. This has been shown to provide a superior, proactive treatment model which achieves acceptable maintenance of visual acuity and anatomical disease stability.

Areas covered: Aspects of a TREX treatment approach are described based on evidence from clinical trials and real-world settings. Gaps in the current understanding of how a TREX regime is enabled are also explored.

Expert opinion: A TREX approach to patients with nAMD is associated with greater visual gains compared to reactive treatment regimens. It shows potential superior outcomes in community settings compared to fixed-dosing regimens which do not allow for individualization of treatment. The chronic, progressive nature of nAMD pathogenesis requires a sustainable management strategy that is able to be further refined and applied to the use of existing, new and upcoming agents being developed for control of neovascularization.

KEYWORDS:

• Anti-vascular endothelial growth factor (anti-VEGF)
• best-corrected visual acuity (BCVA)
• choroidal neovascularisation (CNV)
• neovascular age-related macular degeneration (nAMD)
• treat-and-extend (TREX)
• treatment burden
• treatment regimen

Article highlights

• This article will discuss the evidence basis for the formulation of the treat-and-extend approach to nAMD management. Key clinical trials of anti-VEGF agents used in the treatment of nAMD and properties of agents currently approved for use and under clinical trial for the treatment of nAMD will be summated.

• Explanation of the treat-and-extend methodology is made and compared to fixed-dosing and pro-re-nata regimens. Consideration is given to structural and functional outcomes reported with anti-VEGF therapy for the treatment of nAMD according to both randomised controlled clinical trial outcomes and those from real-world clinical settings.

• Current challenges to facilitating nAMD treatment with anti-VEGF therapies are presented. An emphasis is placed on regimen choice, and barriers to achieving standards met in randomised clinical trial settings compared to experiences in the real-world.

• A TREX approach to nAMD management will become the cornerstone for refining future personalised management strategies for nAMD. Evidence from clinical trials and real-world settings that use a TREX regimen for anti-VEGF therapy in nAMD management are discussed.

• Ongoing research efforts are currently focused on identifying biological markers of nAMD disease pathogenesis, the discovery of new biological therapeutics for the treatment of nAMD, and the potential analysis of diagnostic imaging with artificial intelligence. These advances may better inform and guide treatment-focused decisions of a treat-and-extend approach to nAMD disease and patient management.

Declaration of interest

A Chang is a consultant for Allergan, Bayer, Novartis and Roche. 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

A peer reviewer on this manuscript has disclosed having received lecture fees and honoraria for consultation from Bayer/Regeneron, Novartis, Roche, Allergan/Abbvie. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.