Beneficial switch from aflibercept to ranibizumab for the treatment of refractory neovascular age-related macular degeneration

Abstract

The aim of this study was to evaluate the effects of switching to ranibizumab in patients with neovascular age-related macular degeneration (nAMD) refractory to aflibercept treatment and to identify predictive factors for switch response. Methods A retrospective chart review was conducted including 32 eyes from 26 patients with refractory nAMD, who switched from monthly intravitreal aflibercept treatment (≥ 6 months) to ranibizumab. Outcome measures included changes in visual acuity (VA), intraretinal fluid (IRF), subretinal fluid (SRF), pigment epithelial detachment (PED), and central retinal thickness (CRT), evaluated at 6 months before switch (T1), at the time of switch (T2), and 3 months post-switch (T3). Results There was an increase in CRT from T1 to T2, which decreased after switch from T2 to T3. Regression analysis of the changes per month observed between time points showed significant differences in PED height (p = 0.02), SRF (p = 0.01), and neuroretinal thickness as a measure for IRF (p = 0.03). No significant change was found for VA. Predictive factors for better switch response included an exacerbation between T1 and T2, thicker measurements at T2, male sex, shorter treatment duration before switch, and fewer preceding injections. No association with preceding switch was found. Conclusion Patients with nAMD refractory to aflibercept benefit from switching to ranibizumab, particularly those whose condition worsened prior to the switch. This may be explained by drug tolerance to aflibercept. Our findings may facilitate making appropriate treatment decisions, potentially improving patient outcomes.

Anti-VEGF-Resistant Retinal Diseases: A Review of the Latest Treatment Options

“…In total, 34% of eyes were noted to have an increase of 5 or more letters after the switch in therapy [73]. Other smaller, retrospective studies have demonstrated similar benefits when switching to IVR in a subset of eyes with eAMD unresponsive to IVA [74,75]. In addition, the more recently FDA approved IVBr offers an additional therapeutic option for anti-VEGF-resistant eAMD that has developed tachyphylaxis to other agents.…”

A randomized, open-label, multicenter study of switching to brolucizumab with or without a loading dose for patients with suboptimal anatomically controlled neovascular age-related macular degeneration—the FALCON study

“…If, during the course of treatment, an anti-VEGF agent is found to be neither morphologically nor functionally effective without falling below its effective dose, a switch to another anti-VEGF agent may be appropriate. Several studies showed that switching to another anti-VEGF agent might lead to improvement in anatomical parameters and even stabilization or improvement of visual acuity [14][15][16][17]. For these switch patients, treatment is often initiated with a loading dose of three monthly injections, similarly as in treatment-naïve patients.…”

Optical coherence tomography imaging biomarkers associated with neovascular age-related macular degeneration: a systematic review

“…Although there are reports stating no significant difference between the anti-VEGF drugs ranibizumab and aflibercept, regarding the treatment response of IRC [ 29 ], one study has evaluated the effects of switching between the two [ 46 ]. The authors report that pre-switch structural changes on aflibercept negatively correlated with the post-switch response in morphological improvements to ranibizumab.…”

“…The authors report that pre-switch structural changes on aflibercept negatively correlated with the post-switch response in morphological improvements to ranibizumab. The absolute values of IRF at the point of the switch predicted the degree of response to switching to ranibizumab; thus the more IRF present prior to the switch, the better the eye responded to the switch [ 46 ]. Yet, post-hoc analysis of the VIEW studies highlights that fluid resolution was consistently greater for aflibercept treated 4-weekly compared to aflibercept treated 8-weekly or ranibizumab.…”