Initiation and maintenance of a Treat-and-Extend regimen for ranibizumab therapy in wet age-related macular degeneration: recommendations from the UK Retinal Outcomes Group

Abstract

The treatment of neovascular (wet) age-related macular degeneration (AMD) with ranibizumab is now very well established in terms of efficacy and safety. Recent clinical trials and real-world studies have demonstrated the advantages of a Treat-and-Extend (T&E) regimen, and many hospital departments are now in the process of adopting this new regimen in favor of the pro re nata regimen for initiating and continuing ranibizumab therapy for patients with wet AMD. The comprehensive spectrum of issues related to implementation of the regimen is covered qualitatively in ten didactic topics provided by a group of clinicians with direct experience of this regimen in their department. The topics include definition, new and previously treated eyes, management of high-frequency injections, maximum extensions, discontinuing T&E, bilateral cases, clerical, audit, and patient counseling. This article aims to provide a useful resource for the implementation of the T&E regimen. A quantitative summary of the visual outcomes in key publications is also provided in this article. This article should be a valuable resource for staff training.

Changes in metamorphopsia after the treat-and-extend regimen of anti-VEGF therapy for macular edema associated with branch retinal vein occlusion

“…To maintain the metamorphopsia improvement for a longer time, it may be necessary to modify our TAE regimen to a more aggressive treatment. This could include instituting maximum treatment intervals greater than 12 weeks or prolonging treatment with a 12-week interval for a longer period, as done for the TAE regimen used in patients with age-related macular degeneration [ 16 ]. A previous study demonstrated the mean number of injections within 12, 18, and 24 months was significantly higher in the TAE regimen than in the PRN regimen in the treatments for retinal vein occlusion patients [ 17 ].…”

<p>Trends in Real-World Neovascular AMD Treatment Outcomes in the UK</p>

“…The Retinal Outcomes Group and other expert panels have suggested parameters to record to enable both patient outcomes and service delivery to be audited and compared. 64,65 Three recent publications from the same institution had slightly different visual outcomes. 26,27,41 Some of this relates to the time-point when eyes were included, consistent with a national trend for better outcomes over time.…”

“…66 Fixed interval regimens for year 1 transitioning into T&E longerterm or T&E regimens after loading injections are now preferred to PRN treatment approaches in the UK. 64,67,68…”

<p>Providing a Safe and Effective Intravitreal Treatment Service: Strategies for Service Delivery</p>

“…Such an approach avoids under-and over-treatment, thus reducing patient burden and improving cost-effectiveness, reducing the need to continuously monitor or inject patients. 13,26 Clinical data has demonstrated that a T&E regimen can reduce the number of patient clinic visits in comparison with the monthly visits and diagnostic evaluations necessary for PRN treatment, coupled with better functional outcomes. 12 Overall, an individualised T&E regimen has the potential to reduce clinic burden and improve patient compliance while helping to achieve a safe and effective service for the treatment of nAMD.…”