Switch to aflibercept or ranibizumab after initial treatment with bevacizumab in eyes with neovascular AMD

Abstract

BackgroundTo evaluate changes in central macular thickness (CMT) and visual outcome in patients with neovascular age-related macular degeneration (AMD) treated initially with bevacizumab and subsequently switched to either aflibercept or ranibizumab.MethodsObservational clinical study was performed. We measured the structural outcome (CMT on SD-OCT; μm) and the visual outcome (best corrected visual acuity (BCVA); logMAR), as follows: before treatment (at baseline), following bevacizumab treatment (switch follow-up) and after switching from bevacizumab to aflibercept- or ranibizumab treatment (final follow-up, AG/, RG).ResultsFrom a total of 96 eyes treated with intravitreal injections of bevacizumab (10.5 ± 7.6 (mean ± SD)), 58 eyes switched to aflibercept (6.5 ± 3.9; AG) and 38 eyes switched to ranibizumab (7.1 ± 5.3; RG) (≥ 3 injections, each). In addition, these eyes were compared to 37 eyes under bevacizumab monotherapy.Primary outcome: In the AG, the CMT decreased slightly from 430 ± 220 μm at baseline to 419 ± 212 μm at switch follow-up (p = 0.86), but decreased significantly to 318 ± 159 μm at final follow-up, AG (p < 0.0001). In the ranibizumab group (RG), the CMT increased from 396 ± 174 μm at baseline to 499 ± 333 μm at switch follow-up (p = 0.012), but decreased significantly to 394 ± 202 μm at final follow-up, RG (p = 0.007).Secondary outcome: In the AG, the mean BCVA worsened from logMAR 0.57 ± 0.33 at baseline to 0.63 ± 0.30 at switch follow-up and improved slightly to 0.53 ± 0.71 at final follow-up, AG (p = 0.46). In the RG, mean BCVA worsened from 0.57 ± 0.28 at baseline to 0.64 ± 0.31 at switch follow-up and improved slightly to 0.60 ± 0.36 at final follow-up, RG (p = 0.64).ConclusionSwitching from bevacizumab to either aflibercept, or ranibizumab, has a strong anatomical effect in eyes with neovascular AMD. Nevertheless, even if the switch to aflibercept shows a minimal functional benefit over that to ranibizumab, visual prognosis remains limited.

Aflibercept versus Ranibizumab as a Second Line Therapy After Bevacizumab for Diabetic Macular Edema

“…5 The financial burden of different treatment regimens with anti-VEGF need to be considered whenever the decision of treatment is made. 6 To the best of our knowledge, outcome comparisons of aflibercept and ranibizumab as a second line of treatment for refractory DME after initial bevacizumab injections have not been studied.…”

“… 5 The financial burden of different treatment regimens with anti-VEGF need to be considered whenever the decision of treatment is made. 6 …”

Suspending Treatment of Neovascular Age-Related Macular Degeneration in Cases of Futility

“…Several small-scale studies have reported the potential benefits of switching anti-VEGF agents after poor response to first-line therapy. 51 – 54 In one study, Waizel et al 51 reported that switching from bevacizumab to either aflibercept or ranibizumab led to a significant decrease in mean central macular thickness at the final follow-up. However, mean BCVA only improved slightly at the final follow-up in both the aflibercept and ranibizumab groups, and there was no significant difference between switch treatment groups in both outcomes.…”

“…However, mean BCVA only improved slightly at the final follow-up in both the aflibercept and ranibizumab groups, and there was no significant difference between switch treatment groups in both outcomes. 51 In a retrospective case series of 94 patients with nAMD, 68 of whom were refractory to previous bevacizumab or ranibizumab treatment (categorized by the presence of persistent intraretinal and/or subretinal fluid despite monthly injections), Yonekawa et al 52 reported visual and anatomical outcomes with switching to aflibercept treatment. In refractory patients, stabilization of visual acuity was reported after one aflibercept injection and at the final follow-up compared with visual acuity before switching to aflibercept ( P = 0.897 and P = 0.215, respectively); however, significant improvements in mean central macular thickness compared with before switching were reported at these endpoints ( P < 0.001 for both time points).…”

Interplay between Autophagy and the Ubiquitin-Proteasome System and Its Role in the Pathogenesis of Age-Related Macular Degeneration

“…AMD can occur in dry (atrophic) or wet (exudative, neovascular) form. Dry AMD is manifested in 80–85% of all cases, but treatment options are available only to patients with wet AMD and do not address disease causes, but rely on the inhibition of vascular endothelial growth factor (VEGF) by antiangiogenic agents [6]. Aging is the most serious risk factor for AMD and the number of individuals affected increases significantly after the age of 50 years [7].…”