The Challenges of Treating Neovascular Age-Related Macular Degeneration

Abstract

Age-related macular degeneration (AMD) is one of the main causes of visual impairment and blindness in patients over 60 years in developed countries. Whilst no effective form of therapy is available for the dry form of AMD, intravitreal application of anti-VEGF substances is able to prevent the progression of neovascular AMD (nAMD) in most cases. Aside from the drugs ranibizumab, aflibercept and brolucizumab, other agents such as bevacizumab are often used off-label in order to save expense. The treatment intervals have also been refined, so as to reduce the burden on patients and health care systems. After fixed injection intervals, the pro re nata-regimen has been developed. Each month, it is decided whether the patient receives intravitreal injections based on fixed criteria. In the treat and extend-protocol, patients receive injections on each visit, but the intervals between injections vary due to the clinical outcomes. The observe-and-plan regime allows scheduling of the injection intervals in blocks, for three consecutive injections at a time. However, results of real-world studies were not able to reproduce those obtained in the pivotal studies. A high number of visits and fear of the injection procedure impose a burden on patients, that is mostly accepted due to fear of vision loss. Caregivers also complain of loss of productivity and income from having to provide regular support to patients. Health care systems worldwide are affected by increasing treatment numbers and the costs involved. The treatment of nAMD constitutes an achievement for modern medicine. However, despite the challenges, it must be evaluated and reviewed repeatedly in order to provide the best therapy for patients.

Anti-VEGF therapies for age-related macular degeneration: a powerful tactical gear or a blunt weapon? The choice is ours

“…Experience gained by retina experts in the use of newer therapies during the last decade has also been pivotal in improving outcomes and reducing visual loss in the treated populations. Changes in the strategy of anti-VEGF regimen in real-life settings have conducted to the application of treat-and-extend approaches rather than pro re nata (PRN) with subsequent reduced burden and similar outcomes to the monthly administration regimens applied in registrative trials [ 27 , 28 ]. Recently, a Bayesian network meta-analysis on neovascular AMD concluded that the treat-and-extend regimen proved to be the most effective approach for each anti-VEGF drug available [ 29 ].…”

Traitement topique de la dégénérescence maculaire liée à l’âge

“…Néanmoins, le caractère récidivant de l'oedème maculaire, généralement associé à une baisse visuelle, impose la répétition régulière de ces IVT en fonction de la fréquence de récidive du patient. Bien qu'idéale pour la délivrance du principe actif au plus proche du site d'action ciblé (la macula), cette voie d'administration reste contraignante : dans la littérature, on parle même de « fardeau » thérapeutique pour le praticien, pour le patient et pour le système de santé [3,[14][15][16]. Pour le praticien, cette technique impose en effet une organisation optimale (salle dédiée et conforme aux normes d'asepsie, et matériel adapté à disposition) avec parfois la nécessité d'une assistance (infirmiers ou aides-soignants).…”

“…Le traitement par IVT impose en effet au patient des visites régulières associées à quelques souffrances psychiques (appréhension à chaque visite, peur des éventuels effets indésirables ou complications, peur de la perte de vision) mais aussi physiques (douleur modérée au moment de la piqûre, irritation oculaire post-injection). Malgré une bonne acceptabilité initiale du traitement (à défaut d'alternative), une baisse de la compliance peut s'observer au bout d'un certain temps (baisse de 20 % après 10 injections en deux ans) [15,17]. Des dispositions ont été mises en place afin de prendre en Ces formulations pourraient donc présenter un plus grand intérêt pour le ciblage du segment postérieur de l'oeil.…”

Crosstalk of protein clearance, inflammasome, and Ca2+ channels in retinal pigment epithelium derived from age-related macular degeneration patients

“…Intravitreal injections of anti-vascular endothelial growth factor and drugs ( i.e. bevacizumab, ranibizumab, aflibercept, brolucizumab) have proven to be effective to some extent ( 2 ). AMD etiology is known to be multifactorial.…”