Retinal specialists are increasingly confident in extending treatment intervals beyond traditional limits when using next-generation anti-VEGF therapies for neovascular age-related macular degeneration (AMD) and diabetic macular edema (DME), according to insights from a clinical discussion among leading ophthalmologists Dr. Ehsan Rahimy, Dr. David Miller, and Dr. Michael Klufas.
The physicians report that real-world experience with newer, more durable anti-VEGF agents like faricimab and aflibercept 8 mg is reshaping treatment protocols, with some practitioners now comfortable extending intervals to 16 weeks for appropriate patients, and up to 20 weeks for DME patients with controlled hemoglobin A1c levels.
Extended Interval Strategies Show Promise
Traditional 12-week treatment caps are being reconsidered as physicians gain experience with newer agents. The specialists note that when switching patients from aflibercept 2 mg to the 8 mg formulation, they typically observe 2- to 4-week extensions in treatment intervals, with benefits often improving over time rather than immediately after the switch.
For DME patients specifically, both physicians have become more comfortable with 4-week extensions, while neovascular AMD patients, particularly those who are monocular, continue to receive more conservative 1- to 2-week extensions due to hemorrhage risk concerns.
Patient Compliance and Optimal Intervals
The discussion revealed a critical finding regarding patient compliance: adherence decreases significantly with intervals beyond 4 months. This has led physicians to identify a "sweet spot" of 3- to 4-month intervals for most patients, balancing optimal disease control with patient convenience and compliance.
Despite the durability of newer agents, some patients prefer more frequent visits as a "security blanket," highlighting the importance of incorporating patient preferences and vision dependence into treatment decisions.
Loading Dose Modifications in Real-World Practice
Real-world practice often differs from clinical trial protocols, particularly regarding loading doses and therapy switching. For treatment-naive patients, physicians generally follow recommended loading doses to maximize vision gains. However, for previously treated patients switching to newer agents like faricimab or aflibercept 8 mg, complete reloading may not be necessary.
Disease-specific considerations also influence loading strategies, with AMD typically requiring more strict adherence to loading protocols compared to DME.
Monitoring Challenges and Future Directions
Extended treatment intervals create new challenges in monitoring fellow eyes for conversion to neovascular disease. While home monitoring technologies using optical coherence tomography (OCT) show promise, reimbursement and workflow concerns remain barriers to widespread adoption.
Looking ahead, the specialists identified several emerging therapeutic approaches. Gene therapy shows particular promise with subretinal injection approaches, while tyrosine kinase inhibitors may offer a balance between efficacy and delivery convenience. For DME specifically, suprachoroidal delivery methods show potential for improving treatment outcomes.
Real-World Data Supplements Clinical Trials
The physicians emphasized that real-world data provides crucial safety insights from larger patient populations that supplement clinical trial findings. Clinical trials typically involve treatment-naive patients, while physicians often use new agents in previously treated patients, creating important knowledge gaps that real-world evidence helps fill.
This real-world experience with next-generation anti-VEGF therapies demonstrates how clinical practice continues to evolve as physicians gain confidence with newer, more durable treatment options, ultimately leading to more personalized and convenient care for patients with retinal diseases.
