Optimal approaches and criteria to treat-and-extend regimen implementation for Neovascular age-related macular degeneration: experts consensus in Taiwan

Abstract

The management of neovascular age-related macular degeneration (nAMD) has taken a major stride forward with the advent of anti-VEGF agents. The treat-and-extend (T&E) approach is a refined management strategy, tailoring to the individual patient's disease course and treatment outcome. To provide guidance to implementing anti-VEGF T&E regimens for nAMD in resource-limited health care systems, an advisory board was held to discuss and generate expert consensus, based on local and international guidelines, current evidence, as well as local experience and reimbursement policies. In the experts' opinion, treatment of nAMD should aim to maximize and maintain visual acuity benefits while minimizing treatment burden. Based on current evidence, treatment could be initiated with 3 consecutive monthly injections. After the initial period, treatment interval may be extended by 2 or 4 weeks each time for the qualified patients (i.e. no BCVA loss ≥5 ETDRS letters and dry retina), and a maximum interval of 16 weeks is permitted. For patients meeting the shortening criteria (i.e. any increased fluid with BCVA loss ≥5 ETDRS letters, or presence of new macular hemorrhage or new neovascularization), the treatment interval should be reduced by 2 or 4 weeks each time, with a minimal interval of 4 weeks. Discontinuation of anti-VEGF may be considered for those who have received 2-3 consecutive injections spaced 16 weeks apart and present with stable disease. For these individuals, regular monitoring (e.g. 3-4 months) is recommended and monthly injections should be reinstated upon signs of disease recurrence.

Keywords: Anti-vascular endothelial growth factors; Expert opinion; Neovascular age-related macular degeneration; Treat-and-extend.

Conflict of interest statement

CKC has received consultant fee from Bayer and honorarium from Allergan, Bayer, and Novartis; SJC has received consultant fee from Bayer and Novartis and honorarium from Allergan, Bayer, and Novartis; JTC has received consultant fee from Bayer; LJC has received consultant fee and honorarium from Bayer and Novartis; SNC has received consultant fee from Bayer; WLC has received consultant fee from Bayer and honorarium from Bayer and Novartis; SMH has received consultant fee from Bayer and honorarium from Allergan, Bayer, and Novartis; CHL has received consultant fee from Bayer and Novartis; SJS has received consultant fee from Bayer and honorarium from Allergan, Bayer, and Novartis; PCW has received consultant fee from Bayer and Novartis; WCW has received consultant fee from Bayer and Novartis; WCW has received consultant fee from Bayer and honorarium from Allergan, Bayer, and Novartis; CMY has received consultant fee from Bayer and Novartis and honorarium from Bayer and Novartis; LY has received consultant fee from Bayer and Novartis and honorarium from Allergan; TCC has received consultant fee from Bayer, Novartis; CHY has received consultant fee from Bayer and honorarium from Allergan, Bayer, and Novartis.

© 2022. The Author(s).

Figures

Fig. 1

Management algorithm for nAMD patients undergoing anti-VEGF T&E regimens. 1Stable vision is defined as BCVA gain or BCVA loss < 5 ETDRS letters (or 1 line of Snellen chart). 2VA and OCT assessment should be conducted at visit of the third injection. 3Absence of macular hemorrhage and neovascularization is required. 4Non-increased fluid after 3 more consecutive monthly injections following initial treatment could be considered as persistent fluid, and the injection interval could be extended if VA is stable. 5Active disease is defined as any increased fluid with BCVA loss ≥5 ETDRS letters (or 1 line of Snellen chart), new macular hemorrhage, or new neovascularization. 6For patients with either increased fluid or BCVA loss ≥5 ETDRS letters alone, the treatment interval could be maintained or shortened. 7Patients who have met the exit criteria with serous PED should be monitored frequently (e.g. monthly or bi-monthly). BCVA, best-corrected visual acuity; ETDRS, Early Treatment Diabetic Retinopathy Study; nAMD, neovascular age-related macular degeneration; OCT, optical coherence tomography; PED, pigment epithelial detachment; T&E, treat-and-extend; VA: visual acuity; VEGF, vascular endothelial growth factor