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Advances and Challenges in Anti-VEGF Therapies for Retinal Diseases
Advances and Challenges in Anti-VEGF Therapies for Retinal Diseases
Anti-VEGF therapies have transformed the treatment of retinal diseases such as neovascular (wet) macular degeneration, diabetic macular edema, and retinal vein occlusions. However, injection frequency and treatment burden for the patient remain key challenges. The main goal is to preserve vision while minimizing the impact on the patient's life.
Anti-VEGF Treatment Strategies: Balancing Efficacy and Convenience
There are three main approaches to administering anti-VEGF therapies:
- Fixed Dosing (FIDO): Delivers strong visual outcomes but involves a high treatment burden with very frequent injections (about 11 per year), which significantly affects the patient's time and costs.
- As Needed (PRN – Pro Re Nata): Reduces the number of injections (4 to 8 per year), but carries the risk of undertreatment and possible long-term vision loss if the disease reactivates between visits.
- Treat-and-Extend (TNE – Treat and Extend): Considered the preferred regimen by many specialists, TNE seeks a balance between visual efficacy and a lower treatment burden. It starts with frequent injections and, if the eye remains stable, the intervals are gradually extended. This makes it possible to maintain visual outcomes similar to fixed dosing with fewer injections (8 to 10 per year on average).
Anti-VEGF Drugs and Future Innovations
Anti-VEGF Drugs and Future Innovations
- Current drugs: Aflibercept (Aflivers) and Ranibizumab (Ran Bisumab) are effective in the TNE regimen, allowing longer intervals. Bevacizumab (Bebas Isumap) is a more affordable option used "off label," with debate over possible systemic risks.
- New drugs: Brolucizumab (Brulusumap) promised longer intervals, but raised concerns about intraocular inflammation. Faricimab (Farisim) is a promising development that targets two pathways and aims to extend intervals up to 16 weeks. Higher doses of existing drugs and the arrival of biosimilars, which could lower costs, are also being explored.
The Burden of Treatment and Patient Adherence
Treatment burden goes beyond the injection itself and includes time, logistics, emotional aspects, and dependence. This burden is a key factor in patients' poor adherence, explaining the gap between clinical trial results and everyday practice. Optimal adherence is vital to maintaining vision gains over the long term.
The Future: Fewer Injections, Greater Impact
Research is focused on reducing treatment frequency without compromising efficacy. The main avenues include:
- Long-acting drugs: Such as Faricimab, aiming for intervals of three or four months.
- Sustained-release implantable devices: Small reservoirs that release medication continuously for months (e.g., Sus Bimo), drastically reducing the need for injections, although they require initial surgery.
- Gene therapy: A transformative approach that aims to have the eye produce the anti-VEGF protein continuously, with the potential for a one-time treatment that lasts for years.
In conclusion, the choice of anti-VEGF strategy should be individualized, aiming to maximize vision and minimize treatment burden. The field is advancing rapidly toward less frequent options, which will improve patient adherence and quality of life.
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