Clinical Considerations for Retreatment in Failed Anti-VEGF Therapy

Veeral Sheth, MD, MBA, FACS discusses re-treatment in patients with wet AMD who have previously failed an anti-VEGF therapy.

Jim Kenney, RPh, MBA: Dr Sheth, when we talk about re-treating patients who have wet AMD [age-related macular degeneration] and didn’t respond to anti-VEGF, they essentially failed that. In what patient population is re-treatment appropriate or effective if there is 1?

Veeral Sheth, MD, MBA, FACS, FASRS: It depends on how you’re describing treatment failure. Caesar [Luo] mentioned under-responders and nonresponders. The way I’ll define it for the answer to this question is that patients who are being suboptimally treated—in other words, they have residual fluid, and we’re just not able to get them dry despite frequent therapy—are patients who I consider failures in my clinic because we’re not getting to that end point that we need to get them to. In those patients, before faricimab, we had only 1 option: to switch between anti-VEGF agents, which is what all of us would do in those patients. Today it’s different because we have a different type of agent with a different mechanism of action. If a patient isn’t responding well on anti-VEGF alone, it’s very easy to switch this patient to this dual mechanism of action with faricimab, for example.

Jim Kenney, RPh, MBA: If you have a patient who fails 1 anti-VEGF, what’s the likelihood they would respond to another? In a lot of disease areas—the autoimmune space, for example—we see a lot of this. If you’ve failed 1 anti–TNF [tumor necrosis factor], then it doesn’t make sense to start another 1. You should move to a different mechanism. Do you have a chance of getting a response from a second anti-VEGF agent?

Veeral Sheth, MD, MBA, FACS, FASRS: That’s a great question. We’re treating our own anxiety when we switch them, to be honest. You’re right: when we switch those patients, we don’t see many of them do significantly well. Do we see some patients dry out who weren’t dry on 1 agent and do dry on another agent? Sure, we see that. But to your point, the vast majority are going to do about the same because you’re not changing much other than the label on the actual syringe that you’re using.

Jim Kenney, RPh, MBA: That makes sense.

Transcript edited for clarity.

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