Faricimab: Mechanism of Action, Payers’ Perspective, and Real-World Experience

Key opinion leaders discuss faricimab, its impact on the treatment landscape for wet AMD/DME, and what payers should look for when considering formulary positioning or utilization-management strategies.

Jim Kenney, RPh, MBA: Dr Luo, let’s talk about the recently approved faricimab. It has a dual mechanism that targets both VEGF and Ang2. How does the availability of this agent with a dual mechanism change the treatment landscape for AMD [age-related macular degeneration] and DME [diabetic macular edema]?

Caesar Luo, MD, FASRS, FACS: It changes it dramatically. I’ll build a little on what Dr [Veeral] Sheth said. We don’t know. We don’t have the right biomarkers to identify which patients will respond to what I like to call Ang2-sensitive eyes. There have been Ang2 studies for years. In isolation, it hasn’t been shown to be that effective, certainly not compared with VEGF. In combination, it seems to be more effective. In the phase 3 landmark…trials, faricimab had a superior drying effect of what we traditionally think as the best drying agent: aflibercept, or Eylea. They had better drying and more durability. We won’t cover the nuances of the study design here, but even in our own hands—it was approved last February—we’ve had the opportunity to use faricimab in our clinic. Faricimab isn’t just another anti-VEGF. That’s important because I start to see step therapy in some of my local payers, as if faricimab is just another treatment. When it gets pushed down the line, you forget that it’s a novel mechanism. The blockade of angiopoietin-2 is different from what we’re doing. A subset of patients are dramatic.

In my hands, I’ve looked through my data, and 40% of patients have an improved effect over aflibercept. These are patients who are actively being treated. There might even be a greater effect on treatment-naïve patients who haven’t been exposed to anti-VEGF. Maybe they don’t have some tachyphylaxis or blockade to their VEGF agents. It’s definitely a consideration as we come along to consider faricimab as a new agent, something different from anything we have available and that could be effective for a subset of patients sensitive to angiopoietin-2.

Jim Kenney, RPh, MBA: The good news from payers is that it’s not going to be added to a VEGF because it has VEGF capabilities; that’s a good thing. We see this challenge often in the rare disease or specialty space, where we add additional drugs and costs to the system. What about other considerations, as far as formulary positioning or utilization-management strategies? You mentioned step edits. It seems logical, from a payer perspective, to say that VEGFs would work and are relatively inexpensive, and we have some biosimilars coming into this space that would seem reasonable. Why would that maybe not be a reasonable approach to apply some steps believing, from the payer perspective, that clinically that’s a reasonable approach?

Caesar Luo, MD, FASRS, FACS: Jim, you’re preaching to the choir. You’re talking to 3 clinicians who are tearing our hair out every day in clinic because our hands are tied. We train, we do research, and we feel we’re doing the right thing for our patients. For that person sitting in the chair in front of us, we want the flexibility to do what we think is right. As a society, we tend to move very quickly. We had an improved medication called Beovu [brolucizumab] that worked really well but had some untoward adverse effects, so we stopped using it. It wasn’t a cost consideration, and it wasn’t a utilization question. We said that this was dangerous to our patients and we’re not going to use it. Faricimab is the flip side. We’ve seen some very impressive outcomes, but I can’t use it in all my patients. As you said, that’s because of step edits. It might be the third line. In those patients, they have to get bevacizumab times 3, fail that, and then aflibercept times 3, fail that. That’s 6 potential months before they’re getting something that might work for them. That’s a difficult conversation to have with Ms Smith, who’s sitting in my chair with difficulty seeing.

Our utilization strategy, as you said, is being able to get this on formulary. I had a patient who has specialty pharmacy as a requirement for her insurance. She has to battle with her payer every month because they try to send the drug to her house and have her bring it to us. But they don’t understand that patients aren’t in the drug business. They don’t know how to store $1000 medication or $2000 medication, so I couldn’t give her faricimab because she needed a specialty pharmacy for that to work. These conversations are beyond the scope of our clinical practice, yet we’re having them every day. We would love the flexibility to be able to do what we think is right for our patients.

Transcript edited for clarity.

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