From the Guidelines
The National Institute for Health and Care Excellence (NICE) guidelines for wet age-related macular degeneration recommend anti-vascular endothelial growth factor (anti-VEGF) therapy as first-line treatment, with aflibercept, ranibizumab, or bevacizumab administered as intravitreal injections, and treatment frequency determined by disease activity after a loading phase of three consecutive months 1.
Key Recommendations
- Treatment typically begins with a loading phase of monthly injections for three consecutive months, followed by a maintenance phase where treatment frequency is determined by disease activity, with options including monthly or bimonthly injections, treat-and-extend, or PRN protocols 1.
- The choice of anti-VEGF agent should be based on clinical effectiveness and cost, with the least costly agent preferred when multiple options have similar clinical effectiveness.
- Regular monitoring with optical coherence tomography (OCT) is essential to assess treatment response and determine injection frequency, with additional tests such as OCTA and fluorescein angiography performed as indicated depending on clinical findings and judgment of the treating ophthalmologist 1.
Patient Management
- Patients should be instructed to report symptoms of endophthalmitis, retinal detachment, or decreased vision, and should be re-examined promptly if any new or significant visual symptoms occur 1.
- Patients with unilateral disease should be advised to take AREDS/AREDS2 supplements to lower the risk of developing advanced AMD in the fellow eye, and should be instructed to monitor their vision and return to the ophthalmologist periodically, even in the absence of symptoms 1.
- Ancillary clinical personnel should be aware of the importance of prompt examination for patients with new symptoms suggestive of AMD, and should be trained to conduct certain aspects of testing under the supervision of an ophthalmologist 1.
From the Research
NICE Guidelines for Wet Age-Related Macular Degeneration
- The National Institute for Health and Care Excellence (NICE) guidelines for wet age-related macular degeneration recommend the use of anti-vascular endothelial growth factor (VEGF) agents, such as ranibizumab and aflibercept, for the treatment of the condition 2, 3.
- The guidelines suggest that aflibercept, dosed every 2 months after a monthly loading dose for 3 months, is noninferior to monthly injections of ranibizumab in maintaining or improving vision at 52 weeks 2, 3.
- Other anti-VEGF agents, such as bevacizumab and conbercept, may also be considered for the treatment of wet age-related macular degeneration, although their use may be limited by the need for frequent dosing 4, 5.
- Research is ongoing to develop new anti-VEGF therapies that can decrease injection frequency through longer half-life or port-delivery systems, such as brolucizumab, KSI-301, and ranibizumab port delivery system 6, 4.
- The choice of treatment depends on the exact type, location, and extent of the degeneration, as well as the patient's individual needs and preferences 5.
Treatment Options
- Intravitreal injections of anti-VEGF agents are the current standard of care for wet age-related macular degeneration 2, 3.
- Sustained drug delivery routes, such as the ranibizumab port delivery system, or subconjunctival or suprachoroidal injection, may offer a way to reduce dosing frequency and improve treatment outcomes 6.
- Other methods of VEGF inhibition, such as faricimab and BI-X, are being developed and may offer alternative treatment options in the future 6, 4.
Future Directions
- Research is ongoing to develop more effective and longer-lasting treatments for wet age-related macular degeneration, with the goal of reducing dosing frequency and improving treatment outcomes 6, 4.
- The development of new anti-VEGF therapies and sustained drug delivery systems may offer improved treatment options for patients with wet age-related macular degeneration in the future 6, 4.