In this MD Newsline exclusive interview with vitreoretinal specialist Dr. Alan Franklin, we discuss treatment strategies for wet AMD and the latest research.
What is your treatment strategy for wet AMD and how is it tailored to each patient? How do these treatments work? How do you decide when to switch treatments? Finally, can you share with us your professional opinion of Beovu (brolucizumab) and if you use it with your patients?
Dr. Alan Franklin:
“Current wet AMD treatment is targeted against one vascular growth factor called VEGF, or vascular endothelial growth factor. And our current technology blocks or sequesters VEGF away from its binding site or receptor.
The typical wet AMD treatment is 3 monthly injections, and that’s the standard induction. Some retina specialists will continue monthly injections. Others will only give the patient a monthly injection if they have evidence of active leakage when examined in the office. If they don’t have active leakage, they get a pass for another month.
We do a treat and extend protocol, so after those first 3 injections, if there’s no active leakage, we give patients 6 weeks off. If they remain leak-free at 6 weeks, we’ll give them 7 or 8 weeks off and slowly extend the time in between injections.
Avastin or bevacizumab and Lucentis or ranibizumab are the medications we typically use. There’s an overwhelming amount of data to show that they really act equally and have similar safety profiles. They’re both very safe medicines. I use Avastin (bevacizumab). I don’t use Lucentis (ranibizumab) often because it’s more expensive and acts equally. Eylea or aflibercept does work better in some patients, especially patients with deeper leakage in the retina.
Finally, there’s a drug that was approved called Beovu (brolucizumab). Beovu is a bit more effective at stopping the leakage, but about 1 in 100 people gets inflammation, and a little less than 1 in 1,000 people gets inflammation of the retinal vessels, which leads to irreversible vision loss. So, it has a little bit of an added benefit, but it also has a risk that’s not associated with the other injectable medications. So I don’t use Beovu much because of its potential risks.”
Which of the latest research studies on wet AMD are you most interested in regarding treatment safety and efficacy?
Dr. Alan Franklin:
“There’s a medication called faricimab that just met its endpoints in phase 3 clinical trials. Faricimab blocks VEGF, but it also blocks ANG2 or angiopoietin-2. It shows a little bit more of a durable effect than what we have now, and that’s one of our biggest issues in retinal disease treatment. It’s really difficult for patients to come in for monthly injections. As nice as I try to be, and as much empathy as I can show, nobody wants to see me to get an injection in the eye every month.
So, to have treatments that last longer is a big deal. Recently, a bunch of companies have been trying different approaches to achieve this goal, which is encouraging because right now, we only have one approach. Drug companies have tried a few different approaches over the past 5 to 10 years, and nothing has really worked. But now, there’s a combination of approaches.
The company that developed Lucentis (ranibizumab) has developed a port delivery system to deliver ranibizumab in the eye for 9 months or more. However, surgery is required to sew the port delivery system into the eye, so it’s not everyone.
Another company, Kodiak, developed a VEGF blocker that happens to be a big molecule, so it more slowly gets broken down, and after a few injections, they’re reporting 6-month durability.
Graybug has developed a small molecule that’s complexed to another molecule that breaks down slowly. They’re getting longer duration with good effectiveness.
And then, there’s a genetic treatment, which is kind of the Holy Grail. Some of the companies, Adverum and REGENXBIO, are getting durable effects after a single dose that are lasting 6 months, 12 months, and potentially even longer.
So, between the gene therapy, the small molecules, and other targets besides VEGF, there are a lot of companies coming out with fairly provocative technologies. I think in the next several years, as some of these drugs come to market, we’ll be treating macular degeneration a lot differently.”
Responses have been condensed and lightly edited.