Long-Term Bevacizumab Step Therapy Outcomes Favorable in Neovascular AMD

A bevacizumab step therapy protocol is an effective long-term treatment strategy for patients with neovascular age-related macular degeneration (nAMD), according to a case series published in Eye. After 1 year, patients managed using this approach experienced a mean visual acuity (VA) change from baseline was +8.4 letters (95% CI, +6.1 to +10.6 letters).

Researchers collected records of 347 eyes naïve to intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections between 2012 and 2019 at the Vanderbilt Eye Institute in Nashville. Patients received bevacizumab step therapy, a process by which physicians maintain bevacizumab treatment in patients who achieve success and switch to other anti-VEGF medications for those who fail. All patients were started on 4 monthly injections and evaluated for long-term outcomes.

The patients were aged mean 79.8±8.4 years, 64.6% were women, 27.7% had diabetes, 29.1% had a history of smoking, and baseline VA was 44.3±25.3 letters.

At year 1, all eyes received an average of 9.3 injections and VA increased by 8.4 letters from baseline. At year 2, 261 eyes received 16.0 injections and VA increased by 7.0 letters from baseline. At year 3, 192 eyes received 22.4 injections and VA increased by 4.0 letters. At year 4, 153 eyes received 29.0 injections and VA increased by 4.3 letters. At year 5, 109 eyes received 35.4 injections and VA had increased by 4.4 letters. At year 6, 75 eyes received 41.5 injections and VA increased by 4.2 letters. At year 7, 37 eyes received 47.9 injections and VA decreased by 0.7 letters.

In year 1, the treatment success rate was 85.6% and failure rate was 14.4%. The successes were stable at an 8-week bevacizumab injection schedule and 31.1% received injections at less than 8-week intervals. The failures either switched to aflibercept (6.3%) or were not switched at the providers discretion (8.1%). At year 5, 74.3% experienced treatment success (with 58.7% maintained on 8-week dosing, 15.6% on less than 8-week dosing). For patients who experienced treatment failure (25.7%) 11.9% of the total  were switched to aflibercept, and 13.8% were not switched at all.

Among the patients who switched to aflibercept (n=38) mean VA was 59.8±15.3 letters at baseline, 54.5±20.6 letters at switch, and 47.4±26.2 letters at the final follow-up.

The major limitation of this study was the reliance on Snellen VA measurements.

“A bevacizumab step therapy protocol implemented in routine clinical practice is effective for long-term treatment of nAMD. We hope these findings will inform the current health policy debate,” according to the study authors.