Worth changing? Clinical effects of switching treatment in neovascular age-related macular degeneration from intravitreal ranibizumab and aflibercept to bevacizumab in a region in southern Sweden

Abstract

Purpose: To examine the clinical effects of switching intravitreal drug treatment from the approved vascular endothelial growth factor inhibitors, ranibizumab and aflibercept, to off label use of bevacizumab in patients with wet age-related macular degeneration. Methods: This retrospective study scrutinized medical records of patients with wet age-related macular degeneration who switched therapy to bevacizumab due to a policy decision. Best corrected visual acuity, central retinal thickness, and number of injections before and 1 year after the switch was compared. The non-inferiority margin of best corrected visual acuity was five Early Treatment Diabetic Retinopathy Study letters. Results: A switch from ranibizumab was evaluable in 93 eyes and from aflibercept in 19 eyes. Neither of the groups had a significant non-inferior visual acuity 16 month after the switch. Mean best corrected visual acuity in Early Treatment Diabetic Retinopathy Study letters was 63.8 (95% confidence interval: 61.3–66.4) before and 62.2 (95% confidence interval: 59.3–65.1) after in the ranibizumab group and 68.2 (95% confidence interval: 63.3–73.1) before and 67.7 (95% confidence interval: 62.8–72.6) after in the aflibercept group. Mean central retinal thickness in micrometers decreased from 254 (95% confidence interval: 247–261) to 250 (95% confidence interval: 225–275) in the ranibizumab group and from 265 (95% confidence interval: 255–276) to 262 (95% confidence interval: 251–273) in the aflibercept group. The treatment was changed again after the switch in 18% of the patients in the ranibizumab group and 19% in the aflibercept group and these subjects were excluded from the analyses. Conclusion: In patients with neovascular age-related macular degeneration, a switch from ranibizumab or aflibercept to bevacizumab seems possible without a significant decrease in visual acuity in most patients.

Transitioning from Aflibercept to Biosimilar Ranibizumab in Neovascular AMD (The TRANSFORM Trial): A Multicenter Observational Study

“…In their retrospective study on shifting anti-VEGF, it was noted that switching therapy for medical reasons may have a more beneficial effect on visual acuity than when switching is performed strictly for economic reasons. 16 The current analysis differs from the above studies in that the shift was from aflibercept to biosimilar ranibizumab instead of the innovator molecule.…”

“…Previous studies have compared the effects of aflibercept and ranibizumab on subretinal fluid (SRF) and intraretinal fluid (IRF) resolution in patients with neovascular age-related macular degeneration (nAMD). 16 , 17 A study specifically aimed to compare the effects of three initial doses of aflibercept and ranibizumab on serous pigment epithelial detachment (PED), SRF, and IRF in treatment-naïve nAMD patients. The results indicated that both drugs had similar effects on the regression of PED, SRF, and IRF during the initial loading phase, leading to the conclusion that both drugs had similar effects on these parameters in the macula of treatment-naïve patients with nAMD.…”

Intravitreal Bevacizumab in Neovascular Age-Related Macular Degeneration as First Choice: a New Italian Ruling

“…We would like to mention the case of Sweden where a switch to bevacizumab was imposed by their health authority. While no significant drop of visual acuity was reported after the switch, 18-19% of patients were found to be non-responder to bevacizumab and switched back to ranibizumab or aflibercept [41]. Different attitudes towards the off-label use of bevacizumab in nAMD across the European Nations have been shown by a recent report [42]; indeed in Europe the use of bevacizumab in nAMD may vary considerably, ranging from non-existent (Switzerland, Hungary, Denmark) to very frequent (Romania, Bulgaria, Finland, Ireland, Netherlands).…”

Switching from ranibizumab and aflibercept to bevacizumab therapy in neovascular age-related macular degeneration patients

“…Altogether, the authors’ findings supported the conclusion that a switch of treatment from ranibizumab/aflibercept to bevacizumab was possible in the majority of patients without significant inferior clinical effect. 1 However, the validation, extrapolation, and generalizability of the authors’ conclusion 1 can be made only by statistical analyses including all the missing baseline potential predictors referred above by us in addition to the baseline characteristics already evaluated in this study, serving to identify the putative metrics influencing the assessment of the comparative effectiveness between ranibizumab/aflibercept and bevacizumab therapy. 3,5…”

“…We would like to address several challenges with the study by Bro and Hagg. 1 First, we wondered whether or not the 107 wet agerelated macular degeneration (wet AMD) patients included in this study had active choroidal neovascularization (CNV) confirmed by the fluorescein/indocyanine investigations requiring therapy? After careful examination of the patients' characteristics we inferred that they had been apparently stabilized at baseline, before and after switch with their central retinal thickness values ranging within the normal limits.…”