Aflibercept in Wet AMD Beyond the First Year of Treatment
Aflibercept in Wet AMD Beyond the First Year of Treatment
The goal of T&E (an example of a proactive treatment regimen) is to find the optimal treatment interval at which patients can achieve maximum control of disease activity and stabilisation of VA with minimum treatment burden. T&E begins with an extension of the treatment interval after the seventh injection in Year 1. Treatment should be extended by 2-week intervals, up to a maximum of 12 weeks. The goal should be to maintain a 'stable' outcome, defined by the treating physician in consultation with each patient and based on OCT imaging and VA examination. Both imaging and examination should be carried out at every visit if possible. Monitoring is not required between injections.
As an example, at the seventh injection visit in Year 1, the patient (who has completed an 8-weekly treatment interval) is reviewed and re-injected. If there is no evidence of disease activity on OCT imaging and examination (in the opinion of the treating physician) and the patient has stable VA, the treatment interval is extended by 2 weeks and the next injection is scheduled for 10 weeks' time. At this time, VA is measured, an OCT scan is performed and the patient is re-injected. If the patient has stable disease (in the opinion of the treating physician), the treatment interval is extended by a further 2 weeks, and the next injection is scheduled for 12 weeks' time. Once the patient has achieved a 12-week treatment interval, treatment should continue at this frequency throughout the second year of treatment.
The T&E regimen also allows the physician to shorten the treatment interval if there is new evidence of disease activity (in the opinion of the treating physician) and/or a reduction in VA. In these cases, OCT imaging is performed, VA is assessed and the patient is injected. The interval to the next treatment is shortened as appropriate. For eyes with a small increase in disease activity (e.g. those with some fluid upon OCT but stable VA), shortening the treatment interval by 2 weeks is recommended. Eyes with significant disease recurrence (e.g. those with new CNV activity, a symptomatic reduction in VA, extensive sub-retinal haemorrhage or a marked change upon OCT) should undergo more frequent monitoring, with treatment where necessary.
At the end of Year 1, eyes with inactive disease (in the opinion of the treating physician) and stable VA are eligible for individualised T&E. The rationale for T&E, therefore, is to reduce the treatment burden and avoid unnecessary treatment in patients who have successfully achieved inactive disease at the end of Year 1.
The T&E regimen is suitable for both a one-stop service (where OCT/VA and injection are performed on the same day) and a two-stop service (where OCT/VA and injection are performed on different days). In two-stop clinics, the use of 'virtual clinics' can be employed to refine the patient pathway and improve capacity. Firstly, the injection visit is scheduled based on the OCT imaging and VA assessment from the previous visit. At the injection visit, OCT imaging is performed and VA is recorded prior to the injection. The OCT assessment then takes place either at the time the patient visits, or remotely (ie in the virtual clinic) at a later date by the consultant ophthalmologist or by a non-medical member of staff under supervision. The outcome of the OCT assessment determines when the patient is asked to come back for their next injection.
Approach B: Individualised T&E
Treatment Strategy
The goal of T&E (an example of a proactive treatment regimen) is to find the optimal treatment interval at which patients can achieve maximum control of disease activity and stabilisation of VA with minimum treatment burden. T&E begins with an extension of the treatment interval after the seventh injection in Year 1. Treatment should be extended by 2-week intervals, up to a maximum of 12 weeks. The goal should be to maintain a 'stable' outcome, defined by the treating physician in consultation with each patient and based on OCT imaging and VA examination. Both imaging and examination should be carried out at every visit if possible. Monitoring is not required between injections.
As an example, at the seventh injection visit in Year 1, the patient (who has completed an 8-weekly treatment interval) is reviewed and re-injected. If there is no evidence of disease activity on OCT imaging and examination (in the opinion of the treating physician) and the patient has stable VA, the treatment interval is extended by 2 weeks and the next injection is scheduled for 10 weeks' time. At this time, VA is measured, an OCT scan is performed and the patient is re-injected. If the patient has stable disease (in the opinion of the treating physician), the treatment interval is extended by a further 2 weeks, and the next injection is scheduled for 12 weeks' time. Once the patient has achieved a 12-week treatment interval, treatment should continue at this frequency throughout the second year of treatment.
The T&E regimen also allows the physician to shorten the treatment interval if there is new evidence of disease activity (in the opinion of the treating physician) and/or a reduction in VA. In these cases, OCT imaging is performed, VA is assessed and the patient is injected. The interval to the next treatment is shortened as appropriate. For eyes with a small increase in disease activity (e.g. those with some fluid upon OCT but stable VA), shortening the treatment interval by 2 weeks is recommended. Eyes with significant disease recurrence (e.g. those with new CNV activity, a symptomatic reduction in VA, extensive sub-retinal haemorrhage or a marked change upon OCT) should undergo more frequent monitoring, with treatment where necessary.
Eyes Suitable for T&E
At the end of Year 1, eyes with inactive disease (in the opinion of the treating physician) and stable VA are eligible for individualised T&E. The rationale for T&E, therefore, is to reduce the treatment burden and avoid unnecessary treatment in patients who have successfully achieved inactive disease at the end of Year 1.
Treatment Burden and T&E: use of Virtual Clinics
The T&E regimen is suitable for both a one-stop service (where OCT/VA and injection are performed on the same day) and a two-stop service (where OCT/VA and injection are performed on different days). In two-stop clinics, the use of 'virtual clinics' can be employed to refine the patient pathway and improve capacity. Firstly, the injection visit is scheduled based on the OCT imaging and VA assessment from the previous visit. At the injection visit, OCT imaging is performed and VA is recorded prior to the injection. The OCT assessment then takes place either at the time the patient visits, or remotely (ie in the virtual clinic) at a later date by the consultant ophthalmologist or by a non-medical member of staff under supervision. The outcome of the OCT assessment determines when the patient is asked to come back for their next injection.