Case Study Introduction

Helping to Select the Right Drug for the Job

By John W. Kitchens, MD

When aflibercept (Eylea, Regeneron) first became available, I used it almost exclusively as an agent for “under-responders” (patients who had undergone multiple monthly injections with other agents and still had persistent leakage, particularly subretinal or intraretinal fluid). The response I witnessed in these patients emphasized the efficacy of aflibercept. Not only would many of these patients with chronic intra- or subretinal fluid become significantly drier, but in many instances, their pigment epithelial detachment (PED) would unexpectedly reduce in size. This led me to use aflibercept as a first-line agent for PEDs. My colleagues also reported seeing a reduction in the size of PEDs when using aflibercept. Later, a subset of the VIEW 1 and 2 data revealed aflibercept to be more effective at reducing PEDs than other agents.¹

Because all three anti-VEGF medications (bevacizumab, ranibizumab and aflibercept) show excellent efficacy in the treatment of wet AMD, I typically use insurance coverage as the basis for determining which medication the patient receives. Patient assistance programs and drug sampling also help ease the burden of “out-of-pocket” expenses for patients. In general, I discuss the various treatment options with patients, including the cost of the drugs and the theoretical risks of the additional step for compounding of bevacizumab. If the patient has a PED component, I briefly discuss the benefits of aflibercept on PED resolution as seen in the VIEW 1 and 2 studies. If there is limited room for improvement in the patient’s visual acuity beyond 20/200 and the patient has a normal-seeing fellow eye, then I discuss the cost ramifications of treating their eye with an expensive medication. For everyone else, I discuss the CATT, ANCHOR/MARINA, HARBOR and VIEW results in layman’s terms.

Engaging and educating the patient enables the choice to be his or her own decision. In general, a well-educated patient and family will always make the choice that’s right for them.

See the case studies on the subsequent pages that show how, in certain instances, switching therapies can help improve patient responses.

Reference