Anti-VEGF Medications for Wet AMD: Are They Right for You?

Ophthalmologists most often prescribe:

• Ranibizumab (Lucentis)
• Aflibercept (Eylea)
• Faricimab-svoa (Vabysmo)

Bevacizumab (Avastin) is a medication that was initially used to treat cancer. It has been prescribed off label to treat wet AMD since 2005, according to the AAO. The original anti-VEGF, pegaptanib (Macugen), was approved in 2004 but is no longer available in the United States.

A study examining the long-term outcomes of patients receiving aflibercept, ranibizumab, and bevacizumab found no significant differences among the anti-VEGF medications. And, in a review of studies investigating the safety and effectiveness of anti-VEGF medications for treating wet AMD, researchers concluded the medications in the class were equally effective.

Before anti-VEGF drugs were developed, there were no effective treatments for wet AMD. In fact, as many as two-thirds of people with the condition were expected to become legally blind within two years of developing the eye disease, according to the AAO.

Today, the outlook is different for people with wet AMD, says Sarju Patel, MD, MPH, attending physician at Retinal Consultants Medical Group in Northern California. He notes that many people who receive anti-VEGF treatments can retain their vision.

“It’s very effective. It changed everything,” says Dr. Patel. “And, more importantly, it stabilizes the disease … so that it doesn’t continue to progress.”

Early research suggested that people who took anti-VEGF medications had a small increased risk of cardiovascular problems, including heart attack and stroke, but other research — including a review published in Ophthalmology Retina — has found no increase in mortality rates among people who take anti-VEGF medication.

It may be that many of the people affected by wet AMD who had participated in the early studies tended to be older. So, they were already at an increased risk of heart disease, says Patel. Some doctors wait to give anti-VEGF drugs to people who’ve recently had a stroke. But, in general, it doesn’t stop those patients from receiving the treatment later. Even so, more research is needed to determine the long-term effects and safety of blocking VEGF.

Also, women who are pregnant cannot get anti-VEGF treatment.

There is no cure for wet AMD, so most people require ongoing anti-VEGF treatment, says Patel. Clinical trials have shown that more than 90 percent of people treated with anti-VEGF medications keep their vision, according to the AAO.

In the real world, though, only about 50 percent of people who take anti-VEGF medications keep their vision, partly because, unlike clinical trial participants, they don’t receive the injections as often as they should. Older adults sometimes have trouble getting to appointments and may also have other health conditions, both of which may prevent them from getting regular injections.

People who respond well enough to anti-VEGF treatment may be able to go longer than a month or two between injections, which could make it easier to keep up with them. But, “If you stop treatment completely, there’s a very good chance [you] can lose vision,” says Raj Maturi, MD, a clinical spokesperson for the AAO and retina specialist at Midwest Eye Institute in Carmel, Indiana.

For only a fraction of people does the disease “go quiet,” meaning the vision loss doesn’t get worse, says Patel. And, even people who are able to stop getting injections will need to be monitored regularly by an ophthalmologist for signs of a reemergence of wet AMD.

Faricimab differs from other anti-VEGF medications in that it targets not only VEGF proteins, but also angiopoietin-2 proteins, which can cause abnormal blood vessel growth, too, says Patel.

Targeting these two proteins may allow for less frequent shots, but Yang notes that more studies need to be done to prove this. “In theory, it should work better than the medication that only targets VEGF, but this is a relatively new medication,” says Yang. “We need more data.”

Although anti-VEGF medications are highly effective, researchers continue to look for and develop better approaches to treating wet AMD, including options that don’t require ongoing injections.

One of these is gene therapy — a onetime shot that can help the eye produce its own anti-VEGF therapy. It could be injected underneath the retina in a surgical procedure or into the eye, according to Dr. Maturi.