Combination therapy effective for AMD, especially when administered on the same day

HONG KONG — Double and triple therapies — combining anti-VEGF agents, steroids and photodynamic therapy — are effective in treating age-related macular degeneration, with a slight advantage seen when the therapies are administered in 1 day, a surgeon said.

"If you think of the pathogenesis [as being divided] into four different pathways — hypoxia, inflammation, cytokine expression and, finally, neovascularization — if we were truly trying to attack this, no single treatment modality could attack it. We really need to attack it from multiple fronts," Peter K. Kaiser, MD, said during Retina Subspecialty Day at the World Ophthalmology Congress.

In a subsequent free paper session, Dr. Kaiser presented data on 580 patients with at least 6 months of treatment and a mean of 1 year of follow-up in the QUEST (Registry for QLT Using Visudyne in Evaluation of Sequential and Triple Therapies) registry. The patients were divided nearly equally between predominantly classic, minimally classic and occult lesions, and the group as a whole had a mean gain in visual acuity of one line.

"The patients who were treatment naive did better than those who were previously treated, and again, if you look at the baseline number of treatments, about a quarter required no additional treatment," he said.

The patients who received triple therapy of PDT, an anti-VEGF agent and a steroid had slightly better visual results than double therapy of PDT with an anti-VEGF agent, although Dr. Kaiser noted the difference was not statistically significant.

Overall, he said the results were comparable to the MARINA (Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD) and ANCHOR (Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD) trials, with combination therapy producing slightly better results than ranibizumab monotherapy. The study also yielded a surprising result among lesion type subgroups.

"Interestingly enough, minimally classic patients did the worst with combination therapy. For reasons we simply cannot explain at this time, the occult [lesion] patients did the best," Dr. Kaiser said. Occult lesions also required the fewest number of re-treatments, as opposed to minimally classic lesions, which required the most re-treatments.

With regards to timing, Dr. Kaiser said that patients who started with triple therapy seemed to do better than patients who had another treatment before receiving triple therapy.

Although the results were not statistically significant, the delivery of combination therapy in 1 day showed slightly better results than when the therapies were delivered separately.

"The same-day treatment patients appeared to do the best, and the patients who did the worst were the ones that had anti-VEGF prior," he said. "This is not statistically significant, but it would suggest that either on the same day or where anti-VEGF follows PDT would be the best way to do combination therapy."