Targeting key angiogenic pathways with a bispecific CrossMAb optimized for neovascular eye diseases

Real-World Evidence for Faricimab in Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema: A Scoping Review

Purpose

Since faricimab (Vabysmo) was approved for the treatment of neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME), a growing body of real-world data has been reported, forming an important source of evidence for faricimab in a heterogeneous population. Scoping reviews are an effective approach to comprehensively assess the state of evidence on areas yet to be well characterized, allowing for the inclusion of a wide range of study designs and methodologies. This scoping review aimed to assess the current breadth and nature of real-world evidence (RWE) for faricimab and describe its safety and effectiveness in routine clinical practice.

Design

Scoping review of published articles and grey literature.

Participants

Eligible records included primary research reporting on any real-world data from ≥5 participants treated with faricimab in its licensed indications, published in English since 2022. This review did not involve novel data collection in human participants.

Methods

MEDLINE, Embase, and the Cochrane Database of Systematic Reviews were searched on February 16, 2024, and the results were reviewed by 2 independent reviewers. Manual searches of proceedings from major relevant conferences, ClinicalTrials.gov, and bibliographies of relevant systematic literature reviews were also conducted. Findings were summarized descriptively.

Main Outcome Measures

Data of interest included study design, population characteristics, treatment history, visual function and anatomic outcomes, patient-reported outcomes, safety, and economic outcomes.

Results

A total of 63 studies reporting RWE for faricimab in patients with nAMD or DME (n = 6-12 119 eyes) were identified, including a majority of studies in previously treated patients. Studies spanned 10 countries, with a predominance of retrospective observational studies. Results across the majority of studies suggested that faricimab was associated with improved visual acuity, reduced central choroidal/subfield macular thickness, and reduced/resolved retinal fluid and pigment epithelial detachment in both conditions, even over longer study periods (≥6 months). Adverse events reported were similar to the findings within the registration trials.

Conclusions

Outcomes of faricimab in routine practice align with reports from clinical trials, supporting the effectiveness and safety of faricimab in heterogeneous populations. Further high-quality studies using prospective, multicenter designs are required to provide a more comprehensive understanding of the long-term outcomes associated with faricimab.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A pharmacovigilance study on the safety of faricimab in real-world scenario using FDA adverse event reporting system database

BACKGROUND

Faricimab is predominantly prescribed for conditions such as age-related macular degeneration (AMD), diabetic macular edema (DME), and macular edema related to retinal vein occlusion (RVO-ME). Currently, a notable absence of large-scale, real-world studies focusing on the adverse reactions of faricimab exists.

METHODS

This study assesses the side effects of faricimab by analyzing reports of adverse events (AEs) from the FDA's AE Reporting System (FAERS) database. Through disproportionality analysis, this study substantiates the drug's safety oversight.

RESULTS

Our study revealed 2,746 instances of adverse events linked to faricimab, spanning 21 system organ classes (SOCs). The study retained 121 significant disproportionality preferred terms (PTs) that met criteria across all four analytical methods. Faricimab-associated AEs not documented in the drug instructions included visual impairment, blindness, retinal hemorrhage, anterior chamber inflammation, keratic precipitates, dry eye, chorioretinitis, diabetic retinopathy, and others.

CONCLUSION

The majority of our results align with earlier clinical studies and the details outlined in the product's manual. Additionally, we identified several unforeseen and potential AE signals related to faricimab use. These insights are instrumental for ongoing clinical surveillance and risk assessment associated with the drug.

Immune Checkpoint PD-L1 Modulates Retinal Microglial Activation to Alleviate Vascular Leakage in Choroidal Neovascularization via ERK

Neovascular age-related macular degeneration (NVAMD) is a common retinal disease causing vision loss in the elderly. Neuroinflammation significantly contributes to NVAMD's etiology. This study explores the role of Programmed cell death ligand 1 (PD-L1), an immune checkpoint (ICP) in microglia, known for limiting neuroinflammation in neurodegenerative diseases, and its potential function in NVAMD. This work finds increased PD-L1 expression in retinal microglia following laser injury. PD-L1 knockout (KO) or inhibitory PD-L1 antibody treatment worsens vascular leakage and neoangiogenesis in a laser-induced NVAMD mouse model, effects reversible by microglia depletion with PLX5622. This study underscores that choroidal neovascularization (CNV) may be regulated by multiple mechanisms, with PD-L1 modulation representing one of these pathways. Blocking PD-L1 elevated proinflammatory factors and p-ERK levels, indicating microglial overactivation in NVAMD. Conversely, enhancing PD-L1 signaling reduced neuroinflammation and neovascularization via ERK. These findings highlight PD-L1's role in neoangiogenesis and neuroinflammation in NVAMD, suggesting its potential as a target for immunomodulatory treatment in NVAMD.

[Faricimab in previously treated neovascular age-related macular degeneration : Study design of the prospective noninterventional study PASSENGER]

BACKGROUND

Faricimab was approved in the European Union in 9/2022 as the first bispecific antibody for the treatment of neovascular age-related macular degeneration (nAMD), visual impairment due to diabetic macular oedema (DME) or retinal vein occlusion. To date, the efficacy profile of faricimab has been investigated under pivotal clinical phase 3 study conditions in treatment-naïve nAMD patients. The prospective noninterventional study (NIS) PASSENGER is a multicentre study that aims at contributing to a better understanding of the effectiveness, safety and impact of faricimab on quality of life in previously treated patients with nAMD under real-world conditions in Germany.

METHODS

The planned observation period per patient is 24 months. Patients (n = 620) aged ≥ 50 years with nAMD who switched to faricimab no longer than 12 weeks prior to enrolment in the study, were previously treated with a vascular endothelial growth factor (VEGF) inhibitor for a maximum of 36 months, and had a best corrected visual acuity (BCVA) of 30-80 letters on the Early Treatment Diabetic Retinopathy Study (ETDRS) scale at the start of therapy with faricimab are eligible to participate. The primary outcome measure is the change in BCVA from baseline after 52 weeks. In addition, central subfield thickness, intraretinal, subretinal and subpigment epithelial fluid over time as well as patient-reported outcomes, adherence and adverse events are recorded.

RESULT

The first patient was enrolled in June 2023. According to the current schedule, recruitment (24 months) will be completed by June 2025 and the last patient visit is anticipated in Q2/2027.

CONCLUSION

Data from the PASSENGER study are intended to contribute to a better understanding of therapy management in daily practice in Germany.

Early Outcomes After Initiation of Faricimab for Neovascular Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE

This study assessed treatment patterns and early outcomes among patients with neovascular age-related macular degeneration (nAMD) initiating faricimab in routine clinical practice in the United States.

PATIENTS AND METHODS

FARETINA-AMD is a retrospective study among patients with nAMD initiating faricimab from February 2022 to June 2023 identified from the US IRIS® Registry.

RESULTS

Included were 21,508 patients previously treated with anti-vascular endothelial growth factor (anti-VEGF) (25,784 eyes) and 1,836 treatment-naïve patients (1,982 eyes) with nAMD. Among previously treated eyes, visual acuity remained stable with faricimab. In treatment-naïve eyes, mean ± SD visual acuity improved from 56.7 ± 24.1 letters at index to 61.4 ± 22.3 after faricimab injection 4 (P < 0.01). Mean ± SD central subfield thickness improved from 315.2 ± 80.0 (index) to 264.9 ± 60.1 μm (injection 4) in treatment-naïve eyes and 296.2 ± 95.5 to 273.0 ± 81.4 μm in previously treated eyes (both P < 0.01).

CONCLUSIONS

Among patients with nAMD receiving faricimab, visual acuity improved in treatment-naïve eyes, and both previously treated and treatment-naïve eyes experienced anatomical improvement. [Ophthalmic Surg Lasers Imaging Retina 2025;56:XX-XX.].

Early Outcomes After Initiation of Faricimab in Patients With Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

This study evaluated treatment patterns and outcomes among patients with diabetic macular edema (DME) treated with the bispecific antibody faricimab in routine clinical practice in the United States.

PATIENTS AND METHODS

FARETINA-DME was a retrospective study among patients with DME initiating faricimab from February 2022 to June 2023 identified from the United States IRIS® Registry.

RESULTS

Four thousand five hundred fourteen (4,514) patients (6,204 eyes) previously treated with anti-vascular endothelial growth factor (anti-VEGF) therapy and 691 treatment-naïve patients (851 eyes) were included. In previously treated eyes, mean ± SD visual acuity was 64.0 ± 18.3 letters at index and 65.3 ± 19.0 at faricimab injection 4. In treatment-naïve eyes, visual acuity improved from 60.3 ± 19.8 to 63.9 ± 18.5 letters (P < 0.01). Mean ± SD central subfield thickness improved from 364.3 ± 132.2 to 330.1 ± 121.2 μm in previously treated eyes and 359.6 ± 115.0 to 307.4 ± 114.6 μm in treatment-naïve eyes (both P < 0.01).

CONCLUSIONS

In patients with DME receiving faricimab, visual acuity was maintained in previously treated and improved in treatment-naïve eyes. Both groups had anatomical improvement. [Ophthalmic Surg Lasers Imaging Retina 2025;56:XX-XX.].

Two-year outcomes of treat-and-extend regimen with intravitreal faricimab for treatment-naïve neovascular age-related macular degeneration

PURPOSE

We previously reported 1-year outcomes of a treat-and-extend (TAE) regimen with intravitreal faricimab (IVF) for treatment-naïve neovascular age-related macular degeneration (nAMD). Herein, we evaluated the second-year results of this TAE regimen with IVF in eyes completing the first-year treatment.

STUDY DESIGN

Retrospective, interventional case series.

METHODS

We retrospectively studied 30 eyes with treatment-naïve nAMD that had completed the initial year of treatment, assessing best-corrected visual acuity (BCVA), foveal thickness (FT), central choroidal thickness (CCT), total number of injections over 2 years, and intended injection interval at the last visit.

RESULTS

Twenty-five eyes completed the 2-year IVF treatment. There was no significant difference between pre-treatment and 2 years post-treatment BCVA. FT and CCT both showed significant reductions, maintained during the 2-year study period. The total number of injections was 10.1 ± 1.2 over the 2 years. The intended injection interval at the last visit was 13.0 ± 3.4 weeks. Of 5 eyes not completing 2 years of IVF treatment, 4 were switched to other anti-vascular endothelial growth factor (VEGF) agents due to persistent fluids despite IVF at 8-week intervals. In the remaining eye, IVF treatment was discontinued due to suspected faricimab-related intraocular inflammation.

CONCLUSIONS

The TAE regimen with IVF for treatment-naïve nAMD was effective during a 2-year period for improving exudative changes and maintaining visual acuity. Although IVF was found to be a relatively safe treatment for nAMD, there were cases requiring a switch to other anti-VEGF agents due to inadequate fluid control effect.

Outcomes by Faricimab Treatment Interval at Week 48 of TENAYA-LUCERNE Phase 3 Trials in Neovascular Age-Related Macular Degeneration

PURPOSE

To assess the visual and anatomic outcomes by individualized treatment intervals at week 48 in patients with neovascular age-related macular degeneration (nAMD) treated with the dual angiopoietin-2/vascular endothelial growth factor (VEGF)-A inhibitor faricimab in a post hoc analysis of pooled data from TENAYA/LUCERNE.

DESIGN

TENAYA/LUCERNE (NCT03823287/NCT03823300) were identically designed, randomized, double-masked, active comparator-controlled, noninferiority phase 3 trials.

PARTICIPANTS

Treatment-naïve patients ≥ 50 years of age with nAMD randomized to the faricimab up to every 16 weeks (Q16W; n = 665) arm.

METHODS

Patients in the faricimab arm received 4 initial Q4W doses through week 12. At weeks 20 and 24, they were assigned to fixed Q8W, Q12W, or Q16W treatment intervals through week 60, based on prespecified central subfield thickness (CST) or best-corrected visual acuity (BCVA) disease activity criteria or presence of new macular hemorrhage, per investigator clinical examination. The primary analysis was at week 48.

MAIN OUTCOME MEASURES

Mean changes from baseline in BCVA and CST through week 48 by treatment interval group.

RESULTS

At week 48, the proportion of faricimab-treated patients on each treatment interval was 45.3% (Q16W), 33.4% (Q12W), and 21.2% (Q8W). The baseline patient characteristics were well balanced across faricimab treatment intervals. However, patients assigned to treatment at Q16W and Q12W had less severe disease at baseline versus patients assigned to Q8W. All patients showed sustained BCVA gains and CST reductions through week 48. Mean (95% confidence interval) change from baseline in BCVA was +7.9 letters (6.6, 9.2), +4.0 letters (2.2, 5.7), +5.3 letters (2.4, 8.2); and in CST was -142.9 μm (-156.9, -128.9), -112.5 μm (-131.0, -94.1), and -165.1 μm (-193.8, -136.4) for Q16W, Q12W, and Q8W, respectively.

CONCLUSIONS

Vision and anatomic improvements were achieved and maintained in all faricimab individualized treatment interval groups, with patients treated at longer intervals having more stable outcomes with fewer injections. The clinically relevant disease activity criteria based on vision or anatomy allowed treatment of patients with nAMD to be rapidly extended after the initial dosing phase while maintaining visual gains through week 48 of TENAYA/LUCERNE.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Faricimab Reverts VEGF-A165-Induced Impairment of the Barrier Formed by Retinal Endothelial Cells

VEGF-A165-induced persistent dysfunction of the barrier formed by immortalized bovine retinal endothelial cells (iBREC) is only transiently reverted by inhibition of VEGF-A-driven signaling. As angiopoietin-2 (Ang-2) enhances the detrimental action of VEGF-A165, we studied if binding of both growth factors by the bi-specific antibody faricimab sustainably reverts barrier impairment. Confluent monolayers of iBREC were exposed to VEGF-A165 for one day before 10-1000 µg/mL faricimab was added for additional five days. To assess barrier function, we performed continuous electric cell-substrate impedance, i.e., cell index, measurements. VEGF-A165 significantly lowered the cell index values which recovered to normal values within hours after the addition of faricimab. Stabilization lasted for two to five days, depending on the antagonist's concentration. As determined by Western blotting, only ≥100 µg/mL faricimab efficiently normalized altered expression of claudin-1 and claudin-5, but all concentrations prevented further increase in plasmalemma vesicle-associated protein induced by VEGF-A165; these proteins are involved in barrier stability. Secretion of Ang-2 by iBREC was significantly higher after exposure to VEGF-A165, and strongly reduced by faricimab even below basal levels; aflibercept was significantly less efficient. Taken together, faricimab sustainably reverts VEGF-A165-induced barrier impairment and protects against detrimental actions of Ang-2 by lowering its secretion.

Anatomic Outcomes with Faricimab vs Aflibercept in Head-to-Head Dosing Phase of the TENAYA/LUCERNE Trials in Neovascular Age-related Macular Degeneration

PURPOSE

To compare early anatomic outcomes after treatment with faricimab versus aflibercept in a pooled analysis of the head-to-head dosing phase of the TENAYA/LUCERNE trials in neovascular age-related macular degeneration (nAMD).

DESIGN

TENAYA/LUCERNE (NCT03823287/NCT03823300) were identical, randomized, double-masked, active comparator-controlled phase 3 noninferiority trials.

PARTICIPANTS

Patients aged ≥ 50 years with treatment-naïve nAMD.

METHODS

Patients were randomized (1:1) to intravitreal faricimab 6.0 mg up to every 16 weeks (Q16W) after 4 initial doses every 4 weeks (Q4W) or aflibercept 2.0 mg every 8 weeks (Q8W) after 3 initial doses given Q4W.

MAIN OUTCOME MEASURES

Post hoc analyses comparing faricimab with aflibercept in terms of change in central subfield thickness (CST) from baseline and proportion of patients with an absence of subretinal fluid (SRF) and intraretinal fluid (IRF) during initial 12-week head-to-head dosing phase, when both arms received 3 injections, and time to first absence of IRF and SRF.

RESULTS

A total of 1329 patients were enrolled across TENAYA/LUCERNE (n = 665 faricimab; n = 664 aflibercept). There were greater (nominal P < 0.0001) reductions in adjusted mean CST from baseline with faricimab versus aflibercept at weeks 4, 8, and 12, with comparable vision outcomes. At week 12, more patients (95% confidence interval) achieved an absence of SRF (87.9% [85.4%-90.4%] vs. 79.0% [76.0%-82.1%]) and both IRF and SRF (77.2% [74.0%-80.4%] vs. 66.5% [62.9%-70.0%]) but not IRF (88.4% [86.0%-90.8%] vs. 85.0% [82.3%-87.6%]), with faricimab versus aflibercept, respectively. In patients with IRF or SRF at baseline (n = 581 faricimab; n = 591 aflibercept), the 75th percentile of time to first absence of IRF and SRF was reached at week 8 with faricimab and week 12 with aflibercept. At week 12, cumulative incidence of first-time absence of IRF and SRF was 85.5% (82.3%-88.1%) with faricimab and 75.0% (71.3%-78.3%) with aflibercept.

CONCLUSIONS

Faricimab resulted in greater improvement in anatomic outcomes than aflibercept during the head-to-head dosing phase and a faster time to first absence of retinal fluid.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Targeting the Neonatal Fc Receptor in Autoimmune Diseases: Pipeline and Progress

Autoimmune diseases are highly prevalent and affect people at all ages, women more often than men. The most prominent immunological manifestation is the production of antibodies directed against self-antigens. In many cases, these antibodies (Abs) drive the pathogenesis by attacking the body's own healthy cells, causing serious health problems that may be life threatening. Most autoantibodies are of the immunoglobulin G (IgG) isotype, which has a long plasma half-life and potent effector functions. Thus, there is a need for specific treatment options that rapidly eliminate these pathogenic IgG auto-Abs. In this review, we discuss how the neonatal Fc receptor (FcRn) acts as a regulator of the high levels of not only IgG Abs, but also albumin, by rescuing both these soluble proteins from cellular catabolism, and how a molecular and cellular understanding of this complex biology has spurred an intense interest in the development of FcRn-targeting strategies for the treatment of IgG-driven autoimmune diseases. We find that this emerging therapeutic class demonstrates efficacy within several autoimmune diseases with distinct pathophysiology. This offers hope for both new therapeutic avenues for highly prevalent diseases currently treated by other means, and rare diseases with no approved therapies to date. In addition, we elaborate on studies that have led to approval of the first FcRn antagonists, the clinical progress and structural design of molecules in the pipeline, their position in the overall therapeutic landscape of autoimmunity, the design of next-generation antagonists as well as the use of this receptor-targeting principle for other therapeutic applications.

Efficacy of Aflibercept (8 mg) for Diabetic Macular Edema in Vitrectomized Eyes Refractory to the Other Anti-VEGF Drug Therapies: A Report of Three Cases

Introduction

To report the efficacy of aflibercept (8 mg) for diabetic macular edema (DME) in vitrectomized eyes refractory to other anti-VEGF drug therapies.

Case Presentations

This was a single-center retrospective case series. Three eyes with DME that developed after vitrectomy for diabetic vitreous hemorrhage were resistant to other anti-vascular endothelial growth factor (VEGF) drugs but improved with aflibercept (8 mg). Prior to treatment with aflibercept (8 mg), 2 eyes received multiple injections of faricimab and brolucizumab, and 1 eye received multiple injections of faricimab, but none of the 3 eyes showed morphological or functional improvement. Subsequently, aflibercept (8 mg) was administered, and a single dose of aflibercept resulted in marked improvement in all cases.

Conclusion

The efficacy of anti-VEGF therapy for DME in vitrectomized eyes is thought to be lower than that of DME in non-vitrectomized eyes. In this case, brolucizumab, which has a high anti-VEGF molar concentration, and faricimab, which has a low anti-VEGF molar concentration but anti-angiopoietin (Ang)-2 activity, were not effective, but aflibercept (8 mg), whose VEGF molar concentration was intermediate between the two, was effective. This may be due to the fact that aflibercept (8 mg) is a fusion protein rather than an antibody, has lower clearance than a small molecule like brolucizumab, and has a higher anti-VEGF molar concentration than faricimab. It is suggested that aflibercept (8 mg) may be effective for DME in vitrectomized eyes and may merit preferential administration in such cases.

Switching to Faricimab in Therapy-Resistant Macular Edema Due to Retinal Vein Occlusion: Initial Real-World Efficacy Outcomes

Background/Objectives: Macular edema (ME), due to retinal vein occlusion (RVO), is a major cause of vision impairment. Many patients experience suboptimal responses to anti-vascular endothelial growth factor (anti-VEGF) monotherapy, necessitating alternative treatment approaches. Faricimab, a bispecific antibody targeting VEGF-A and angiopoietin-2 (Ang-2), introduces a novel dual-mechanism therapy. This study evaluates the short-term real-world efficacy of switching to Faricimab in patients with treatment-resistant ME secondary to RVO. Methods: This retrospective study included patients from LMU University Hospital who were switched to Faricimab due to an inadequate response or adverse events related to prior intravitreal therapy (Ranibizumab, Aflibercept, or OzurdexTM). All patients completed a structured loading phase of four monthly injections. Key outcome measures included changes in best-corrected visual acuity (BCVA, logMAR), central subfield thickness (CST, µm), and intraretinal fluid (IRF) presence on optical coherence tomography (OCT). Changes were assessed from baseline (mo0) to three months (mo3). Results: The study included 19 eyes from 19 patients (mean age 63.0 ± 14.2 years). BCVA improved from 0.20 logMAR at baseline to 0.00 logMAR at mo3 (p < 0.01). CST decreased from 325 µm to 280 µm (p < 0.01). The proportion of eyes with IRF reduced from 100% to 32% (p < 0.01). Significant reductions in retinal volume within the 1 mm and 6 mm (both p < 0.01) circles of the ETDRS grid were observed. Conclusions: Switching to Faricimab in patients resulted in significant short-term improvements in BCVA, CST, and IRF resolution. Given the small sample size and retrospective design, these findings should be interpreted as exploratory and hypothesis-generating. Further studies are needed to evaluate long-term efficacy and optimal treatment regimens.

Faricimab maintains substance integrity and sterility after compounding and storage in two different polypropylene syringe types

BACKGROUND

Compounding and storage of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents in syringes is commonly performed in an off-label manner. However, the preservation of compound integrity and microbiological safety must be guaranteed. The aim of this study was to compare the chemical and physical stability, sterility and binding affinity to vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2) of faricimab, a novel bispecific anti-VEGF/Ang-2 biologic, after compounding and storage in two different polypropylene syringe types for up to 28 days.

METHODS

Faricimab was compounded into silicone oil-free and silicone oil-containing polypropylene syringes under controlled aseptic clean room conditions and stored under light protection at 2-8 °C for up to 28 days. Compound integrity was analysed by size exclusion chromatography, nano differential scanning fluorimetry, UV-vis and dynamic light scattering. The analysis of the simultaneous binding of VEGF and Ang-2 was performed by grating-coupled interferometry. Additionally, samples were tested for sterility and presence of bacterial endotoxins. One-way ANOVA test was used to analyse statistical significance (p ≤ 0.05).

RESULTS

No significant differences in VEGF and ANG-2 binding affinity were found in faricimab samples stored in either syringe type after 28 days compared to control. Chemical and physical stability testing revealed no statistically significant variation. Furthermore, sterility and the absence of bacterial endotoxins could be maintained.

CONCLUSION

Our findings confirm the pharmaceutical safety of compounded faricimab after storage for up to 28 days. This may facilitate a cost-effective off-label use of faricimab in clinical practice while maintaining safety in the treatment of patients.

Bispecific receptor decoy proteins block ocular neovascularization via simultaneous blockade of vascular endothelial growth factor A and C

Several debilitating eye diseases that lead to vision loss are driven by ocular neovascularization, which entails abnormal blood vessel growth in the eye. Neovascularization is often induced by the upregulation of vascular endothelial growth factor (VEGF) ligands, which activate angiogenesis through engagement of VEGF receptor (VEGFR) proteins on endothelial cells. Therapeutic interventions that block ocular neovascularization by targeting VEGF ligands, particularly VEGF-A, have revolutionized eye disease treatment. However, a significant population of patients are either non-responders or develop resistance, which can be driven by the upregulation of other VEGF family ligands such as VEGF-C. Here, we engineered two bispecific receptor decoy fusion proteins that incorporate domains of VEGFR-1 and VEGFR-2 for more effective and comprehensive inhibition of VEGF ligands. We demonstrated that our engineered proteins bind all VEGF ligands and can sequester two ligands simultaneously. We further showed that these molecules block VEGF activity to potently inhibit proliferation, migration, and survival of human endothelial cells. Moreover, these receptor decoy proteins significantly reduced ocular neovascularization in two mouse models at doses wherein the current standard-of-care anti-VEGF therapy is ineffective. Collectively, our engineered receptor decoy proteins present a new architecture for VEGF pathway inhibition, offering a promising treatment paradigm for ocular diseases.

Faricimab Treat-and-Extend Dosing for Macular Edema Due to Retinal Vein Occlusion: 72-Week Results from the BALATON and COMINO Trials

PURPOSE

To assess the efficacy, durability, and safety of dual angiopoietin-2/VEGF inhibition with faricimab dosed per a modified treat-and-extend-based regimen in patients with retinal vein occlusion.

DESIGN

Single-arm treatment period after a randomized, double-masked, active comparator-controlled period in the phase III BALATON/COMINO (NCT04740905/NCT04740931) trials.

PARTICIPANTS

Patients with treatment-naïve foveal center-involved macular edema due to branch (BALATON; N = 553) or central/hemiretinal (COMINO; N = 729) retinal vein occlusion.

METHODS

Patients randomized to faricimab 6.0 mg every 4 weeks (Q4W) or aflibercept 2.0 mg Q4W up to week 20 received faricimab 6.0 mg dosed per a modified treat-and-extend-based regimen from week 24 to 72. The dosing frequency was adjusted from Q4W to Q16W based on changes in central subfield thickness (CST) and best-corrected visual acuity.

MAIN OUTCOME MEASURES

Change from baseline through week 72 in best-corrected visual acuity and CST; durability and safety through week 72.

RESULTS

Visual acuity gains and CST reductions achieved at week 24 were maintained through week 72. Adjusted mean best-corrected visual acuity (95.03% confidence interval [CI]) changes from baseline averaged over weeks 64, 68, and 72 in the prior faricimab Q4W and prior aflibercept Q4W arms were +18.1 letters (16.9-19.4) and +18.8 letters (17.5-20.0), respectively, in BALATON and +16.9 letters (15.2-18.6) and +17.1 letters (15.4-18.8), respectively, in COMINO. Adjusted mean (95.03% CI) CST changes from baseline averaged over weeks 64, 68, and 72 in the prior faricimab Q4W and prior aflibercept Q4W arms were -310.9 μm (-315.6 to -306.3) and -307.0 μm (-311.7 to -302.3), respectively, in BALATON and -465.9 μm (-472.5 to -459.3) and -460.6 μm (-467.2 to -453.9), respectively, in COMINO. In the prior faricimab Q4W and prior aflibercept Q4W arms, 64.1% and 56.9% of patients from BALATON and 45.5% and 50.1% from COMINO, respectively, were on ≥Q12W dosing at week 68. Faricimab continued to be well tolerated from weeks 24 to 72; the safety profile was consistent with that established for diabetic macular edema and neovascular age-related macular degeneration.

CONCLUSIONS

These findings support the sustained efficacy and safety of faricimab in patients with macular edema due to retinal vein occlusion up to 72 weeks, with the potential for reduced treatment burden due to response durability.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Efficacy of switching to brolucizumab for neovascular age-related macular degeneration refractory to faricimab

PURPOSE

To evaluate the treatment outcomes of switching to intravitreal brolucizumab (IVBr) for neovascular age-related macular degeneration (nAMD) which did not achieve a dry macula even with 4- or 8-week intervals of intravitreal faricimab (IVF).

STUDY DESIGN

Retrospective, interventional case series.

METHODS

We retrospectively studied 33 eyes of 33 consecutive patients with nAMD who switched to IVBr from IVF, assessing best corrected visual acuity (BCVA), foveal thickness (FT), central choroidal thickness (CCT), and exudative status at baseline and after the switch. For patients that switched 4 weeks after the last IVF (4-week interval group), treatment outcomes were evaluated 4 weeks after the switch. For patients that switched 8 weeks after the last IVF (8-week interval group), treatment outcomes were evaluated after the first 8-week interval following the switch.

RESULTS

Thirty-one eyes had completed IVBr treatment up to the evaluation point after the switch. There were no significant changes in BCVA at baseline and after the switch in either group. FT and CCT significantly decreased after the switch compared with baseline in both groups. Moreover, in both groups, exudative changes disappeared or decreased in most cases after the switch. The dry macula rate after the switch was 37.5% and 34.8% in the 4-week and 8-week interval group, respectively. Although brolucizumab-related intraocular inflammation was observed in 3 eyes (9.1%) after the switch, it was ameliorated in response to steroid therapy.

CONCLUSION

Switching to IVBr for nAMD refractory to IVF was generally effective in improving exudative changes in the short term.

Comparison of intraocular pressure changes in Japanese patients with neovascular age-related macular degeneration treated with aflibercept or faricimab

PURPOSE

To assess the short-term changes in intraocular pressure (IOP) following intravitreal injections of aflibercept or faricimab in Japanese patients with neovascular age-related macular degeneration (nAMD).

STUDY DESIGN

Retrospective observational study.

METHODS

This retrospective observational study included 161 eyes from 160 Japanese patients diagnosed with nAMD. Of these, 127 eyes (127 patients) were treated with 2 mg/0.05 mL aflibercept, and 34 eyes (33 patients) received 6 mg/0.05 mL faricimab. Each group underwent three consecutive monthly injections. The IOP in each treated eye was measured using non-contact tonometry at each visit over a 3-month period following the initial injection.

RESULTS

The mean baseline IOP in the aflibercept group was 14.4 ± 2.8 mmHg, decreasing to 13.2 ± 3.0 mmHg after 3 months (P < 0.001), whereas the mean baseline IOP in the faricimab group was 13.8 ± 2.1 mmHg, with a change to 13.5 ± 1.5 mmHg after 3 months (P = 0.1873).

CONCLUSION

The loading phase treatment with aflibercept resulted in a decrease in IOP. Faricimab showed a similar trend, there was no significant difference between the two treatments.

Interventional Retrospective Case Series of Patients Undergoing Treatment Intervals of More Than Twenty-Four (24) Weeks With Faricimab

Purpose: The aim of this study is to evaluate the efficacy and safety of intravitreal faricimab dosing interval at and beyond 24 weeks in patients with diabetic macular edema (DME) and neovascular age-related macular degeneration (nAMD). Methods: This study is a retrospective case series of eight patients with persistent DME and nAMD who received intravitreal faricimab at and beyond the 24-week (6-month) dosing interval regimen. Results: The majority of patients experienced an improved mean best-corrected visual acuity (BCVA) of 9.9 letters; congruent anatomical improvement (mean central macular thickness (CMT)) decrease of 44 μm on optical coherence tomography (OCT) is demonstrated at 6 months despite extended faricimab dosing intervals. Conclusions: Extended intravitreal faricimab dosing intervals at and beyond 24 weeks maintained visual and anatomical outcomes in patients over 1 year. This suggests the feasibility of personalized extended dosing tailored to each patient's disease activity, potentially reducing treatment burden.

Systemic counterregulatory response of angiopoietin-2 after intravitreal injections with faricimab for nAMD

PURPOSE

Recently, a systemic counterregulatory response of angiopoietin-2 after intravitreal application of the anti vascular endothelial growth factor (anti-VEGF) drug aflibercept in neovascular age-related macular degeneration (nAMD) has been described. The aim of the study was to find out wether faricimab, a combined anti-VEGF/angiopoietin-2 drug, had an effect on systemic cytokine levels.

METHODS

20 women and 11 men (mean age 79.5 ± 7.3 years) were included into this cohort study. Plama levels of VEGF-A and angiopoietin-2 were determined before and after intravitreal application of faricimab (6 mg/0.05 ml/eye) using ELISA-technique. These results were correlated with central macular thickness (CMT). Responders were defined as having had CMT thinning ≥ 50 μm.

RESULTS

CMT decreased from 384.8 ± 108.8 μm prior to intravitreal injection (IVI) to 286.1 ± 63 μm one month after IVI (p < 0.0001). Angiopoietin-2 levels increased from 526.9 ± 129 pg/ml to 597.2 ± 174.8 pg/ml (p = 0.0087) one week after IVI and dropped to 547.4 ± 165 pg/ml (ns) four weeks after IVI. Responders revealed higher angiopoietin-2 (p = 0.0035) as well as higher VEGF-A (p = 0.0248) levels throughout the study period compared to non-responders. Initial CMT revealed to be the only independent factor influencing CMT 4 weeks after IVI in linear regression models with a positive correlation between initial thickness and effect size.

CONCLUSION

The trending increase in systemic angiopoietin-2 levels, may be interpreted as an escape mechanism of the concomitant anti-VEGF component of therapy. Angiopoietin-2 levels could serve as a positive predictive factor of therapy response in the future. Further research regarding this effect as well as differences between responders and non-responders is mandatory.

KEY MESSAGES

What is known Bispecific antibodies may be more beneficial compared to monospecific antibodies in neovascular age related macular degeneration (nAMD). For monospecific antibodies, there are systemic effects on systemic vascular endothelial growth factor (VEGF) levels. What is new The knew bispecific antibody faricimab entails an increase in systemic angiopoietin-2 levels, as well as a decrease in VEGF levels. The increase in systemic angiopoietin-2 may be interpreted as a counterregulatory effect. The decrease in systemic VEGF levels resembles the effects of monospecific antibodies.

Human Factors Studies to Assess the Usability of the Faricimab Prefilled Syringe

Purpose

Faricimab, the first bispecific antibody designed for intraocular use, is approved for the treatment of neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO). Here, we report the usability of a novel faricimab 6 mg pre-filled syringe (PFS) configuration that has been designed specifically for intravitreal use.

Patients and Methods

A simulated-use human factors validation study enrolling 15 retina specialists and 15 ophthalmic assistants was conducted in a market research facility configured to represent an ophthalmology clinic. Participants' ability to complete tasks related to package handling, dose preparation, and injection of a faricimab 6 mg dose into a polymer eye using the PFS was assessed. In a second Phase 3b, single-arm, actual-use study, the ability of seven retina specialists and six ophthalmic assistants to prepare and administer the PFS in accordance with the instructions for use was assessed. Injections were performed into single eyes of 35 patients with nAMD or DME in three US clinics and patients were followed for 7 days for safety reporting (ClinicalTrials.gov identifier: NCT05569148).

Results

In the simulated-use study, most retina specialists and ophthalmic assistants completed all tasks deemed essential for PFS preparation and administration correctly and without error. Of the 22 tasks, the pass rate was 86.7-100%; 16 tasks had a pass rate of 100%. No use errors were observed during the actual-use study. One patient experienced one mild adverse event of eye irritation that resolved the same day and was deemed unrelated to the study drug.

Conclusion

Participants were able to safely and correctly prepare and administer a faricimab 6 mg dose using the PFS in accordance with the instructions for use, under realistic conditions representing the real world. The faricimab 6 mg PFS may therefore offer a more convenient, safe-handling alternative to vial administration.

Photosensitizer formulations in photodynamic therapy of age-related macular degeneration

Age-related macular degeneration (AMD) is a progressive degenerative disease that leads to visual impairment, predominantly affecting the elderly. Despite significant advancements in treatment, a definitive cure remains elusive. Current therapeutic strategies only slow down disease progression, inhibiting abnormal blood vessels growth, and preserving or improving vision. Among these strategies, photodynamic therapy (PDT) has emerged as a promising treatment, particularly for neovascular form, the most severe form of the disease. Although several photosensitizers (PS) have been developed, only one has received clinical approval for use in AMD. This treatment involves the intravenous administration of a photosensitizing agent that preferentially accumulates in the abnormal blood vessels beneath the macula. Upon activation by targeted laser light, the PS triggers photochemical reactions, leading to vascular occlusion and the reduction of choroidal neovascularization. This review provides a comprehensive overview of both experimental and clinical studies on PDT for AMD, discussing the current state of research, challenges in treatment optimization, and potential future directions to enhance this therapeutic approach.

YBX1-driven TUBB6 upregulation facilitates ocular angiogenesis via WNT3A-FZD8 pathway

Background: Pathological ocular neovascularization, a characteristic feature of proliferative ocular diseases, is a primary contributor to global vision impairment. The dynamics of tubulin are crucial in maintaining ocular homeostasis, closely linked to cellular proliferation and angiogenesis. Elucidating the molecular mechanisms driving this process is vital for formulating effective therapeutic strategies. Methods: Multiple transcriptome analyses revealed upregulation of endothelial tubulin beta-6 chain (Tubb6) in oxygen-induced retinopathy (OIR) and laser-induced choroidal neovascularization (CNV) mice models. Transwell migration assay, wound healing assay, tube formation assay, flow cytometry, and immunofluorescent staining were employed to identify the role of TUBB6 knockout (KO) in vitro. The effects of Tubb6 silencing on retinal angiogenesis and choroidal neovascularization were subsequently evaluated. Results: We identified upregulated Tubb6 expression in retinas from OIR mice through combination analyses of single-cell RNA sequencing (scRNA-Seq) and bulk RNA-Seq. The RNA expression profiles of endothelial cells (ECs) from proliferative diabetic retinopathy (PDR) patients and neovascular age-related macular degeneration (nAMD) patients also exhibited an elevation in TUBB6. Notably, Tubb6 was abundantly expressed in ECs and pericytes, and was predominantly localized to proliferative ECs and vascular tip cells. Functional studies demonstrated that TUBB6 knockdown reduced the expression of proliferative and tip cell markers in vitro. Tubb6 deficiency decreased vascular sprouting and tip cell formation of OIR mice retina and retarded CNV progression in vivo. Mechanistically, YBX1, an RNA-binding protein, was identified as an upstream regulator of TUBB6 via binding to its 3' untranslated region (3'UTR) and maintaining mRNA stability. Transcriptome analysis further linked TUBB6 to the activity of WNT pathway. TUBB6 silencing suppressed the WNT signaling pathway, with WNT3A and FZD8 identified as downstream targets. Conclusions: Collectively, our research shed light on the pivotal function of TUBB6 in maintaining ocular homeostasis and uncovered the YBX1-TUBB6-WNT3A/FZD8 pathway's involvement in sprouting angiogenesis. Targeting TUBB6 and developing its specific inhibitor could pioneer new approaches for treating ocular microvascular diseases.

Switching to faricimab from the current anti-VEGF therapy: evidence-based expert recommendations

Dual inhibition of the angiopoietin (Ang)/Tie and vascular endothelial growth factor (VEGF) signalling pathways in patients with retinal diseases, such as neovascular age-related macular degeneration (nAMD) and diabetic macular oedema (DME), may induce greater vascular stability and contribute to increased treatment efficacy and durability compared with treatments that only target the VEGF pathway. Faricimab, a bispecific intravitreal agent that inhibits both VEGF and Ang-2, is the first injectable ophthalmic drug to achieve treatment intervals of up to 16 weeks in Phase 3 studies for nAMD and DME while exhibiting improvements in visual acuity and retinal thickness. Data from real-world studies have supported the safety, visual and anatomic benefits and durability of faricimab, even in patients who were previously treated with other intravitreal agents. These evidence-based expert recommendations from a panel of retina specialists consolidate current evidence with clinical experience for the optimal use of faricimab in patients with nAMD or DME, with a focus on switching from an anti-VEGF agent to faricimab.

Duration of Vascular Endothelial Growth Factor Suppression after Intravitreal Injection of Faricimab in Macaque Eyes

Purpose: To evaluate the duration of vascular endothelial growth factor (VEGF) suppression in the aqueous humor of macaque eyes after intravitreal faricimab (IVF) injection. Methods: Faricimab (6 mg/50 µL) was injected into the vitreous cavity of the right eye of 6 macaques. Aqueous humor samples (150 μL) were collected from both eyes immediately before injection and on days 1, 3, 7, 14, 21, 28, 42, 56, 84, and 112 after injection. The VEGF concentrations in the aqueous humor were measured using an enzyme-linked immunosorbent assay. Results: The VEGF was undetectable until 4 weeks after IVF injection in 4 eyes and until 6 weeks in the remaining 2 eyes. The mean duration of complete VEGF suppression was 4.7 weeks (range, 4-6 weeks). The VEGF concentration did not decrease in the aqueous humor of the non-injected fellow eyes. Conclusions: Faricimab effectively suppressed the VEGF concentrations in the aqueous humor of macaques for an average of 4.7 weeks after a single intravitreal injection. It did not reduce the VEGF concentrations in the aqueous humor of the fellow eyes.

Unveiling the therapeutic potential and mechanisms of stanniocalcin-1 in retinal degeneration

Retinal degeneration (RD) is a group of ocular diseases characterized by progressive photoreceptor apoptosis and visual impairment. Mitochondrial malfunction, excessive oxidative stress, and chronic activation of neuroglia collectively contribute to the development of RD. Currently, there is a lack of efficacious therapeutic interventions for RD. Stanniocalcin-1 (STC-1) is a promising candidate molecule to decelerate photoreceptor cell death. STC-1 is a secreted calcium/phosphorus regulatory protein that exerts diverse protective effects. Accumulating evidence suggests that STC-1 protects retinal cells from ischemic injury, oxidative stress, and excessive apoptosis through enhancing the expression of uncoupling protein-2 (UCP-2). Furthermore, STC-1 exerts its antiinflammatory effects by inhibiting the activation of microglia and macrophages, as well as the synthesis and secretion of proinflammatory cytokines, such as TNF-α, IL-1, and IL-6. By employing these mechanisms, STC-1 effectively shields the retinal photoreceptors and optic nerve, thereby slowing down the progression of RD. We summarize the STC-1-mediated therapeutic effects on the degenerating retina, with a particular focus on its underlying mechanisms. These findings highlight that STC-1 may act as a versatile molecule to treat degenerative retinopathy. Further research on STC-1 is imperative to establish optimal protocols for its clinical use.

Efficacy, durability and safety of faricimab for patients with neovascular age-related macular degeneration: 48-week results from the phase 3 LUCERNE China subpopulation

PURPOSE

To evaluate the efficacy, durability and safety of intravitreal faricimab versus aflibercept over 48 weeks in patients with neovascular age-related macular degeneration (nAMD) from the LUCERNE China subpopulation.

DESIGN

LUCERNE (NCT03823300) was a phase 3 global, double-masked, active comparator-controlled trial. The China subpopulation comprised patients from mainland China, Taiwan and Hong Kong.

METHODS

Treatment-naïve patients aged ≥50 years with nAMD were randomized 1:1 to receive faricimab 6.0 mg up to every 16 weeks (Q16W) based on prespecified disease criteria after four initial Q4W doses or aflibercept 2.0 mg Q8W after three initial Q4W doses. The primary endpoint was mean change from baseline in best-corrected visual acuity (BCVA) averaged over weeks 40 to 48. Anatomical, durability and safety outcomes were also evaluated.

RESULTS

The China subpopulation comprised 119 patients (faricimab: n = 59, aflibercept: n = 60). At weeks 40 to 48, adjusted mean (95% confidence interval [CI]) BCVA letter gains from baseline were +9.7 (7.4 to 12.0) and +9.8 (7.5 to 12.1) with faricimab and aflibercept, respectively. Central subfield thickness was reduced from baseline by weeks 40 to 48 in both arms, with an adjusted mean (95% CI) change of -145.4 µm (-156.2 to -134.6) and -156.5 µm (-167.3 to -145.7) for faricimab and aflibercept, respectively. By week 48, 87.3% of the patients were on extended ≥Q12W faricimab dosing. Faricimab was well tolerated with no new safety signals.

CONCLUSIONS

Faricimab up to Q16W showed durable efficacy in the LUCERNE China subpopulation, consistent with global findings. Faricimab may reduce treatment burden for patients with nAMD in China, without compromising efficacy.

Analysis of the aqueous humor before and after the administration of faricimab in patients with nAMD

This study aimed to evaluate the changes in cytokine levels in the aqueous humor and factors of treatment resistance following intravitreal faricimab injection in treatment-naïve patients with neovascular age-related macular degeneration. A total of 32 eyes were analyzed before and after a single faricimab injection. Although the best-corrected visual acuity (BCVA) showed no significant improvement, the mean central retinal thickness decreased significantly by 73.7% (P < 0.01), and more than 90% of the eyes showed improvement in exudative changes 1 month after faricimab injection. Moreover, the aqueous humor concentrations of vascular endothelial growth factor (VEGF)-A, angiopoietin (Ang)-2, and placental growth factor considerably decreased 1 month after faricimab injection. Multivariate analyses adjusted for age, sex, BCVA, central choroidal thickness, and aqueous humor cytokines revealed that higher Ang-2 levels in the aqueous humor at baseline were associated with better treatment response to faricimab injection. These findings suggest that the dual inhibition of VEGF-A and Ang-2 by faricimab is effective in reducing exudative changes and that Ang-2 may serve as a potential biomarker for predicting faricimab treatment response.

Beyond Longer Intervals: Advocating for Regular Treatment of Neovascular AMD

Personalizing the management of neovascular age-related macular degeneration (nAMD) poses significant challenges for practicing retina specialists and their patients. This commentary addresses some of these complexities, particularly those that arise in the context of an expanding array of intravitreal agents targeting vascular endothelial growth factor (VEGF) and related retinal disease targets. Many of these newer agents approved by the Food and Drug Administration (FDA) for the treatment of nAMD have labeling that indicates that they can provide non-inferior visual outcomes when compared head-to-head with previously available treatments and can be used at significantly extended dosing intervals in some patients. It can be difficult to know if patients should be transitioned to these agents, especially those who are doing well on existing therapies. Although offering extended intervals may be appropriate for some patients with excellent disease control, retina specialists know that undertreatment risks the loss of visual acuity (VA). It can also be challenging for clinicians to interpret the results delivered by clinical trial treatment protocols compared with what is likely to occur in real-world office settings. Many retina specialists use less liberal treatment paradigms than employed in clinical study protocols and consequently many patients experience shorter injection intervals. Since VA is most closely linked to quality of life, it should be prioritized compared with other endpoints. The authors advocate for maintaining consistent treatment schedules dictated by disease control instead of switching therapies even in the presence of small amounts of macular fluid that may occur with longer injection intervals.

Emerging clinical evidence of a dual role for Ang-2 and VEGF-A blockade with faricimab in retinal diseases

Anti-vascular endothelial growth factor (VEGF) therapies have transformed the treatment of retinal diseases. However, VEGF signaling is only one component of the complex, multifactorial pathophysiology of retinal diseases, and many patients have residual disease activity despite ongoing anti-VEGF treatment. The angiopoietin/tyrosine kinase with immunoglobulin and epidermal growth factor receptor-2 (Ang/Tie2) signaling pathway is critical to endothelial cell homeostasis, survival, integrity, and vascular stability. Ang-2 can interfere with Ang-1/Tie2 signaling and is increased in several retinal diseases. Lack of Tie2 signaling due to elevated Ang-2 levels drives vascular instability through pericyte dropout, neovascularization, vascular leakage, inflammation, and fibrosis. Although Ang-2 and VEGF can synergistically promote vascular instability and neovascularization, Ang-2 may also mediate vascular instability independently of VEGF. Faricimab is a bispecific antibody designed for intraocular use that inhibits two distinct pathways via Ang-2 and VEGF-A blockade. Clinical biomarkers of vascular instability are important for evaluating disease control and subsequent treatment decisions. These biomarkers include measurement/evaluation with optical coherence tomography (OCT) of intraretinal fluid, subretinal fluid, central subfield thickness, and pigment epithelial detachments (PEDs), and fluorescein angiography imaging of macular leakage and PEDs. Hyperreflective foci (HRF), thought to be representative of activated microglia, indicating an inflammatory microenvironment, and epiretinal membranes (ERMs), a marker for retinal fibrotic proliferation in diabetic macular edema (DME), are both also identified using OCT. Here we summarize data (secondary endpoint and prespecified exploratory analyses as well as post hoc analyses) from six Phase III trials suggest that dual therapy Ang-2/VEGF-A inhibition with faricimab (6 mg) has a greater effect on reducing/resolving biomarkers of vascular instability than aflibercept (2 mg), by both controlling neovascularization and vascular leakage (with resultant resolution of exudation associated with DME, neovascular age-related macular degeneration, and retinal vein occlusion), as well as by targeting inflammation (reduction of HRF in DME) and retinal fibrotic proliferation (reducing the risk of ERMs in eyes with DME). Modulation of both the Ang-2 and VEGF-A pathways with faricimab may therefore provide greater disease control than anti-VEGF monotherapy, potentially leading to extended treatment durability and improved long-term outcomes.

Acute intra ocular inflammation following intravitreal injections of faricimab: A multicentric case series

PURPOSE

To report 8 cases of acute intra ocular inflammation (IOI) following intravitreal injections (IVI) of faricimab in patients with age related macular degeneration (AMD), retinal vein occlusion (RVO) and macular neovascularization associated with chronic central serous retinopathy (CSR).

METHODS

This is a multicentric retrospective observational case-series. Cases of acute IOI that occurred in 5 different institutions in France and Italy between November 2023 and June 2024 were reported.

RESULTS

8 eyes of 8 patients presented with acute IOI following IVI of faricimab. Best corrected visual acuity (BCVA) at the time of the IOI event varied between counting fingers and 20/25. 6 patients had neovascular AMD, 1 patient had a macular edema secondary to central RVO and 1 patient had a macular neovascularization associated with chronic CSR. Mean delay between the last IVI of faricimab and the assessment of the IOI event was 10.0 days. Presentation of IOI varied among patients. 6 patients presented with vitritis with varying severity. One of them had an associated papillitis. One patient presented with an anterior uveitis without vitritis. Corticosteroids were used in 5 cases. 2 cases resolved spontaneously. Surgery was needed in 1 case. These 8 cases of IOI occurred out of a total of 1923 IVI of faricimab performed with an estimated frequency of 0.41%.

CONCLUSION

Acute IOI may happen after IVI of faricimab. Severity of inflammation varies and treatment should be adjusted according to the clinical presentation.

Intravitreal Faricimab for Previously Treated Neovascular Age-Related Macular Degeneration

Purpose

To report our real-world experience using intravitreal faricimab, a novel anti-vascular endothelial growth factor (anti-VEGF) therapy, in eyes with neovascular age-related macular degeneration (nAMD) previously treated with other anti-VEGF therapy.

Patients and Methods

A retrospective, single-center study of previously treated nAMD eyes treated with faricimab.

Results

In 88 eyes (73 patients), mean baseline best-corrected visual acuity (BCVA) was 20/63 (range 20/20 to CF) with mean anti-VEGF injection interval of 6.1+2.0 weeks. Mean baseline central subfield thickness (CST) was 291+73 µm. During mean follow-up of 30.1+13.5 (range 7.0 to 50.3) weeks on faricimab, the eyes received an average of 5.1+2.4 injections (range 1 to 11). Mean BCVA remained at 20/63 (p=0.11), but injection interval increased to 7.4+2.6 weeks (p<0.001), and CST decreased to 262+63 µm (p<0.001). Multiple linear regression analysis revealed that higher number of different anti-VEGF drugs used at baseline was associated with a lower decrease in CST on faricimab (p=0.04) while total number of anti-VEGF injections at baseline (p=0.56) and time on faricimab (p=0.68) were not associated. Faricimab was discontinued in 23 eyes (26.1%), including 8 eyes for poor response, 2 eyes for persistent new floaters and 4 eyes for new vision decrease which reversed after stopping faricimab.

Conclusion

In previously treated nAMD eyes, intravitreal faricimab was associated with increased mean treatment interval and decreased CST but no improvement in mean BCVA. The benefit of faricimab on CST reduction may be diminished in eyes previously treated with multiple different types of anti-VEGF therapy.

Changes in Aqueous Angiopoietin-1/2 Concentrations During the Induction Phase of Intravitreal Faricimab Injections for Diabetic Macular Edema

Purpose

The purpose of this study was to investigate the dynamic changes in aqueous concentrations of angiopoietin (Ang)-1/2 and vascular endothelial growth factor (VEGF) during injection in treatment-naïve patients with diabetic macular edema (DME) receiving faricimab during the induction phase (3 consecutive monthly doses) and retrospectively analyze the data.

Methods

Thirty-five eyes of 26 patients (age = 63.1 ± 12.9 years) with treatment-naïve DME received faricimab injections monthly, 3 consecutive times. Additionally, 59 eyes of 59 patients (age = 63.9 ± 8.8 years) who underwent cataract surgery were recruited as controls. Aqueous humor samples were collected from each injection or surgery and stored at -80°C, and the concentration of each cytokine was quantified using a multiple enzyme-linked immunosorbent assay (Luminex). The clinical parameters of best-corrected visual acuity (BCVA) and central foveal thickness (CFT) at each visit were also recorded.

Results

Three induction phases of faricimab significantly suppressed each aqueous cytokine, rapidly for VEGF, gradually for Ang-2, and slightly for Ang-1. The Ang-1/2 ratio was lower (<1.0) at baseline and gradually increased, but did not reach a control ratio of 1.58. The baseline CFT correlated with VEGF, but not with the Ang-2, Ang-1, or Ang-1/2 ratios. After three injections, CFT did not correlate with VEGF, but it positively correlated with Ang-2 and negatively correlated with Ang-1, and it strongly negatively correlated with the Ang-1/2 ratio.

Conclusions

The Ang-1/2 ratio in the aqueous humor significantly negatively correlated with the degree of residual edema after faricimab treatment for DME.

Translational Relevance

The Ang-1/2 ratio in aqueous humor is thus a useful biomarker of the treatment response for DME.

Real-World Results in Treating Diabetic Macular Edema With Faricimab at a London-Based Tertiary Eye Hospital

Diabetic macular edema (DMO) poses a significant risk to vision, primarily caused by the leakage of retinal vessels. Traditional treatments involve anti-vascular endothelial growth factor (VEGF) agents and corticosteroids, though responses vary, necessitating frequent treatments. This retrospective study at a London-based tertiary eye hospital evaluates the efficacy of faricimab, a bispecific antibody inhibiting angiopoietin 2 (Ang-2) and VEGF-A, in treating DMO. Seventy-six eyes from 60 patients were treated with intravitreal faricimab injections over six months. Participants were divided into treatment-naïve and previously treated groups. The primary outcomes measured were best-corrected visual acuity (BCVA) and central subfield thickness (CST). Treatment-naïve patients showed significant improvement in BCVA from 0.86 ± 0.31 to 0.23 ± 0.26 logarithm of the minimum angle of resolution (Log MAR) and a reduction in CST from 385.71 ± 103.59 to 299.14 ± 76.00 μm. Previously treated patients also demonstrated improvements, with BCVA enhancing from 0.43 ± 0.38 to 0.31 ± 0.34 Log MAR and CST decreasing from 427.00 ± 129.40 to 318.88 ± 89.40 μm. Few adverse events were noted, affirming the safety profile of faricimab. The study concludes that faricimab significantly improves visual and anatomical outcomes in DMO patients, supporting its potential as a reliable treatment with extended dosing intervals.

Targeting pericyte retention in Diabetic Retinopathy: a review

Diabetic retinopathy is a common yet severe complication of diabetes mellitus and is the leading cause of blindness in middle-aged adults. After years of poorly managed hyperglycemia, complications begin as non-proliferative diabetic retinopathy but can then progress into the proliferative stage marked by neovascularization of the retina. Multiple pathologic mechanisms caused by chronic hyperglycemia damage the retinal vasculature leading to pericyte drop out and the progression of the disease. This review outlines the major pathways of pathogenesis in diabetic retinopathy, highlighting the protective role pericytes play in preserving the blood-retinal barrier. Given the loss of this cell line is a defining feature of the disease, ways in which to prevent pericyte dropout within retinal vasculature is discussed, targeting various pathogenesis pathways of diabetic retinopathy.

Three-month outcomes of treatment with faricimab or aflibercept for neovascular age-related macular degeneration: a propensity score matching study in a Japanese population

PURPOSE

This study aimed to compare the treatment outcomes of patients with neovascular age-related macular degeneration (nAMD) who initially received faricimab or aflibercept treatment using propensity score matching (PSM) to align patient backgrounds.

METHODS

Patients with treatment-naïve nAMD who received either faricimab or aflibercept for three consecutive monthly injections as the loading phase were enrolled in this study. In the 1:1 PSM, sex, age, best-corrected visual acuity (BCVA), central macular thickness (CMT), central choroidal thickness (CCT), and AMD subtypes in the pre-treatment state were selected as covariates. We examined the BCVA, CMT, CCT, and remaining fluid at 1-, 2-, and 3-month after the first injection.

RESULTS

After PSM, 43 eyes were included in the faricimab and aflibercept group each. Both groups showed significant improvements in BCVA, CMT, and CCT at 1-, 2-, and 3-month after the initial injection compared with baseline. Meanwhile, no significant differences were observed between the two groups at any time point regarding BCVA, CMT, and CCT. At 1-month, 18.6% of patients in the faricimab group and 41.9% in the aflibercept group demonstrated residual subretinal fluid or intraretinal fluid, with a significant difference between the groups (P = 0.03).

CONCLUSION

The BCVA improved after three loading injections of both faricimab and aflibercept. Faricimab may provide a favorable early treatment response in reducing subretinal fluid in a Japanese cohort.

Real-world six-month outcomes in patients switched to faricimab following partial response to anti-VEGF therapy for neovascular age-related macular degeneration and diabetic macular oedema

BACKGROUND

Landmark studies reported on faricimab efficacy and safety predominantly in treatment naïve patients, but outcomes following switch from other anti-VEGF therapies are lacking. We evaluated patients switched to faricimab who had previously shown a partial response to other anti-VEGF injections for neovascular age-related macular degeneration (nAMD) and diabetic macular oedema (DMO).

METHODS

Retrospective study at the Oxford Eye Hospital. Patients switched to faricimab from January to April 2023 with six months follow-up were identified via electronic medical records.

RESULTS

A total of 116 patients (151 eyes) were included. In 88 patients with nAMD (107 eyes), mean visual acuity remained stable: 62±17 ETDRS letters at baseline; 62±18 at six months (p > 0.05). Central subfield thickness (CST) reduced from 294 ± 73 μm to 270 ± 53 μm (p < 0.05) at six months. Subretinal or intraretinal fluid was present in 102 eyes (95%) at baseline and 75 eyes (70%) at follow-up (p < 0.05). Pigment epithelial detachment height decreased from 233 ± 134 μm to 188 ± 147 μm (p < 0.05). Mean treatment interval increased by 1.7 weeks (p < 0.05) and was extended in 61 eyes (57%) at six months. In 28 patients with DMO (44 eyes), visual acuity remained stable: 69 ± 15 letters at baseline; 70±15 at six months (p > 0.05). CST reduced from 355 ± 87 μm to 317 ± 82 μm (p < 0.05). Mean treatment interval increased by 1.4 weeks (p < 0.05) and was extended in 21 eyes (46%) by six months.

CONCLUSIONS

Switching to faricimab in treatment resistant eyes led to improved anatomical response and extended treatment interval in a significant proportion of patients. Ongoing review of real-world data will inform longer-term outcomes of safety and effectiveness.

Resolution of Angiographic Macular Leakage with Faricimab versus Aflibercept in Patients with Diabetic Macular Edema in YOSEMITE/RHINE

PURPOSE

To evaluate if dual angiopoietin-2 (Ang-2)/VEGF-A inhibition with faricimab resulted in greater macular leakage resolution versus aflibercept in patients with diabetic macular edema (DME).

DESIGN

Post hoc analysis of macular leakage assessments prespecified in the YOSEMITE/RHINE (NCT03622580/NCT03622593) phase III trials.

PARTICIPANTS

Adults with visual acuity loss due to center-involving DME.

METHODS

Patients were randomized 1:1:1 to faricimab 6.0 mg every 8 weeks (Q8W), faricimab 6.0 mg according to a personalized treat-and-extend (T&E)-based regimen, or aflibercept 2.0 mg Q8W. This analysis included the first 16 weeks (head-to-head dosing period) when all patients received assigned study drug every 4 weeks (Q4W); patients were assessed 4 weeks after receiving 4 doses of assigned study drug Q4W.

MAIN OUTCOME MEASURES

Macular leakage area on fluorescein angiography assessed by a reading center; proportion of patients with resolution of macular leakage (defined as macular leakage area 0-1 mm2) and high macular leakage (defined as macular leakage area ≥10 mm2) at baseline and week 16; and the proportion of faricimab T&E patients receiving Q16W dosing at week 52 among those with resolution of and high macular leakage at week 16.

RESULTS

Among patients with macular leakage data available at baseline, there were 1216 patients in the pooled faricimab (Q8W + T&E) arms and 593 patients in the aflibercept arm. Baseline median macular leakage area was similar between the faricimab (24.6 mm2) and aflibercept arms (25.6 mm2). At week 16, median macular leakage area was 3.6 mm2 with faricimab versus 7.6 mm2 with aflibercept (nominal P < 0.0001). More faricimab-treated patients (28%) achieved resolution of macular leakage versus aflibercept at week 16 (15%; nominal P < 0.0001). In the faricimab T&E arm, 63% of patients with resolution of macular leakage and 45% of patients with high macular leakage at week 16 achieved Q16W dosing at week 52 (nominal P < 0.01).

CONCLUSIONS

Faricimab demonstrated greater macular leakage resolution versus aflibercept during head-to-head dosing. These findings suggest that dual Ang-2/VEGF-A inhibition promotes vascular stability beyond VEGF inhibition alone, supporting faricimab's potential to offer greater disease control and extend durability for patients with DME.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ocular Pharmacokinetics of Faricimab Following Intravitreal Administration in Patients With Retinal Disease

Purpose

To characterize faricimab ocular and systemic pharmacokinetics (PK) in patients with neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) and to assess the effect of faricimab ocular exposure on clinical endpoints.

Methods

A population PK (popPK) model was developed using pooled data from phase 1 to 3 studies in patients with nAMD/DME. The dataset included 1095 faricimab aqueous humor (AH) concentrations from 284 patients and 8372 faricimab plasma concentrations from 2246 patients.

Results

Following intravitreal administration, faricimab PK was accurately described by a linear three-compartment model with sequential vitreous humor (VH), AH, and plasma compartments. Faricimab VH elimination to AH is the slowest process, with an estimated half-life (t1/2) of 7.5 days. Due to flip-flop kinetics, plasma, AH, and VH concentrations declined in parallel. Disease had no effect on faricimab PK. Plasma exposure was ∼6000-fold lower than VH exposure. Age, anti-drug antibodies, body weight, and sex statistically significantly influenced PK parameters but had no clinically meaningful effect on ocular and systemic exposure. VH t1/2 alone could not explain faricimab dosing frequency. Exposure-response analyses showed similar gains in best-corrected visual acuity across faricimab exposure ranges and dosing regimens.

Conclusions

Faricimab ocular and systemic pharmacokinetics were quantified and accurately described by the popPK model, developed using a large dataset from patients with nAMD/DME. Exposure-response analyses suggest that faricimab phase 3 dosing algorithms are appropriate to select the most suitable dosing regimen.

Translational Relevance

The popPK analysis suggested that faricimab dosing frequency was influenced by several factors and not by VH t1/2 alone.

Ocular Pharmacodynamics of Intravitreal Faricimab in Patients With Neovascular Age-Related Macular Degeneration or Diabetic Macular Edema

Purpose

Evaluate the ocular pharmacodynamics (PD) of intravitreal faricimab, a bispecific inhibitor of angiopoietin-2 (Ang-2) and vascular endothelial growth factor-A (VEGF-A), in patients with neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME).

Methods

Aqueous humor (AH) samples (1025 free Ang-2 concentrations and 1345 free VEGF-A concentrations) were collected from approximately 300 faricimab-treated patients with nAMD or DME in phase 2/3 trials. A population pharmacokinetic pharmacodynamic (popPKPD) model was developed to describe the dynamic effect of faricimab on free AH Ang-2 and VEGF-A.

Results

Mean baseline Ang-2 concentrations were 8.1 and 13.4 pg/mL in patients with nAMD and DME, respectively. The corresponding mean baseline VEGF-A concentrations were 58 and 135 pg/mL, respectively. Overall, approximately 79% of Ang-2 (84% within 8 weeks postdose and 55% beyond 12 weeks postdose) and 7% of VEGF-A postdose observations were below the lower limit of quantification. Model-derived Ang-2 and VEGF-A concentration-time profiles for patients on every 4-week/every 8-week dosing were predicted to maintain greater than 50% suppression of Ang-2 concentrations for the entire dosing period. Patients on every 12-week/16-week dosing were predicted to have greater than 50% Ang-2 suppression for 12 or more weeks, whereas 50% VEGF-A suppression was maintained for 9 to 10 weeks. At 8 weeks postdose, the median Ang-2 concentrations remained suppressed by approximately 80%. At 16 weeks postdose, the median VEGF-A concentrations returned to baseline, but median Ang-2 levels remained below baseline.

Conclusions

A popPKPD analysis demonstrated faricimab's rapid and sustained suppression of AH Ang-2 and VEGF-A.

Translational Relevance

A popPKPD analysis suggested that sustained suppression of ocular Ang-2 contributes to faricimab's extended durability, observed in clinical trials.

Dual pathway inhibition with faricimab for previously treated neovascular age-related macular degeneration and diabetic macular oedema: guidance from a UK panel of retina specialists

BACKGROUND/OBJECTIVES

Some eyes with neovascular age-related macular degeneration (nAMD) and centre-involving diabetic macular oedema (DMO) fail to respond sufficiently or lose response over time to standard of care intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy. This paper explores clinical scenarios for switching to dual action angiopoietin-2 (Ang-2)/VEGF-A inhibitor faricimab (Vabysmo, Roche Products Limited) in previously anti-VEGF-treated patients.

METHODS

A national steering group meeting of UK retina specialists was held in London on 27 October 2023. Clinician practice and experience were reviewed together with pivotal clinical trial data and early findings from real-world settings. Roche Products Limited facilitated and funded the meeting.

RESULTS

While there is no standardised protocol for identifying suboptimal response, the authors review relevant clinical biomarkers of disease activity used in routine clinical practice to determine patient response and guide treatment decisions. Common reasons identified for considering a change of treatment were lack of efficacy demonstrated by suboptimal anatomic or visual improvement and insufficient durability of response. The panel outline strategies for switching to faricimab among eligible patients with a prior anti-VEGF treatment history, with initial monthly loading doses or maintaining the previous treatment interval before attempting to extend, that may be integrated into current treat-and-extend (T&E) clinical pathways for treating patients with nAMD and DMO. General considerations for switching between treatments are also reviewed.

CONCLUSION

Clinicians may consider a treatment switch to faricimab in nAMD and DMO patients who have suboptimal disease control or insufficient durability of response on initial anti-VEGF therapy.

Mechanism of Action and Pharmacokinetics of Approved Bispecific Antibodies

Bispecific antibodies represent a significant advancement in therapeutic antibody engineering, offering the ability to simultaneously target two distinct antigens. This dual-targeting capability enhances therapeutic efficacy, especially in complex diseases, such as cancer and autoimmune disorders, where drug resistance and incomplete target coverage are prevalent challenges. Bispecific antibodies facilitate immune cell engagement and disrupt multiple signaling pathways, providing a more comprehensive treatment approach than traditional monoclonal antibodies. However, the intricate structure of bispecific antibodies introduces unique pharmacokinetic challenges, including issues related to their absorption, distribution, metabolism, and excretion, which can significantly affect their efficacy and safety. This review provides an in-depth analysis of the structural design, mechanisms of action, and pharmacokinetics of the currently approved bispecific antibodies. It also highlights the engineering innovations that have been implemented to overcome these challenges, such as Fc modifications and advanced dimerization techniques, which enhance the stability and half-life of bispecific antibodies. Significant progress has been made in bispecific antibody technology; however, further research is necessary to broaden their clinical applications, enhance their safety profiles, and optimize their incorporation into combination therapies. Continuous advancements in this field are expected to enable bispecific antibodies to provide more precise and effective therapeutic strategies for a range of complex diseases, ultimately improving patient outcomes and advancing precision medicine.

Efficacy of Faricimab versus Aflibercept in Diabetic Macular Edema in the 20/50 or Worse Vision Subgroup in Phase III YOSEMITE and RHINE Trials

PURPOSE

Diabetic Retinopathy Clinical Research Network Protocol T suggests that the response to treatment among patients with diabetic macular edema (DME) may vary depending on baseline best-corrected visual acuity (BCVA). We evaluated the efficacy of faricimab 6 mg versus aflibercept 2 mg over 2 years in patients with DME and baseline BCVA of 20/50 or worse enrolled in faricimab phase III trials.

DESIGN

YOSEMITE and RHINE were identically designed, multicenter, randomized, double-masked, active comparator-controlled, noninferiority trials.

PARTICIPANTS

Adults ≥18 years of age with center-involving macular edema secondary to type 1 or 2 diabetes.

METHODS

Patients were randomized to faricimab every 8 weeks (Q8W), faricimab personalized treat-and-extend (T&E) regimen, or aflibercept Q8W. Post hoc subgroup analyses were conducted using the intention-to-treat population with baseline BCVA of 20/50 or worse.

MAIN OUTCOME MEASURES

Changes in ETDRS BCVA and central subfield thickness (CST) from baseline to years 1 and 2 were compared between treatment arms using mixed-model repeated measures analyses.

RESULTS

In YOSEMITE and RHINE, respectively, 220 and 217 patients in the faricimab Q8W arm, 220 and 219 patients in the faricimab T&E arm, and 219 and 214 patients in the aflibercept Q8W arm showed baseline BCVA of 20/50 or worse. In both trials, mean change in ETDRS BCVA was comparable between treatments across trials at years 1 and 2. In YOSEMITE, adjusted mean change from baseline in CST (μm) at year 1 was greater with faricimab Q8W (-232.8; P < 0.0001) and faricimab T&E (-217.4; P = 0.0004) ) versus aflibercept Q8W (-190.4). In RHINE, this was faricimab Q8W (-214.2; P = 0.0006) and faricimab T&E (-206.6; P = 0.0116) versus aflibercept Q8W (-186.6). In both trials, change from baseline in CST at year 2 was greater with faricimab Q8W versus aflibercept. The median time to first CST of <325 μm and first absence of intraretinal fluid was shorter in the faricimab arms versus the aflibercept arm, with fewer injections on average.

CONCLUSIONS

In patients with DME and baseline ETDRS BCVA of 20/50 or worse, faricimab treatment resulted in comparable visual acuity, greater reduction in retinal thickness, and fewer injections compared with aflibercept.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Faricimab for neovascular age-related macular degeneration and diabetic macular edema: from preclinical studies to phase 3 outcomes

Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is the standard of care for diabetic macular edema (DME) and neovascular age-related macular degeneration (nAMD); however, vision gains and anatomical improvements are not sustained over longer periods of treatment, suggesting other relevant targets may be needed to optimize treatments. Additionally, frequent intravitreal injections can prove a burden for patients and caregivers. Angiopoietin-2 (Ang-2) has been explored as an additional therapeutic target, due to the involvement of Ang-2 in DME and nAMD pathogenesis. Recent evidence supports the hypothesis that targeting both VEGF and Ang-2 may improve clinical outcomes in DME and nAMD compared with targeting VEGF alone by enhancing vascular stability, resulting in reduced macular leakage, prevention of neovascularization, and diminished inflammation. Faricimab, a novel bispecific antibody that targets VEGF-A and Ang-2, has been evaluated in clinical trials for DME (YOSEMITE/RHINE) and nAMD (TENAYA/LUCERNE). These trials evaluated faricimab against the anti-VEGFA/B and anti-placental growth factor fusion protein aflibercept, both administered by intravitreal injection. In addition to faricimab efficacy, safety, and pharmacokinetics, durability was evaluated during the trials using a treat-and-extend regimen. At 1 year, faricimab demonstrated non-inferior vision gains versus aflibercept across YOSEMITE/RHINE and TENAYA/LUCERNE. In YOSEMITE/RHINE, faricimab improved anatomic parameters versus aflibercept. Reduction of central subfield thickness (CST), and absence of both DME and intraretinal fluid were greater in faricimab- versus aflibercept-treated eyes. In TENAYA/LUCERNE, CST reductions were greater for faricimab than aflibercept at the end of the head-to-head phase (0-12 weeks), and were comparable with aflibercept at year 1, but with less frequent dosing. CST and vision gains were maintained during year 2 of both YOSEMITE/RHINE and TENAYA/LUCERNE. These findings suggest that dual Ang-2/VEGF-A pathway inhibition may result in greater disease control versus anti-VEGF alone, potentially addressing the unmet needs and reducing treatment burden, and improving real-world outcomes and compliance in retinal vascular diseases. Long-term extension studies (RHONE-X, AVONELLE-X) are ongoing. Current evidence suggests that dual inhibition with faricimab heralds the beginning of multitargeted treatment strategies inhibiting multiple, independent components of retinal pathology, with faricimab providing opportunities to reduce treatment burden and improve outcomes compared with anti-VEGF monotherapy.

Ophthalmic Use of Targeted Biologics in the Management of Intraocular Diseases: Current and Emerging Therapies

BACKGROUND

Monoclonal antibodies (mAbs) have demonstrated substantial potential in the treatment of intraocular diseases. This review aimed to comprehensively evaluate the applications, efficacy, and safety of mAbs in the management of intraocular conditions.

METHODS

A comprehensive literature search was conducted in major medical databases through July 2024. Relevant studies on monoclonal antibodies for intraocular diseases were included. Two independent researchers screened the literature, extracted data, and assessed study quality. Cost-effectiveness analyses were also reviewed.

RESULTS

Anti-vascular endothelial growth factor (VEGF) antibodies, such as bevacizumab, ranibizumab, and aflibercept, showed significant therapeutic effects in neovascular age-related macular degeneration (NVAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO). Tumor necrosis factor-alpha (TNF-α) inhibitors demonstrated promising results in treating noninfectious uveitis. Complement system-targeted therapies like pegcetacoplan offered new options for geographic atrophy. Anti-VEGF antibodies showed potential in managing retinopathy of prematurity (ROP). However, challenges persist, including high costs, potential drug resistance, and limited long-term safety data in certain scenarios.

CONCLUSIONS

Monoclonal antibodies are vital for treating intraocular diseases, but continuous innovation and rigorous clinical evaluation are essential. Future research should focus on developing novel delivery systems, exploring combination therapies, conducting long-term follow-up studies, and investigating personalized treatment strategies to provide safer, more effective, and cost-effective therapeutic solutions.

Optimization of individualized faricimab dosing for patients with diabetic macular edema: Protocol for the SWAN open-label, single-arm clinical trial

PURPOSE

In patients with diabetic macular edema (DME) from YOSEMITE/RHINE, dual angiopoietin-2/vascular endothelial growth factor-A (VEGF-A) inhibition with faricimab resulted in visual/anatomic improvements with extended dosing. The SWAN trial (jRCTs031230213) will assess the efficacy, durability, and safety of faricimab during the treatment maintenance phase in patients with DME using a treat-and-extend (T&E)-based regimen adapted to clinical practice and the characteristics of patients achieving extended dosing intervals.

METHODS

SWAN is a 2-year, open-label, single-arm, interventional, multicenter trial enrolling adults with center-involving DME. All patients will receive three initial faricimab 6.0 mg doses every 4 weeks (Q4W). From week 12 onwards, in patients without active DME, dosing intervals will be extended in 8-week increments up to Q24W. In contrast, patients with active DME (central subfield thickness [CST] >325 μm and intraretinal fluid [IRF] or subretinal fluid [SRF] resulting in vision loss/disease aggravation) will receive a dose within a day and the dosing interval will be shortened by 4 weeks to a minimum of Q8W relative to the previous dosing interval. Recruitment commenced in August 2023 across a planned 16 sites in Japan.

RESULTS

The primary endpoint is change in best-corrected visual acuity (BCVA) from baseline at 1 year (averaged over weeks 52, 56, and 60). Key secondary endpoints include: change from baseline in BCVA, CST, and National Eye Institute Visual Function Questionnaire scores over time; proportion of patients with BCVA (decimal visual acuity) ≥0.5, ≥0.7, ≥1.0, or ≤0.1; proportion of patients with absence of DME, and IRF and/or SRF over time. Safety endpoints include incidence/severity of ocular/nonocular adverse events.

CONCLUSIONS

The SWAN trial is expected to provide evidence to support individualized faricimab dosing regimens, with the potential to reduce the burden of frequent treatments on patients, caregivers, and healthcare systems.

Evaluating Faricimab in Treatment-Naive Neovascular Age Related Macular Degeneration: A Retrospective Analysis of Real-World Data

Purpose

To evaluate the efficiency and safety of Faricimab on treatment-naive neovascular age related macular degeneration (nAMD) in a real world UK clinic.

Patients and Methods

This single centre, retrospective note review was conducted on treatment-naive patients with nAMD. The data collected included demographics, best corrected visual acuity (BCVA), central macular thickness (CMT), total retinal fluid (TRF), the presence of intraretinal fluid (IRF) and subretinal fluid (SRF).

Results

A total of 66 eyes from 62 patients were analysed. The average age was 77 years (range 36-91) and 54% of patients were female. After the first dose of faricimab, the average BCVA improved by 0.05 LogMAR (+2.5 letters), the average CMT decreased by 65.9μm and 41% of patients were found to be inactive. The follow-up intervals after the third loading dose were divided into 2 subsets of 4 and 8 week extensions. The 4 week extension subset saw a smaller improvement in BCVA (+3 letters) than the 8 week extension (+6 letters) while both had an average decrease in CMT by 86.6 μm. The total retinal fluid decreased by 45% and 70.7%, leaving only 30% and 12.2% residual intraretinal fluid (IRF) and 30% and 24.4% residual subretinal fluid (SRF), respectively. Over a ten-month period, the average number of injections received was 6.6, including 3 initial loading doses. There was only one reported case of an adverse event out of 66 eyes (1/66, 1.5%).

Conclusion

Three loading doses of Faricimab appear efficacious and safe for the treatment of nAMD.

Role of Plasma Angiopoietin-1 and VEGF Levels as Potential Biomarkers in Chronic Central Serous Chorioretinopathy with Macular Neovascularization

To evaluate the plasma levels of angiopoietin-1 and vascular endothelial growth factor (VEGF) and their association with macular neovascularization (MNV) in patients with chronic central serous chorioretinopathy (cCSC). Correlations between plasma cytokine levels, CSC duration, and mean choroidal thickness (CT) were also investigated. Of the 59 patients with cCSC, 10 patients with MNV secondary to cCSC and 10 patients with cCSC without MNV were enrolled in the study. The control group included 15 healthy volunteers matched for age, sex, smoking status, and comorbidities. Chronic CSC was diagnosed based on typical findings on swept-source optical coherence tomography (OCT), fundus fluorescein angiography, and indocyanine green angiography. Additionally, all patients underwent OCT angiography to help detect MNV. Plasma angiopoietin-1 and VEGF levels were assessed using multiplex immunoassay. The plasma angiopoietin-1 levels differed between the 3 groups (p = 0.005). The angiopoietin-1 levels were lower in patients with cCSC with MNV than in controls (p = 0.006). There were no differences in the plasma VEGF levels between all the 3 groups (p = 0.329). The VEGF levels were negatively correlated with mean CT in cCSC patients with MNV (rho = -0.683, p = 0.042) but correlated positively with disease duration in patients with cCSC without MNV (rho = 0.886, p = 0.003). Our study confirms that MNV is a common complication of cCSC and provides new insights into the role of angiopoietin-1 in cCSC and MNV. Reduced angiopoietin-1 levels in cCSC patients, regardless of MNV status, highlight the importance of the Ang-Tie2 pathway in disease pathogenesis and may point to new therapeutic targets and future novel treatments to improve the management of these patients.

Efficacy and Safety of Intravitreal Faricimab in Neovascular Age-Related Macular Degeneration, Diabetic Macular Edema, and Retinal Vein Occlusion: A Meta-Analysis

INTRODUCTION

Intravitreal anti-vascular endothelial growth factor (VEGF) therapy has become the mainstay of treatment in many retinal diseases. The comparative efficacy and safety of newer bispecific anti-VEGF/angiopoietin 2 (Ang2) agents in the treatment paradigm versus widely used monospecific anti-VEGF agents remains unclear.

METHODS

A systematic literature search of MEDLINE, Embase, and Cochrane Library was conducted to identify comparative observational studies and randomized controlled trials published from 2015 to Jul 2024. With assessment by three independent reviewers, original English peer-reviewed full-text articles evaluating faricimab versus monospecific anti-VEGF agent(s) in FDA-indicated retinal disease with data on at least one set of efficacy and/or safety outcomes for each treatment arm and a minimum 3-month follow-up period were included. Data were appraised using the Cochrane RoB2 and ROBINS-I tools, PRISMA, and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines. All outcomes were collected at the last follow-up. Random effects meta-analyses with 95% confidence intervals were conducted to calculate weighted mean differences and risk ratios. Change in best-corrected visual acuity (BCVA, ETDRS letters), change in central subfield thickness (CSFT, μm), and presence of retinal fluid were primary endpoints; ocular adverse events were secondary endpoints.

RESULTS

Across 13 studies, in the context of neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO), 2,226 eyes received anti-VEGF monotherapy and 3,022 received faricimab. Final and change in BCVA were similar between treatment groups. Faricimab was associated with a significantly higher reduction in CSFT in DME and RVO eyes but not in nAMD eyes. The incidence of ocular adverse events was similar between groups.

CONCLUSION

There was no difference in BCVA between faricimab and anti-VEGF monotherapy in nAMD, DME, and RVO. While faricimab offered superior improvement in CSFT at the final follow-up for DME and RVO eyes, this effect was not seen in nAMD eyes. Future studies are needed to establish the long-term safety and efficacy of faricimab for retinal vascular disease.