Effect of High-Dose Intravitreal Aflibercept, 8 mg, in Patients With Neovascular Age-Related Macular Degeneration: The Phase 2 CANDELA Randomized Clinical Trial

IMPORTANCE Aflibercept, 8 mg, may have greater therapeutic benefits compared with aflibercept, 2 mg, in patients with neovascular age-related macular degeneration (nAMD), including potentially improved outcomes and decreased treatment burden. OBJECTIVE To assess safety and efficacy of aflibercept, 8 mg, in patients with nAMD. DESIGN, SETTING, AND PARTICIPANTS The CANDELA trial was a phase 2, randomized, single-masked, open-label, 44-week clinical trial conducted in the US. Treatment-naive patients with active subfoveal choroidal neovascularization secondary to nAMD and a best-corrected visual acuity score of 78 to 24 letters (approximately 20/32 to 20/320) in the study eye were enrolled between November 2019 and November 2021. INTERVENTIONS Eligible participants were randomized 1:1 to receive 3 monthly doses of 8 mg (70 mu L) or 2 mg (50 mu L) of aflibercept followed by doses at weeks 20 and 32. MAIN OUTCOMES AND MEASURES Coprimary end points were the proportion of eyes without fluid (absence of intraretinal and subretinal fluid) in the central subfield at week 16 and safety. RESULTS All 106 eligible eyes were randomized to receive aflibercept, 8 mg (n=53), or aflibercept, 2 mg (n=53). Overall, 66 participants (62.3%) were female. The proportion of eyes without fluid in the central subfield with 8-mg vs 2-mg aflibercept was 50.9% (n=27) vs 34.0% (n=18) (difference, 17.0 [95% CI, -1.6 to 35.5] percentage points; P=.08) at week 16 and 39.6% (n=21) vs 28.3% (n=15) (difference, 11.3 [95% CI, -6.6 to 29.2] percentage points; nominal P=.22) at week 44. At week 44, mean (SE) change in central retinal thickness was -159.4 (16.4) vs -137.2 (22.8) mu m with 8 mg vs 2 mg of aflibercept, respectively (least squares mean difference, -9.5 [95% CI, -51.4 to 32.4]; nominal P=.65) and mean (SE) change in best-corrected visual acuity score was +7.9 (1.5) vs +5.1 (1.5) letters (least squares mean difference, +2.8 [95% CI, -1.4 to +7.0]; nominal P=.20). No differences in safety profiles between the groups were observed. CONCLUSIONS AND RELEVANCE Although aflibercept, 8 mg, did not achieve the primary efficacy end point at week 16 at the 2-sided significance level of 5%, the observed trends in anatomic and visual improvements over 44 weeks with aflibercept, 8 mg, indicate potential additional therapeutic benefit over aflibercept, 2 mg. No new safety signals were observed over 44 weeks. These findings support further evaluation of aflibercept, 8 mg, in pivotal trials of exudative retinal diseases including nAMD and diabetic macular edema.