Anti vascular endothelial growth factor sequential therapy for neovascular age-related macular degeneration: is this the new deal?

Objective: To review clinical data on the sequential use of the non-selective vascular endothelial growth factor (VEGF) inhibitors (ranibizumab and bevacizumab) and the selective VEGF inhibitor (pegaptanib) in the treatment of neovascular age related macular degeneration (n-AMD). Methods: This is a selective review of the literature based on a PubMed search using the terms 'age-related macular degeneration', 'selective anti-VEGF', 'non-selective anti-VEGF' and 'combination therapy' from 2000 to date in the English language. Studies on the management of n-AMD reporting adherence, patient-reported outcomes, costs, side effects, resource use and cost effectiveness were also included. Results: The trial data suggest that pan-VEGF inhibition provides improved treatment outcomes in patients with n-AMD with selective anti-VEGF agents offering better tolerability on long-term treatment. A pilot trial and a large-scale, multicentre study confirmed the long-term efficacy of a selective VEGF inhibitor when used as maintenance therapy. Importantly, there is evidence that selective VEGF inhibition also reduces the risks associated with pan-VEGF blockade in patients with n-AMD. Discussion: Anti-VEGF agents play a principal role in the management of n-AMD. The most potent are the pan-VEGF agents although there is some discussion regarding their long-term tolerability. The sequential use of nonselective VEGF inhibitors as booster therapy with a selective VEGF inhibitor as maintenance therapy seems to offer a promising safety/efficacy profile, as well as improved cost/effectiveness.