Loading Dose Recommendations of Faricimab in Neovascular AMD
Drs Nathan Steinle, Adrienne Scott, Carl Regillo, and Prethy Rao share their approaches to dosing recommendations for faricimab in the treatment of neovascular AMD.
Nathan Steinle, MD: On label for faricimab, it’s 4 loading doses. In your real-world clinical practice, do you follow the loading dose regimen of 4 injections up front monthly for your patients?
Adrienne Scott, MD: I do, Dr Steinle.
Nathan Steinle, MD: Oh, you do. All right.
Adrienne Scott, MD: I do, and the reason why is I look, and I say, well if I want to come close or approximate these types of outcomes for my patients, I’ll try to adhere the best I can to what evidence base I have. Now, that of course is based upon how I feel, like is a patient most likely to follow up? But I tend to try to adhere to the clinical trial recommendations.
Nathan Steinle, MD: Good to hear.
Adrienne Scott, MD: Well, I try. I feel like there’s some induction period in which I want to try to get the eye acclimated to this new molecule. So, I feel like there is a period of time where I like to consider myself achieving some induction or steady state dose of this before I start trying to extend it.
Nathan Steinle, MD: That’s great. How about this side?
Carl Regillo, MD, FACS, FASRS: Maybe a little disagreement. By the nature of the studies, and the way they were designed, it was somewhat arbitrary choosing 3 vs 4 monthly loads, and a lot of that is based on the shape of the curves, both the vision curves and the OCT [optical coherence tomography] curves. Meaning you get most of the initial benefits in efficacy, visually and anatomically, within the first 3 injections. It doesn’t necessarily mean all patients need 3 monthly loading doses. Plus, we’re not doing 3 and then stopping and watching and waiting.
In fact, even going back to the CATT study, it was 1 dose and monthly follow-up PRN as needed, and patients still did well. So taking the totality of the data and so forth, I will treat until I think the macula is as good as it’s going to be. We do usually achieve that in the majority of our patients, meaning essentially a dry macula, within 3 injections. So, it ends up being that we’re probably doing the same thing in the long run, but I’ll start to extend the dose little by little from the get-go, even if they’re dry at 2 months.
Nathan Steinle, MD: In the studies that are out, they did 4 injections, and then they did a disease assessment, and they put them in the different swim lanes, Q8, Q12, Q16 [every 8, 12, or 16 weeks]. Are you doing that at all, or do you do a slow treat and extend after the 4 loading doses?
Prethy Rao, MD, MPH: I think what’s interesting about the clinical trials is they are quick to extend with a longer treatment interval. In practice, I’m a little hesitant to do that because while we control the disease, I think it’s still active underlying, so my concern is the extension is maybe a bit too far out. I do about the 1 to 2 weeks, as Dr Scott does. Then I think time will tell. Once we have a better understanding of how these drugs work long term, we’ll feel more comfortable doing the longer extension, once we know they’re a bit well controlled.
Transcript edited for clarity
