Introduction

Faricimab is the latest drug in the toolbox to treat neovascular age-related macular degeneration (nAMD) and diabetic macular oedema (DMO). It works on two pathways to stop the growth of new blood vessels and leakage of fluid into the macula, which left untreated can cause loss of vision. It is given via injection into the eye, and while previous injections have targeted vascular endothelial growth factor A (VEGF-A) alongside other molecules, faricimab is the first to target angiopoietin-2 (Ang-2). Evidence from clinical trials indicate that faricimab might be more effective in preventing leakage from blood vessels and allow longer intervals between treatments, but does this play out in real life?

Some patients with nAMD and DMO can have disease that is difficult to treat, and sometimes the fluid in the retina does not go away despite regular injections. Researchers at Oxford looked at how faricimab worked in a real-world setting, focusing on patients who did not have complete disease control, with persistent retinal fluid while frequently having other anti-VEGF drugs. A retrospective review was performed of 116 patients (151 eyes) who were switched to faricimab. It was found that on average, faricimab treatment could keep the vision stable over six months which is good news.

Non-invasive, high-resolution images of the retina can be taken using optical coherence tomography (OCT) scans, which is part of routine clinical practice. This allows a clinician to visualise a cross section of the retina and assess markers of disease activity, such as fluid within or under the retina, in nAMD and DMO, and features of subretinal hyperreflective material and pigment epithelial detachments in eyes with nAMD. Using these scans, retinal thickness (central subfield thickness, CST) can be measured over time which is useful to track disease activity, since when fluid builds up in the retina due to active disease, the thickness of the retina increases. Faricimab treatment in this group of patients led to a decrease in retinal thickness on average, by reducing fluid in the retina, confirming its effectiveness in nAMD and DMO. However, there was still a spectrum of responses to faricimab with some eyes responding really well, others remaining stable and a few not responding as well as on other anti-VEGF drugs.

Most promising for patients was the potential to extend the time between injections by an average of 1.7 weeks (from approximately an injection every 5 weeks to that every 7 weeks), with more than half of eyes requiring fewer injections after 6 months than on previous therapies.

Why does this matter?

Chronic eye conditions such as nAMD and DMO can be challenging for both patients and healthcare systems, particularly when frequent injections are required. There are small risks carried with each injection, patients and carers might need to take time off work to come to appointments, and in addition there are environmental burdens with transport and plastic waste associated with each procedure. Delivering these frequent injections is also a huge burden on health care systems. Faricimab was able to reduce the treatment frequency in the group of patients studied, whilst also maintaining vision and improving retinal health to ease the burden of treatment for patients and pressure on healthcare systems.

While the results are promising, more data is needed to investigate faricimab with long-term follow up in the real world. It would be worthwhile developing a better understanding of disease features that might predict who might benefit best from faricimab, and it would be useful to be aware of any factors that might suggest anyone should avoid faricimab. This discernment regarding faricimab is fundamental in progressing towards personalised medicine for individual patients.