Altersbedingte Makuladegeneration – Teil 2: therapeutische Optionen bei der AMD

Bis zur Einführung der intravitrealen Anti-VEGF-Therapie im Jahr 2006 war eine langfristige Visusverbesserung mit den bis dahin bestehenden Behandlungsmethoden nicht erreicht worden. Dieser Beitrag gibt einen Überblick über die gegenwärtigen Behandlungsmethoden der frühen und intermediären altersbedingten Makuladegeneration (AMD), der exsudativen AMD und den therapeutischen Ansätzen bei geografischer Atrophie.

Abstract

Currently, intravitreal anti-VEGF therapy is the only way to maintain function with continuous monitoring in neovascular AMD. Several robust morphological biomarkers, such as intraretinal and subretinal fluid, are important to guide treatment decisions at baseline and during the course of the disease. Higher concentrations of anti-VEGF agents and the development of bispecific antibodies combining anti-VEGF and anti-angiopoietin-2 antibodies have been shown to prolong the duration of action in pivotal trials. In particular, a longer duration of action may improve patient adherence by reducing the treatment burden. Several ranibizumab biosimilars are also approved and available for the treatment of neovascular AMD. In addition, bevacizumab is now approved in its originator form for the treatment of neovascular AMD in Europe. For the treatment of geographic atrophy, the intravitreal complement inhibitors approved in the US are not approved in Europe. With these drugs, continuous monthly or bimonthly injections were associated with significantly slower growth of the atrophic area in registration studies. Visual function after two years of treatment showed no difference compared to untreated eyes. In a post-hoc analysis of the largest supplementation studies AREDS and AREDS2, a significantly slower increase in RPE atrophy from the atrophic edge to the fovea was observed compared to placebo (AREDS [n = 208]: p = 0.012; AREDS2 [n = 392]: p = 0.011). This effect needs to be confirmed in controlled randomised trials.

Kernaussagen

• Gegenwärtig ist bei der neovaskulären altersbedingten Makuladegeneration (nAMD) die intravitreale Therapie mit VEGF-Inhibitoren die Therapie der Wahl.

• Durch eine Erhöhung der Konzentration konnte in den Zulassungsstudien von Brolucizumab und Aflibercept 8 mg eine verlängerte Wirksamkeit nachgewiesen werden.

• Bei Faricimab wird ein bispezifischer Antikörper aus Anti-VEGF und Anti-Angiopoietin-2 verwendet. Auch hier wurde in der Zulassungsstudie eine verlängerte Wirksamkeit gesehen.

• Bei der geografischen Atrophie sind in der EU zur Therapie keine Medikamente zugelassen.

• Eine wirksame Therapie zur Verhütung einer Konversion der frühen und intermediären AMD (iAMD) in eine späte Form gibt es weiterhin nicht.

• In den USA sind die Komplementinhibitoren (Pegcetacoplan und Apacincaptad Pegol) zur intravitrealen Therapie zugelassen, bei denen sich in den Zulassungsstudien eine signifikante verzögerte Flächenzunahme der Atrophie zeigte, aber keine Unterschiede in der Funktion gesehen wurden.

Schlüsselwörter

Neovaskuläre AMD - Anti-VEGF-Therapie - morphologische Biomarker - geographische Atrophie - Komplementinhibitoren

Keywords

Neovascular AMD - Anti-VEGF-Therapy - Morphological Biomarkers - Geographic Atrophy - Complement Inhibitors

Publication History

Article published online:
19 May 2025

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