Failure to Complete Induction in Anti-VEGF Therapy for Neovascular Age-Related Macular Degeneration

Purpose: To evaluate the proportion and characteristics of patients diagnosed with neovascular age-related macular degeneration (AMD) who do not complete the loading dose of bevacizumab, given as first line agent. Methods: Using the electronic medical records of all patients affiliated to the largest health maintenance organization in Israel who received intravitreal injections of bevacizumab between September 2008 and October 2014, we isolated patients aged of 60 years or more treated for neovascular age-related macular degeneration. We considered patients with less than three injections and those having completed the initial course within 100 days as two separate groups. We then compared patients living at the end of follow-up in terms of demographics and baseline conditions. Results: 22.3% of all patients started with bevacizumab did not fulfill the loading dose within 100 days. Mortality was higher in patients not achieving induction (32.5% vs. 20.2%, OR = 2.39, CI: 2.04 2.80, p < 0.001). When considering patients living at the end of the follow-up, 13.7% did not receive the loading dose. We found a larger proportion of rural residents in patients who failed induction than in those who received three injections or more (OR = 1.54, 95% CI: 1.23 1.92, p < 0.001). Patients, living at the end of follow-up, who failed to complete the loading dose were relatively younger than patients with three or more injections (79.6 vs. 80.7 vs. years, p < 0.001). No other demographic variable and no specific medical condition was found to be associated with failure to complete induction. Conclusions: In this nationwide retrospective study, we report that a large number of patients do not comply with treatment guidelines. Since the area of residence was identified as the main risk factor for failing to receive the loading dose, we think distance to anti-VEGF delivering facilities should be seriously taken into account when defining global policies relating to retinal care.