Real-world comparative effectiveness of faricimab versus aflibercept 2 mg in treatment-naïve exudative neovascular AMD patients treated with a treat-and-extend regimen

Purpose: To compare the real-world effectiveness of faricimab versus aflibercept 2 mg in treatment-naïve patients with neovascular age-related macular degeneration (nAMD). Methods: We analysed treatment-naïve nAMD patients aged ≥50 years initiating intravitreal anti-VEGF therapy between March 2024 and September 2024. Patients received either faricimab or aflibercept 2 mg. Inverse probability of treatment weighting was used to minimise selection bias. Primary outcomes were best-corrected visual acuity (BCVA) changes from baseline to post-loading phase and 1-year follow-up. Secondary outcomes included anatomic resolution of intraretinal fluid (IRF), subretinal fluid (SRF), and subretinal hyperreflective material (SHRM), treatment burden, and safety. Results: A total of 172 patients were included (86 faricimab, 86 aflibercept). Baseline characteristics were well-balanced between groups. The faricimab regimen was associated with greater BCVA improvement compared with aflibercept at post-loading phase (adjusted mean difference -0.075 logMAR; 95% confidence interval [CI], -0.130 to -0.020; P = 0.008) and at 1 year (-0.073 logMAR; 95% CI, -0.128 to -0.018; P = 0.011). Patients receiving faricimab achieved significantly higher rates of SRF resolution (odds ratio 2.446; 95% CI, 1.012 to 5.912; P = 0.047). The faricimab group was associated with fewer injections from the post-loading phase to 1 year (median 3 vs. 4; P < 0.001) and lower therapy switching rates (7.9% vs. 25.6%; P = 0.003). Conclusions: In treatment-naïve nAMD patients, faricimab achieved greater visual acuity gains, enhanced anatomic outcomes, and reduced treatment burden compared with aflibercept. However, these findings should be interpreted in light of the non-randomised design, different loading regimens, and potential differences in early treatment exposure.