Extending Treatment Intervals in nAMD and DME

Opinion
Video

Rishi P. Singh, MD, and M. Ali Khan, MD, FACS, FASRS, discuss the need for extending treatment durability for neovascular age-related macular degeneration [nAMD] and diabetic macular edema [DME], as well as approaches to applying treat-and-extend strategies.

Rishi P. Singh, MD: Hello, and thank you for joining this Peers & Perspectives presentation titled “Extending Treatment Intervals With Durable Therapies for Neovascular AMD and Diabetic Macular Edema.” I am Dr Rishi Singh, staff physician and president of Cleveland Clinic Martin Hospital and Cleveland Clinic, [in] Florida. And joining me today is my colleague and friend, Dr Ali Khan. He’s a vitreoretinal surgeon in Granite Bay, California. Welcome, Ali.

M. Ali Khan, MD, FACS, FASRS: Thanks, Rishi, happy to be here.

Rishi P. Singh, MD: Our discussion today will focus on therapies that promise to reduce the treatment burden with extended durability. And we’ll highlight some of the recent clinical trial data and safety for these therapies. We’ve been very fortunate, as in retina for so many years to have anti-VEGF [vascular endothelial growth factor] therapy for primary therapy for our patients for both neovascular AMD [age-related macular degeneration] and diabetic macular edema [DME]. I know that both of us as retina specialists have encountered durability issues with these drugs.Many of our patients can’t be extended very fast. Some of them have to be unfortunately reduced in their interval of retreatment to get an effective improvement in visual acuity and anatomical improvement. And we’re going to talk about some of those opportunities today, but also talk about some of the newer therapies that we have that are more recently FDA approved that will help us manage these patients over time. So let’s talk about, first, Dr Khan, the patient burden. What are the factors in which you sort of talk to patients about the burden of these anti-VEGF treatments in general late clinical practice?

M. Ali Khan, MD, FACS, FASRS: I think it’s a big part of it. I think the initial discussion you have with any patient you start treatment on, one of the first questions is, “How many of these am I going to need and for how long?” So treat-and-extend has become, I think, the protocol of choice for many retina specialists, simply because you can explain to the patient, “We’re going to treat you monthly for a little while and then depending on how you respond, we’ll try to go longer and we’ll go as long as we possibly can in between your visits, but a lot will depend on your vision and your pictures,” meaning their OCT [optical coherence tomography] images. So I explain the patients, we’re going to have to do this for as long as we need to. For diabetics, it’s easier to tell them, “Look, over time, we tend to expect fewer injections,” but for the neovascular AMD [nAMD] patients, I do give them a heads-up that this might be years and as long as we need to and the goal being your vision. So it takes a little while to break them into the idea that they might need this for a while, which is why the durability issue is particularly important. Some of these people are working age or they have caregivers who need to bring them, so they’re often always worried about how they can get [into the office]. Getting a durable treatment for as long as possible, I think, is what most patients want.

Rishi P. Singh, MD: We always want to strive to treat our patients less. I don’t think any retina specialist goes into this saying, “I want to see you frequently.” I use that phrase that you did just kind of use that in a different way. I say, “I’m going to get to know you very well through this treatment approach,” because obviously there are a lot of treatments to be given for this condition, and we’re always trying to [give] fewer injections. We want to have the less probability of these anti-VEGF–related ocular [adverse] effects and potentially inflammation in various rare cases, but certainly we know that there’s a correlation between high frequency of injections and certainly complications of these treatments. You talked a little bit about that treat-and-extend strategy—can you talk to us about what factors you use in determining treat-and-extend for somebody who may be in practice now or just new to practice. What is the sort of way in which we use treat-and-extend mechanisms, the definitions by which we define it to really apply to our patients in practice?

M. Ali Khan, MD, FACS, FASRS: It can be quite variable in practice what people truly use as their criteria, which I think is why many of the more recent clinical trials have very strict criteria for why they allow patients to go longer within the trials, which I think is a good idea to standardize things. For me personally, I look at their visual acuity, and again we’re using Snellen visual acuity so there’s some variability there visit to visit, but mainly the OCT. Honestly I think if there’s fluid that’s clinically evident on the OCT image, that’s reason enough for me to either shorten the interval and, conversely, if the OCT looks good in terms of any residual fluid, to extend the interval. Lastly, there’s symptoms, and some patients who tell me “By a day or 2 before my injection, I’m starting to notice my vision change.” And even if the OCT looks clean and their vision seems stable, I will take that into account to decide whether or not to truly extend them. So a combination of their OCT vision and symptoms, but OCT being probably the biggest decider for me.

Rishi P. Singh, MD: I think you’re right about that. And I think you pointed out the fact that sometimes vision does play a role in these discussions because we all know that the OCT is only mostly correlated with activity; not always correlated, but mostly correlated with activity. Clearly, there could be people with a dry retina and still have an active coronary neovascular complex present there. So, what we think is what we’re managing on the OCT, which we think is a very valuable tool, is valuable for the most part of what we do, but certainly there are outliers in that. And the other part of this that I think also factors into this is clinical exam. So if you see the presence or absence of subretinal hemorrhage, the presence would mean that you may consider even shortening the interval further; the absence of which [means] you would continue to extend the patients over time. So that’s another kind of factor to look at clinically to make sure that you’re following the right paradigm.

Transcript is AI-generated and edited for clarity and readability.

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