Promoting Treatment Adherence in nAMD and DME

Opinion
Video

Retina specialists discuss treatment and adherence strategies for patients with nAMD and DME. They also comment on the future of nAMD and DME management.

Rishi P. Singh, MD: Through this discussion today, we haven’t talked about treatment adherence. This can be a significant challenge. We know from [results of] many studies [that] 50% of patients discontinue anti-VEGF therapy within the first 3 years. [Findings from] some studies have said within the first year, 30% to 40% of patients may discontinue therapy depending on the practice environment. And we know that adherence is an issue. First, I’d like to hear your strategy on keeping patients adherent to therapy. And with the change in this durability, do you think adherence would change as well and potentially improve?

M. Ali Khan, MD, FACS, FASRS: [Diabetes] and neovascular AMD [age-related macular degeneration] are slightly different because the adherence for treatment with [patients with diabetes] has traditionally been worse, likely because these patients are more active, they’re working, it’s harder for them to take off work. But for both populations, AMD and DME [diabetic macular edema], having the patients understand what is happening and why they’re coming is big for me. Showing them their OCT [optical coherence tomography] [scans] and telling them, “These are what I’m looking at; these are the findings that I see improving” and explain[ing] to them why we’re changing things, whether in terms of the number of weeks or the drug, [so that] they’re being brought in and not being passive in the process has been the most successful for me.

And [to] the second part of your question about [whether] extended intervals improve adherence, in some ways, yes, [it’s] fewer visits, [it’s] easier for people to take off time and have it [be] more predictable. Once every 4 months [is something] people can plan for. Once every 6 weeks gets tough, depending on the type of job you’re in, and for caregivers, we need to bring [in] some of our older patients [with] neovascular AMD [nAMD]. So extended interval duration will help with adherence. On the flip side, I don’t want to go too long because sometimes if patients forget about “I have my eye doctor or my retina specialist appointment,” that can be a little bit of a drop-off. And when you’re at the end of an extended treatment interval, that’s when I’m worried that if they go maybe 2 or 3 weeks longer, I don’t want something terrible happening [such as] a hemorrhage. So finding a happy medium where they have an expected appointment once every 4 months, for example, [and] it might not go much longer than that, simply keep[s] them in the fold and keep[s] them in our scheduling processes.

Rishi P. Singh, MD: I agree. There are so many things we could do to improve adherence. We have to talk to them about missed appointments and getting back in right away, not wait until the next interval appointment, try to give them encouragement on the OCT [optical coherence tomography] [scans], [and] show them pictures…to say that they are getting better. I like to show them a graph of their OCT [scan]. They show them the central subfoveal thickness over time, which our software does very well, show them the benefits of their incredible adherence to therapy and what’s happening over time. Overall, we have to encourage this because we know there’s a huge dropout rate with these patients over time. Getting them to come back and keep their appointments in high fidelity is important for us to be able to do this in a good way. Let’s touch a little bit on future treatments. What excites you? What do you think is interesting? You know the space very well. Is there something that you look at and say, “That’s going to make our patients have a great durable option with [fewer] injections and potentially [fewer] complications”?

M. Ali Khan, MD, FACS, FASRS: Much has been spoken about gene therapy options and how we deliver them surgically or in the office with suprachoroidal therapy. If we do have treatments that we can do in the office with every-4-months durability, that’s tough to beat. So the suprachoroidal delivery of gene therapy is interesting. That’s office based, which most people can get their head around, and doesn’t require going in the operating room, which has its own risks. If that can be delivered at scale with durability as good as our current drugs or perhaps longer, that has the potential to change my mind in terms of how I would approach treatment in these patients. So office-based [therapy] with extended durability is what could work at scale. And the suprachoroidal option is potentially promising. There are data being presented at our current meetings, and everyone will look forward to the full trial data for those delivery options. But gene therapy delivered in the office is another paradigm shift that can happen.

Rishi P. Singh, MD: I would agree with you. I would also add tyrosine kinases to the mix there. That’s been a burgeoning area of understanding of the new MOA [mechanisms of action] that tyrosine kinases can offer. And I agree with you on gene therapy; surgical delivery of this is probably impractical. And office-based delivery of gene therapy may be the best approach to suprachoroidal delivery platforms. Tyrosine kinases at least offer another ability, which is that they affect all isoforms of VEGF, not only VEGF-A but other isoforms of VEGF, including downstream effects of inhibiting ANG2. So it can have a synergistic effect alongside some of the other drugs that we’ve had in clinical practice so far.

M. Ali Khan, MD, FACS, FASRS: I agree. It’s going to be a busy few years with clinical trial results coming out but exciting nonetheless.

Rishi P. Singh, MD: We have so much promise that’s happening and so many great opportunities in our field in the next few years. I want to thank you all for joining this Peers & Perspectives® presentation entitled Extending Treatment Intervals for Durable Therapies for Neovascular AMD and Diabetic Macular Edema. Thank you again for watching, and thank you, Dr Khan, for participating.

Transcript is AI generated and edited for clarity and readability.

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