Optimizing Anti-VEGF Treatment Outcomes in Neovascular AMD and DME - Episode 2

Barriers to Optimal Treatment Outcomes

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Experts discuss barriers that prevent optimal outcomes for patients with age-related macular degeneration (AMD) or diabetic macular edema (DME).


Ehsan Rahimy, MD: Studies have shown that patients with AMD [age-related macular degeneration] or DME [diabetic macular edema] in routine clinical practice don’t achieve similar visual gains that we typically see from anti-VEGFtherapy in clinical trials. How do you reconcile this difference? Why are we seeing such a divide? What are the barriers we see on a day-to-day basis in our clinics that prevent patients from achieving the same type of outcomes?

Veeral Sheth, MD, MBA, FASRS, FACS: We really benefit from real-world information. Our clinical trials have been phenomenal, with the results we’re getting. But there’s been a disconnect between what we see in clinical trials and reality. It’s nice to be getting neovascular AMD data or DME data that show us that in the real world we’re not getting visual outcomes even close to what we’re getting in clinical trials. The correlation is we’re most likely not treating patients as much as we should be treating them. The question is why aren’t we doing that? It depends on which patients we’re talking about.

There’s definitely a difference between patients with AMD and patients with DME. For example, patients with AMD tend to be older and sometimes require help getting to the clinic or a family member to bring them in. For those reasons, it’s hard to keep them up with the number of injections they need to achieve the best outcomes. Our patients with diabetes are often working and finding it hard to make time to make it to clinic, or they have a lot of other doctor’s appointments to go to. They have to pick and choose when to come in. Because of that they often come in too late, so we’re working from behind with those patients. There are a lot of reasons. Those are a couple of them, but there are lots of reasons patients don’t make it in. That’s a big reason why we’re looking for better treatments and longer-acting treatments, because they may help us bridge that gap.

Jonathan Jonisch, MD: To tack on to what Veeral said, I’ll add 2 points. In clinical trials, patients often have specific recruitment tools that they need or characteristics. In the real world, a lot of patients present later on, so there was a delay in diagnosis initially. Those patients aren’t going to be able to have the vision gains of a patient who recently presented. Veeral touched on treatment fatigue from the physician and patient sides. The third 1 is that we don’t live in a 2- to 3-year clinical trial world. We live in a longer-treatment, chronic-disease world. Often, especially in AMD, you have progression of atrophy. Even though the neovascular component is well controlled, over time that atrophy progresses and patients lose a lot of the gain that they had early on.

Ehsan Rahimy, MD: That’s a wonderful point. As retina specialists, we’re accustomed to treating visit to visit based on the OCT [optical coherence tomography] and the prior visits. When we see things, they are roughly the same. We can easily lose sight of the longer-term outcome and picture. Sometimes it’s eye-opening to go back to the beginning to see what they look like when they [first] came. You see this atrophy take effect in years 5, 6, 7-plus. That’s a wonderful point.

Ali, do you feel that we deal with noncompliance where you’re practicing? How you tackle this issue with patients and their families?

Ali Khan, MD, FACS, FASRS: A lot depends on the patient population and the disease process. Diabetic macular edema tends to be younger, working-age adults, who are busy, have their own kids, and have to get to work. Sometimes noncompliance is not being able to make it. With COVID-19 and other recent events, that’s been made worse. Some of our older patients with macular degeneration who have family support are able to come in for their injections on time. These are all things that doctors can’t necessarily control or affect. All we can do is try to get patients in on time. If they can’t make it for whatever reason-, who are we to judge?

The goals of a lot of the upcoming trials and treatments are that increased durability effect. So that if there’s a gap in care of even a few weeks, then perhaps we can at least cover these patients a bit longer. Noncompliance or nonpersistence with the injections—[there are] a lot of things going on that could be contributing. A lot of studies have come out recently looking at risk factors, like older age, needing transportation, and distance from the treating physician. All these things make sense and truly matter. [We’re doing the] best we can to try to mitigate those as specialists. It’s worth it.

Transcript edited for clarity.