The approval of new, more durable treatments is an exciting development for the management of neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME), but how do these therapies and their unique mechanisms stack up outside of clinical trials? Join Dr. Durga Borkar, Dr. Sabin Dang, Dr. Jayanth Sridhar, and Dr. Christina Weng as they discuss these new treatments and the emerging data surrounding their use in the real world.
Reconsidering the Algorithm: nAMD
Reconsidering the Algorithm: nAMD
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We’ve discussed both clinical trials and real-world data around more durable treatment modalities, so let’s take a look at some actual patients. This is CME on ReachMD. I’m Dr. Sabin Dang.
I’m Dr. Jay Sridhar. Sabin, great to join you. I’ve got a patient case for you. So, I have a 72-year-old gentleman who has gotten multiple anti-VEGF injections monthly for wet macular degeneration in his left eye. And when I say monthly, and I say multiple, I mean this is multiple. This has been going on for years. And despite monthly injections most recently with 6 aflibercept injections, he still has persistent subretinal fluid and pigment epithelial detachment every visit. He is frustrated by the lack of improvement in his visual acuity. What he’s most frustrated about is the need to keep coming back to see me and getting treatment. He travels frequently for work and for pleasure, and so he was really pushing me for options.
So, we had a newer option on the market with faricimab I was really excited to offer to him. And this shows his trend. And so, you can see from initial OCT [optical coherence tomography], he’s had 6 aflibercept injections monthly coming into this and he still has a huge pocket of subretinal fluid, a very large pigment epithelial detachment, and vision is 20/60. He’s unhappy with seeing me again, and I say okay, let’s do faricimab. We did a faricimab injection. Four weeks later, the fluid is better, even epithelial attachment is better, his visual acuity is already better, and so we did another monthly treatment. This is now the OCT after 2 treatments. The fluid is gone at this point and he’s really pushing me. He says there’s no fluid doc, I want to extend out further. I’ll usually do a 2-week extension and be a little more cautious, but he really pushed me to do 8 weeks. So, we did a third injection with faricimab and said come back in 8 weeks. When he comes back in 8 weeks now, he’s 8 weeks after his third faricimab injection, we have no subretinal fluid, a low-lying pigment epithelial detachment, he’s 20/25 after a 20/60 baseline. And again, he pushes me. He says, I want to go out to 3 months. And he’s continued on this progress, Sabin. It’s changed his life and I’m curious, have you seen cases like this in your own practice?
I mean, this is game changing, right? I mean, this is a patient who I think you mentioned is traveling a lot for work. How much more flexibility does your patient have with all this stuff? So, I think this is so exciting for us as retina specialists. I personally have similar cases, Jay, and they describe this as finally feeling a sense of freedom. Visiting their grandkids for extended periods of time for the first time. So, I’m so glad we got this stuff. I’ve got a case for you too if you don’t mind, I’d like to share. This is on a different long high-durability treatment. This is a port delivery system. I’m just going to start with the OCT, because that’s how I live my life when I take care of patients. This is a patient who came in with neovascular AMD with 20/40 vision. You could see she had the subretinal fluid underneath the retina. I gave her ranibizumab and I gave her ranibizumab monthly, and I tried to extend her out as best as I could, but, Jay, all I could do was get her to 6 weeks. Anytime I went beyond 6 weeks, unfortunately this woman started reaccumulating her fluid and she was starting to notice the decrease in vision. My patient is a retired grandmother and I kind of alluded to travel as kind of a big thing, and she truly felt paralyzed.
I’m in Saint Louis, she hates the winters in Saint Louis, but she felt like she was not able to go see her grandkids down south during those cold months because she always had to come back to me to get her treatments. So, I talked to her about port delivery system as something that may be potentially able to give her some more flexibility in life, and let me show you this next OCT, Jay, and you’re going to tell me this looks almost identical and the reality is, it really is. She is now on q24-week, or every 6-month dosing, with ranibizumab port delivery refills. Her vision has completely remained unchanged. She’s still 20/25 to this day, and now she’s only needing treatment every 6 months. So, when I say this is potentially life changing, I mean, I’m not mincing words. She has said this has completely revolutionized her quality of life and it has gotten her life back. She doesn’t feel that neovascular AMD is a burden anymore. She sees me more than twice a year just because we’ve got to do our mid-interval checks, so it’s not like she’s completely free and clear of all those office visits, but her burden of visits is substantially less.
Have you had similar type of responses from your patients, Jay?
Yeah. I mean, this to me, this is the human side of everything we do. This is you changed someone’s life, and really the take home, even though the PDS is, we mentioned in the previous episodes, currently on voluntary recall due to issues with the septum dislodgement, it just shows how we need to stay on the cutting edge and continue to push the envelop in terms of these newer therapies, because it really allows our patients a greater sense of freedom.
I couldn’t agree more. Unfortunately, Jay, that’s all the time we have for today. Thank you for joining me. Always great to talk to you.
It’s always a pleasure, Sabin. Thank you.
You have been listening to CME on ReachMD. This activity is provided by Prova Education and is part of our MinuteCE curriculum.
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In accordance with the ACCME Standards for Integrity and Independence, Global Learning Collaborative (GLC) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any ineligible company. GLC mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.
Durga Borkar, MD, MMCi
Assistant Professor of Ophthalmology
Duke University Eye Center
Consulting Fees: AbbVie/Allergan, Genentech, Glaukos, Iveric Bio, Verana Health
Christina Y. Weng, MD, MBA
Professor of Ophthalmology
Program Director, Vitreoretinal Diseases & Surgery Fellowship Program
Baylor College of Medicine
Consulting Fees: AbbVie/Allergan, Alcon, Alimera Sciences, DORC, EyePoint, Genentech, Iveric Bio, Novartis, Regeneron, REGENXBIO
Royalties: Springer Publishers
Research: AGTC, Alimera Sciences, DRCR Retina Network
Jayanth Sridhar, MD
Chief of Ophthalmology, Vitreoretinal Surgeon
Olive View Medical Center
University of California, Los Angeles
Los Angeles, CA
Consulting Fees: Genentech, Regeneron
Sabin Dang, MD
The Retina Institute
St. Louis, MO
Consulting Fees: Bausch and Lomb, Genentech, Regeneron
Research: Bausch and Lomb, Genentech
- Stephan Chavez has nothing to disclose.
- Cindy Davidson has nothing to disclose.
- Ann Early has nothing to disclose.
- Andrea Mathis has nothing to disclose.
- Brian P. McDonough, MD, FAAFP, has nothing to disclose.
- Tim Person has nothing to disclose.
- Stephanie Wenick, MPhil, has nothing to disclose.
After participating in this educational activity, participants should be better able to:
- Explore recent clinical evidence for the treatment of retinal diseases
- Examine real-world evidence for the treatment of retinal diseases
- Evaluate costs associated with durable treatments of retinal diseases
- Integrate cost-effective, durable treatments for the management of retinal diseases
This activity is designed to meet the educational needs of ophthalmologists and optometrists.
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