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Age-Related Macular Degeneration—Determining Appropriate Use of Treatments: A Stakeholder Summit

Age-Related Macular Degeneration—Determining Appropriate Use of Treatments: A Stakeholder Summit

In April 2017, in Washington, DC, AJMC® Peer Exchange® hosted a panel of ophthalmology and managed care decision makers and providers to define age-related macular degeneration (AMD) and to provide insight regarding its impact on patients and caregivers. Panelists included Peter Dehnel, MD, medical director of Integrated Health Management at Blue Cross Blue Shield of Minnesota; Jared Nielsen, MD, ophthalmologist specializing in vitreoretinal diseases and surgery at Wolfe Eye Clinic in West Des Moines, Iowa; Charles Wykoff, MD, PhD, director of Clinical Research for Retina Consultants of Houston, and deputy chair for Ophthalmology at Blanton Eye Institute—Houston Methodist Hospital in Houston, Texas; and Gary L. Johnson, MD, MS, MBA, practicing physician and regional medical director in Madison, Wisconsin. The moderator was Peter L. Salgo, MD, a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital in New York.
Risk Factors
AMD predominantly affects Caucasians and Asians; they have a higher risk profile than individuals of African or Hispanic descent.1 Other risk factors include increasing age, dietary fat intake, and family history.1 Smoking is an environmental risk factor that has been consistently shown in studies to be linked to AMD.1 It is remarkable, Salgo noted, that for AMD and “disease after disease after disease, you come up with the same basic prevention recommendations: They’re all the cardiovascular risk prevention strategies, which are watch your LDL [low-density lipoprotein cholesterol], watch your smoking, watch your hypertension, all of that stuff. It applies to the eyes, too.”

Management of AMD focuses on treating patients with choroidal neovascularization, or wet AMD; to date, no therapy exists to treat dry AMD.2 AREDS and AREDS2 (the same research group’s second study to improve the original AREDS formulation) were designed to test benefits of antioxidant vitamins and minerals in patients with intermediate or advanced AMD in at least 1 eye to slow the progression to wet AMD.1 Both are prospective, randomized controlled trials, and both studies determined that supplementation with antioxidant vitamins and minerals should be considered for patients with AMD.1 AREDS showed that the effects on AMD were most pronounced in patients who received antioxidant vitamins with both zinc and copper; the benefits were a 19% reduction in the risk of losing vision (3 or more lines) and a 25% reduction in progressing to advanced AMD.1 AREDS2 further refined the recommended regimen; its results demonstrated the benefit of replacing beta-carotene with lutein and zeaxanthin. In other study results, in other populations, beta-carotene has been associated with a decrease in the absorption of nutrients and higher incidence of lung cancer. AREDS2 also showed the noninferiority of reducing the amount of zinc from the original formulation and the lack of benefit from the addition of 2 supplemental omega-3 fatty acids, docosahexaenoic and eicosapentaenoic acids.1

However, Wykoff cautioned that the decision whether to treat AMD with vitamins comes with caveats. “The challenge is that not all people at risk of AMD should be on the vitamins,” he said. “It’s a relatively small [percentage] of our entire global population who should be on them, so don’t put everybody on vitamins just because they’re at the age where they could have macular degeneration. You [still have] to get the dilated eye exam. Every year, all adults over 50 should at least get 1 exam.”

According to retina specialist Nielsen, his primary goal for wet AMD patients is to try to get the lesions to dry out as quickly as possible, for the disease to become as inactive as possible, and to try to administer the least number of treatments possible. The patients’ treatment options include laser photocoagulation, photodynamic therapy, surgery, and the current standard of care, pharmacologic treatment with anti-angiogenic drugs, which are anti-VEGF agents.2

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