Age-Related Macular Degeneration Treatments: Determining Appropriate Use - Episode 7

Goals of Therapy in Wet Age-Related Macular Degeneration

Peter L. Salgo, MD: Let’s say we make the diagnosis and the diagnosis is accurate. You’ve got their attention because it’s going to cost something to treat it. What are your goals? At any stage of this disease, what are we looking for?

Jared Nielsen, MD: We’re looking to manage this chronic disease. So, when we employ anti-VEGF therapy, most people do so with monthly treatment. If we sit down and have a discussion with a patient and their family and we initiate treatment, this treatment tends to be monthly injections until the disease is inactive or stable. And at that point, most people in the United States employ what’s called a treat-and-extend strategy, where we try to lengthen out the treatment intervals in the absence of disease activity.

Peter L. Salgo, MD: Let me be very specific. In each state of the disease, you’ve got to have something that you’re looking for. Is it possible to halt the progression of this disease, and is that what our goal is? Or are we actually looking to improve vision?

Charles Wykoff, MD, PhD: The way I put this to patients is that we have a 90% chance, if we adequately treat you, of maintaining or improving the vision that you have when I first find the wet disease. About 10% of patients over 2 years will lose vision despite adequate and appropriate treatment.

Peter L. Salgo, MD: But 90%...And this was a certain diagnosis of blindness how long ago?

Jared Nielsen, MD: Well, the anti-VEGF era really started around the mid-2000s.

Peter L. Salgo, MD: So, 10 to 15 years?

Jared Nielsen, MD: Yes. So, you’re looking at 10 to 12 years of having effective anti-VEGF agents that can really improve vision for a lot of patients. The best treatments that we had prior to that were just slowing the disease down and making patients less worse.

Peter L. Salgo, MD: I must tell you that when you take a look across the whole waterfront of medicine, these last 10 to 15 years have been dramatic in so many areas: heart disease, the statins, and now anti-VEGF.

Jared Nielsen, MD: Well, I would argue that if you take all of medicine—and certainly, I’m biased—that this is one of the greatest innovations we have had in the last 20 years. We’ve talked about the economic impact and the impact that it can have on patients, their well-being, and their quality of life. It’s amazing to be able to do this, it really is. I have to pinch myself sometimes and say, “What we can do for you is amazing.” My partner used to say that I was a minister who only did funerals. That’s what he did when he treated wet AMD prior to this era, and the fact that we can offer these treatments is very exciting.

Peter L. Salgo, MD: And restore vision. You mentioned that you can hold in place or restore vision—take it back a couple of clicks.

Charles Wykoff, MD, PhD: I must admit, I have tempered excitement about this.

Peter L. Salgo, MD: Why is that?

Charles Wykoff, MD, PhD: I love the era that we’re in. VEGF blockade works really well, but it’s not great, actually. If you look at actual ultimate visual acuity outcomes—you guys are seeing 20/20 right now, and you kind of like it—the successes that we’re talking about are often not 20/20. That’s why it’s important that Jared and I and the whole field continue to push forward. We’re doing pretty well with the VEGF blockade, but we’ve got further to go, and those drugs are going to be expensive.

Peter L. Salgo, MD: Again, everybody would like 20/20. Somebody would like 20/15—that would be very nice. But if I’m 20/80 or 20/100 and you can bring me back toward 20/20, I’m going to be pretty darn happy.

Charles Wykoff, MD, PhD: If you look at the percentages though, again, 90% stay the same or get better. That’s not saying 90% are getting a lot better. In fact, about one-third get a lot better, which is pretty good, but that means that two-thirds are not getting a lot better. We’re doing really well, and we need to do even better with what we have, but there is a future.

Jared Nielsen, MD: And the treatment burden is substantial. That’s why we’re here today: the burden is substantial, not just from an economic standpoint, but also from a visit standpoint. Charlie mentioned new drugs. I’m also optimistic that, at some point, we’ll have ways of administering therapy that will last longer for patients.

Charles Wykoff, MD, PhD: To get those percentages, you’ve got to treat them aggressively. And as Jared pointed out, the real-world data that we have from around the world are that we are grossly under-dosing our patients for many reasons.

Peter L. Salgo, MD: I want to get into why in just a minute. But I want to put 2 things together here and then sympathize for just a moment with the payer groups. I’ve heard, “Oh, it’s great, but maybe not so great.” And in order to even get not so great, there’s a tremendous treatment burden. It’s monthly, and there are drugs and they cost money. Is it worth it in terms of population dynamics and health dynamics from the payer perspective if he says, “I’m not too sure”?

Peter Dehnel, MD: Absolutely worth it from a population health standpoint. If you’re going to look through the lens of population health, you are going to do much better with that population over the next 5 to 10 years if they have vision. Now, from a payer standpoint, sometimes our horizon is a little bit shorter than 5 to 10 years, and that’s just because people can shift plans or go to another carrier. The value that I get from treating aggressively or covering that aggressive treatment isn’t something that’s going to accrue to me, and that’s part of the conversation we also need to have.

Peter L. Salgo, MD: Do you know what I heard you say, but I really like? You said, “When I treat,” which means that you’re taking some responsibility other than just paying for treatment. You’re concerned about the patient’s well-being and concerned about your policies influencing patients’ well-being. Is that how you see it?

Peter Dehnel, MD: Definitely. Because even though payers obviously do not treat patients, if we don’t cover something, it’s the same as not allowing for the treatment. So, we do have a responsibility, and I think we need to take a very fiduciary role here in terms of coverage of payments. But on the other hand, vision is an incredibly important thing, so we need to figure out a way to do that.

Gary L. Johnson, MD, MS, MBA: But, really, I don’t think that most payers will restrict or try to limit, as you said, the marginal improvement. I just haven’t seen that.

Charles Wykoff, MD, PhD: I think I need to re-clarify here. There are 3 outcomes, right? There’s natural history, which is terrible for this disease. Patients cannot care for themselves, which is abominable. We need to end that. Then, there’s the outcome that you can get with maximal VEGF blockade, which is regular dosing indefinitely for most patients. But then, there’s what Jared and I are talking about, which is the future of research where we can do even better than current treatments. But to get the second outcomes, you’ve got to treat them aggressively, and we’re falling short for our patients—both as treating physicians and as payers. The patients are not coming back frequently enough. We are not giving enough treatments, and we’re probably not using the right drugs.