Important Considerations Regarding Treatment Selection for Wet AMD and DME Patient Populations

Dr Coney and Veeral Sheth, MD, MBA, FACS, FASRS, discuss treatment selection, treatment goals, and unmet needs for patients diagnosed with wet AMD and DME.

Jim Kenney, RPh, MBA: What are some important considerations regarding treatment selection for each of these patient populations, wet AMD [age-related macular degeneration] and DME [diabetic macular edema]?

Joseph Coney, MD, FASRS, FACS: I think [what’s] really important, particularly when it comes to AMD, is the health of the other eye. Oftentimes, individuals may have lost 1 eye, so when you’re treating the other eye, which may have a [50%] risk of bleeding…when 1 eye actually turns wet, I think for those individuals, sometimes I consider a more long-term therapy. I’m sure we’ll get into that a little bit more in detail. I think the most important thing for me when it comes to diabetes is the level of presentation that individuals present with. We know the individuals who present with more advanced disease—let’s say, if they have severe nonproliferative disease, I know they have a 50% chance of having severe visual loss over the next 3 to 5 years. Those things are really, really important to me. Also, lesion types are really, really important; the size of the lesion and how much bleeding is present. If they have a typical form of macular degeneration like a RAP [retinal angiomatous proliferation] lesion or a polypoidal lesion, those individuals tend to have a much more burden therapy to stabilize their disease with our current therapy.

Jim Kenney, RPh, MBA: It sounds like the presentation of these patients can be quite varied and it takes a good review of their condition to determine the direction you’re going to go in, in terms of how aggressive you’re going to treat or what approach you might take.

Joseph Coney, MD, FASRS, FACS: Absolutely.

Jim Kenney, RPh, MBA: Dr Sheth, what are the overall goals of treatment for wet AMD and DME?

Veeral Sheth, MD, MBA, FACS, FASRS: I think first and foremost, vision is always top of mind. It’s top of mind for patients. When patients come in and by the time they get to us as specialists, they’re usually suffering from some degree of vision loss and so their primary goal, at least in the short run, is to, again, stabilize that vision or improve that vision. For us, we look at it and it again depends on the patient. Some people, we want to just stabilize their disease. Let’s say, like Joe [Dr Coney] mentioned, we have a lot of bad diabetics. Bad diabetics, sometimes all we can do is stabilize them until they get their blood sugars under control. Disease stabilization is one of those things, and then quality of life. Quality of life is very important. When it comes to these treatments, a lot of times there’s a heavy treatment burden in order to get those maximum visual impacts that we want. The trade-off here is that these patients are coming in quite often and so we want to balance that out with maximizing their vision but also helping from a treatment burden standpoint. Then along the same lines of treatment burden, a lot of times patients come in and this may be a difference between our diabetics and our elderly patients who tend to present with macular degeneration. A lot of times they have caretakers who bring them, and so that kind of halo effect of what’s happening to them in their clinic also impacts their family members. Keeping all those things in mind and understanding that each patient is going to have a different set of needs is important.

Jim Kenney, RPh, MBA: Thank you. Dr Luo, what are some of the biggest unmet needs currently in these 2 conditions, wet AMD and DME?

Caesar Luo, MD, FASRS, FACS: That’s a great question. I think that Dr Coney actually hit on a really important point here, which is that there’s really a true heterogeneity of the disease. I think in 2006, when we first had anti-VEGFs [vascular endothelial growth factors] come out, it actually made us kind of dumb, honestly, as specialists. We just started giving anti-VEGF therapies to everybody, and it was great. It worked incredibly well. For the first time, we saw patients’ vision improve with wet macular degeneration, and we saw similar data with diabetic macular edema, and we thought, this is great. But for me, one of the biggest unmet needs is that as we’ve gotten better and more nuanced in our treatments, we’ve actually found that not all patients respond the same way, and sometimes sitting in their chair, it’s a different conversation than we used to have 10 years ago. For me, certainly, I think being able to address that heterogeneous disease, like we know even in the clinical trials where these patients were treated monthly, 30% of some patients with wet AMD still required monthly therapies and still had an active leak. We saw the same things with DME. We saw patients, 10% to 13%, who still needed to be on Q4-week treatment intervals, even with our strongest medication. There is a group of patients who don’t do as well with our currently available FDA [US Food and Drug Administration]-approved therapies. Building on that, I think for those patients who do respond very well, Dr Sheth is correct. I think that some of these patients have a very high treatment burden. They do incredibly well, but if you’re coming in every 4 weeks to keep that excellent vision and you’re 86 and you’re relying on multiple caregivers, that’s not an easy task. So having durability, but being able to maintain that efficacy of functional vision, is what we’re looking for. It’s the holy grail to try to get these patients extended but still maintain their vision. For me, it’s kind of finding that subset of more efficacious therapies, but also having something that might be more durable for us. I think as part of this conversation there will also be cost. As we know, this is a very expensive medication. It continues to be one of the largest costs to Medicare and health care investments in general. Being able to minimize that—there are only so many dollars out there—I think is an important consideration as well. I think durability will be able to help us do that.

Jim Kenney, RPh, MBA: Thank you very much.

Transcript edited for clarity.

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