Retina specialists discuss which factors impact treatment selection and how to incorporate shared decision-making into treatment selection when treating patients with AMD and DME.
Caroline Baumal, MD: David, when I consider the treatment regimen for my patient, I like to consider things like durability, patient approach, and what patients would prefer to have. Do they want to have the treatment that will have them observe more frequently? Or do they come in and say, “Doctor, I don’t want to come in to see you very often; I want to see you as little as possible”? One of the key things I like to consider is safety. In the past, we were so comfortable with anti-VEGF agents. As a profession, we were even nonchalant about injecting medicines into the eye until there was an agent a few years ago that had some inflammation and occlusive vasculitis.
One of the biggest things that affects what I use is safety. I don’t want to use an agent that’s going to have any adverse events in our very frail or diabetic populations, which are prone to have other illnesses. I don’t want to give them another problem. All these factors play a role in what I use for a patient. If I have a patient who’s doing well on what they’re doing, they’re at status quo and they’re happy. There are some patients who like to see me every 8 to 10 weeks. They want to know if they’re doing well [even if] we’ve been doing it for 10 years. I let them stay what they’re on. I’m in Massachusetts where it’s cold. Many patients say, “Doctor, I don’t want to come in over the winter. I want you to give me something that’s going to make it so I don’t have to come in.” For those patients, I’ll try and give them the most durable agent.
David A. Eichenbaum, MD, FASRS: That’s a really interesting thing because it goes into the process of shared decision-making. I have similar conversations with patients. Granted, I’m in Florida. We don’t talk about being cold. We talk about being able to go on a cruise, to the mountains, to Massachusetts, or wherever the patients want to go and get gaps from the summer. But the shared decision-making with patients isn’t always about the medicine. They don’t want to know the details of the medicine, or they don’t understand the details of the medicine. They want to know what their options are from a lifestyle standpoint. They want to have the safety discussion and have that be relatable. Patients don’t know what occlusive vasculitis is. They want to know what the odds are of something bad and something good happening when you inject them. It’s nice to have confidence when you’re helping them through this process of shared decision-making and the agents that you’re recommending. It’s a huge benefit to those agents.
The overall discussion becomes more about lifestyle and tolerance of injection and what you learn with your relationship with every individual patient about their ability to be adherent to a treatment plan. All of that goes into the shared decision-making. Patients will often ask me to recommend an agent. They don’t say, “I’ve thought about aflibercept vs ranibizumab vs brolucizumab vs faricimab, and I want this 1.” They often say, “Based on what we’ve talked about, Doc, what do you think? What should we do? Can I go longer if we switch? I’ve been doing great on this drug for years. Should I switch?” Or, “I really don’t want shots anymore. Can I come in and just get checked?” We have these different conversations, and you make a recommendation based on their desires and what you know about the technical aspect and the clinical aspect of being a retinal specialist. That’s the shared decision-making that we have.
Caroline Baumal, MD: You bring up an important point. We have the knowledge that we have from clinical studies, which must have some regimen to them. How can we get everyone to follow a similar protocol so the results are comparable? But when we bring these medications in the real world, we have real-world issues. It’s not always easy to follow those regimented protocols.
Also, many of us do things a little differently. Treat and extend could be different if you do it 1 way and I do it another way. For example, treat and extend many clinicians use 2 weeks, but in many clinical studies, treat and extend is by 4-week intervals because it’s easier to see patients at 4-week intervals. Monthly injections and as needed might mean a different thing to different people. We all have slightly different variations in the way we treat patients. It’s important to set the expectations for your patients. I tell my patients that we’ll need to treat them often in the first year because so many protocols, especially for neovascular AMD [age-related macular degeneration], treat patients quite frequently in year 1 to make the retina as dry as it will be. Over time, patients can typically come in for fewer injections, but that’s not guaranteed. It depends on how they respond.
Transcript edited for clarity