Key opinion leaders discuss factors to consider when selecting treatments in wet AMD including insurance considerations and degree of clinical response.
Charles C. Wykoff, MD, PhD: Diana, you start a patient on an anti-VEGF agent, 1 of the big 3 that you laid out. And you treat them monthly. They’re compliant, as Sophie brought in—great point. You’re 3 or 4 injections in, and there’s persistent fluid. They’ve gotten better, but they’re not 20/20, and their symptoms haven’t totally resolved. At what point do you think about switching agents? What’s your driver for switching? How do you switch agents in clinic?
Diana V. Do, MD: This is a common clinical scenario that we face as retina specialists. Often we may, for insurance purposes, start a patient with bevacizumab because of step therapy that’s being employed in a lot of insurance plans. If the patient in my hands does not have a good clinical response—defined by resolution of active fluid compartments on the OCT [optical coherence tomography] or significant improvements in vision—then I would like to switch to an FDA-approved rapid agent if possible. I tend to try to switch them to aflibercept because there are robust efficacy and safety data that suggest that it is a good therapeutic agent for patients. We’re able to extend patients every 8 weeks or longer with aflibercept therapy. I usually wait 3 to 4 months if I had started them on bevacizumab before seriously switching to a different agent.
Charles C. Wykoff, MD, PhD: Very reasonable. Is there such a thing as a nonresponder? If this is wet AMD [age-related macular degeneration] and not a masquerade syndrome—we’re not talking vitelliform dystrophy that someone misdiagnosed; you really got wet AMD—is there such thing as a nonresponder? What’s an incomplete responder or poor responder? What are the words you use?
Mark P. Breazzano, MD: That’s a great question. I wish there was a better way to figure out who these patients are going to be. Ultimately, you’re trying to do every 28 days—as frequently as you can get with bevacizumab—and it’s just not getting results, or the resolution of the fluid or improvement that we’re really looking for. As Diana just pointed out, for a lot of these patients, we convert them to aflibercept, and there is an improvement in vision. There definitely is a role for that switching and with the different agents. To get that really aggressive treatment, it can really get some good success with that switching.
Charles C. Wykoff, MD, PhD: Sophie, what’s your goal? We talked about how you communicate goals to patients early on, but you have a little puddle of subretinal fluid in the center. It’s stable with monthly dosing. The patient is happy; the vision is OK. Do you ever tolerate fluid and begin to extend, or are you a treat-to-dry physician? What do you think about fluid?
Sophie J. Bakri, MD: I’m definitely a treat-to-dry retina specialist. Sometimes you learn that based on 1 case. The reason we treat to dry is because we have drugs that are just about controlling the disease in those who have a little fluid. If you extend by another month, you may tip the balance into getting a lot more fluid and vision loss. It’s important to understand that we’re about keeping them stable if they have a little fluid. In my opinion, they’re not the ones to extend.
The question of how much we discuss with patients depends on how much they want to know. Some patients want to see the OCT and they want to see each kind of fluid, and they ask you to pull them up and compare them. Others just say, “My vision is fine,” and they may be doing well on whatever regimen of injections they’re used to. Everyone is different, and you have to cater to each patient’s needs because if someone is generally happy with their vision and is doing fine on injections—say, every 4 or 6 weeks, and they come in for a quick injection—perhaps they don’t want to know all the details of the OCT. And vice versa for the other kinds of patients when you just say, “You’re vision is great.” They really want to see their OCT. Every patient is an individual, and it’s important to understand what they want to hear about as well.
Charles C. Wykoff, MD, PhD: Great comments. Diana, this is a little philosophical, but what about PDT [photodynamic therapy]? Is there any role for verteporfin? We have the EVEREST II trial that suggests maybe at least with ranibizumab it adds value. But you have the PLANET trial, which suggests that with aflibercept, it doesn’t really add much value. Is there a role for PDT in IPCV [idiopathic polypoidal choroidal vasculopathy] cases?
Diana V. Do, MD: A lot of retina specialists are not keeping their PDT machine. It’s at some select centers, but it’s not widely used. I use PDT most of the time for central serous retinopathy but not wet AMD because it’s effective in stopping leakage from that. Some physicians still think polypoidal choroidal vasculopathy if you aren’t getting the response you want with monotherapy intravitreal anti-VEGF agents; the combination may be helpful in select patients. PDT’s role in wet AMD is much smaller and maybe just for a few niche patients.
Transcript edited for clarity.