Impressions and Takeaway Points From Case #1

Daniel F Kiernan, MD, FACS, discusses impressions and key takeaways from a neovascular AMD patient case, focusing on treatment intervals.

Daniel F. Kiernan, MD, FACS: In this case, the patient had classic symptoms for wet AMD [age-related macular degeneration] and choroidal neovascular membrane, and they were treated in a way many other patients are treated: by starting with preferred generic products, such as aflibercept. Their insurance allowed them to avoid the need for step therapy with a potentially less effective agent and go straight to aflibercept. They responded very well. Unfortunately, because of their health issues and the burden of care from their other health considerations—specifically chemotherapy for their cancer—they missed several appointments.

For patients who are treated, I usually follow an initial 3 loading doses. Then, following the label, maybe I go to every other month. If they have recurrent fluid, I switch back to every month for Eylea. In this case, the patient missed a few appointments and was stable after these tests of proof of stability. I felt comfortable going farther out sooner than I might have otherwise. I went 2 and then 3 months, even within a year of treatment. The on-label indication is to treat patients with 3 initial loading doses and then every month or every other month for the remainder of the first year. Usually, this can be safely extended. Greater than 50% of patients can often be extended to 12 weeks. This patient was extended to 12 weeks within the first year of treatment. This was extended to 6 months after that, not by design but because of other health issues. Six months is what we hear about when we talk about a fourth delivery system: Susvimo, not Eylea. That was definitely something that could have made a turn for the worse, so I don’t recommend that normally. That’s why I had the patient follow up with quarterly dosing every 3 or 4 months. That would be quite effective for this patient.

You don’t want to extend them too far. Something untoward could happen. They could definitely lose vision or have permanent vision loss if they were to have a subretinal hemorrhage, for example. In this case, by the way everything worked out, this patient stayed quite stable at 2, 3, 4, and even 6 months between shots. That’s not how we want to handle this patient, or any patient, because of the risk of something else happening.

As for the takeaways from this discussion: these injections work, and some patients respond better and last longer than others. When you go past a reasonable period of 2 or 3 months, you’re increasing the risk margin a little too much, and you should be cautious. With some of the newer agents that have clinical trial data showing 3- and 4-month time intervals, I feel more comfortable extending the patient. Even then, how long do these drugs last? A half-life is short, so erring on the side of caution is better. We see that in long-term studies, if patients receive more shots, they tend to have vision preserved for longer, and that erring on the side of more treatment is better than less treatment.

Transcript edited for clarity

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