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Impressions and Takeaways From Patient Case #1


Daniel F Kiernan, MD, FACS, shares impressions of a patient case, focusing on challenges in access to care, and implementing treat and extend strategy in DME.

Daniel F. Kiernan MD, FACS: First of all, the patient’s insurance type can oftentimes present the first barrier to their treatment. In this case, the patient had a commercial insurance, which typically dictates step edits or step therapy. And even though the patient should have qualified earlier for aflibercept because their visual acuity was worse than 20/40, and we know from DRCR, the Diabetic Retinopathy Clinical Research Network, that patients with worse vision do better with products such as aflibercept or ranibizumab compared to bevacizumab. Those patients should be able to receive those products regardless of prior authorization or any other factors. But as we know in real life, we often have to jump over the hurdles of the insurance and get their authorization. Otherwise, it can be a financial burden on our practice. We were able to switch the first patient to aflibercept in both eyes after 2 initial treatments of bevacizumab, but that’s still an ongoing problem. Now, how can we implement step therapy without causing vision loss? That’s a great question. Unfortunately, we do have risk of vision loss when we’re giving an inferior product to a patient who needs something that we know works better, and the onus is on the insurance companies to let us give what we think is right for the patient. How does baseline visual acuity impact the choice of anti-VEGF therapy? As mentioned, if it’s worse than 20/40 for diabetic macular edema patients, aflibercept or ranibizumab should be approved rather than bevacizumab, which is an inferior product in those cases. And these are all the factors that we consider before switching patients to other anti-VEGFs. Some total of their fluid and their vision, the most important things. Other treatments we might consider for this patient certainly might be a corticosteroid. There are approved corticosteroids, such a dexamethasone implant or a fluocinolone acetonide 0.19 implant for recalcitrant edema, especially for more chronic appearing edema that might be more inflammatory in nature. In this case, the patient did well, although had limited response to bevacizumab and was able to be switched early on to aflibercept and had a great response to that. Their decision to not undergo cataract surgery is a personal one. I think they would improve with cataract surgery, but once they get stabilized from a retina standpoint, it’s good to then approach them about that rather than the other way around. Diabetic macular edema can certainly worsen if it’s not under control prior to cataract surgery.

Transcript edited for clarity

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