Experts share best practices for managing the treatment burden of wet AMD including treat-and-extend, loading doses, monitoring, and hybrid telemedicine.
Charles C. Wykoff, MD, PhD: Let’s talk about treatment burden. Sophie, you’re a treat-to-dry physician. I’m a treat-to-dry. You treat them, and they’re dry. You’ve given them X number of shots, and it doesn’t really matter how many, at least for the initial question. What do you do now? Are you a PRN [pro re nata] treater? Are you a treat and extend? What do you do?
Sophie J. Bakri, MD: I’m a slow treat and extend. If they’re dry and they’ve had 4-week injections, then I’ll do a few more injections at 6 weeks and then reevaluate. That way, they can have a few injection-only visits. Extending by 2 weeks, patients usually do fantastic. And then I’ll see them back again and they go a little longer. I know some of the data have shown, especially with Eylea, that you can extend by an extra month. I have done that, but if I were to extend by an extra month, I would definitely see the patient back at that time. But for 2-week extensions, I’m comfortable doing a treat-and-extend theory.
Charles C. Wykoff, MD, PhD: Mark, what’s your pattern? PRN or treat and extend? What’s your mechanism?
Mark P. Breazzano, MD: I also like to treat and extend. The data support that role for a lot of these patients. I’ll usually start with every 4 weeks and then go from that point. Just follow them closely and make sure we’re getting a good response and, as Sophie was saying before, really make sure that compliance component is understood and that we stay on the ball for their eyes.
Charles C. Wykoff, MD, PhD: Diana, what about the loading doses? If you’re going to do treat and extend, do you have to have a certain amount of loading doses, or is 1 enough if they’re dry? How many do you have to give up front?
Diana V. Do, MD: I still like doing loading doses, and I base that on all the prior clinical trials when we look at both ranibizumab and aflibercept. There was a steep improvement in visual acuity and reduction in retinal thickening during that first 3- to 6-month period. I like giving loading doses to ensure that I aggressively treat the choroidal neovascularization.
Charles C. Wykoff, MD, PhD: How far can we go for treatment extend? Who wants to take that? Do we maximize at 8, 12, 16 weeks? How far will you go?
Diana V. Do, MD: It depends on the patient. There are some patients where you can extend them to 16 weeks. It just depends on the size of their choroidal neovascular membrane and if you can control it. But that’s not the majority. It’s the minority that can be extended that far.
Charles C. Wykoff, MD, PhD: What do you think, Sophie?
Sophie J. Bakri, MD: I agree. I can extend most patients to 8 to 12 weeks. I would say most to 8 and then fewer to 12 weeks. I have a few patients, though, who are 16, 20, 24 weeks. I’m wondering, is it time to stop? If we stop then, instead of treat and extend, then they must come in monthly, which is even more of a burden for them. I give them the choice at that point. I say we could stop, and you could come in monthly, or I could inject you now and see you in 5 or 6 months. Some choose option A; some choose option B.
Charles C. Wykoff, MD, PhD: I’m going to push that a little, Sophie. That’s great logic. They stop. They say, “I don’t like these shots. They hurt. You told me they wouldn’t hurt.” They hurt a little, at least when Dr Wykoff does them. When you stop, how often do you see them monthly before they say, “Can’t I go 2 months? Can’t I go 3 months? I’ve been dry for a year.” How long do you have to see them monthly?
Sophie J. Bakri, MD: This is a great question. It’s also a tough question. I guess maybe monthly for a few months. I’ll try every couple of months. But this is a great segue into why home OCT is going to be so useful. Once we have technology and we are super comfortable with the resolution, and that patients can use and that will use, that’s exactly the patient home OCT is useful for. There is another option, which is a hybrid telemedicine visit. Perhaps they come in for an OCT, a screening visit. We read the OCT and have them come back. We must think about that. We’ve been increasingly learning more about possible hybrid telemedicine, especially with COVID-19 because it’s all about minimizing the patient’s time in the office. Certainly those types of screening clinics are something that we are going to be instituting, on a regular basis for exactly those kind of patients, we’re really looking at 1 disease. They may be pseudophakic, for example. There are not pressures; everything else is fine. But all we really want to know is, when is that fluid going to recur, if at all?
Transcript edited for clarity.