The approval of new, more durable treatments is an exciting development for the management of neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME), but how do these therapies and their unique mechanisms stack up outside of clinical trials? Join Dr. Durga Borkar, Dr. Sabin Dang, Dr. Jayanth Sridhar, and Dr. Christina Weng as they discuss these new treatments and the emerging data surrounding their use in the real world.
Reconsidering the Algorithm: Treatment-Resistant DME
Reconsidering the Algorithm: Treatment-Resistant DME
Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum.
Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.
We’ve all had those patients that we can’t get dry after a few injections of anti-VEGF, so let’s take a look at some of the strategies we are thinking about now that a treatment with a new mechanism of action is available.
This is CME on ReachMD, and I’m Dr. Durga Borkar.
And I’m Dr. Christina Weng, and I’ve got a case here of a patient with an incomplete response that I think will launch an interesting discussion. This is a 66-year-old female with insulin-dependent diabetes mellitus and a history of PDR [proliferative diabetic retinopathy] in both eyes, who came to me with blurry vision in her left eye.
Now she’s had multiple anti-VEGF injections over the past 2 years, and you’ll notice that she also has multiple ocular comorbidities including cataracts in both eyes, glaucoma in both eyes, and even a lamellar hole in the left eye – the eye that we’re going to be discussing. Like many of our younger diabetic patients, she works full-time and is also juggling family responsibilities as well. Here is her initial OCT, and I decided to initiate treatment with bevacizumab. You can see that after 6 monthly doses, even though there is some improvement, some fluid definitely persists. So I transitioned her to aflibercept, and treated her with monthly injections over the next one and a half years, and she did improve a bit further, but I decided to switch her to faricimab when it became available at our institution. And similar to you, Durga, I also injected 4 loading faricimab injections, and you can appreciate the significant improvement in anatomy and visual acuity, which improved to 20/20-. She has also been able to subsequently extend her intervals, which has been helpful from a treatment burden standpoint.
Great case, Christina. I think this highlights a lot of really interesting points. You know, one is that there is a limitation of steroids for some patients. I think this is a perfect example – a young patient who may not be interested in cataract surgery and also has a glaucoma history. But I think, really, what I took away from this case is that given that these patients are mostly working age, durability is really key for them, and what I see from that aflibercept switch to faricimab is very similar to what we saw in the FARETINA-DME study – is that many of these patients, they may only gain a couple letters, but what we may really be going after here is durability. As you mentioned, you know, these patients can hopefully be extended the way that she has been.
Yeah, I really like how you said it, and I know you’ve done a lot of work in this area, Durga, but durability really does have a major impact on the patient experience, and remember that a lot of these conditions are going to be treated indefinitely. And so you’re absolutely right, and interesting just from my own experience with my patients in the chair, you know, taking somebody from 6 injections a year to 4 injections a year can really make a huge difference, especially when they’re juggling other responsibilities, as this patient was doing herself.
So again, faricimab can be really helpful in patients with a suboptimal response, but it’s also similarly important to remember that you could also very reasonably use it in patients with a complete response, as you said, who want to reduce their treatment burden, or even for treatment-naïve patients, as comprise the majority of patients included in the pivotal trials, especially in light of the well-tolerated safety profile we’ve observed so far. And the last thing I’ll mention, just as an aside here, is this patient was complex – like you said, bilateral cataracts, glaucoma in both eyes, but also you’ll notice a lamellar hole in the left eye, and there’s a small preretinal membrane you can probably appreciate there.
And so, just a reminder thatfor patients with DME that may not respond completely, it’s always important to consider alternative contributors to what their OCT looks like. And those common things that we might see include Irvine-Gass, if a patient’s had cataract surgery, especially recently, or an epiretinal membrane as this patient had in this case. And just keep those things in mind, and do the appropriate diagnostic tests to make sure that we’re really addressing all the root causes of their current condition.
I couldn’t agree more. Unfortunately, that’s all the time we have for today. Christina, thank you for joining me.
Thanks for having me, Durga. It was great to be here with you.
You have been listening to CME on ReachMD. This activity is provided by Prova Education and is part of our MinuteCE curriculum.
To receive your free CME credit, or to download this activity, go to ReachMD.com/Prova. Thank you for listening.
In accordance with the ACCME Standards for Integrity and Independence, Global Learning Collaborative (GLC) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any ineligible company. GLC mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.
Durga Borkar, MD, MMCi
Assistant Professor of Ophthalmology
Duke University Eye Center
Consulting Fees: AbbVie/Allergan, Genentech, Glaukos, Iveric Bio, Verana Health
Christina Y. Weng, MD, MBA
Professor of Ophthalmology
Program Director, Vitreoretinal Diseases & Surgery Fellowship Program
Baylor College of Medicine
Consulting Fees: AbbVie/Allergan, Alcon, Alimera Sciences, DORC, EyePoint, Genentech, Iveric Bio, Novartis, Regeneron, REGENXBIO
Royalties: Springer Publishers
Research: AGTC, Alimera Sciences, DRCR Retina Network
Jayanth Sridhar, MD
Chief of Ophthalmology, Vitreoretinal Surgeon
Olive View Medical Center
University of California, Los Angeles
Los Angeles, CA
Consulting Fees: Genentech, Regeneron
Sabin Dang, MD
The Retina Institute
St. Louis, MO
Consulting Fees: Bausch and Lomb, Genentech, Regeneron
Research: Bausch and Lomb, Genentech
- Stephan Chavez has nothing to disclose.
- Cindy Davidson has nothing to disclose.
- Ann Early has nothing to disclose.
- Andrea Mathis has nothing to disclose.
- Brian P. McDonough, MD, FAAFP, has nothing to disclose.
- Tim Person has nothing to disclose.
- Stephanie Wenick, MPhil, has nothing to disclose.
After participating in this educational activity, participants should be better able to:
- Explore recent clinical evidence for the treatment of retinal diseases
- Examine real-world evidence for the treatment of retinal diseases
- Evaluate costs associated with durable treatments of retinal diseases
- Integrate cost-effective, durable treatments for the management of retinal diseases
This activity is designed to meet the educational needs of ophthalmologists and optometrists.
In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.
Global Learning Collaborative is accredited by COPE to provide continuing education to optometrists.
Global Learning Collaborative (GLC) designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Global Learning Collaborative (GLC) designates this activity for 1.0 nursing contact hours. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
This course is to be approved for 1.0 CE credit. Course ID is 87276-TD. Check with your local state licensing board to see if this counts toward your CE requirement for relicensure.
Prova Education designs and executes continuing education founded on evidence-based medicine, clinical need, gap analysis, learner feedback, and more. Our mission is to serve as an inventive and relevant resource for clinical content and educational interventions across a broad spectrum of specialties.
Prova Education's methodology demonstrates a commitment to continuing medical education and the innovative assessment of its effects. Our goal is clear—to develop and deliver the very best education in the most impactful manner and to verify its results with progressive outcomes research.
This activity is supported by an independent educational grant from Genentech, a member of the Roche Group.
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of GLC and Prova Education. This presentation is not intended to define an exclusive course of patient management; the participant should use his/her clinical judgment, knowledge, experience, and diagnostic skills in applying or adopting for professional use any of the information provided herein. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Links to other sites may be provided as additional sources of information. Once you elect to access a site outside of Prova Education you are subject to the terms and conditions of use, including copyright and licensing restriction, of that site.
Reproduction of this material is not permitted without written permission from the copyright owner.
Our site requires a computer, tablet, or mobile device and a connection to the Internet. For best results, a high-speed Internet connection is recommended (DSL/Cable/Fibre). We also recommend using the latest version of your favorite browser to ensure compliance with W3C standards, such as Chrome, Safari, Firefox, or Microsoft Edge.