‘Ideal’ disease control leads to better nAMD outcomes

January 24, 2017

Neovascular age-related macular degeneration (nAMD) is well-known as a heterogeneous disease with variable natural history and variable treatment response, said Carl D. Regillo, MD, FACS. Many patients do well without monthly treatment as noted in HARBOR PRN arms.

Neovascular age-related macular degeneration (nAMD) is well-known as a heterogeneous disease with variable natural history and variable treatment response, said Carl D. Regillo, MD, FACS. Many patients do well without monthly treatment as noted in HARBOR PRN arms.

“It’s well known patients in this study did well on both ends of the spectrum,” Dr. Regillo said. “Frequent fixed dosing, as were done in the registration studies (for aflibercept [Eylea, Regeneron Pharmaceuticals] and ranibizumab [Lucentis, Genentech]), does lead to some degree of overtreatment and overtreatment does translate into increased expense burden and risk.”

Dr. Regillo is director of the Retina Service, Wills Eye Hospital, Philadelphia.

Individualized treatment in attempts to avoid overtreatment can be accomplished by PRN or treat-and-extend or some combination of the two, “with the goal of suppression of both choroidal neovascularization growth and exudation and it’s going to require frequent optical coherence tomography (OCT) testing with a zero tolerance for exudation,” Dr. Regillo said.

 

Studies support PRN

Both the CATT and IVAN studies confirmed PRN treatment “does work well in many patients,” Dr. Regillo said. For many patients, PRN regimens are impractical as dosing is reduced, but not office visits.

“Even with close monitoring, the best available imaging techniques–and a zero tolerance for any signs of recurrent exudation–CATT, IVAN, and HARBOR studies indicated that the PRN approach doesn’t control the disease as well over time,” Dr. Regillo explained. “The visual improvements that were achieved early in the course of treatment didn’t hold up as well as continuous treatment.”

Some vision loss in the long-term study cohorts may be related to undertreatment, but small lesions at baseline and baseline vision are predictors of final visual acuity.

“If patients start off with good vision, they’ll end with even better vision,” Dr. Regillo said.

In a recently published study, in patients with 20/40 or better baseline vision, the vision can be maintained over 2 years “in better than 75% of patients,” he added.

 

 

Early detection

“The reality in practice is that we don’t catch wet AMD very early on when the vision is very good, at 20/40 or better,” Regillo said. “Studies show that we're doing this probably only 20 to 40% of the time. So we have to do better and we can do better.”

Among his suggestions: Public awareness programs, patient education, and compliance with home-monitoring programs “should make a favorable impact,” he pointed out.

The Home Monitoring of the Eye study with the ForeseeHome AMD monitoring device found the percentage of patients with 20/40 or better vision at the time of choroidal neovascularization diagnosis was 87%, he said.

“Regular use of such a device has the potential to find or pick up wet AMD when the visual acuity is 20/40 or better in close to 90% of the time, which is far better than what we could do in the past,” Dr. Regillo said.

 

 

Carl D. Regillo, MD, FACS

E: cregillo@aol.com

This article was adapted from a presentation Dr. Regillo delivered at the Retina Subspecialty Day before the 2016 American Academy of Ophthalmology annual meeting.

Dr. Regillo is a consultant or on the speaker’s bureau for Abbott, Acucela, Aerpio, Alcon Laboratories, Allergan, Bausch + Lomb, Bayer Healthcare, Genentech, GlaxoSmithKline, Notal Vision, Novartis Pharmaceuticals, Regeneron Pharmaceuticals, and ThromboGenics.