Long-term efficacy for DME with fewer injections? Yes, please!

August 20, 2016
Joshua Mali, MD
Joshua Mali, MD

Joshua Mali, MD, is a vitreoretinal surgeon at The Eye Associates, a private multispecialty ophthalmology practice in Sarasota, Florida.

As a physician passionate about treating and helping patients with retinal disease, I continuously seek out and study new treatment modalities. It can be a very scary time for patients when faced with retinal conditions, such as macular degeneration, retinal detachments, and diabetic macular edema (DME).

Editor’s Note: Welcome to “Eye Catching: Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Joshua Mali, MD, a vitreoretinal surgeon at The Eye Associates, a private multispecialty ophthalmology practice in Sarasota, FL. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or UBM Medica.

As a physician passionate about treating and helping patients with retinal disease, I continuously seek out and study new treatment modalities. It can be a very scary time for patients when faced with retinal conditions, such as macular degeneration, retinal detachments, and diabetic macular edema (DME). My goal is to calm their fear and anxiety by offering what I know to be the most advantageous and effective treatments available. It is very rewarding for me to guide patients through their treatments as we work to save their vision and provide the best possible patient outcomes. 

What patients want

It should come as no surprise that patients are generally averse to monthly intravitreal injections. This regimen presents a difficult situation for all involved parties: patients, their caregivers, the healthcare system, and the doctors that must see a large base of patients just for monthly injections.

Pharmaceutical companies have heard our pleas for less troublesome, less painful treatment options and emerging retinal pharmacological treatments are addressing the burden of frequent and expensive treatments for DME. After all, diabetes is a chronic disease, and ideally, treatment should mirror that chronic nature.

Enter the fluocinolone acetonide intravitreal implant (Iluvien, Alimera Sciences). The nonbioerodable implant is designed to deliver a continuous microdose of fluocinolone acetonide (FAc) to treat DME. Designed specifically for intraocular use, the tiny implant (3.5 mm x 0.37 mm) lasts for 36 months, and may possibly eliminate, or at least significantly reduce, the need for and frequency of anti-VEGF injections.

During my retina fellowship in Albany (NY), I had the opportunity to participate in the initial launch of the implant. My patients were among the very first recipients, and all have continued to do well. I have been using the device since then, and have injected over 10 patients with the deivce; all have met treatment goals. With the gradual release of medication over an extended period, the implant offers us the pharmacokinetic profile we are looking for to help us to achieve our patients’ visual goals.

Reimbursement is a breeze

 

Reimbursement is a breeze

To date, I have not had any difficulties receiving reimbursement. In the event of any problem, Alimera representatives have stepped forward and provided support in resolving issues that might otherwise consume my time or my staff’s time. We bill using the permanent J-Code J7313 and provide documentation on each patient indicating that a long-term corticosteroid treatment will produce the desired effect. (Prior to placing the long-term implant, I monitor and document my patients following injection of a traditional corticosteroid to ensure they do not experience a steroid response.)

I also like to believe that insurance companies are willing to cover the best treatment for the patient. However, at the end of the day, the implant makes economic sense to insurance companies. For example, if a single device can reduce the dependency on monthly anti-VEGF injections, this will represent a significant cost savings for our healthcare system.  

 Improving compliance

Diabetes is a multi-system disease and usually involves multiple doctors for one patient. Anything we can do to keep patients’ eyes stable for longer and decrease the number of office visits can serve as an aid in keeping their overall health in shape and increasing compliance with their array of medications and visits to other medical specialists.

The less we require of patients, the more they can actively focus their energies on the controllable aspects of diabetes. Let’s face it-the prospect of having a needle stuck in your eye every month doesn’t yield itself to excited, compliant patients. It is basic human nature to avoid unnecessary pain and to comply with a regimen when it is easier to do so-it just makes sense.

Simply put, my patients are quite willing to swap monthly injections for fewer annual injections.

Before adopting a new treatment modality

 

Adopting a new treatment modality 

Before adopting any new regimen into your practice, study it. Study the information, the clinical data, and ask other practitioners about their experiences and gather a few pearls. Think about how you treat DME and your current treatment algorithm. Will this benefit your patients as a primary or combination treatment option?

The device has proven itself to me as a highly effective treatment option. My patients here in Florida are happy to shed the burdens of inconvenience, pain, and expense of monthly injections for a comparable, or even better, visual outcome.

 

Joshua Mali, MD, is a vitreoretinal surgeon at The Eye Associates, a private multispecialty ophthalmology practice in Sarasota, Florida. He can be reached at 941-792-2020. He is currently a consultant and shareholder at Alimera Sciences and a consultant at Allergan, where he also receives research and clinical study funding.