Do retinal physicians approach wet age-related macular degeneration differently when treating themselves versus treating their patients? This question was explored in a recent presentation by Jonathan Prenner, M.D., at the 32nd Annual Meeting of the American Society of Retina Specialists in San Diego, California.
The mission of the American Society of Retina Specialists is to provide a scientific forum for education, advance the understanding and treatment of retinal diseases, and enhance the ability of its members to provide the highest quality of patient care.
The supporting research, entitled Retina Specialists Treating Age-Related Macular Degeneration Recommend Different Approaches for Patients than They Would Choose for Themselves, has been published online ahead-of-print in the May 22, 2014 edition of Retina. Retina focuses exclusively on retinal disorders and provides current information on diagnostic, surgical, and therapeutic techniques.
The authors are Karen W. Jeng; John Wilgucki; Scott Halperin; William J. Feuer; Howard F. Fine; Daniel Roth; and Jonathan L. Prenner, who represent the following institutions: Rutgers-Robert Wood Johnson Medical School, Piscataway, New Jersey; Bascom Palmer Eye Institute, Miami, Florida; and NJ Retina, New Brunswick, New Jersey.
About the Research
Excerpted from Retina Docs Prescribe for Themselves, Patients Differently, via Medscape (registration required):
Retina specialists would treat [wet] age-related macular degeneration differently in themselves than in their patients, a new survey shows.
“We’re more likely to recommend [Avastin] for our patients than for ourselves, and we’re more likely to choose a conservative treatment paradigm for ourselves than for our patients,” said Jonathan Prenner, M.D. Dr. Prenner presented the survey results at the 32nd Annual Meeting of the American Society of Retina Specialists.
To explore potential inconsistencies in prescribing, Dr. Prenner and his team identified two random samples of retina specialists from the American Society of Retina Specialists database. The groups were matched by age, sex, and geographic location. Of the [retina] specialists surveyed, 226 responded, for a rate of 28.3%.
All specialists were presented the case of a 70-year-old with 20/100 visual acuity in the left eye secondary to [wet] age-related macular degeneration, … choroidal neovascularization …, and subretinal fluid [i.e., fluid accumulating beneath the retina] and cystoid macular edema on optical coherence tomography. The right eye demonstrated high-risk drusen.
[Editor’s note: “Choroidal neovascularization” refers to new and abnormal blood vessels that grow, multiply, and develop into a cluster beneath the macula. “Cystoid macular edema” is a swelling of, or accumulation of fluid in, the macula. The macula is the part of the retina that provides the clearest central vision.
“Optical coherence tomography,” or OCT, is a type of optical ultrasound test that produces a high-resolution cross-sectional image of the retina. “Drusen” are small white or yellowish deposits that form on the retina, beneath the macula, causing it to deteriorate or degenerate over time. They are composed of cholesterol, protein and fats.]
One group of specialists was asked to recommend treatment for a hypothetical patient, and the other group was asked to recommend treatment if they themselves were the patient.
The respondents were significantly more likely to prescribe [Avastin] to the patient than to themselves. They were also significantly more likely to recommend a treat-and-extend approach for the patient than for themselves, and much less likely to inject on a monthly schedule.
In published results, [Dr. Prenner] and his colleagues speculate that economics could be a factor. They report that the annual cost is estimated to be up to $23,400 for [Lucentis], up to $14,800 for [Eylea] (8 doses), and about $595 for [Avastin].
Physicians are more likely to have extensive health insurance and the financial means to afford more expensive drugs, the researchers explain.
“In contrast, physicians may prefer treatment with [Lucentis] or [Eylea] because of the safety profile, U.S. Food and Drug Administration (FDA) approval status, and the ability to obtain the drug from sources other than a compounding pharmacy,” they write.
[Editor’s note: Avastin, unlike Lucentis, does not come prepared in single-dose ready-made vials for eye injections because the FDA has not yet approved it for that purpose. Pharmacies, therefore, must “compound” (i.e., remix or prepare a single dose of) Avastin for eye injections from packaging that is intended for intravenous use. This has raised concerns about Avastin sanitation and sterility issues.]
About Age-Related Macular Degeneration (AMD)
In wet, or exudative, macular degeneration (AMD), the choroid (a part of the eye containing blood vessels that nourish the retina) begins to sprout abnormal blood vessels that develop into a cluster under the macula (called choroidal neovascularization).
The macula is the part of the retina that provides the clearest central vision. Because these new blood vessels are abnormal, they tend to break, bleed, and leak fluid under the macula, causing it to lift up and pull away from its base. This damages the fragile photoreceptor cells, which sense and receive light, resulting in a rapid and severe loss of central vision.
Anti-Angiogenic Drugs and Anti-VEGF Treatments
Angiogenesis is a term used to describe the growth of new blood vessels and plays a crucial role in the normal development of body organs and tissue. Sometimes, however, excessive and abnormal blood vessel development can occur in diseases such as cancer (tumor growth) and AMD (retinal and macular bleeding).
Substances that stop the growth of these excessive blood vessels are called anti-angiogenic (anti=against; angio=vessel; genic=development), and anti-neovascular (anti=against; neo=new; vascular=blood vessels).
The focus of current anti-angiogenic drug treatments for wet AMD is to reduce the level of a particular protein (vascular endothelial growth factor, or VEGF) that stimulates abnormal blood vessel growth in the retina and macula; thus, these drugs are classified as anti-VEGF treatments. At present, these drugs are administered by injection directly into the eye after the surface has been numbed.
Avastin
Avastin is an anti-VEGF drug that is FDA-approved since 2004 for intravenous use in colorectal cancer. It is currently used on an “off-label” basis (i.e., via eye injection) to treat wet AMD.
Lucentis
Lucentis is derived from a protein similar to Avastin, specifically for injection in the eye to block blood vessel growth in AMD. In 2005, clinical trials established Lucentis as highly effective for the treatment of wet AMD. The FDA approved Lucentis in 2006.
Eylea
Eylea was approved by the FDA in late 2011 as an effective treatment for wet AMD. It is administered once every two months after three initial once-a-month injections.
More about the Research from Retina
From the article abstract:
Purpose: To evaluate the presence of cognitive biases among retina physicians when recommending treatment options for [wet] age-related macular degeneration.
Methods: Two random samples of retina specialists were surveyed regarding their treatment and dosing regimen choices among three anti-vascular endothelial growth factor biologics [Eylea, Avastin, and Lucentis].
One group was asked to provide recommendations for a standardized hypothetical patient with [wet] age-related macular degeneration, whereas the other group was asked to provide recommendations as if they themselves were the standardized hypothetical patient with [wet] age-related macular degeneration.
Results: Two hundred and twenty-six respondents (28.3%) completed the survey and were divided equally between the survey groups. For patients, most physicians recommended [Avastin] (52.2%), but when choosing for themselves, physicians were divided equally among all three biologics.
The results were influenced by geographical location of the physician but not by the gender or length of practice. Furthermore, physicians differed in dosing regimen selection with the majority (73%) choosing treat-and-extend for patients, whereas only 63% selected this regimen for themselves.
Conclusion: When considering cases of [wet] age-related macular degeneration, physicians would recommend different treatments for themselves than they would for a patient.
Additional Information
- Read about developments in AMD treatments on the VisionAware blog.
- What Is the Age-Related Eye Disease Study?