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Dr. Borkar:
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.
Dr. Weng:
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.
Dr. Borkar:
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.
Dr. Weng:
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.
Dr. Borkar:
I couldn’t agree more. Unfortunately, that’s all the time we have for today. Christina, thank you for joining me.
Dr. Weng:
Thanks for having me, Durga. It was great to be here with you.
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