Maintenance Treatment for Diabetic Macular Edema

Nancy Holekamp, MD: It’s important for our audience to understand that when we initiate treatment, it will likely be monthly because we want to give everyone the best chance to end up on that curve. That curve is improvement in vision. It happens early, and we want everyone to maximally be there. Monthly injections are difficult because of the treatment burden once we’ve established that someone is responding. Joe, are you using therapy when necessary? Are you using a treat-and-extend? Do you observe and reinstitute therapy if there’s a relapse? What are you doing after that initiation? Because these patients have diabetes and are at risk for DME [diabetic macular edema], what do you do for their maintenance phase?

Joseph M. Coney, MD: [First I make sure] they’re stable, meaning the OCT [optical coherence tomography] is the best I can get. Let’s take an eye that’s completely dry, with no fluid in the retina. I don’t have to do all the loading doses. In clinical trials we have the set criteria where we do 5 loading doses depending on the drugs. If they’re dry after 2 successive injections, I typically extend them out. Each time they’re dry, I’d go out by 2 weeks longer. Typically I would go out to about 12 weeks before I skipped an injection. This was about a year of therapy, a year and a half of therapy, depending on how many injections they had.

COVID-19 has taught me several things. I was surprised how many people did better than I thought they would—this is more in my AMD [age-related macular degeneration] population, but it was also true for some of my DME population. Some of these people I had been treating for many years. They’ve had recurrent fluid multiple times or recurrent blood vessels, etc, but some of these people held up. Now I have those people out 14, 16 weeks, and some of our newer trials are also going to 16 weeks. Whether those biologics are stronger, we don’t know, but we’re looking at that now. Early studies were never powered to go beyond 12 weeks, and now we’re doing that.

I’m pushing my patients more than they can, and I’m trying to customize their therapy. I personalize their therapy to what’s going on in their life, and I’m using everything I have to decrease their drug burden by maximizing everything else. It’s a treat and extend, and you’d be amazed once you get someone stable. After year 2 or 3, and this is reproduced in our studies, people who have been stable don’t require as many injections. It’s important that you still monitor these patients. As long as the patient is about equity, where they were and where they’re going, they’re more likely to keep their appointments.

In medicine at some point, we must make the eye a higher priority. Once we start moving the chain and make it a priority, where we can see eyes earlier, those patients are more likely to come in for therapy. I keep them on a maintenance therapy because people on maintenance therapy tend to keep their appointments, engage, and often do better. There is a pro to continue them on a dosing of every 3, 4, 6 months because they’re less likely to get in trouble and less likely to have a progression in their disease itself, not just in DME.

Nancy Holekamp, MD: Joe, you mentioned something very important, and that’s dosing patients, perhaps those who don’t have active DME but have varying degrees of nonproliferative diabetic retinopathy, such as moderately severe or severe. Regular injections as far as every 16 weeks could keep people from progressing and getting sight-threatening complications.

Ted, we’re talking about the PANORAMA study, and I’m wondering if you could give us an overview and the recommendations that come from it for patients with nonproliferative diabetic retinopathy?

Theodore Leng, MD, FACS: This was an interesting study, and it led to the use of aflibercept molecule to treat diabetic retinopathy in the absence of DME. It showed that a significant portion of patients had a reduction in the severity of diabetic retinopathy. It paved the way to using this therapy for patients with diabetes, which is another problem in that it presents many patients who might need intravitreal therapy and will need our services. There are resource constraints with the number of patients we’re seeing.

However, there are benefits to a treatment using anti-VEGF therapy in patients with diabetic retinopathy. It prevents progression to more advanced stages, and it reduces the risk of having vitreous hemorrhage or needing vitreous surgery, such as vitrectomy and laser. You have the added benefit of prophylactic treatment—more or less of having diabetic macular edema—which was the primary cause of vision loss in these patients. For many reasons, the treatment of diabetic retinopathy is beneficial to our patients.

Nancy Holekamp, MD:Thanks to all of you for this rich and informative discussion, and thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box.

Transcript edited for clarity.