Author: Kate Roche (United Kingdom)
Co-authors: Anusha Phillip, Jessica Moll
The purpose of the research was to investigate the changes in EU4 and UK physicians’ planned treatment approach in a cohort of their personally managed neovascular age-related macular degeneration (nAMD) patients in response to the COVID-19 pandemic. Willingness to extend injection intervals and the relevant reasons for extension were also focused on.
The COVID-19 pandemic caused an urgent need to develop new measures within the ophthalmic community to manage patients with retinal diseases receiving intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents, while mitigating the risk of COVID-19 infection. Guidelines provided focused mainly on limiting the number of outpatient visits by suggesting fixed dosing regimens or a modified treat-and-extend (T&E) approach with reduced monitoring appointments for nAMD patients. Variable-interval regimens (T&E and pro-re-nata, PRN) that required frequent monitoring were generally not recommended, unless patients stopped responding to the fixed-interval dosing or experienced significant vision loss.
A multi-country, multi-centre online medical chart review study of patients with nAMD was conducted in 3 waves between December 2019 and December 2020. Ophthalmologists and retinal specialists in hospitals and office practices provided de-identified data on a sample of nAMD patients under their care who were recently treated in the EU4 (France, Italy, Spain, Germany) and UK. Physicians were screened for duration of practice (3-35 years) and patient volume (≥ 10 nAMD patients in the last 3 months) and recruited from a respondent access panel. Patient charts were recorded for their next 6-8 nAMD patients seen during the screening period. Respondents documented patient demographics, treatment strategy and management, as well as treatment history and personal awareness and concerns for drugs in development. Data were analysed using descriptive statistics.
At the end of 2020, 38% of sampled nAMD patients who started anti-VEGF treatment within the last 12 months were recommended fixed dosing regimens, of either monthly or bi-monthly intravitreal injections (n=543) – an increase on the 35% (n=501) and 27% (n=577) of patients earlier that year and at the end of 2019, respectively. The bi-monthly approach, in particular, saw a growing trend during the pandemic, from 17% at the end of 2019, to 24% mid 2020, then at 27% by the end of 2020 (n=577, 501, 543 respectively). Consequently , variable-interval dosing regimens such as PRN saw a downward trend during the pandemic. In 2019, the highest proportions of nAMD patients in our data were intended for PRN (40%, n=577); this dropped to 29% by the end of 2020 (n=543). The T&E approach saw marginal fluctuations between years 2019 and 2020 (+/- 3-5%). For reasons behind extending injection intervals in eligible patients, aside from the key functional reasons (such as visual acuity/fluid/central retinal thickness etc), “minimise risk of under/over treatment”, “reduce need for travel” and “ease burden on clinic and improve clinic flow” have increased from mid-2020 to late 2020 (albeit still low) as key reasons for interval extensions.
Within our sample, the data suggest that the EU4 and UK respondents expressed an increasing need to maintain fixed treatment intervals in response to the COVID-19 pandemic. Of the two fixed dosing regimens, the bi-monthly approach saw a notable rise amongst sampled nAMD patients throughout the course of the pandemic. This trend could be due to physicians’ intention of reducing the frequency of visits, to limit the risk of exposure resulting from additional monitoring appointments, while ensuring treatment was not disrupted. With higher proportions of sampled nAMD patients on a fixed dosing schedule, the proportion of patients receiving PRN declined. This data aligns with the assumption that physicians consciously wanted to reduce the number of patients on treatment regimens that required frequent monitoring. T&E saw little fluctuation during the pandemic. T&E is a proactive and more personalised approach, hence can be modified to fit patients’ needs. The data further suggest that besides reducing hospital visits and injection burden, respondents perceive extending treatment intervals would also help to minimise risk of over/under treatment, ease burden on clinic and improve clinic flow. Further investigation is required to ascertain the reasons behind these decisions.