PAT Survey shows treat-and-extend holding steady as preferred strategy

Issue: September 25, 2014

SAN DIEGO — The same questions have yielded different answers over the years.

Perspective from Andrew P. Schachat, MD

About 32% of the membership responded to the 2014 Preferences and Trends (PAT) Survey, Thomas Stone, MD, told colleagues at the annual meeting of the American Society of Retina Specialists here. Of the 75 questions included, some are asked from year to year, giving the opportunity to track trends, Stone said.

Thomas Stone

“In terms of treatment strategy, treat-and-extend became steadily more popular until 2013, and it remains the predominant treatment method for seeing and treating patients with macular degeneration,” Stone said.

Since the question was posed in 2007, the survey showed a fairly dramatic increase in the number of physicians choosing to treat bilateral, wet age-related macular degeneration at one visit rather than injecting only one eye per visit, according to Stone.

In 2005, observation was the main course of action in about 30% of cases of submacular hemorrhage due to AMD, he said.

“There really wasn’t much to offer; we really didn’t have anti-VEGF therapy on the scene at that point,” Stone said.

However, in 2014, anti-VEGF therapy predominates as treatment, according to Stone.

In 2010, primary management for macular edema with visual acuity of 20/25 and fluid seen on optical coherence tomography was likely to be laser.

“That number has decreased substantially over the last 4 years,” Stone said, attributing the trend to the availability of Lucentis (ranibizumab, Genentech) for diabetic macular edema.

Disclosure: Stone has no relevant financial disclosures.

Perspective

Andrew P. Schachat, MD

The 2014 Preferences and Trends (PAT) ASRS survey continues to show that the “treat and extend” protocol for management of neovascular age-related macular degeneration remains the predominant treatment method relied on by the 32% of ASRS members who responded to this year’s survey.

There are three standards of care that are reasonable and appropriate strategies to rely on based on evidence from a series of clinical trials: monthly treatment, pro ne rata (PRN) treatment and treat and extend (T and E) treatment.
Because results of PRN treatment appear to be comparable with results of monthly treatment, and because PRN allows fewer injections and lower cost, I prefer PRN treatment to monthly. But, it does not allow fewer visits, because monthly monitoring is needed, and it does not allow knowing what will happen at each visit. Patients prefer fewer visits, and patients and doctors often prefer knowing what to expect at the upcoming visit.

A number of case series now support the T and E strategy, which can allow not only fewer injections but also fewer visits and greater predictability whether an injection should be anticipated.

Large prospective, carefully performed studies are lacking, however. Recently, though, the LUCAS investigators from Norway have reported their findings, and their manuscript in press shares their results, which align with the T and E option. I understand and agree with the popularity of the T and E approach for the management of neovascular AMD.

Andrew P. Schachat, MD

Vice Chairman for Clinical Affairs, Cole Eye Institute

Disclosures: Schachat is a consultant for Bausch and Lomb, Allergan, and honoraria and travel expenses from Fellows Forum, Inc.