Factors influencing treatment choice and the importance of shared decision-making

Caroline Baumal, MD: David, when considering my patient’s treatment regimen, I like to consider things like durability, patient approach, and what patients would prefer to have. Do they want to have the treatment that will make them observe more frequently? Or do they come in and say, “Doctor, I don’t want to come see you very often; I want to see you as little as possible”? One of the key things I like to consider is security. In the past, we were so comfortable with anti-VEGF agents. As a profession, we were even nonchalant about injecting drugs into the eye until a few years ago an agent presented with inflammation and occlusive vasculitis.

One of the biggest things that affects what I use is security. I don’t want to use an agent that will have adverse effects in our very fragile or diabetic populations, which are prone to other diseases. I don’t want to give them another problem. All of these factors play into what I use for a patient. If I have a patient who does what he does well, he is at the status quo and he is happy. There are patients who like to see me every 8 to 10 weeks. They want to know if they’re okay [even if] we have been doing it for 10 years. I let them stay on what they are. I’m in Massachusetts where it’s cold. Many patients say, “Doctor, I don’t want to come in the winter. I want you to give me something that will feel good so I don’t have to come in. For these patients, I will try to give them the most durable agent.

David A. Eichenbaum, MD, FASRS: It’s a really interesting thing because it goes into the shared decision-making process. I have similar conversations with patients. Granted, I’m in Florida. We’re not talking about being cold. We’re talking about being able to go on a cruise, to the mountains, to Massachusetts, or wherever patients want to go and fill in the gaps of summer. But shared decision-making with patients is not always about the drug. They don’t want to know the details of the medicine, or they don’t understand the details of the medicine. They want to know what their lifestyle options are. They want to have a discussion about safety and make it relatable. Patients do not know what occlusive vasculitis is. They want to know what the chances are of something bad and good happening when you inject them. It’s nice to have confidence when you help them through this shared decision-making process and the agents you recommend. This is a huge advantage for these agents.

The general discussion is more about lifestyle and injection tolerance and what you learn from your relationship with each patient about their ability to stick to a treatment plan. This all goes into shared decision making. Patients often ask me to recommend an agent. They don’t say, “I thought about aflibercept versus ranibizumab versus brolucizumab versus faricimab, and I want that 1.” They often say, “Based on what we talked about, Doc, what do you think? What should we do? Can I go longer if we change? I have been doing very well with this medication for years. Should I change ? Or, “I really don’t want any more shots. Can I come in and get checked? We have these different conversations, and you make a recommendation based on their wishes and what you know about the technical side and the clinical aspect of being a retina specialist It’s shared decision making that we have.

Caroline Baumal, MD: You raise an important point. We have the knowledge that we have from clinical studies, which must have a certain diet. How do you get everyone to follow a similar protocol so that the results are comparable? But when we bring these drugs into the real world, we have real problems. It is not always easy to follow these regimented protocols.

Plus, many of us do things a little differently. Treat and extend might be different if you do it one way and I do it another way. For example, treatment and extension many clinicians use 2 weeks, but in many clinical studies treatment and extension are done at 4 week intervals because it is easier to see patients at 4 week intervals . Monthly and as-needed injections can mean a different thing to different people. We all have slightly different variations in how we treat patients. It is important to set the expectations of your patients. I tell my patients that they will have to be treated often in the first year because there are so many protocols, especially for neovascular AMD [age-related macular degeneration], treat patients frequently enough during the first year to make the retina as dry as it will be. Over time, patients can usually receive fewer injections, but this is not guaranteed. It depends on how they react.

Transcript edited for clarity

Martin E. Berry