Factors Affecting Compliance to Anti-Vascular Endothelial Growth Factor Treatment of Diabetic Macular Edema in a Cohort of Jordanian Patients

Non-adherence and non-persistence to intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy: a systematic review and meta-analysis

BACKGROUND

Intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections play a key role in treating a range of macular diseases. The effectiveness of these therapies is dependent on patients' adherence (the extent to which a patient takes their medicines as per agreed recommendations from the healthcare provider) and persistence (continuation of the treatment for the prescribed duration) to their prescribed treatment regimens. The aim of this systematic review was to demonstrate the need for further investigation into the prevalence of, and factors contributing to, patient-led non-adherence and non-persistence, thus facilitating improved clinical outcomes.

METHODS

Systematic searches were conducted in Google Scholar, Web of Science, PubMed, MEDLINE, and the Cochrane Library. Studies in English conducted before February 2023 that reported the level of, and/or barriers to, non-adherence or non-persistence to intravitreal anti-VEGF ocular disease therapy were included. Duplicate papers, literature reviews, expert opinion articles, case studies, and case series were excluded following screening by two independent authors.

RESULTS

Data from a total of 409,215 patients across 52 studies were analysed. Treatment regimens included pro re nata, monthly and treat-and-extend protocols; study durations ranged from 4 months to 8 years. Of the 52 studies, 22 included a breakdown of reasons for patient non-adherence/non-persistence. Patient-led non-adherence varied between 17.5 and 35.0% depending on the definition used. Overall pooled prevalence of patient-led treatment non-persistence was 30.0% (P = 0.000). Reasons for non-adherence/non-persistence included dissatisfaction with treatment results (29.9%), financial burden (19%), older age/comorbidities (15.5%), difficulty booking appointments (8.5%), travel distance/social isolation (7.9%), lack of time (5.8%), satisfaction with the perceived improvement in their condition (4.4%), fear of injection (4.0%), loss of motivation (4.0%), apathy towards eyesight (2.5%), dissatisfaction with facilities 2.3%, and discomfort/pain (0.3%). Three studies found non-adherence rates between 51.6 and 68.8% during the COVID-19 pandemic, in part due to fear of exposure to COVID-19 and difficulties travelling during lockdown.

DISCUSSION

Results suggest high levels of patient-led non-adherence/non-persistence to anti-VEGF therapy, mostly due to dissatisfaction with treatment results, a combination of comorbidities, loss of motivation and the burden of travel. This study provides key information on prevalence and factors contributing to non-adherence/non-persistence in anti-VEGF treatment for macular diseases, aiding identification of at-risk individuals to improve real-world visual outcomes. Improvements in the literature can be achieved by establishing uniform definitions and standard timescales for what constitutes non-adherence/non-persistence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020216205.

Real-World Outcomes of Anti-VEGF Therapy in Diabetic Macular Oedema: Barriers to Treatment Success and Implications for Low/Lower-Middle-Income Countries

Diabetic macular oedema (DMO) is the leading cause of vision loss associated with diabetic eye disease. The exponential increase in the diabetic population and thus, of DMO is an impetus for optimizing the management of DMO. One major challenge in DMO management is the discrepancy between treatment outcomes seen in clinical trials and the real world. Contrary to the homogeneity, better patient motivation and shorter study durations seen in randomised control trials, routine clinical practice is fraught with more diverse populations, undertreatment and variable compliance with long-term therapy. Under both circumstances, this review aims to compare efficacy outcomes and adverse events of DMO therapies within the scope of anti-vascular endothelial growth factor (anti-VEGF) medications, specifically the commonly used ones-bevacizumab, ranibizumab and aflibercept. Impediments and methods to achieve better treatment outcomes in the real world will be addressed to achieve better outcomes. Low- to lower-middle-income countries are faced with even more barriers which range from paucity of data on epidemiology and treatment response to scarce human and financial resources to poorer national level attention and then basic issues like transportation. Additionally, to address the lack of a global consensus in DMO treatment, this review generates and recommends, for clinical and research purposes, an up-to-date consensus algorithm for DMO management universally. Underpinned by results from clinical trials and recent guidelines, this therapeutic flowchart can be utilised in various resource settings including low- and lower-middle-income countries where affordability is a major deterrent to treatment access.

Determination of Factors Influencing the Health Belief Model (HBM) and Adherence to Intravitreal Anti-vascular Endothelial Growth Factor (VEGF) Among Patients With Diabetic Macular Edema (DME)

Background Diabetic macular edema (DME) is becoming one of the leading causes of blindness worldwide with a significant impact on quality of life. The effectiveness of intravitreal (IVT) anti-vascular endothelial growth factor (VEGF) therapy has been established by clinical trials and has become the treatment of choice in the majority of DME patients in reducing macular edema and improving visual acuity. Frequent drop-out and discontinuation of treatment are major issues. Lack of compliance can lead to worsening outcomes and be a burden to patients and the healthcare system. Purpose The purpose of this study is to assess multiple factors that affect adherence to IVT anti-VEGF treatment among patients with DME, including socioeconomic causes and the Health Belief Model (HBM) domains, in addition to exploring the relationship between them. Methods This cross-sectional study was conducted among DME patients in Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia, from December 2020 to June 2021. We identified eligible patients using a retrospective chart review of clinical findings and optical coherence tomography (OCT) findings. Included subjects were of Malaysian nationality, aged 18 years and above, who were initiated or re-initiated IVT anti-VEGF treatment regime and on follow-up for at least six months from initial injection from January 2019 onwards. A translated and validated self-administered questionnaire was given to the respondents. Data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). Demographics of the patient were summarized using descriptive statistics, independent sample t-test was used to compare the difference in components of the HBM questionnaire. Linear regression was further used to explore the relationship between patients' demographics and the HBM component. Results A total of 141 patients participated in this study, of whom 56.2% patients were adherent to treatment. The majority were aged 60 years and above (56.7%), male (52.5%), Malay (38.9%), and married (71.6%). There was a significant statistical difference in patients who were adherent to treatment, in terms of life entourage (p=0.004, Fisher Exact test). HBM domains that influenced adherence to treatment included perceived severity, perceived barriers, perceived benefits, cues to action, and self-efficacy (p<0.05, independent sample t-test). Further, multiple logistic regression tests on sociodemographic factors and HBM domains after eliminating confounding factors narrowed down the significant variables to perceived susceptibility (p= 0.023), perceived benefits (p< 0.001), and self-efficacy (p< 0.001). Conclusion Patients' adherence to IVT anti-VEGF is influenced by perceived susceptibility to complications from DME, perceived benefits to the treatment, and self-efficacy.

Impact of COVID-19-related lockdown on retinal disorders treated with intravitreal injections

PURPOSE

To study functional changes in vision and morphological changes on optical coherence tomography (OCT) scans in patients where intravitreal therapy (IVT) with injections has been delayed due to COVID-19 pandemic lockdown.

METHODS

Retrospective cross-sectional study included 77 eyes with the diagnosis of exudative age-related macular degeneration (eAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO), regularly receiving IVT with anti-vascular endothelial growth factor (Anti-VEGF) injections or dexamethasone implant and were not able to receive the injections as intended due to lockdown. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and qualitative morphological features on OCT were analyzed pre- and post-therapy break off.

RESULTS

The mean duration of IVT break-off was 57 days. Mean BCVA logarithm of minimum angle of resolution (logMAR) worsened from 0.33 (20/42) to 0.35 (40/44) (P = 0.02) and mean CFT increased from 297.90 μm to 402.16 μm (P < 0.01), from pretherapy break-off to return visit. Worsening of the visual acuity was seen across all the three disease cohorts, significantly more in the eyes with eAMD.

CONCLUSION

Marginal decline in the visual acuity and worsening of the OCT features were observed as a result of delay in the IVT injections of DME, eAMD and RVO patients.

Importance of Treatment Duration: Unmasking Barriers and Discovering the Reasons for Undertreatment of Anti-VEGF Agents in Neovascular Age-Related Macular Degeneration

Purpose

Since non-adherence (NA) to intravitreal therapy with VEGF drugs is one of the most important modifiable factors compromising treatment outcome of nAMD, the purpose of this study was to investigate the contributing factors and barriers during long-term nAMD treatment.

Methods

Barriers and potential reasons for NA were prospectively measured using the Adherence Barriers Questionnaire Intravitreal Therapy (ABQ-IVT). A random sample of patients receiving intravitreal therapy was drawn based on data for different treatment periods. Three age-sex matched groups included the treatment periods of ≤30 months (group 1), between >30 months and ≤60 months (group 2), and >60 months (group 3). The occurrence of gaps between treatments and/or OCT visits was evaluated.

Results

NA with gaps of >56 days after the scheduled appointment was detected in 39%, 89%, and 100% of patients in group 1, 2, and 3, respectively (groups 1 and 2 vs group 3, p < 0.001). Two or more of such gaps were observed in 6%, 72%, and 94% of patients in group 1, 2, and 3, respectively. The overall ABQ-IVT score showed corresponding differences between the groups: 25.89 ± 7.68 (group 1, 95% CI 22.07–29.71), 34.72 ± 10.32 (group 2, 95% CI: 29.59–38.86), and 33.28 ± 9.04 (group 3, 95% CI 28.78–37.77). Accordingly, the score was inversely correlated with the number of regular follow-up visits in groups 2 and 3 (Pearson correlation coefficient r = −0.65 (p = 0.003) and r = −0.5 (p = 0.034), respectively). Within the groups of longer treatment duration, univariate logistic regression analysis showed higher odds of time commitment and challenge accompanying person to be relevant barriers.

Conclusion

NA is an arising problem with increasing duration of intravitreal therapy. Treatment barriers, detected by the ABQ-IVT, might change or increase during the course of the treatment.

Rho-Kinase Inhibitors for the Treatment of Refractory Diabetic Macular Oedema

Diabetic macular oedema (DMO) is one of the leading causes of vision loss associated with diabetic retinopathy (DR). New insights in managing this condition have changed the paradigm in its treatment, with intravitreal injections of antivascular endothelial growth factor (anti-VEGF) having become the standard therapy for DMO worldwide. However, there is no single standard therapy for all patients DMO refractory to anti-VEGF treatment; thus, further investigation is still needed. The key obstacles in developing suitable therapeutics for refractory DMO lie in its complex pathophysiology; therefore, there is an opportunity for further improvements in the progress and applications of new drugs. Previous studies have indicated that Rho-associated kinase (Rho-kinase/ROCK) is an essential molecule in the pathogenesis of DMO. This is why the Rho/ROCK signalling pathway has been proposed as a possible target for new treatments. The present review focuses on the recent progress on the possible role of ROCK and its therapeutic potential in DMO. A systematic literature search was performed, covering the years 1991 to 2021, using the following keywords: "rho-Associated Kinas-es", "Diabetic Retinopathy", "Macular Edema", "Ripasudil", "Fasudil" and "Netarsudil". Better insight into the pathological role of Rho-kinase/ROCK may lead to the development of new strategies for refractory DMO treatment and prevention.

Adherence of patients with diabetic macular oedema to intravitreal injections: A systematic review

The purpose of this study was to review adherence rates to intravitreal injections in the treatment of diabetic macula oedema and to identify factors associated with adherence. A systematic search of Embase, Medline, PsycINFO and CINAHL was conducted up to May 2020. Two authors independently screened, selected and appraised the studies. Seven articles on anti-VEGF treatment were found to meet the inclusion criteria. No studies were found on intravitreal corticosteroids or dexamethasone implants. Attendance rates varied between studies from 35% to 85%. The rate of missed or delayed attendance ranged from 14% to 51%, whereas 25% of patients were lost to follow-up at 12 months. Non-adherence was found to be multifactorial and included patient related reasons, demographic characteristics and clinical factors. Enablers to adherence included patient understanding of the disease and treatment. Further research in this area is warranted in order to better understand adherence in these patients and to improve patient outcomes.