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Roubelat FP, Barioulet L, Varenne F, Escudier C, Meyer P, Gomane C, Butterworth J, Pagot-Mathis V, Fournié P, Gualino V, Soler V. The Reinforced Treat-and-Extend Protocol for Exudative Age-Related Macular Degeneration: Retrospective Assessment of 24-Month Real-World Outcomes in France. Ophthalmol Ther 2024:10.1007/s40123-024-00938-7. [PMID: 38625500 DOI: 10.1007/s40123-024-00938-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/13/2024] [Indexed: 04/17/2024] Open
Abstract
INTRODUCTION The aim of this work is to evaluate the real-world outcomes of the reinforced treat-and-extend (RTE) protocol for the treatment of exudative age-related macular degeneration with intravitreal injections of aflibercept or ranibizumab (anti-vascular endothelial growth factor therapies). METHODS This was a retrospective review of patients from two tertiary ophthalmology centers in France initiating the RTE protocol between February 2018 and June 2021. The primary outcome was change in best-corrected visual acuity (BCVA) after 24 months. Secondary outcomes were change in central retinal thickness (CRT), recurrence, and management-related factors (injection interval, number of injections/consultations). Outcomes were additionally evaluated after protocol changes (strict versus modified RTE protocol groups). RESULTS Sixty-eight patients (72 eyes) were included (68% females; mean age 82.2 ± 7.8 years). After 24 months, mean BCVA significantly improved (65.22 ± 14 vs. 71.96 ± 13 Early Treatment Diabetic Retinopathy Study letters; p < 0.001) and CRT significantly decreased (388.6 ± 104 vs. 278.8 ± 51 μM; p < 0.001) with 21% of eyes showing signs of exudation. Over the 24 months, a mean total of 14.9 ± 4.0 injections and 8.6 ± 1.4 consultations were performed. Mean 24-month injection interval was 7.9 ± 2.3 weeks. Initial and 24-month ophthalmic outcomes for eyes in the strict (47%) versus modified (53%) groups were not significantly different, but mean time interval to first recurrence of disease activity was significantly shorter for the modified group (7.3 ± 2.4 vs. 9.9 ± 2.5 weeks; p < 0.001). Patients in the strict RTE group received significantly less injections (13.9 ± 3.6 vs. 16.5 ± 3.9; p = 0.006) and mean 24-month injection interval was significantly longer (9.5 ± 2.7 vs. 6.5 ± 2.1 weeks; p < 0.001). Consultation number was similar (8.5 ± 1.9 vs. 8.8 ± 1.6; p = 0.93). Treatment with aflibercept versus ranibizumab did not influence ophthalmic or management outcomes. CONCLUSIONS The RTE protocol, even when modified, reduced consultations but improved ophthalmic outcomes. The RTE protocol could reduce hospital visits and overall burden while also encouraging better patient compliance. Video Abstract available for this article. VIDEO ABSTRACT Vincent Soler and François-Philippe Roubelat summarize the Reinforced Treat-and-Extend Protocol and main results (MP4 225022 KB).
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Affiliation(s)
- François-Philippe Roubelat
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Lisa Barioulet
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Fanny Varenne
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Clément Escudier
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Pauline Meyer
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Clément Gomane
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Jacqueline Butterworth
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Véronique Pagot-Mathis
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
| | - Pierre Fournié
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
- Faculty of Medicine, University of Toulouse III, Toulouse, France
| | - Vincent Gualino
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France
- Ophthalmology Department, Clinique Honoré-Cave, Montauban, France
| | - Vincent Soler
- Retina Unit, Ophthalmology Department, Hôpital Pierre-Paul Riquet, CHU Toulouse, Place Baylac, 31059, Toulouse Cedex, France.
- Faculty of Medicine, University of Toulouse III, Toulouse, France.
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Bakri SJ, Delyfer MN, Grauslund J, Andersen S, Karcher H. Real-World Persistence and Treatment Interval in Patients with Diabetic Macular Edema Treated with Anti-Vascular Endothelial Growth Factors in the USA. Ophthalmol Ther 2023; 12:2465-2477. [PMID: 37347405 PMCID: PMC10441838 DOI: 10.1007/s40123-023-00750-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION There is little understanding of long-term treatment persistence in patients receiving anti-vascular endothelial growth factor (anti-VEGF) injections for diabetic macular edema (DME), particularly relating to treatment intervals. The aim of this study was to investigate the association between treatment interval and discontinuation rate after 24 months of unilateral anti-VEGF treatment in patients with DME under routine clinical care in the USA. METHODS This was a non-interventional, retrospective cohort study to review the health insurance claims of adults with DME linked with the IBM MarketScan® Commercial and Medicare Supplemental databases, who were continuously enrolled in a health plan for at least 6 months prior to their first anti-VEGF treatment and for a duration of at least 24 months between July 2011 and June 2017. Patients were grouped on the basis of the injection interval they achieved at 24 months of treatment. Discontinuation rate beyond 24 months and its association with treatment intervals at 24 months was estimated using the Kaplan-Meier method and Cox proportional hazards models. RESULTS The overall discontinuation rate among the 1702 eligible patients from 24 to 60 months after treatment initiation was 30%. At 60 months, patients were more likely to remain on treatment in shorter (75.3% [4-week interval group]) versus longer treatment interval groups (62.1% [> 12-week interval group], difference = 13.2%, [95% confidence interval (CI) 1.06, 2.06], p = 0.01). Patients on a > 12-week interval were twice as likely to discontinue treatment compared with those on an 8-week interval (hazard ratio = 2.01 [95% CI 1.43, 2.82], p < 0.001). CONCLUSION Patients with DME on longer anti-VEGF treatment intervals at 24 months consistently had higher discontinuation rates in the following years than those on shorter treatment intervals.
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Affiliation(s)
- Sophie J Bakri
- Department of Ophthalmology, Mayo Clinic, 200 First St SW, Rochester, MN, 55902, USA.
| | - Marie-Noelle Delyfer
- University of Bordeaux, Team "Lifelong Exposures, Health and Aging" (LEHA), Inserm U1219, Bordeaux Population Health Research Center, Bordeaux, France
- Department of Ophthalmology, Bordeaux University Hospital, Bordeaux, France
| | - Jakob Grauslund
- Department of Ophthalmology & Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Vestfold University Trust, Tønsberg, Norway
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Ruscheweyh R, Förderreuther S, Gaul C, Gendolla A, Holle-Lee D, Jürgens T, Neeb L, Straube A. [Treatment of chronic migraine with botulinum neurotoxin A : Expert recommendations of the German Migraine and Headache Society]. Nervenarzt 2019; 89:1355-1364. [PMID: 29947936 DOI: 10.1007/s00115-018-0534-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Injection of botulinum neurotoxin A (BoNT-A) according to the PREEMPT (Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy) paradigm has been approved for the treatment of refractory chronic migraine in Germany in 2011. OBJECTIVE The practical application raises some questions, such as the choice of dose and injection intervals during the course of the treatment, and the appropriate time point for discontinuation of BoNT-A treatment. MATERIAL AND METHODS Taking into account the existing literature, the German Migraine and Headache Society (Deutsche Migräne- und Kopfschmerzgesellschaft, DMKG) gives recommendations for the treatment of chronic migraine with BoNT-A. RESULTS Treatment is usually started with a dose of 155 U BoNT-A. During the first year of treatment, 3‑month injection intervals are recommended. Goal of the treatment is an improvement of migraine by ≥30%. If needed, dose escalation up to 195 U can be used to reach this goal. If improvement by ≥30% is not reached after the third injection cycle, the treatment is usually considered to be insufficiently efficient and discontinuation is recommended. If a stable success is reached during the first year of treatment, prolongation of injection intervals to 4 months can be considered. If success continues to be stable for at least two 4‑month intervals, discontinuation of BoNT-A treatment can be tried. CONCLUSION The literature on these points is insufficient for recommendations at the guideline level. The present recommendations are based on an expert consensus of the DMKG for the structured approach to the treatment of chronic migraine with BoNT-A.
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Affiliation(s)
- R Ruscheweyh
- Neurologische Klinik und Poliklinik, Klinikum der LMU München, München, Deutschland.
| | - S Förderreuther
- Neurologische Klinik und Poliklinik, Klinikum der LMU München, München, Deutschland
| | - C Gaul
- Migräne- und Kopfschmerzklinik Königstein, Königstein im Taunus, Deutschland
| | | | - D Holle-Lee
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Deutschland
| | - T Jürgens
- Klinik und Poliklinik für Neurologie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - L Neeb
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - A Straube
- Neurologische Klinik und Poliklinik, Klinikum der LMU München, München, Deutschland
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Trompetto C, Marinelli L, Mori L, Puce L, Pelosin E, Serrati C, Fattapposta F, Rinalduzzi S, Abbruzzese G, Currà A. Do flexible inter- injection intervals improve the effects of botulinum toxin A treatment in reducing impairment and disability in patients with spasticity? Med Hypotheses 2017; 102:28-32. [PMID: 28478825 DOI: 10.1016/j.mehy.2017.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/13/2017] [Accepted: 03/06/2017] [Indexed: 10/20/2022]
Abstract
In patients treated with botulinum toxin-A (BoNT-A), toxin-directed antibody formation was related to the dosage and frequency of injections, leading to the empirical adoption of minimum time intervals between injections of 3months or longer. However, recent data suggest that low immunogenicity of current BoNT-A preparations could allow more frequent injections. Our hypothesis is that a short time interval between injections may be safe and effective in reducing upper limb spasticity and related disability. IncobotulinumtoxinA was injected under ultrasound guidance in spastic muscles of 11 subjects, who were evaluated just before BoNT-A injection (T0), and 1month (T1), 2months (T2) and 4months (T3) after injecting. At T1, in the case of persistent disability related to spasticity interfering with normal activities, patients received an additional toxin dose. Seven subjects received the additional dose at T1 because of persistent disability; 4 of them had a decrease of disability 1month later (T2). Rethinking the injection scheme for BoNT-A treatment may have a major impact in the management of spasticity and related disability. Future studies with larger sample sizes are warranted to confirm that injection schedules with short time intervals should no longer be discouraged in clinical practice.
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Affiliation(s)
- Carlo Trompetto
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy.
| | - Laura Mori
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Luca Puce
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Elisa Pelosin
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Carlo Serrati
- Department of Neurology, San Martino Hospital, Genova, Italy
| | - Francesco Fattapposta
- Neurology Unit, Policlinico Umberto I, Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Steno Rinalduzzi
- Neurology and Neurophysiopathology Unit, Sandro Pertini Hospital, Rome, Italy
| | - Giovanni Abbruzzese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Antonio Currà
- Academic Neurology Unit, A. Fiorini Hospital, Terracina (LT), Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Italy
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