GA drugs

[eyeeye_captain]

Thoughts? I’ve gotten a streak of referrals of 90+ yo, poorly functioning patients with bilateral counting fingers vision where the family was told by the referring doctor/TV commercial that now I can fix Granny.

Even when I have a reasonable candidate (younger, high functioning, lesion adjacent to the fovea), almost everyone declines treatment when they hear about no visual improvement and us seeing each other every 1-2 months indefinitely. The efficacy data is pretty unimpressive anyway.

I’ve got a couple of comp practices out past my satellite that do their own injections, and they seem to love the stuff.

Maybe something newer and more useful will come out before I hang it up.

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[MstaKing10]

I have a handful of patients we are using them on. I discuss it with most patients with GA with decent vision and very few want it. Obviously once the macula is wiped out and patient is CF it’s useless. I also discuss the occlusive vasculitis issues, conversion to neovascular AMD risk etc so my “sales” tactics may not be the best. I’m not really a huge believer in these drugs and prefer to hold out for the next thing or consider one of our clinical research trials.

Also when I found out Izervay was only approved for 1 year of use and insurance may not cover injections after that I became even more disillusioned.

 

[Slide]

I have two handfuls of patients on it - I'm very selective in who I use it in. Most of my patients who are on it have already expressed desire to use it even before I mention it. Like you all have mentioned, once most of my patients understand that it's a reduction of progression, not a cure or reversal, they aren't as interested. The way I describe it is that if your vision is a sinking ship due to 5 holes, the medication plugs one (maybe two) of the holes. There is better stuff down the road probably but I only give Izervay because there's really nothing else. I only use Izervay due to the theoretical safety profile compared to Syfovre. My colleagues and I have discussed these medications ad-nauseum in various channels and opinion on it is very ... strong. I do think that the price needs to come down in the near future as these medications are more widely used (from inside sources I know there is pressure to use Syfovre in Cencora-owned practices), else there's going to be further reckoning for injectibles.

I’ve got a couple of comp practices out past my satellite that do their own injections, and they seem to love the stuff.

Of course they love it, once you initiate someone on it, it's a brainless task to inject them once a month for a year with minimal exam/OCT. It's another easy revenue source.

 

[MstaKing10]

I have two handfuls of patients on it - I'm very selective in who I use it in. Most of my patients who are on it have already expressed desire to use it even before I mention it. Like you all have mentioned, once most of my patients understand that it's a reduction of progression, not a cure or reversal, they aren't as interested. The way I describe it is that if your vision is a sinking ship due to 5 holes, the medication plugs one (maybe two) of the holes. There is better stuff down the road probably but I only give Izervay because there's really nothing else. I only use Izervay due to the theoretical safety profile compared to Syfovre. My colleagues and I have discussed these medications ad-nauseum in various channels and opinion on it is very ... strong. I do think that the price needs to come down in the near future as these medications are more widely used (from inside sources I know there is pressure to use Syfovre in Cencora-owned practices), else there's going to be further reckoning for injectibles.


Of course they love it, once you initiate someone on it, it's a brainless task to inject them once a month for a year with minimal exam/OCT. It's another easy revenue source.

What are you doing about izervay one year label issue? We are being told after a year of use it won’t be covered. What’s been your experience?

 

[Slide]

What are you doing about izervay one year label issue? We are being told after a year of use it won’t be covered. What’s been your experience?

Right now, head in the sand and will continue injecting for now. The rep I spoke to a few weeks ago said that Astellas was submitting a supplemental NDA to remove the 12 month approval indication (kind of dumb of them to include that in the first place) for ongoing reimbursement past 1 year. I imagine that it won't be long before it goes through and the 12 month limit will be removed - else the drug is pretty much done. If for some reason it's still not covered after 12 months, either the patients sign an ABN or I stop. I have several more months until my first patient reaches a year anyway so I have some leeway.

 

[Dusn]

I absolutely would not want to be treated with them myself and recommend against using them. The functional benefit does not outweigh the risks.

Given the nonexistent vision benefit, if a patient gets a day or even a few hours, of blurry vision with each injection procedure, they’d have more days of clear vision in their life without treatment than with treatment. And given the risks of cnv, vasculitis, endophthalmitis, IOP spikes leading to RNFL loss, and naion, it’s not worth it.

 

[percyeye]

Any opinions on the potential of Red light therapy for Dry AMD that has recently been FDA approved and came out of Duke?

FDA Approves First Treatment for Dry AMD with the Help of Duke Researchers

The FDA has approved a new light delivery system termed photobiomodulation for treating intermediate dry age-related macular degeneration (AMD), a major cause of vision loss in people over 55. This is the first FDA-approved treatment for vision loss in dry AMD patients. The therapy has shown to...

dukeeyecenter.duke.edu

 

[eyeeye_captain]

Of course they love it, once you initiate someone on it, it's a brainless task to inject them once a month for a year with minimal exam/OCT. It's another easy revenue source.

$hhh, don’t say the quiet part out loud. One of them is still doing nothing but monthly Lucentis for anything resembling wet AMD and DME. Why $pace anybody out?

Any opinions on the potential of Red light therapy for Dry AMD that has recently been FDA approved and came out of Duke?

The data is actually pretty promising, with patients gaining a line of vision and having reduced rates of progression to GA. It could be a useful tool.

There are some problems with the logistics though. The FDA approval doesn’t mean that insurance will cover it. It looks like in the UK, they charge the equivalent of ~$2k for the first round, then ~$1.5k for subsequent rounds. That’s going to be a cost-prohibitive out of pocket expense for many.

The protocol may be too much as well. 9 sessions over 3-5 weeks every 4 months is a lot of visits. A smaller concern is how clinic staffing and flow would be affected. Some offices may not have enough space to make it work.

 

[percyeye]

$hhh, don’t say the quiet part out loud. One of them is still doing nothing but monthly Lucentis for anything resembling wet AMD and DME. Why $pace anybody out?



The data is actually pretty promising, with patients gaining a line of vision and having reduced rates of progression to GA. It could be a useful tool.

There are some problems with the logistics though. The FDA approval doesn’t mean that insurance will cover it. It looks like in the UK, they charge the equivalent of ~$2k for the first round, then ~$1.5k for subsequent rounds. That’s going to be a cost-prohibitive out of pocket expense for many.

The protocol may be too much as well. 9 sessions over 3-5 weeks every 4 months is a lot of visits. A smaller concern is how clinic staffing and flow would be affected. Some offices may not have enough space to make it work.

Right, like anything it comes down to treatment cost, cost of the machine, and work efficiency. I will say though, a lot of the patients you show that they have the early start of dry armd and they saw what their parents or grandparents went through they often desperately ask what can they do to treat it? It is tough at this point to not offer much real help.

 

[RetinaDude]

I use the GA drugs. Mostly on patients referred to me by outside docs or current patients who’ve read up on these drugs and want to try them. To be honest, I didn’t want to use these drugs because my patientmload is already very busy. Adding another injection, that has to be administered every 4-8 weeks (forever), was not something I was looking forward to.

I don’t hold back when talking to patients about GA drugs and strongly emphasize how these drugs will NOT restore vision, they will continue to lose vision (but hopefully at a slower rate), and there’s potential for devastating issues with some patients treated with Syfovre. I definitely turn away more patients for treatment than I start. Dry AMD is frustrating but I’m hoping these GA drugs are the first of many to come along and lead us to more promising changes for our patients.

 

[Slide]

$hhh, don’t say the quiet part out loud. One of them is still doing nothing but monthly Lucentis for anything resembling wet AMD and DME. Why $pace anybody out?



The data is actually pretty promising, with patients gaining a line of vision and having reduced rates of progression to GA. It could be a useful tool.

There are some problems with the logistics though. The FDA approval doesn’t mean that insurance will cover it. It looks like in the UK, they charge the equivalent of ~$2k for the first round, then ~$1.5k for subsequent rounds. That’s going to be a cost-prohibitive out of pocket expense for many.

The protocol may be too much as well. 9 sessions over 3-5 weeks every 4 months is a lot of visits. A smaller concern is how clinic staffing and flow would be affected. Some offices may not have enough space to make it work.

I'm skeptical. One of my friends made a very good argument of why it's dumb - the tl;dr is that Tim Kern, the person who initially proposed it, shows the science that you're better off shining it on your back or somewhere else than your eyes, and the gains are fairly minimal over placebo. You could buy a $10 red light from Temu that gives you just as much benefit. Fernando Arevallo at ACR stated they've used it for years in South America for years and it doesn't work in real-life - take that for what it's worth.

 

[percyeye]

Straight From the Cutters Mouth Podcast just did a show with one of the Doctors who did some of the trials at their clinic. The findings still sound promising. They admitted at the 13 month mark the gains are just a little better than sham treatment, but what wasn't in that study was that at the 24 month mark there is a much larger discrepancy between the treated vs control group. They weren't specifically studying GA with this trial, but incidentally found that GA progressed much slower with this treatment vs control. Sounds like some academic centers are purchasing this machine and all of the clinical sites that helped with the study.

 

[Dusn]

Maybe we should be telling our AMD patients to spend more time outdoors without sunglasses. The wavelengths of light used in PBM are found in sunlight and probably at higher doses.

I do hope they do more studies with true sham controls.