黄斑变性治疗方案

1/15/20131TREATANDEXTENDSHERIFEMBABI,MDAinShamsUniversity,CairoAMDTreatmentProtocolsMonthlyinjections:standardofcareAlternativeindividualizedtreatmentstrategies:PRN(treatandobserve)PrONTOprotocol(treatandobserve).TreatandextendorInjectandextend.1/15/20132Whatistreatandextend?Thedosingstrategyconsistsofaninitialinductionor‘‘loading’’sequenceofatleastthreeinitialmonthlyinjections.Ifstablevisualacuity,anabsenceofmacularhemorrhage,andadryOCThavebeenachievedatthispoint,patientscontinuetoreceiveregularmaintenanceinjectionsatincreasingintervals.Whatistreatandextend?At6weeksafterthelastofthe3initialmonthlyinjections,visualacuity,clinicalfindings,andOCTchangesarerecordedagain,andpatientsreceiveaninjectionregardlessofthepresenceorabsenceofdiseaseactivity.1/15/20133Whatistreatandextend?However,theintervaltothenextvisit(andscheduledinjection)isbasedonanobservedchangeintheseparameters.Iftherearenochanges,thenextvisitforexaminationandinjectionisscheduledfor8weeks.Ifthereisachange,thepatientreturnsforanotherscheduledinjectionandexaminationafter4weeks.Whatistreatandextend?Theobservationandscheduledtreatmentintervalisextended(hencethephrase‘‘treatandextend’’)10weeksandsometimes12weekswaschosenasthelongestintervalbetweenofficevisitsandtreatments.1/15/20134Whatistreatandextend?BaselineAfter3monthly(4weeks)injectionsExtendedto6weeksintervalsExtendedto8weeksintervalsExtendedto10weeksintervalsBackto8weeksWhatarethedisadvantagesoftreatandobserve(PRN/PrONTO)Thisstrategydoesrequiremonthlyvisits,clinicalexaminations,andOCTs.Thismeansmorefrequentvisitswhichisahugeburdenonthepatient(elderly)andtheirfamiliesandhealthcaresystem!1/15/20135Whatarethedisadvantagesoftreatandobserve(PRN/PrONTO)?Patientsuncertain(anddoctorstoo!)iforwhentheywillneedtreatment?!Andthismaybeareasonforsomepatientstoskipvisits!Whatarethedisadvantagesoftreatandobserve(PRN/PrONTO)?Somepatientsmanagedwiththisstrategywillreturnforassessmentshavingalreadydevelopedhemorrhagesintheinjection-freeintervalwithirreversiblevisionloss!1/15/20136Whatarethedisadvantagesoftreatandobserve(PRN/PrONTO)?Youtreatonlywhenyouseefluid!.UnlikeDMEandRVO,AMDisunforgivingdisease!Eachtimefluidaccumulates,thismeansCNVisgrowingandmorephotoreceptorsloss!!Whatarethedisadvantagesoftreatandobserve(PRN/PrONTO)?Intheory,adosingregimenthatdoesnotmaintainthemaculaina“dry”statecoulddenysomepatientstheopportunityforfurthervisualrecovery!1/15/20137WhataretheAdvantagesofTreatandExtendprotocol?Toputitinanutshell:The“TreatandExtend”dosingregimenisastrategyintendedtoresolvemacularexudationandmaintainthemaculainthis“dry”stateindefinitelywith,whenpossible,fewerpatientvisitsandtreatmentsthanmonthlydosingWhataretheAdvantagesofTreatandExtendprotocol?Reductionoftreatmentburdenbyreducingthenumberofpatientvisitsandthenumberofimagingstudiesperformedbyeliminatingtheneedforthemonthlyvisitsnecessitatedbyalternativedosingstrategies.1/15/20138WhataretheAdvantagesofTreatandExtendprotocol?Effectivegivingsimilarresultstomonthlyinjectionsbutwithfewerinjections.WhataretheAdvantagesofTreatandExtendprotocol?JustaseffectiveandevenbetterthanPrONTOprotocol!patientsona‘‘treatandextend’’dosingregimenreceiveamandatedinjectionateachvisit,theireyesreceiveslightlymoreinjectionsin1styear,butasimilarnumberofinjectionsasreceivedbypatientswhocompleted24-monthfollow-upinthePrONTOstudy.1/15/20139WhataretheAdvantagesofTreatandExtendprotocol?Thesignificantreductioninpatientvisitsofnearly50%withoutanincreaseinthenumberoftreatmentscouldpotentiallydecreasetheburdenonpatients,practitioners,andthehealthcaresystemasawhole.WhataretheAdvantagesofTreatandExtendprotocol?Reducestheriskofnewsight-threateningsubmacularhemorrhages(maintainedVEGFsuppression/moreaggressivethanPrONTO).RareprogressionofGAoverlyingtheneovascularlesionssuggestadditionallong-termbenefitsofthe‘‘treatandextend’’dosingregimen(lessaggressivethanmonthlyRx).1/15/201310WhataretheAdvantagesofTreatandExtendprotocol?Patientsanddoctorsaremorecompliantbecausebothpartiesknowwhenwillbethenextscheduledinjection.Noplaceforuncertainty!.Patientwillbelessinclinedtoskipvisits…becausetheyknowtheywillhaveaninjection!WhataretheAdvantagesofTreatandExtendprotocol?Youcanknowwhatisoptimalinjectionfreeintervalforeachindividualpatientwithoutmacularexudation.Somepatientscouldbe6weeks,others8or10weeks.1/15/201311Evidenceinliterature“TREATANDEXTEND”DOSINGOFINTRAVITREALANTIVASCULARENDOTHELIALGROWTHFACTORTHERAPYFORTYPE3NEOVASCULARIZATION/RETINALANGIOMATOUSPROLIFERATIONMICHAELENGELBERT,MD,PHD,SANDRINEA.ZWEIFEL,MD,K.BAILEYFREUND,MDRETINA29:1424–1431,2009Evidenceinliterature“INJECTANDEXTENDDOSINGVERSUSDOSINGASNEEDED.AComparativeRetrospectiveStudyofRanibizumabinExudativeAge-RelatedMacularDegeneration.HASSIBAOUBRAHAM,MD,SALOMONY.COHEN,MD,PHD,SEPIDEHSAMIMI,MD,DAVIDMAROTTE,MD,INESBOUZAHER,MD,PIERREBONICEL,MD,FRANCKFAJNKUCHEN,MD,RAMINTADAYONI,MD,PHDRETINA31:26–30,20111/15/201312EvidenceinliteratureLONG-TERMFOLLOW-UPFORTYPE1(SUBRETINALPIGMENTEPITHELIUM)NEOVASCULARIZATIONUSINGAMODIFIED‘‘TR