Nonadherence or Nonpersistence to Intravitreal Injection Therapy for Neovascular Age-Related Macular Degeneration

Abstract

Topic Systematic review of risk factors for non-adherence and non-persistence to intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection therapy for neovascular age-related macular degeneration (nAMD). Clinical Relevance Lack of adherence (non-adherence) or under-treatment (non-persistence) with respect to evidence from clinical trials remains a significant barrier to optimizing real-world outcomes for patients with nAMD. Contributing factors and strategies to address this are poorly understood. Methods Studies that reported factors for non-adherence and/or non-persistence to anti-VEGF therapy as well as studies examining strategies to improve this were included. Trial eligibility and data extraction were conducted according to Cochrane review methods. Risk of bias was assessed using the Mixed Method Assessment Tool and certainty of evidence evaluated according to the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) tool. Data were collated descriptively. Results Of the 1284 abstract results screened, 124 articles were assessed in full and 37 studies met the inclusion criteria. Definitions of non-adherence and non-persistence varied or were not reported. Non-persistence occurred early with up to 50% of patients stopping treatment by 24 months. High rates of non-adherence were similarly reported, occurring in 32 – 95% of patients. Certainty of this finding was downgraded to moderate level due to heterogeneity in definitions used across studies. Multiple factors determine non-adherence and non-persistence, including at condition, therapy, patient, social/economic and health systems/health-care team level. Moderate quality evidence points to lower baseline vision and poorer response to treatment as condition-related variables. The effects of other factors were of lower certainty, predominantly due to small numbers and potential biases in retrospective assessment. Although many factors are non-modifiable (e.g., patient co-morbidity), other factors are potentially correctable (e.g., lack of transport or mismatched patient expectations). Evidence on strategies to improve adherence and persistence is limited, but where available, these have proven effective. Conclusions Awareness of factors related to poor patient adherence and persistence in nAMD could help identify at-risk populations and improve real world outcomes. Further work is required to develop uniform definitions as well as establishing high quality evidence on interventions that can be easily implemented.

Patient preferences in retinal drug delivery

“…Since IVT injection therapy is typically prescribed on a pro re nata basis, it may not be achieving the same functional outcomes as primary clinical trials had shown. Under-prescription is influenced by similar factors to non-compliance such as socioeconomic status, transportation, and access to other resources 25 , 27 . For IVT therapy, there are no precise definitions for non-compliance, non-persistence, or non-adherence which may cause biases when assessing these rates in the literature 27 .…”

“…Under-prescription is influenced by similar factors to non-compliance such as socioeconomic status, transportation, and access to other resources 25 , 27 . For IVT therapy, there are no precise definitions for non-compliance, non-persistence, or non-adherence which may cause biases when assessing these rates in the literature 27 . Thus, despite the efficacy of IVT therapeutics, poor persistence and compliance rates may continue to hinder the overall number of positive outcomes among affected patients.…”

Treatment for neovascular age-related macular degeneration: reasonable expectations of physicians and patients

“…Неприверженность лечению и несоблюдение режима дозирования в настоящее время рассматриваются в качестве одной из важнейших проблем, препятствующих предотвращению потери зрения при нВМД, несмотря на успех основных клинических исследований, доказывающих эффективность применения анти-VEGF терапии [26]. В некоторых публикациях указывается, что частота несо-Обзоры блюдения режима терапии и неприверженности лечению достигает 60% при сроке наблюдения 2 года.…”

Acceptability of intravitreal injections in geographic atrophy: protocol for a mixed-methods pilot study

“… 15 16 The nAMD literature suggests that loss to follow-up after initiating treatments is highest in the first year. 16–18 Many determinants of non-adherence/non-persistence in patients treated with intravitreal injections for nAMD are unmodifiable, such as age, visual acuity and ocular or systemic comorbidities when commencing treatment. However, other key barriers—such as distance from the hospital, 17 18 travel times and transportation implications 19 —could be addressed by improving health service delivery, with some small studies suggesting that ‘one-stop’ style services combining monitoring and injections could improve adherence.…”

“… Summary of factors that may affect acceptability of intravitreal treatments, based on the neovascular age-related macular degeneration literature. 16 58 59 …”