Diabetic Eye Conditions Contribute to Psychosocial, Financial, and Adherence Challenges

Diabetic eye disease, which includes diabetic retinopathy and macular edema, is on specialty pharmacy’s radar, especially because diabetic retinopathy alone increased 89% between 2000 and 2010. Currently, approximately 7.7 million Americans are affected. Visual impairment creates a tremendous psychosocial burden as patients’ activities become more limited.

H. Eric Cannon, PharmD, FAMCP, is assistant vice president of Pharmacy Benefit Services at SelectHealth, an Intermountain Healthcare company in Salt Lake City, Utah. During a session on diabetic retinopathy and diabetic macular edema at the Asembia Specialty Pharmacy Summit 2019, he joined a panel to discuss the conditions’ impact on the significantly larger elderly population in the United States.

People rarely talk about diabetes and blindness at the same time, but this is a topic that needs exposure, according to Cannon. “Diabetes is the leading cause of blindness in adults in the United States at this time,” he said. “Primary approach should be prevention with tight control of blood glucose levels, but some treatments are also available.”

Daniel F. Kiernan, MD, FACS, a vitreoretinal surgeon at Ophthalmic Consultants of Long Island in New York, augmented Cannon’s presentation by discussing risk factors. “It’s essential for every clinician to encourage their patients who have diabetes to achieve the tightest control possible and address hypertension, smoking, dyslipidemia, nephropathy, and pregnancy aggressively,” he said.

Loss of vision is costly, and individuals who lose their vision or become blind incur almost twice the medical costs as nonblind individuals. These people may need long-term care, home nursing support, assistive devices, and, often, home modifications.

Formulary considerations are available to treat these conditions, Cannon said, noting that health care systems need to examine the clinical, economic, and patient-specific issues. Systems need to look beyond efficacy and safety, which are clinical considerations, and factor in treatment costs and appropriate use, as well as be sure of appropriate adherence by patients.

Because the typical patient affected with retinopathy or macular edema is elderly, Medicare is a primary insurer. In a review of Medicare data, Cannon found that these conditions are costly. Treatment options include the injectables aflibercept, ranibizumab, and bevacizumab.

Adherence is a special concern because patients will require multiple injections. In addition, patients need transportation to and from appointments, which can be a barrier. When making formulary decisions, health care systems should also look at nondrug treatments, including focal laser photocoagulation and vitrectomy.

In terms of the pathophysiology, Kiernan emphasized that the 2 conditions are tremendously disabling; initially, the main goal is to reverse vision loss. Clinicians also need to try to prevent additional vision loss and blindness.

As with many conditions, real-world application differs from the way these drugs were used in clinical trials. Anti-VEGF biologics are now considered the cornerstone of therapy and standard of care. Patients are monitored less frequently and receive far fewer injections than those enrolled in clinical trials.

“Pharmacists are integral team members when patients have diabetic eye applications. They see these patients more frequently than many prescribers, and they can educate them about their disease and encourage good adherence to treatment,” Kiernan said. “They can also help patients find patient assistance programs when they are financially challenged.”