Juan Pablo Real

Accessibility as a conditioning factor in treatment for exudative age-related macular degeneration

Purpose Ranibizumab and bevacizumab coexist as the main therapeutic strategies for the treatment of neovascular age-related macular degeneration (NV-AMD). In Argentina, the access pathways to the drugs are different. Patients with different pathways and gatekeepers to access may experience different outcomes. The purpose of this work was to estimate the impact on therapeutic effects and visual outcome of the different accessibilities to NV-AMD treatment. Methods A retrospective analysis of the charts of 78 patients with previously untreated exudative AMD, who were treated with ranibizumab or bevacizumab between January 2009 and December 2011, was conducted. The main outcomes measured included time delay and change in mean best-corrected visual acuity (BCVA) between diagnosis and treatment and mean BCVA change at 1-year follow-ups. Results The delay between diagnosis and treatment and decrease in visual acuity over this time was significantly higher for patients treated with ranibizumab. At 1 year after the initiation of treatment, BCVA had a mean increase from baseline of 0.11 letters in the bevacizumab group with a mean of 4.71 injections, compared with a decrease of 8.87 letters with a mean of 2.98 injections in the ranibizumab group. Conclusions Access to treatment can be a key factor for success of therapy. Waiting times and availability of doses are crucial in the treatment of NV-AMD. Solving the problems related to delayed initiation of therapy and the difficulties in the maintenance phase are more important than define whether bevacizumab or ranibizumab is used.

Visual outcomes in relation to time to treatment in neovascular age-related macular degeneration

Editor, T he article by Rasmussen et al. (2015) established that visual outcome improved markedly with earlier injections in their study group of patients treated with anti-angiogenics drugs for neovascular age-related macular degeneration (nAMD). The improvement in visual outcome was the equivalent of five Early Treatment Diabetic Retinopathy Study protocol (ETDRS) letters for a shortening of a median delay from 2 weeks in the first cohort (2007) to 1 day in the last cohort (2012) spread over a 6-year period, despite unchanged age and baseline best corrected visual acuity (BCVA). The authors explanation about the findings were that the five ETDRS letters gained in their cohorts by injecting on the day of diagnosis rather than 2 weeks later exceed the effect of the longer untreated period, and it suggests that the response characteristics of the choridal neovascularization (CNV) lesion may change within the first weeks after diagnosis. We published a study recently where we explored decline in visual acuity in patients with (nAMD) awaiting intravitreal bevacizumab or ranibizumab treatment following initial diagnosis and after disease reactivation (Real et al. 2014). In the study, we stated that early treatment of nAMD is critical to achieve best clinical outcomes. We provide correlation between delay to both initial anti-vascular endothelial growth factor (VEGF) treatment and retreatment (associated with administrative decisions and/or reasons intrinsic to the patient) with deterioration of vision over time. We also found a nonlinear decline in such vision loss. There is an initial rapid loss of vision in the early period of disease followed by a slowing in the velocity of visual loss. The polynomial equations obtained in the study predicted a loss of one logMAR line (five letters) in <3 weeks. In contrast, Muether et al. (2011) and Wong et al. (2008) both reported such decline at 3 months. The explanation to Rasmussen et al. (2015) results could be because refraction and visual acuity assessment was not repeated between the baseline examination and the initial injection the patients in the first cohort having a deterioration of the visual acuity during the time they wait for the intravitreal injection. In the first cohort, patients lost at least five letters and as we learned, the recovery of visual acuity is always less than the loss of that vision between the diagnosis of the disease and intravitreal anti-angiogenic. In other words, after treatment with anti-VEGF, it is very difficult to recover 100% of visual acuity lost until diagnosis as demonstrated Holz et al. (2011). So, the patients’ visual acuity lost during the 16-day period between diagnosis and treatment probably was only partially recovered after loading doses in the 2007 group of patients contrary to the 2012 cohort that they were immediately injected after diagnosis. So, we agreed with the authors as nAMD is a time critical disorder every day that treatment is delayed counts, whether by delay in diagnosis or impediment in access to intravitreal medication. Once either matter is detected, treatment with intravitreal anti-VEGF should be considered as a matter of clinical urgency. We also congratulate the authors to bring to our attention the importance of the time to treatment in nAMD.

Challenges and opportunities related to health promotion in community pharmacies: Obstacles and professional perspectives

The community pharmacy is an excellent place to identify those with undiagnosed diseases and refer them to their health professionals for treatment and continuing care. However the process of implementation of campaigns and activities to this end in community pharmacy has been slow and implemented by a pharmaceutical minority. It is crucial understand what are the barriers to participation, in order to design enabling actions to achieve greater adherence of pharmacists in these activities. In order to identify and analyze the elements that hinder the dissemination, implementation and sustainability of pharmaceutical services aimed at the promotion and prevention, in the Argentine community pharmacies, a participatory diagnosis workshop was designed. Although pharmacists stressed that the absence of such professional activities entails a deterioration of pharmacists’ image recognition in society, they expressed lack of constancy, economic incentive, specific training in the subject, time and physical space as own barriers to implementation thereof. Pharmacists think that these limitations are generally not taken into account when designing or planning campaigns. The university, must encourage interaction and involvement of different actors (patients, caregivers, family, health professionals) in order to engage them in solving the issues together and that they design activities according to local characteristics, to create actions and benefits that can be sustained in the long term.