Treating Persistent DME: Comparison of 3 Anti-VEGF Drugs
JAMA Ophthalmology, March 2018
Treatment of diabetic macular edema (DME) with anti–vascular endothelial growth factors has improved visual acuity and retinal thickness but not the persistent DME (pDME) or chronic persistent DME (cpDME) that some patients experience, thus raising questions about the benefits and long-term outcomes associated with these drugs. To provide answers, Bressler et al. analyzed data from a DRCR.net trial and found that pDME was more common with bevacizumab than aflibercept or ranibizumab at 24 weeks of treatment—and that cpDME was more likely to occur in eyes that received bevacizumab than in those that received aflibercept. They also noted that the risk of vision loss was minimal regardless of the agent used or whether there was chronic persistence of DME.
The authors’ post hoc analysis was based on data for 546 eyes in the DRCR.net Protocol T trial. All treated eyes had central-involved DME and a best-corrected visual acuity letter score of 24 to 78. They were assigned randomly to receive up to 6 injections monthly, initially, of aflibercept, bevacizumab, or ranibizumab. Additional injections or focal/grid laser sessions were administered to achieve stability.
Through week 24, the rate of pDME was higher with 1.25-mg bevacizumab (118 of 180 eyes; 65.6%) than with 2-mg aflibercept (60 of 190 eyes; 31.6%) or 0.3-mg ranibizumab (73 of 176 eyes; 41.5%). At 1 year, 98 eyes treated with bevacizumab had cpDME, versus 59 of those treated with ranibizumab and 47 treated with aflibercept. At 2 years, the number of eyes with cpDME were as follows: 70 bevacizumab eyes, 38 ranibizumab eyes, and 29 aflibercept eyes.
Among eyes with pDME at 24 weeks, the proportion with gains of 10 or more letters from baseline to 2 years did not differ significantly by the presence or absence of cpDME: 51%, 62%, and 44% of eyes with cpDME that received bevacizumab, aflibercept, and ranibizumab (respectively) gained 10 or more letters, as did 54.8%, 63.3%, and 65.5% (respectively) of those without cpDME. Only 3 eyes with cpDME lost ≥ 10 letters.
This research indicates that aflibercept and ranibizumab are better than bevacizumab at preventing pDME through 24 weeks and that aflibercept is superior to bevacizumab for resolving cpDME by 2 years. The authors cautioned against switching agents after just a few injections because the edema may resolve by continuing treatment with the same agent. (Also see related commentary by Rajendra S. Apte, MD, PhD, in the same issue.)
The original article can be found here.