Aflibercept in Diabetic Macular Oedema Previously Refractory to Standard Intravitreal Therapy: An Irish Retrospective Study

Brolucizumab versus aflibercept for recalcitrant diabetic macular edema in Indian real-world scenario - The BRADIR study

Purpose

To compare the safety and efficacy of aflibercept with brolucizumab for recalcitrant diabetic macular edema (DME).

Observations

At week 52, no significant visual improvement was noted in the eyes treated with either brolucizumab (P = 0.527) or aflibercept (P = 0.393). The CMT decreased significantly after brolucizumab therapy (P = 0.012), but not with aflibercept (P = 0.284) at 52 weeks. The proportion of patients with IRF and SRF reduced significantly in both arms. The mean number of brolucizumab injections was significantly lower (3.93[±1.28]) than aflibercept (4.75[±1.62]) (P = 0.037) over the 52 weeks. At 52 weeks, 76.67 % of eyes treated with brolucizumab attained full macular dryness (CMT<300 μm with absence of SRF and IRF) compared to 50 % of eyes treated with aflibercept (P = 0.036). Subconjunctival hemorrhage was the only adverse event observed in the study (P = 0.701); no other systemic or ocular adverse events, such as intraocular inflammation, were reported.

Conclusion and importance

The BRADIR study suggests that brolucizumab might have an edge over aflibercept in visual and anatomical outcomes that lasted 52 weeks with reduced injection frequency in case of recalcitrant DME.

Comparative Analysis of Intravitreal Dexamethasone Implant (Ozurdex) and Brolucizumab Injection in the Treatment of Diabetic Macular Edema with Hyperreflective Intraretinal Dots: A Retrospective Study

Purpose

This retrospective study aimed to compare the efficacy and safety of intravitreal Dexamethasone Implant (DEX) and Brolucizumab Injection in treating Diabetic Macular Edema (DME) with Hyperreflective Intraretinal Dots (HRID).

Patients and Methods

A single-center retrospective study in India included 40 eyes (20 per group) with controlled diabetes and HRID on optical coherence tomography. Patients received either DEX or Brolucizumab, with outcomes assessed at various intervals up to 24 weeks. Primary measures included Best-Corrected Visual Acuity (BCVA), Central Macular Thickness (CMT), and safety parameters.

Results

Both treatment groups demonstrated comparable baseline characteristics. Both treatments significantly improved the BCVA at weeks 4, 12, and 24, with the DEX implant showing significantly better results at week 12 than brolucizumab (P=0.04). In treatment-naïve eyes, BCVA improvements were similar across all time points. In recalcitrant DME eyes, DEX showed significant BCVA improvements at all time points, while brolucizumab showed significant improvements only at weeks 4 (P=0.005) and 24 (P=0.04). The CMT also improved with both treatments, with DEX showing superior reduction at weeks 4 (P=0.003), 12 (P=0.003), and 24 (P=0.002) respectively. In treatment-naïve eyes, DEX showed consistently better CMT reductions. In refractory DME eyes, both treatments significantly reduced CMT, with DEX performing better at week 12 (P=0.042). DEX required fewer injections (DEX: 1.5±0.61; brolucizumab: 2.4±0.82; P=0.0002) and less supplementary laser treatment (DEX:8/20, 40% eyes; brolucizumab: 16/20, 80%; P=0.01) compared to brolucizumab. No adverse events were observed in either group.

Conclusion

The study suggests the potential superiority of intravitreal DEX implant over brolucizumab in managing DME with HRID. DEX exhibited sustained positive responses in BCVA and CMT, requiring fewer injections and supplementary interventions. Future research should explore extended follow-up durations, personalized treatment strategies, and refined biomarkers to optimize DME management.

Switching to Conbercept in Diabetic Macular Edema After Unsatisfactory Response to Previous Intravitreal Injection of Ranibizumab

Objective

To assess the functional and anatomical effects of transitioning to conbercept intravitreal injection (IVC) treatment in patients with diabetic macular edema (DME) who had inadequate responses to prior anti-vascular endothelial growth factor (anti-VEGF) injections.

Methods

We retrospectively included eyes with persistent DME after at least 3 injections of intravitreal ranibizumab (IVR). The analysis included the assessment of best corrected visual acuity (BCVA) and central macular thickness (CMT) during 6 months after the switch.

Results

A total of 30 patients (30 eyes) were included. CMT dropped sharply from 437.8±40.67μm at baseline to 363.59±45.09,312.52 ± 39.15, 278.51 ± 37.92, and 292.59 ± 38.09 after 1, 2, 3 and 6 months of IVC, respectively (p <0.001). BCVA in log MAR units was significantly improved from 0.73±0.15 at baseline to 0.50±0.09,0.46±0.72, 0.40±0.06 and 0.48±0.04 after 1, 2, 3 and 6 months, respectively (p <0.001).

Conclusion

Switching to Conbercept effectively improved visual and anatomical structure in DME patients who had not responded satisfactorily to previous anti-VEGF injections.

Switching between anti-VEGF agents in the management of refractory diabetic macular edema: A systematic review

Refractory diabetic macular edema (DME) to monthly intravitreal anti-vascular endothelial growth factor (VEGF) monotherapy has a prevalence of approximately 40% in landmark clinical trials. Options for these patients include use of intravitreal steroids, focal laser, or switching to an alternative anti-VEGF agent. We summarize the key conclusions from studies analyzing the efficacy of switching anti-VEGF agents for refractory DME. Twenty-four studies were included in analysis. The most common definitions of refractory in the included studies were a central retinal thickness (CRT) greater than 300μm or a reduction in CRT less than 10% after at least 3-6 prior anti-VEGF injections. Switching to intravitreal aflibercept (IVA) from either intravitreal ranibizumab (IVR) or bevacizumab (IVB) is associated with moderate to significant improvement in central subfield thickness and may be an appropriate choice for patients with refractory DME. The improvement in retinal thickness and edema is typically seen after the first 3 injections of IVA post-switch. Switching to IVR has also demonstrated improvement in CRT at 3-6 months post-switch in large sample population studies. Future studies are required to elucidate the ideal time point for a switch in anti-VEGF agent or which patients would benefit from this change.

Functional and structural characteristics in patients with diabetic macular oedema after switching from ranibizumab to aflibercept treatment. Three year results in real world settings

Background

Our aim was to examine the long term anatomical and functional outcomes in patients with refractory diabetic macular oedema (DMO) undergoing treatment switch from ranibizumab to aflibercept.

Methods

Retrospective review of patients with DMO undergoing treatment switch from ranibizumab to aflibercept at a single centre between 2015 and 2017. Primary outcomes were best corrected visual acuity (BCVA) and central macular thickness (CMT).

Results

57 eyes from 44 patients were included. Following switch to aflibercept, median (IQR) BCVA improved to 73 (64–77) letters at 3 months (p = 0.0006), to 73 (61–78) letters at 6 months (p = 0.0042), to 73 (65–77) at 9 months (p = 0.0006), and to 73 (63–75) letters at 18 months (p = 0.0444). At 36 months following switch, 12 eyes had gained > 10 letters, 5 eyes had gained 5–9 letters, 25 remained stable (± 5 letters), 7 eyes lost 5–9 letters and 8 eyes lost > 10 letters. A significant reduction in CMT at all trimesters following treatment switch was found except at month 24.

Conclusions

We provide real world data suggesting a sustained anatomical and functional benefit of switching from ranibizumab to aflibercept in the treatment of refractory DMO.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00373-5.

Efficacy and safety of aflibercept therapy for diabetic macular edema: A systematic review and meta-analysis

Purpose:

To assess the real-world efficacy and safety of aflibercept for the treatment of diabetic macular edema (DME).

Methods:

A systematic search was conducted across multiple databases. Articles were included if participants had DME and received aflibercept treatment for a minimum of 52 ± 4 weeks. Primary outcomes included changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT). A risk of bias assessment of studies was completed, pooled estimates were obtained, and a meta-regression was performed. Information on adverse events was collected.

Results:

The search yielded 2112 articles, of which 30 were included. Aflibercept was more effective than laser photocoagulation functionally (12-month BCVA-weighted mean difference [WMD] = 10.77 letters, P < 0.001; 24 months = 8.12 letters, P < 0.001) and anatomically (12-month CMT WMD = –114.12 μm, P < 0.001; 24 months = –90.4 μm, P = 0.004). Compared to bevacizumab, aflibercept was noninferior at improving BCVA at 12 months (WMD = 1.71 letters, P = 0.34) and 24 months (WMD = 1.58 letters, P = 0.083). One study found that aflibercept was more effective than bevacizumab anatomically at 1 and 2 years (P < 0.001 at 12 and 24 months). Compared to ranibizumab, aflibercept rendered a greater improvement in BCVA at 1 year (WMD = 1.76 letters, P = 0.001), but not 2 years (WMD = 1.66 letters, P = 0.072). CMT was not significantly different between both therapies at 12 months (WMD = −14.30 μm, P = 0.282) and 24 months (P = 0.08). One study reported greater functional improvement with aflibercept compared with dexamethasone (P = 0.004), but inferiority in reducing CMT (P < 0.001). Meta-regression analysis demonstrated that dosing schedule was found to impact outcomes at 12 and 24 months, while study design and sample size did not impact outcomes at 12 months. There were minimal safety concerns using aflibercept therapy.

Conclusions:

Aflibercept is a safe and effective therapy option for DME in the clinical setting, performing superiorly to laser photocoagulation. Evidence regarding comparisons with bevacizumab, ranibizumab, and dexamethasone is mixed and limited.

AS1411 Nucleolin-Specific Binding Aptamers Reduce Pathological Angiogenesis through Inhibition of Nucleolin Phosphorylation

Proliferative retinopathies produces an irreversible type of blindness affecting working age and pediatric population of industrialized countries. Despite the good results of anti-VEGF therapy, intraocular and systemic complications are often associated after its intravitreal use, hence novel therapeutic approaches are needed. The aim of the present study is to test the effect of the AS1411, an antiangiogenic nucleolin-binding aptamer, using in vivo, ex vivo and in vitro models of angiogenesis and propose a mechanistic insight. Our results showed that AS1411 significantly inhibited retinal neovascularization in the oxygen induced retinopathy (OIR) in vivo model, as well as inhibited branch formation in the rat aortic ex vivo assay, and, significantly reduced proliferation, cell migration and tube formation in the HUVEC in vitro model. Importantly, phosphorylated NCL protein was significantly abolished in HUVEC in the presence of AS1411 without affecting NFκB phosphorylation and -21 and 221-angiomiRs, suggesting that the antiangiogenic properties of this molecule are partially mediated by a down regulation in NCL phosphorylation. In sum, this new research further supports the NCL role in the molecular etiology of pathological angiogenesis and identifies AS1411 as a novel anti-angiogenic treatment.

Off-label intravitreal brolucizumab for recalcitrant diabetic macular edema: A real-world case series

Purpose

To report the efficacy of intravitreal injection (IVI) of brolucizumab for recalcitrant diabetic macular edema (DME) in a real-world setting.

Observations

This was a single-center, prospective uncontrolled non-randomized case series. Three eyes with recalcitrant DME, who have received a minimum of ten intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, underwent IVI brolucizumab and were followed-up for minimum of 16 weeks. Patients underwent best-corrected visual acuity (BCVA) testing, ophthalmic examination, and optical coherence tomography at baseline and all the scheduled follow-up visits (Weeks 4, 8, 12, and 16). All three patients demonstrated notable improvement in BCVA and reduction in the fluid on SD-OCT lasting up to week 12. At week 16, all three eyes maintained the visual acuity gains. However, early increase in fluid was noted in all the three cases, for which second dose of IVI brolucizumab was planned. No ocular or systemic adverse events were noted in any of the cases.

Conclusions and Importance

In this real-world case series, treatment with IVI brolucizumab exhibited excellent visual acuity outcomes lasting up to 16 weeks for the treatment of recalcitrant DME. Single dose IVI brolucizumab achieves good anatomical improvement based on SD-OCT persisting up to 12 weeks, followed by early recurrence of fluid at week 16. The results did not show any ocular or systemic safety concerns for IVI brolucizumab.

A 12-month prospective study to evaluate the efficacy of using the treat-and-extend regimen with intravitreal aflibercept as a Second-Line Treatment for Diabetic Macular Oedema (the TADI Study)

PURPOSE

To evaluate the efficacy of intravitreal aflibercept as a second-line therapy in eyes with persistent diabetic macular oedema (DMO) despite receiving initial bevacizumab treatment.

METHODS

A prospective multicentre study was conducted in nine academic clinics in Israel. Starting from the first follow-up visit, a treat-and-extend regimen was applied in which the treatment intervals were extended by 2 weeks based on macular thickness using SD-OCT. The primary outcome was central subfield thickness (CST) at week 52.

RESULTS

Forty-four patients (n = 48 eyes) were recruited to the study, and 43 eyes completed 52 weeks of follow-up. Patients received a mean (±SD) of 7.9 ± 3.5 bevacizumab injections before enrolment. The mean (±SD) CST under aflibercept therapy decreased from 468 ± 131 μm at baseline to 303 ± 67 μm at 52 weeks (p = 0.002), and best corrected visual acuity improved from 64 ± 15 ETDRS letters at baseline to 75 ± 8 letters at week 52 (p = 0.001). Twenty (46%) eyes met the treat-and-extend criteria and received a mean (±SD) of 10.9 ± 2 aflibercept injections.

CONCLUSIONS

Eyes with persistent DMO following initial bevacizumab therapy had a marked reduction in macular thickness and improved visual acuity following 1 year of treatment with intravitreal aflibercept. Less than half of the patients met eligibility criteria for extension of the treatment interval; for these patients, the treat-and-extend regimen resulted in a maximum treatment interval of 10 weeks during the first year.

Efficacy of switching therapy to aflibercept for patients with persistent diabetic macular edema: a systematic review and meta-analysis

BACKGROUND

To evaluate functional and anatomical consequences of switching anti-vascular endothelial growth factor (anti-VEGF) therapy from bevacizumab and/or ranibizumab to aflibercept intravitreal injection for the treatment of persistent diabetic macular edema (DME).

METHODS

Analysis of switching treatment in patients with persistent DME was performed using a literature search across multiple databases (PubMed, Medline, EMBASE, Cochrane Library and Web of Science) prior to May 2019. Therapeutic effect parameters, including mean change of best-corrected visual acuity (BCVA) and central macular thickness (CMT), were extracted from baseline to different follow-up times post initial injections. The quality of studies was assessed with the Downs and Black checklist. Data pertaining to ocular and systemic safety adverse events (SAEs) were collected as well as subgroup analysis stratified by pre-switch anti-VEGF reagents. All results were analyzed and pooled using random-effects models with 95% confidence intervals (CI).

RESULTS

Fourteen studies involving 489 eyes met the inclusion criteria. The mean differences in BCVA were significantly improved at 1, 2 and 3 months with -0.11 logMAR (P=0.016), -0.22 logMAR (P<0.001) and -0.24 logMAR (P<0.01), respectively. Vision gain was also assessed following the aflibercept injection with a mean change of -0.10 logMAR (P<0.001) at 6 months and -0.08 logMAR (P=0.01) at 12 months. CMT reduction was significant from baseline with a mean decrease of 80.52 µm (P<0.001) at 1 month, 89.6 µm (P<0.013) at 2 months, 113.88 µm (P<0.001) at 3 months and 125.12 µm (P<0.001) at 6 months. Mean CMT continued to decline by 75.70 µm (P<0.001) at 12 months as well.

CONCLUSIONS

This meta-analysis indicated the comparable efficacy and safety of a conversion treatment to aflibercept in cases of unsatisfactory responses to other anti-VEGF drugs. Switching treatment produces significant advantage for vision acuity recovery and macular edema improvement among persistent DME patients.