1
|
Ali Ali MA, Hegazy HS, Abdelkhalek Elsayed MO, Tharwat E, Mansour MN, Hassanein M, Ezzeldin ER, GadElkareem AM, Abd Ellateef EM, Elsayed AA, Elabd IH, Abd Rbu MH, Amer RS, Gabbar AGAE, Mahmoud H, Abdelhameed HM, Abdelkader AME. Aflibercept or ranibizumab for diabetic macular edema. MEDICAL HYPOTHESIS, DISCOVERY & INNOVATION OPHTHALMOLOGY JOURNAL 2024; 13:16-26. [PMID: 38978826 PMCID: PMC11227664 DOI: 10.51329/mehdiophthal1490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/19/2024] [Indexed: 07/10/2024]
Abstract
Background Vascular endothelial growth factor (VEGF) is the primary substance involved in retinal barrier breach. VEGF overexpression may cause diabetic macular edema (DME). Laser photocoagulation of the macula is the standard treatment for DME; however, recently, intravitreal anti-VEGF injections have surpassed laser treatment. Our aim was to evaluate the efficacy of intravitreal injections of aflibercept or ranibizumab for managing treatment-naive DME. Methods This single-center, retrospective, interventional, comparative study included eyes with visual impairment due to treatment-naive DME that underwent intravitreal injection of either aflibercept 2 mg/0.05 mL or ranibizumab 0.5 mg/0.05 mL at Al-Azhar University Hospitals, Egypt between March 2023 and January 2024. Demographic data and full ophthalmological examination results at baseline and 1, 3, and 6 months post-injection were collected, including the best-corrected distance visual acuity (BCDVA) in logarithm of the minimum angle of resolution (logMAR) notation, slit-lamp biomicroscopy, dilated fundoscopy, and central subfield thickness (CST) measured using spectral-domain optical coherence tomography. Results Overall, the 96 eyes of 96 patients with a median (interquartile range [IQR]) age of 57 (10) (range: 20-74) years and a male-to-female ratio of 1:2.7 were allocated to one of two groups with comparable age, sex, diabetes mellitus duration, and presence of other comorbidities (all P >0.05). There was no statistically significant difference in baseline diabetic retinopathy status or DME type between groups (both P >0.05). In both groups, the median (IQR) BCDVA significantly improved from 0.7 (0.8) logMAR at baseline to 0.4 (0.1) logMAR at 6 months post-injection (both P = 0.001), with no statistically significant difference between groups at all follow-up visits (all P >0.05). The median (IQR) CST significantly decreased in the aflibercept group from 347 (166) µm at baseline to 180 (233) µm at 6 months post-injection, and it decreased in the ranibizumab group from 360 (180) µm at baseline to 190 (224) µm at 6 months post-injection (both P = 0.001), with no statistically significant differences between groups at all follow-up visits (all P >0.05). No serious adverse effects were documented in either group. Conclusions Ranibizumab and aflibercept were equally effective in achieving the desired anatomical and functional results in patients with treatment-naïve DME in short-term follow-up without significant differences in injection counts between both drugs. Larger prospective, randomized, double-blinded trials with longer follow-up periods are needed to confirm our preliminary results.
Collapse
Affiliation(s)
| | - Hanan Saied Hegazy
- Department of Ophthalmology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | | | - Ehab Tharwat
- Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Mona Nabeh Mansour
- Department of Ophthalmology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Mohamed Hassanein
- Department of Ophthalmology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
| | | | | | | | - Ahmed A. Elsayed
- Department of Ophthalmology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
| | - Ibrahim Hassan Elabd
- Department of Ophthalmology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
| | - Mahmoud H Abd Rbu
- Department of Ophthalmology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
| | - Ramy Saleh Amer
- Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | | | - Hatem Mahmoud
- Department of Ophthalmology, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
| | | | | |
Collapse
|
2
|
Chen H, Shi X, Zhang W, Han Q. Aflibercept versus ranibizumab for diabetic macular edema: A meta-analysis. Eur J Ophthalmol 2024; 34:615-623. [PMID: 37226427 PMCID: PMC11067396 DOI: 10.1177/11206721231178658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 05/10/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the efficacy and safety of aflibercept (AFL) versus ranibizumab (RAN) for the treatment of diabetic macular edema (DME). METHODS The PubMed, Embase, Cochrane Library, and CNKI databases were searched up to September 2022 to identify prospective randomized controlled trials (RCTs) comparing AFL with RAN for the treatment of DME. Review Manager 5.3 software was used for data analysis. We used the GRADE system to evaluate the quality of the evidence for each outcome. RESULTS A total of 8 RCTs involving 1067 eyes (939 patients) were included; there were 526 eyes in the AFL group and 541 eyes in the RAN group. Meta-analysis revealed that there was no significant difference between RAN and AFL in the best-corrected visual acuity (BCVA) of DME patients at 6 months (WMD: -0.05, 95% CI = -0.12 to 0.01, moderate quality) and 12 months after injection (WMD: -0.02, 95% CI = -0.07 to 0.03, moderate quality). Additionally, there was no significant difference between RAN and AFL in the reduction of central macular thickness (CMT) at 6 months (WMD: -0.36, 95% CI = -24.99 to 24.26, very low quality) and 12 months after injection (WMD: -6.36, 95% CI = -16.30 to 3.59, low quality). Meta-analysis showed that the number of intravitreal injections (IVIs) for AFL was significantly lower than that for RAN (WMD: -0.47, 95% CI = -0.88 to -0.05, very low quality). There were fewer adverse reactions to AFL than to RAN, but the difference was not significant. CONCLUSION This study found that there was no difference in BCVA, CMT or adverse reactions between AFL and RAN at 6 and 12 months of follow-up, but AFL needed fewer IVIs than RAN.
Collapse
Affiliation(s)
- Haiyan Chen
- Department of Ophthalmology, the Sixth Hospital of Beijing, Beijing, China
| | - Xuehui Shi
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wang Zhang
- Department of Ophthalmology, the Sixth Hospital of Beijing, Beijing, China
| | - Qianqian Han
- Department of Ophthalmology, the Sixth Hospital of Beijing, Beijing, China
| |
Collapse
|
3
|
Parca O, Cetin EN. Comparison of ranibizumab, aflibercept, and dexamethasone implant monotherapy in treatment-naive eyes with diabetic macular edema: A 12-month real-life experience. Indian J Ophthalmol 2024; 72:S453-S458. [PMID: 38648453 PMCID: PMC467021 DOI: 10.4103/ijo.ijo_2310_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 04/25/2024] Open
Abstract
PURPOSE To compare the functional and anatomical outcomes of ranibizumab, aflibercept, and dexamethasone implant monotherapy in treatment-naive eyes with diabetic macular edema (DME) in real-life conditions. METHODS In this retrospective cohort study, data were obtained from the hospital database of treatment-naive patients diagnosed with DME with at least 12 months of follow-up. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) at baseline, third month, sixth month, ninth month, and 12th month were recorded. In addition, a subgroup analysis was performed based on having good (below 0.4 log of minimum angle of resolution [logMAR]) or poor (0.4 logMAR and above) vision. RESULTS A total of 219 eyes of 142 patients were included in the study. The change in the mean BCVA from baseline to 12th month was from 0.62 logMAR to 0.42 logMAR (P < 0.001) in the ranibizumab group, from 0.56 logMAR to 0.39 logMAR (P < 0.001) in the aflibercept group, and from 0.46 logMAR to 0.5 logMAR (P = 0.653) in the dexamethasone group. There was no significant difference between the treatment groups at any time point (P > 0.05). The mean amount of CRT change was statistically significant at 12 months in all groups (ranibizumab: -175.4 µm, aflibercept: -153.3 µm, dexamethasone: -71.4 µm) (P < 0.05). In eyes with initially good vision, the final BCVA at 12 months was significantly better in the ranibizumab group compared to the dexamethasone group (P = 0.008). The aflibercept group had better visual acuity than the dexamethasone group, but there was no statistically significant difference (P = 0.059). There was no significant difference in final BCVA in eyes with initially poor vision. No serious ocular/systemic complications were noted. CONCLUSION At the 12th month, a significant decrease in CRT was achieved in all treatment groups, whereas only ranibizumab and aflibercept groups had a significant BCVA increase. In eyes with initially good vision, the final BCVA at 12 months was better in the ranibizumab group compared to the dexamethasone group, whereas it was similar in all groups having initially poor vision.
Collapse
Affiliation(s)
- Osman Parca
- Department of Ophthalmology, Pamukkale University, Denizli, Turkey
| | - Ebru N Cetin
- Department of Ophthalmology, Pamukkale University, Denizli, Turkey
| |
Collapse
|
4
|
Boscia F, Veritti D, Iaculli C, Lattanzio R, Freda S, Piergentili B, Varano M. Management of treatment-naïve diabetic macular edema patients: Review of real-world clinical data. Eur J Ophthalmol 2024:11206721241237069. [PMID: 38462923 DOI: 10.1177/11206721241237069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The high prevalence of Diabetic macular edema (DME) is a real global health problem. Its complex pathophysiology involves different pathways. Over the last decade, the introduction of intravitreal treatments has dramatically changed the management and prognosis of DME. Among the different treatment options, inhibitors of vascular endothelial growth factor (anti-VEGF) and intravitreal steroids implants represent the first-line therapy of DME. We conducted a review of electronic databases to compile the available evidence about the clinical management of DME in a clinical setting, with a special focus on treatment-naïve patients. Anti-VEGF therapies represent a valuable option for treating DME patients. However, many patients do not respond properly to this treatment and, due to its administration regimen, many patients receive suboptimal treatment in real life. Current evidence demonstrated that in patients with DME, DEX-i improved significantly both anatomic and visual outcomes. Besides eyes with insufficient anti-VEGF respond or recalcitrant DME cases, DEX-i can be effectively and safely used in treatment-naïve DME patients as first line therapy. DEX-i may be considered first line therapy in different clinical scenarios, such as DME eyes with a greater inflammatory component, patients with cardiovascular events, vitrectomized eyes, or those requiring cataract surgery. In conclusion, there are still many points for improvement pending in the clinical management of the patient with DME. Since DME treatment must follow a patient-tailored approach, selecting the best therapeutic approach for each patient requires a good understanding of the pathophysiology of DME.
Collapse
Affiliation(s)
- Francesco Boscia
- Department of Translational Medicine and Neurosciences (DiBraiN), University of Bari, Bari, Italy
| | - Daniele Veritti
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy
| | - Cristiana Iaculli
- Department of Ophthalmology, Policlinico Riuniti Di Foggia, University of Foggia, 71122, Foggia, Italy
| | - Rosangela Lattanzio
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simona Freda
- AbbVie S.r.l., SR 148 Pontina, 04011, Campoverde, LT
| | | | - Monica Varano
- Ophthalmology Department, IRCCS - Fondazione Bietti, Rome, Italy
| |
Collapse
|
5
|
Watkins C, Paulo T, Bührer C, Holekamp NM, Bagijn M. Comparative Efficacy, Durability and Safety of Faricimab in the Treatment of Diabetic Macular Edema: A Systematic Literature Review and Network Meta-Analysis. Adv Ther 2023; 40:5204-5221. [PMID: 37751021 PMCID: PMC10937806 DOI: 10.1007/s12325-023-02675-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/31/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION A systematic literature review (SLR) and network meta-analysis (NMA) were conducted to evaluate the comparative efficacy, durability and safety of faricimab, used in a Treat & Extend (T&E) regime with intervals up to every 16 weeks (Q16W), relative to other therapies currently in use for treatment of diabetic macular oedema (DME). Of particular interest were anti-vascular endothelial growth factor (VEGF) therapies applied in flexible dosing regimens such as Pro re nata (PRN) and T&E, which are the mainstay in clinical practice. METHODS An SLR identifying randomised controlled trials (RCTs) published before August 2021 was conducted, followed by a Bayesian NMA comparing faricimab T&E treatment to aflibercept, ranibizumab, bevacizumab, dexamethasone and laser therapy. Outcomes included in the analysis were change in best-corrected visual acuity (BCVA), change in central subfield thickness (CST), injection frequency, ocular adverse events (AE) and all-cause discontinuation, all of which were evaluated at 12 months. Subgroup analyses including patients' naïve to anti-VEGF were conducted where feasible. RESULTS Twenty-six studies identified in the SLR were included in the NMA. Most importantly for decision making in clinical practise, faricimab T&E was associated with a statistically greater (95% credible intervals exclude zero) and clinically meaningful decrease in retinal thickness compared to all other flexible dosing regimens (greater retinal drying by 55-125 microns). Anatomical outcomes determine treatment efficacy and retreatment of patients. The NMA also showed a statistically greater increase in mean change in BCVA for faricimab T&E vs. flexible regimens using ranibizumab and bevacizumab (increase of 4.4-4.8 letters) as well as a numerical improvement vs. aflibercept PRN (two letters, 95% credible intervals including zero). Accordingly, the injection frequency was numerically lower versus other treatments using flexible dosing regimens (decrease by 0.92-1.43 injections). The analyses also indicated that the safety profile of faricimab T&E was comparable to those of ranibizumab and aflibercept, which have well-established safety profiles, with similar results for the number of all-cause discontinuations. CONCLUSION Faricimab provides a new treatment option in DME with dual-pathway inhibition of VEGF and angiopoeitin-2 (Ang-2). To the authors' knowledge, this is the first indirect comparison of faricimab T&E in DME. The analyses indicate that faricimab T&E is associated with superior retinal drying along with numerically fewer injections compared to all other treatments given in flexible dosing regimens. It also showed superior visual acuity outcomes compared to ranibizumab and bevacizumab.
Collapse
Affiliation(s)
| | - Tatiana Paulo
- F. Hoffmann-La Roche Ltd, Grenzacherstrasse, Basel, Switzerland
| | - Christian Bührer
- F. Hoffmann-La Roche Ltd, Grenzacherstrasse, Basel, Switzerland.
| | | | - Marloes Bagijn
- F. Hoffmann-La Roche Ltd, Grenzacherstrasse, Basel, Switzerland
| |
Collapse
|
6
|
Virgili G, Curran K, Lucenteforte E, Peto T, Parravano M. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2023; 2023:CD007419. [PMID: 38275741 PMCID: PMC10294542 DOI: 10.1002/14651858.cd007419.pub7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Background Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) can reduce oedema, improve vision, and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. In the previous update of this review, we found moderate-quality evidence that, at 12 months, aflibercept was slightly more effective than ranibizumab and bevacizumab for improving vision in people with DMO, although the difference may have been clinically insignificant (less than 0.1 logarithm of the minimum angle of resolution (logMAR), or five Early Treatment Diabetic Retinopathy Study (ETDRS) letters, or one ETDRS line). Objectives The objective of this updated review was to compare the effectiveness and safety of the different anti-VEGF drugs in RCTs at longer followup (24 months). Search methods We searched various electronic databases on 8 July 2022. Selection criteria We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham, or no treatment in people with DMO. Data collection and analysis We used standard Cochrane methods for pairwise meta-analysis and we augmented this evidence using network meta-analysis (NMA) methods. We used the Stata 'network' meta-analysis package for all analyses. We used the CINeMA (Confidence in Network Meta-Analysis) web application to grade the certainty of the evidence. Main results We included 23 studies (13 with industry funding) that enrolled 3513 people with DMO (median central retinal thickness (CRT) 460 microns, interquartile range (IQR) 424 to 482) and moderate vision loss (median best-corrected visual acuity (BCVA) 0.48 logMAR, IQR 0.42 to 0.55. One study that investigated ranibizumab versus sham and one study that mainly enrolled people with subclinical DMO and normal BCVA were not suitable for inclusion in the efficacy NMA. Consistent with the previous update of this review, we used ranibizumab as the reference drug for efficacy, and control (including laser, observation, and sham) as the reference for systemic safety. Eight trials provided data on the primary outcome (change in BCVA at 24 months, in logMAR: lower is better). We found no evidence of a difference between the following interventions and ranibizumab alone: aflibercept (mean difference (MD) -0.05 logMAR, 95% confidence interval (CI) -0.12 to 0.02; moderate certainty); bevacizumab (MD -0.01 logMAR, 95% CI -0.13 to 0.10; low certainty), brolucizumab (MD 0.00 logMAR, 95% CI -0.08 to 0.07; low certainty), ranibizumab plus deferred laser (MD 0.00 logMAR, 95% CI -0.11 to 0.10; low certainty), and ranibizumab plus prompt laser (MD 0.03 logMAR, 95% CI -0.04 to 0.09; very low certainty). We also analysed BCVA change at 12 months, finding moderate-certainty evidence of increased efficacy with brolucizumab (MD -0.07 logMAR, 95%CI -0.10 to -0.03 logMAR), faricimab (MD -0.08 logMAR, 95% CI -0.12 to -0.05), and aflibercept (MD -0.07 logMAR, 95 % CI -0.10 to -0.04) compared to ranibizumab alone, but the difference could be clinically insignificant. Compared to ranibizumab alone, NMA of six trials showed no evidence of a difference with aflibercept (moderate certainty), bevacizumab (low certainty), or ranibizumab with prompt (very low certainty) or deferred laser (low certainty) regarding improvement by three or more ETDRS lines at 24 months. There was moderate-certainty evidence of greater CRT reduction at 24 months with brolucizumab (MD -23 microns, 95% CI -65 to -1 9) and aflibercept (MD -26 microns, 95% CI -53 to 0.9) compared to ranibizumab. There was moderate-certainty evidence of lesser CRT reduction with bevacizumab (MD 28 microns, 95% CI 0 to 56), ranibizumab plus deferred laser (MD 63 microns, 95% CI 18 to 109), and ranibizumab plus prompt laser (MD 72 microns, 95% CI 25 to 119) compared with ranibizumab alone. Regarding all-cause mortality at the longest available follow-up (20 trials), we found no evidence of increased risk of death for any drug compared to control, although effects were in the direction of an increase, and clinically relevant increases could not be ruled out. The certainty of this evidence was low for bevacizumab (risk ratio (RR) 2.10, 95% CI 0.75 to 5.88), brolucizumab (RR 2.92, 95% CI 0.68 to 12.58), faricimab (RR 1.91, 95% CI 0.45 to 8.00), ranibizumab (RR 1.26, 95% CI 0.68 to 2.34), and very low for conbercept (RR 0.33, 95% CI 0.01 to 8.81) and aflibercept (RR 1.48, 95% CI 0.79 to 2.77). Estimates for Antiplatelet Trialists Collaboration arterial thromboembolic events at 24 months did not suggest an increase with any drug compared to control, but the NMA was overall incoherent and the evidence was of low or very low certainty. Ocular adverse events were rare and poorly reported and could not be assessed in NMAs. Authors' conclusions There is limited evidence of the comparative efficacy and safety of anti-VEGF drugs beyond one year of follow-up. We found no clinically important differences in visual outcomes at 24 months in people with DMO, although there were differences in CRT change. We found no evidence that any drug increases all-cause mortality compared to control, but estimates were very imprecise. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated, and the individuals exposed to these drugs may be less healthy than trial participants.
Collapse
Key Words
- Angiogenesis Inhibitors [adverse effects, *therapeutic use]
- Aptamers, Nucleotide [adverse effects, therapeutic use]
- Bevacizumab [adverse effects, therapeutic use]
- Diabetic Retinopathy [*complications]
- Laser Coagulation [methods]
- Macular Edema [*drug therapy, etiology, surgery]
- Network Meta-Analysis
- Quality of Life
- Randomized Controlled Trials as Topic
- Ranibizumab [adverse effects, therapeutic use]
- Receptors, Vascular Endothelial Growth Factor [therapeutic use]
- Recombinant Fusion Proteins [adverse effects, therapeutic use]
- Triamcinolone [adverse effects, therapeutic use]
- Vascular Endothelial Growth Factor A [*antagonists & inhibitors]
- Visual Acuity [*drug effects, physiology]
Collapse
Affiliation(s)
- Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | | | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Mariacristina Parravano
- Ophthalmology, Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia-IRCCS, Rome, Italy
| |
Collapse
|
7
|
Xie X, Lian C, Zhang Z, Feng M, Wang W, Yuan X, Shi Y, Liu T. Aflibercept for long-term treatment of diabetic macular edema and proliferative diabetic retinopathy: a meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1144422. [PMID: 37260449 PMCID: PMC10227619 DOI: 10.3389/fendo.2023.1144422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023] Open
Abstract
Purpose This meta-analysis compared the long-term (12 months or 24 months) efficacy and safety of intravitreal aflibercept injection (IAI) for diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Methods We selected 16 randomized controlled trials (RCTs) performed after 2015 that had a minimum of 12 months and up to 24 months of treatment and conducted a meta-analysis with Review Manager version 5.3. Visual acuity (VA), central subfield thickness (CST) and adverse events were the outcomes selected for evaluation from the eligible studies. Results Based on 16 RCTs, we evaluated a total of 7125 patients. For PDR and severe DME with poor baseline vision, after a minimum of 12 months and up to 24 months of treatment, the aflibercept treatment group obtained better VA improvement than the focal/grid laser photocoagulation treatment group (MD=13.30; 95%CI: 13.01~13.58; P<0.001) or other treatments (ranibizumab, focal/grid laser photocoagulation, PRP, et al.) group (MD=1.10; 95%CI: 1.05~1.16; P<0.001). In addition, the aflibercept treatment group got higher CST reduction than the focal/grid laser photocoagulation treatment (MD=-33.76; 95%CI: -45.53 ~ -21.99; P<0.001) or other treatments (ranibizumab, focal/grid laser photocoagulation, et al.) group (MD=-33.76; 95%CI: -45.53 ~ -21.99; P<0.001). There was no significant difference in the overall incidence of ocular and non-ocular adverse events in each treatment group. Conclusions This meta-analysis showed that the advantages of IAI are obvious in the management of DME and PDR with poor baseline vision for long-term observation (a minimum of 12 months and up to 24 months) with both VA improvement and CST reduction. Applied IAI separately trended to be more effective than panretinal photocoagulation separately in VA improvement for PDR. More parameters should be required to assess functional and anatomic outcomes.
Collapse
Affiliation(s)
- Xiao Xie
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Chao Lian
- Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Zhiping Zhang
- Chinese Medicine College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Meng Feng
- Laboratory Department, Affiliated Hospital of Shanxi University of Chinese Medicine, Xianyang, China
| | - Wenqi Wang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Xiaomeng Yuan
- Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Yanmei Shi
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Tingting Liu
- Eye Hospital of Shandong First Medical University, Shandong Eye Hospital, Jinan, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| |
Collapse
|
8
|
Munayco-Guillén F, Vazquez-Membrillo MA, Garcia-Roa MR, De La Cruz-Vargas JA, García-Perdomo HA, Pichardo-Rodriguez R. Effectiveness of the Use of Three-Dose Intravitreal Ziv-Aflibercept in the Management of Diabetic Macular Edema in a Real-Life Setting. Clin Ophthalmol 2023; 17:1129-1135. [PMID: 37077223 PMCID: PMC10106786 DOI: 10.2147/opth.s398359] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/03/2023] [Indexed: 04/21/2023] Open
Abstract
Purpose It has been reported that intravitreal Ziv-aflibercept is a safe and effective drug for the treatment of diabetes macular edema (DME). The objective of this study was to evaluate in a real-life setting, the efficacy of intravitreal Ziv-aflibercept in the treatment of DME after the administration of three consecutive monthly doses. Methods A single arm, prospective cohort study. We included patients with DME who received three doses of intravitreal Ziv-aflibercept. Data such as best corrected visual acuity (BCVA) and tomographic biomarkers before treatment and a month after the third dose were collected. DME was staged using the Panozzo classification. Results Thirty-eight patients participated for a total of 53 eyes. The mean age was 59 ± 8.1 years. We observed significant changes after the third dose in the parameters studied (BCVA in LogMAR pre-treatment (0.6 ± 0.33) and post-treatment (0.4 ± 0.29) [p<0.001], macular thickness pre-treatment (501 ± 167 µm) and post-treatment (324 ± 114 µm) [p<0.001], macular volume pre-treatment 10.8 (7.5-17.8) mm3 and post-treatment 9.3 (0-13.6) mm3 [p<0.005]). And 73.6% of the patients presented an advanced severe stage during their pre-treatment evaluation and after post-treatment, 64.2% of the patients no longer presented edema. No systemic or ocular adverse events occurred. Conclusion The use of three consecutive monthly doses of intravitreal Ziv-aflibercept in a real-life setting is effective and safe in the management of diabetic macular edema.
Collapse
Affiliation(s)
- Fernando Munayco-Guillén
- Department of Retina and Vitreous Surgery, Instituto Mexicano de Oftalmología (IMO), Querétaro, México
- Universidad Nacional Autónoma de México (UNAM), México City, México
- Correspondence: Fernando Munayco-Guillén, Fray Servando Teresa de Mier 202, Quintas del Marqués, Querétaro, México, Tel +51 985-558886, Email
| | - Miguel Angel Vazquez-Membrillo
- Department of Retina and Vitreous Surgery, Instituto Mexicano de Oftalmología (IMO), Querétaro, México
- Universidad Nacional Autónoma de México (UNAM), México City, México
| | - Marlon Rafael Garcia-Roa
- Department of Retina and Vitreous Surgery, Instituto Mexicano de Oftalmología (IMO), Querétaro, México
- Universidad Nacional Autónoma de México (UNAM), México City, México
| | | | - Herney Andrés García-Perdomo
- Division of Urology/Urooncology, Deparment of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | | |
Collapse
|
9
|
Wang P, Hu Z, Hou M, Norman PA, Chin EK, Almeida DRP. Relationship Between Macular Thickness and Visual Acuity in the Treatment of Diabetic Macular Edema With Anti-VEGF Therapy: Systematic Review. JOURNAL OF VITREORETINAL DISEASES 2022; 7:57-64. [PMID: 37008395 PMCID: PMC9954155 DOI: 10.1177/24741264221138722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Purpose: To examine the relationship between central macular thickness (CMT) measured by optical coherence tomography (OCT) and visual acuity (VA) in patients with center-involving diabetic macular edema (DME) receiving antivascular endothelial growth factor (anti-VEGF) treatment. Methods: Peer-reviewed articles from 2016 to 2020 reporting intravitreal injections of bevacizumab, ranibizumab, or aflibercept that provided data on pretreatment (baseline) and final retinal thickness (CMT) and visual acuity (VA) were identified. The relationship between relative changes was assessed via a linear random-effects regression model controlling for treatment group. Results: No significant association between the logarithm of the minimum angle of resolution (logMAR) VA and CMT was found in 41 eligible studies evaluating 2667 eyes. The observed effect estimate was a 0.12 increase (95% CI, −0.124 to 2.47) in logMAR VA per 100 µm reduction in CMT after treatment change. There were no significant differences in logMAR VA between the anti-VEGF treatment groups. Conclusions: There was no statistically significant relationship between the change in logMAR VA and change in CMT as well as no significant effect of the type of anti-VEGF treatment on the change in logMAR VA. Although OCT analysis, including measurements of CMT, will continue to be an integral part of the management of DME, further exploration is needed on additional anatomic factors that might contribute to visual outcomes.
Collapse
Affiliation(s)
- Patrick Wang
- Department of Ophthalmology, Queen’s University, Kingston, ON, Canada
| | - Zoe Hu
- Department of Radiology, Queen’s University, Kingston, ON, Canada
| | - Maggie Hou
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Eric K. Chin
- Retina Consultants of Southern California, Redlands, CA, USA
- Loma Linda University Medical Center, Veterans Affair Hospital, Loma Linda, CA, USA
| | | |
Collapse
|
10
|
Gündoğdu KÖ, Doğan E, Çelik E, Alagöz G. Effect of intravitreal ranibizumab on serous retinal detachment in diabetic macular edema. J Diabetes Complications 2022; 36:108228. [PMID: 35691875 DOI: 10.1016/j.jdiacomp.2022.108228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Kübra Özata Gündoğdu
- Sakarya University Education and Research Hospital, Department of Ophthalmology, Sakarya, Turkey.
| | - Emine Doğan
- Sakarya University Education and Research Hospital, Department of Ophthalmology, Sakarya, Turkey
| | - Erkan Çelik
- Sakarya University Education and Research Hospital, Department of Ophthalmology, Sakarya, Turkey
| | - Gürsoy Alagöz
- Sakarya University Education and Research Hospital, Department of Ophthalmology, Sakarya, Turkey
| |
Collapse
|
11
|
Nawar AE, Wasfy T, Shafik HM. Switching to ziv-aflibercept in resistant diabetic macular edema non responsive to ranibizumab injection. BMC Ophthalmol 2022; 22:287. [PMID: 35768859 PMCID: PMC9241277 DOI: 10.1186/s12886-022-02503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/09/2022] [Indexed: 11/20/2022] Open
Abstract
Background Diabetic macular edema (DME) is a leading cause of visual loss in diabetic patients and is managed using multiple anti-vascular endothelial growth factor (VEGF) agents such as bevacizumab, ranibizumab and aflibercept. The present study evaluates effectiveness of intravitreal injection of ziv-aflibercept in resistant diabetic macular edema. Methods This is a prospective interventional study that was carried out on 59 eyes of 40 diabetic patients with diabetic macular edema resistant to three prior consecutive ranibizumab injections. On all patients, thorough ophthalmic evaluation including optical coherence tomography was performed. In patients with persistent intraretinal or subretinal fluid, ziv- aflibercept 1.25 mg (0.05 ml) was administered by intravitreal injection monthly during the 6 month study period from June to December 2019. Results The central macular thickness (CMT) decreased significantly from 395.08 ± 129.9 um at baseline to 282.39 ± 95.278, 245.36 ± 79.861 and 201.17 ± 54.042 after 1, 3 and 6 months of treatment respectively (p < 0.001). Best corrected visual acuity (BCVA) in log MAR units was significantly improved from 0.95 ± 0.21 to 0.51 ± 0.23 after 6 months (p = 0.001). After treatment, negative correlations were detected between age, number of injections, duration of DM and level of glycated hemoglobin (HbA1c) and variation of both CMT and BCVA. The only significant predictor for low final CMT after 6 months of injection was the CMT after 3 months of injection (p = 0.001). Conclusion Ziv-aflibercept is a highly effective and safe drug in cases of DME resistant to previous ranibizumab injections especially in low-income countries. Trial registration This study was retrospectively registered at clinicaltrials.gov (ID: NCT04290195) on 28-2-2020.
Collapse
Affiliation(s)
- Amin E Nawar
- Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, 31516, Egypt.
| | - Tamer Wasfy
- Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, 31516, Egypt
| | - Heba M Shafik
- Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, 31516, Egypt
| |
Collapse
|
12
|
Ebrahimi M, Balibegloo M, Rezaei N. Monoclonal antibodies in diabetic retinopathy. Expert Rev Clin Immunol 2022; 18:163-178. [PMID: 35105268 DOI: 10.1080/1744666x.2022.2037420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Diabetic retinopathy (DR), as one of the main complications of diabetes, is among the leading causes of blindness and visual impairment worldwide. AREAS COVERED Current clinical therapies include photocoagulation, vitrectomy, and anti-vascular endothelial growth factor (VEGF) therapies. Bevacizumab and ranibizumab are two monoclonal antibodies (mAbs) inhibiting angiogenesis. Intravitreal ranibizumab and bevacizumab can decrease the rate of blindness and retinal thickness, and improve visual acuity whether as monotherapy or combined with other treatments. They can increase the efficacy of other treatments and decrease their adverse events. Although administered intravitreally, they also might enter the circulation and cause systemic effects. This study is aimed to review our current knowledge about mAbs, bevacizumab and ranibizumab, in DR including superiorities, challenges, and limitations. Meanwhile, we tried to shed light on new ideas to overcome these limitations. Our latest search was done in April 2021 mainly through PubMed and Google Scholar. Relevant clinical studies were imported. EXPERT OPINION Future direction includes detection of more therapeutic targets considering other components of DR pathophysiology and shared pathogenesis of DR and neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease, the treat-and-extend regimen, and new ways of drug delivery and other routes of ocular drug administration.
Collapse
Affiliation(s)
- Moein Ebrahimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maryam Balibegloo
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA),Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
13
|
Santhakumaran S, Salimi A, Brunetti V, Galic J. Efficacy and safety of aflibercept therapy for diabetic macular edema: A systematic review and meta-analysis. J Curr Ophthalmol 2022; 34:133-147. [PMID: 36147265 PMCID: PMC9486998 DOI: 10.4103/joco.joco_308_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 04/24/2022] [Accepted: 04/28/2022] [Indexed: 11/05/2022] Open
Abstract
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.
Collapse
|
14
|
Zhang X, Liu Y, Wang M, Li Q, Zhang W, Zhang R, Wu Y. Efficacy of Antiangiogenic Drugs in the Treatment of Diabetic Macular Edema: A Bayesian Network Analysis. Front Pharmacol 2021; 12:637667. [PMID: 33935727 PMCID: PMC8082725 DOI: 10.3389/fphar.2021.637667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/11/2021] [Indexed: 11/22/2022] Open
Abstract
Aims: To compare the efficacy of five kinds of antiangiogenic drugs in the treatment of diabetic macular edema Methods: A comprehensive search of seven databases without language restrictions includes PubMed, EMBASE, Web of Science, CBM, the Cochrane Library, CNKI, and WanFang date. All literature used was published before October 2020. Eligible randomized trials were screened for inclusion in this study, and Bayesian framework was used to perform a network meta-analysis (NMA). Data on the mean change of best-corrected visual acuity (BCVA), central macular thickness (CMT) and intraocular pressure (IOP) at 6 months were extracted. Results: 25 randomized controlled trials (RCTs) that covered 2214 eyes, which received treatment of more than 3 months durations were included. In the pooled pair-wise meta-analysis, there was no statistically significant difference between all treatments. The same result was observed in the network meta-analysis with 0-37.82% Global I-squared. For BCVA at 6 months, conbercept and ranibizumab may be favorable than bevacizumab, aflibercept, triamcinolone acetonide and sham injections according to the ranking probabilities. As for CMT at 6 months, ranibizumab may be the most effective compared to bevacizumab, aflibercept and triamcinolone acetonide. In terms of IOP at 6 months, ranibizumab have better effect than bevacizumab, triamcinolone acetonide and sham injections. The results of sensitivity analysis also confirm it. Conclusion: The analysis confirms that ranibizumab may be the most favorable for BCVA improvement and have a stronger efficacy in decreasing CMT and IOP than other drugs when taking all the indicators into consideration. This conclusion may provide clinical evidence to guide treatment decisions. However, more high-quality randomized controlled trials will be necessary to further confirm this.
Collapse
Affiliation(s)
- Xuexue Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- China Academy of Chinese Medical Sciences, Beijing, China
| | - Yi Liu
- Chongqing Medical University, Chongqing, China
| | - Miaoran Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiuyan Li
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wantong Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Rui Zhang
- Beijing University of Chinese Medicine, Beijing, China
| | - Yufei Wu
- Beijing University of Chinese Medicine, Beijing, China
| |
Collapse
|
15
|
Türkseven Kumral E, Erçalık NY. Intravitreal Ranibizumab Versus Aflibercept for Diabetic Macular Edema in Vitrectomized Eyes: 12 Month Results. Semin Ophthalmol 2021; 36:723-727. [PMID: 33760698 DOI: 10.1080/08820538.2021.1900287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate and compare the effect of intravitreal ranibizumab and aflibercept on the treatment of diabetic macular edema in previously vitrectomized eyes. MATERIALS AND METHODS A total of fifty-two vitrectomized eyes with diabetic macular edema were retrospectively evaluated. Patients were divided into two groups; Group 1 (n = 30 eyes) received 0.5 mg/0.05 mL intravitreal ranibizumab and Group 2 (n = 22 eyes) received 2 mg/0.05 mL intravitreal aflibercept for 3 monthly injections and thereafter as needed over 12 months. Best-corrected visual acuity (BCVA), central macular thickness (CMT) and injection number of the drugs were the outcomes of the study. RESULTS Fifty-two previously vitrectomized eyes were enrolled in this study. Thirty-eight of them (73.1%) were male and 14 (26.9%) were female. The mean age was 61.54 ± 7.33 year (range: 50-72 year). BCVA increased and CMT decreased significantly in both groups at the end of the follow-up period (p < .05). The change in BCVA and CMT was not statistically different between the groups (p > .05). However, there was a statistically significant difference between the groups in terms of the injection number (p < .05). CONCLUSION Both ranibizumab and aflibercept were found to be effective on diabetic macular edema in previously vitrectomized eyes. There was no difference between the groups in terms of visual acuity gain and CMT improvement. However, the number of injections was found to be lower in aflibercept group. Therefore, aflibercept may be preferred in the treatment of macular edema in previously vitrectomized eyes.
Collapse
Affiliation(s)
- Esra Türkseven Kumral
- Department of Ophthalmology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Nimet Yeşim Erçalık
- Department of Ophthalmology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
16
|
Huang CH, Yang CH, Hsieh YT, Yang CM, Ho TC, Lai TT. Hyperreflective foci in predicting the treatment outcomes of diabetic macular oedema after anti-vascular endothelial growth factor therapy. Sci Rep 2021; 11:5103. [PMID: 33658601 PMCID: PMC7930178 DOI: 10.1038/s41598-021-84553-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 02/18/2021] [Indexed: 12/30/2022] Open
Abstract
This retrospective study evaluated the association of hyperreflective foci (HRF) with treatment response in diabetic macular oedema (DME) after anti-vascular endothelial growth factor (VEGF) therapy. The medical records, including of ophthalmologic examinations and optical coherence tomography (OCT) images, of 106 patients with DME treated with either intravitreal ranibizumab or aflibercept were reviewed. The correlations between best-corrected visual acuity (BCVA) changes and HRF along with other OCT biomarkers were analysed. The mean logMAR BCVA improved from 0.696 to 0.461 after an average of 6.2 injections in 1 year under real-world conditions. Greater visual-acuity gain was noted in patients with a greater number of HRF in the outer retina at baseline (p = 0.037), along with other factors such as poor baseline vision (p < 0.001), absence of epiretinal membrane (p = 0.048), and presence of subretinal fluid at baseline (p = 0.001). The number of HRF after treatment was correlated with the presence of hard exudate (p < 0.001) and baseline haemoglobin A1C (p = 0.001). Patients with proliferative diabetic retinopathy had greater HRF reduction after treatment (p = 0.018). The number of HRF in the outer retina, in addition to other baseline OCT biomarkers, could be used to predict the treatment response in DME after anti-VEGF treatment.
Collapse
Affiliation(s)
- Chu-Hsuan Huang
- Department of Ophthalmology, Cathay General Hospital, Taipei, Taiwan
| | - Chang-Hao Yang
- Department of Ophthalmology, National Taiwan University Hospital, No 7, Chung-Shan S. Rd., Taipei, 100, Taiwan.,Department of Ophthalmology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ting Hsieh
- Department of Ophthalmology, National Taiwan University Hospital, No 7, Chung-Shan S. Rd., Taipei, 100, Taiwan
| | - Chung-May Yang
- Department of Ophthalmology, National Taiwan University Hospital, No 7, Chung-Shan S. Rd., Taipei, 100, Taiwan.,Department of Ophthalmology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzyy-Chang Ho
- Department of Ophthalmology, National Taiwan University Hospital, No 7, Chung-Shan S. Rd., Taipei, 100, Taiwan
| | - Tso-Ting Lai
- Department of Ophthalmology, National Taiwan University Hospital, No 7, Chung-Shan S. Rd., Taipei, 100, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, No 7, Chung-Shan S. Rd., Taipei, 100, Taiwan.
| |
Collapse
|
17
|
Comparison of the efficacy of aflibercept and ranibizumab after a 3-month loading dose in patients with diabetic macular edema. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.850861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
18
|
Veritti D, Sarao V, Soppelsa V, Lanzetta P. Managing Diabetic Macular Edema in Clinical Practice: Systematic Review and Meta-Analysis of Current Strategies and Treatment Options. Clin Ophthalmol 2021; 15:375-385. [PMID: 33551641 PMCID: PMC7856351 DOI: 10.2147/opth.s236423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/22/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose This meta-analysis aims to summarize 12-month best-corrected visual acuity (BCVA) outcomes in response to anti-vascular endothelial growth factor (VEGF) therapy and dexamethasone implant for the treatment of diabetic macular edema (DME) and to identify factors affecting treatment response using evidence generated from meta-regression. Methods A systematic review of electronic databases was conducted to identify randomized controlled trials (RCTs) and real-life/observational studies that reported 12-month changes in BCVA in patients with DME on anti-VEGF or dexamethasone implant treatment in monotherapy. Study factors that were analyzed are baseline patient characteristics, study type, drug employed, number of injections and 12-month change in BCVA. Data were pooled in a random-effects meta-analysis with BCVA change as the main outcome. Meta-regression was conducted to assess the impact of multiple covariates. Results One-hundred-five heterogeneous study populations (45,032 eyes) were identified and included in the analysis. The use of anti-VEGFs and dexamethasone implant induced an overall increase of +8.13 ETDRS letters in BCVA at 12 months of follow-up. Meta-regression provided evidence that mean BCVA change using anti-VEGFs was not statistically higher for RCTs (p=0.35) compared to observational studies. Dexamethasone implant showed a trend for better results in observational studies over RCTs. Populations following a fixed aflibercept regimen performed better than those following a reactive treatment regimen. Mean BCVA gain was higher in younger populations (p<0.001), with lower baseline BCVA (p<0.0001) and longer diabetes duration (p<0.0001), receiving a higher number of injections (p<0.0001). Conclusion Intravitreal therapy with anti-VEGFs or dexamethasone implant produces a significant improvement in BCVA at 12 months in patients with DME. Meta-regression identified the modifiable covariates that can be targeted in order to maximize functional results.
Collapse
Affiliation(s)
- Daniele Veritti
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy
| | - Valentina Sarao
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy.,Istituto Europeo di Microchirurgia Oculare (IEMO), Udine, Italy
| | - Valentina Soppelsa
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy
| | - Paolo Lanzetta
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy.,Istituto Europeo di Microchirurgia Oculare (IEMO), Udine, Italy
| |
Collapse
|
19
|
Holbach B, Zeman F, Helbig H, Gamulescu MA. [Ranibizumab and aflibercept for diabetic macular edema-retrospective study with real-life data after 12 months]. Ophthalmologe 2019; 117:687-692. [PMID: 31705192 DOI: 10.1007/s00347-019-01004-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Currently only few data are available on a direct comparison of the treatment reality with ranibizumab and aflibercept in patients with diabetic macular edema (DME). This study assessed best corrected visual acuity (BCVA) outcomes and central retinal thickness (CRT) under treatment with ranibizumab and aflibercept. MATERIAL AND METHODS Patients with DME involving the fovea in treatment-naïve eyes and a follow-up period of least 12 months were retrospectively identified. Patients underwent treatment with ranibizumab 0.5 mg or aflibercept 2.0 mg. The findings were obtained using clinical examination, fluorescein angiography and spectral domain optical coherence tomography (SD-OCT, measuring CRT). RESULTS A total of 41 treatment-naïve eyes were identified in 29 patients with DME involving the fovea. The mean 12-month improvement was +9.5 letters in 19 eyes treated with ranibizumab and BCVA improving from 0.57 log MAR (95% confidence interval, CI 0.45-0.70 log MAR) to 0.38 log MAR (95% CI 0.25-0.50 log MAR; p < 0.001) and +8.5 letters in the aflibercept group with 22 eyes and BCVA improving from 0.38 log MAR (95% CI 0.25-0.51 log MAR) to 0.21 log MAR (95% CI 0.08-0.34 log MAR; p < 0.001). The difference between the two groups was not statistically significant (p = 0.599). When the initial visual acuity was 0.4 or less, the mean BCVA improved in 14 eyes treated with ranibizumab from 0.62 log MAR (95% CI 0.47-0.79 log MAR) to 0.38 log MAR (95% CI 0.21-0.55 log MAR), an improvement of 12.0 letters (p < 0.001), in 11 eyes treated with aflibercept from 0.63 log MAR (95% CI 0.42-0.84 log MAR) to 0.29 log MAR (95% CI 0.08-0.50 log MAR), an improvement of 17.0 letters (p < 0.001). The difference between the two groups was significant (p < 0.001). The mean number of intravitreal injections was 6.4 (95% CI 5.1-7.7) in the ranibizumab group, 7.5 (95% CI 6.2-8.8) in the aflibercept group (p = 0.199). The mean CRT decreased significantly (p < 0.001) in patients treated with both ranibizumab and aflibercept without any evidence of a significant difference between the two groups (p = 0.514). DISCUSSION In the patients studied ranibizumab and aflibercept showed a good safety and efficacy in the treatment of DME regarding BCVA and CRT under real-life conditions after 12 months. In cases of lower initial visual acuity (0.4 or 20/50 or less) aflibercept was more effective at improving vision.
Collapse
Affiliation(s)
- B Holbach
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - F Zeman
- Zentrum für klinische Studien (ZKS), Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - H Helbig
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - M A Gamulescu
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| |
Collapse
|
20
|
Plaza-Ramos P, Borque E, García-Layana A. Evaluation of ranibizumab and aflibercept for the treatment of diabetic macular edema in daily clinical practice. PLoS One 2019; 14:e0223793. [PMID: 31644594 PMCID: PMC6808425 DOI: 10.1371/journal.pone.0223793] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/27/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To evaluate the efficacy and safety of ranibizumab and aflibercept in the treatment of diabetic macular edema in a real world study, and to compare the two treatments with each other. METHODS Retrospective observational study of 213 eyes from 141 patients with diabetic macular edema was completed between June 2014 and June 2016. 122 were treated with ranibizumab intravitreal injection and 91 with aflibercept intravitreal injection, with a loading phase of 3 injections and a Pro Re Nata protocol. The drug was selected by the physician and fluorescein angiography was performed by physician`s criteria. Re-treatment was performed when a decline in BCVA, an increase of central macular thickness or an increase or persistence of intraretinal fluid in OCT was observed. The primary outcome was the mean change in best corrected visual acuity at 1 year, while central macular thickness, central macular volume, the number of injections and visits were evaluated as secondary outcomes. The correlation between BCVA at 4th month visit and BCVA at 12th month visit was also evaluated. RESULTS The mean baseline best corrected visual acuity for the eyes treated with ranibizumab was 0.55 (+/- 0.35) logMAR, and with aflibercept it was 0.48 (+/- 0.29) (P = 0.109). Best corrected visual acuity improved in both groups, and at the end of the follow-up was 0.40 (+/- 0.35) in the ranibizumab group and 0.40 (+/- 0.29) in the aflibercept group (P = 0.864). Best corrected visual acuity at 4th month visit is correlated at a high value (R = 0.789) with the one at the end of the study. No differences were found in central macular thickness, central macular volume and glycosylated hemoglobin when adjusting with baseline values. The overall number of injections was 5.77 (+/- 2.01), being 5.56 (+/- 2.0) in the ranibizumab group and 6.07 (+/- 1.99) in the aflibercept group (P = 0.069). The main outcome determining final best corrected visual acuity was the baseline best corrected visual acuity (P<0.001). CONCLUSION There are no differences in efficacy between ranibizumab and aflibercept in diabetic macular edema treatment in this real world study.
Collapse
Affiliation(s)
- Pablo Plaza-Ramos
- Ophthalmology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
- * E-mail:
| | - Enrique Borque
- Ophthalmology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | | |
Collapse
|
21
|
Pham B, Thomas SM, Lillie E, Lee T, Hamid J, Richter T, Janoudi G, Agarwal A, Sharpe JP, Scott A, Warren R, Brahmbhatt R, Macdonald E, Straus SE, Tricco AC. Anti-vascular endothelial growth factor treatment for retinal conditions: a systematic review and meta-analysis. BMJ Open 2019; 9:e022031. [PMID: 31142516 PMCID: PMC6549720 DOI: 10.1136/bmjopen-2018-022031] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To evaluate the comparative effectiveness and safety of intravitreal bevacizumab, ranibizumab and aflibercept for patients with choroidal neovascular age-related macular degeneration (cn-AMD), diabetic macular oedema (DMO), macular oedema due to retinal vein occlusion (RVO-MO) and myopic choroidal neovascularisation (m-CNV). DESIGN Systematic review and random-effects meta-analysis. METHODS Multiple databases were searched from inception to 17 August 2017. Eligible head-to-head randomised controlled trials (RCTs) comparing the (anti-VEGF) drugs in adult patients aged ≥18 years with the retinal conditions of interest. Two reviewers independently screened studies, extracted data and assessed risk of bias. RESULTS 19 RCTs involving 7459 patients with cn-AMD (n=12), DMO (n=3), RVO-MO (n=2) and m-CNV (n=2) were included. Vision gain was not significantly different in patients with cn-AMD, DMO, RVO-MO and m-CNV treated with bevacizumab versus ranibizumab. Similarly, vision gain was not significantly different between cn-AMD patients treated with aflibercept versus ranibizumab. Patients with DMO treated with aflibercept experienced significantly higher vision gain at 12 months than patients receiving ranibizumab or bevacizumab; however, this difference was not significant at 24 months. Rates of systemic serious harms were similar across anti-VEGF agents. Posthoc analyses revealed that an as-needed treatment regimen (6-9 injections per year) was associated with a mortality increase of 1.8% (risk ratio: 2.0 [1.2 to 3.5], 2 RCTs, 1795 patients) compared with monthly treatment in cn-AMD patients. CONCLUSIONS Intravitreal bevacizumab was a reasonable alternative to ranibizumab and aflibercept in patients with cn-AMD, DMO, RVO-MO and m-CNV. The only exception was for patients with DME and low visual acuity (<69 early treatment diabetic retinopathy study [ETDRS] letters), where treatment with aflibercept was associated with significantly higher vision gain (≥15 ETDRS letters) than bevacizumab or ranibizumab at 12 months; but the significant effects were not maintained at 24 months. The choice of anti-VEGF drugs may depend on the specific retinal condition, baseline visual acuity and treatment regimen. PROSPERO REGISTRATION NUMBER CRD42015022041.
Collapse
Affiliation(s)
- Ba' Pham
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Sonia M Thomas
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Erin Lillie
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Taehoon Lee
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Jemila Hamid
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Trevor Richter
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada
| | - Ghayath Janoudi
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada
| | - Arnav Agarwal
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jane P Sharpe
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Alistair Scott
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rachel Warren
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Ronak Brahmbhatt
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Erin Macdonald
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Geriatric Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Aflibercept with adjuvant micropulsed yellow laser versus aflibercept monotherapy in diabetic macular edema. Graefes Arch Clin Exp Ophthalmol 2019; 257:1373-1380. [PMID: 31127381 DOI: 10.1007/s00417-019-04355-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To assess the impact of micropulsed laser (MPL) on modifying the number of aflibercept injections when used as an adjuvant therapy in diabetic macular edema (DME). METHODS A prospective randomized interventional clinical study included patients with DME attending Al Hadi Clinic, Kuwait, during the period from May 2017 to December 2018. Patients were allocated in two groups; group A received aflibercept injections alone and group B received combined aflibercept injections followed by MPL within a week. The primary outcome was the number of Aflibercept injections in each group guided by the change in central macular thickness (CMT). All the patients were followed for 18 months. Secondary outcome measures included best corrected visual acuity (BCVA), contrast sensitivity (CS), and any recorded complications. RESULTS Fifty-four eyes of 51 patients were included (27 in each group). There was no statistically significant difference between the two groups in baseline characteristics except for the age that was statistically higher in group B (p = 0.001). The number of injections were significantly lower in group B (4.1 ± 1.1) than group A (7.3 ± 1.1) (p < 0.005). At 18th month, there was significant reduction in CMT in both groups (p < 0.005) with no statistical difference between the two groups (p = 0.989). Final BCVA in both groups showed statistically significant improvement (p < 0.005) without statistically significant difference between the two groups (p = 0.082). In both groups, the CS showed significant improvement from baseline (p < 0.005). No ocular or systemic adverse effects were observed in either group. CONCLUSION Supplemental MPL in eyes with DME may decrease the burden of the aflibercept injection frequency while resulting in comparable anatomical and visual outcomes.
Collapse
|
23
|
Kaldırım H, Yazgan S, Kırgız A, Atalay K, Savur F. A Comparison Study of Ranibizumab and Aflibercept in Patients with Naive Diabetic Macular Edema in Presence of Serous Retinal Detachment. Curr Eye Res 2019; 44:987-993. [PMID: 30983426 DOI: 10.1080/02713683.2019.1608260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aim of the study: The aim of this study is to compare the efficacy of intravitreal injection of Aflibercept and Ranibizumab in the treatment of naive diabetic macular edema (DME) with serous retinal detachment (SRD). Materials and methods: In this prospective, non-randomized-cohort study, 60 eyes with DME with SRD were divided into 2 groups: group 1 consisted of 30 eyes treated with intravitreal injection of 0.5 mg/0.1 mL Ranibizumab (IVR) and group 2 consisted of 30 eyes treated with intravitreal injection of 2 mg/0.05 mL Aflibercept (IVA). After three sequential injections with 30-40-day interval as a loading dose, all patients were followed up for 12 months. The best-corrected visual acuity (BCVA), central macular thickness (CMT), SRD's height (SRDH) and the number of reinjections of the drugs were compared. Results: The groups were similar in terms of age and sex (p > 0.05). There was no difference between groups in terms of the baseline BCVA, CMT and SRDH (p > 0.05). There was no significant difference between groups with regard to BCVA and CMT values for 12 months (p > 0.05). SRDH decreased significantly in both groups; however, the reduction of SRDH was considerably higher in group 2 for 12 months (p < 0.05). The mean number of reinjection was 4.40 ± 0.85 in group 1 and 3.16 ± 0.75 in group 2 and it was noticeably lower in group 2 (p < 0.001). The number of cases with persistent SRD at the end of the study was 14 (46.6%) in group 1 and 5 (16.6%) in group 2 (p < 0.001). Conclusions: Aflibercept may treat SRD more efficiently in patients with DME compared to Ranibizumab with fewer injections.
Collapse
Affiliation(s)
- Havva Kaldırım
- Bagcilar Training and Research Hospital, Ophthalmology Department, Istanbul Health Sciences University , Istanbul , Turkey
| | - Serpil Yazgan
- Medical Faculty, Department of Ophthalmology, Bulent Ecevit University , Zonguldak , Turkey
| | - Ahmet Kırgız
- Beyoglu Eye Training and Research Hospital, Ophthalmology Department, Istanbul Health Sciences University , Istanbul , Turkey
| | - Kursat Atalay
- Bagcilar Training and Research Hospital, Ophthalmology Department, Istanbul Health Sciences University , Istanbul , Turkey
| | - Fatma Savur
- Bagcilar Training and Research Hospital, Ophthalmology Department, Istanbul Health Sciences University , Istanbul , Turkey
| |
Collapse
|
24
|
Yuan J. Role of inflammatory factors in the effects of aflibercept or ranibizumab treatment for alleviating wet age-associated macular degeneration. Exp Ther Med 2019; 17:4249-4258. [PMID: 30988797 DOI: 10.3892/etm.2019.7427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 09/13/2018] [Indexed: 12/12/2022] Open
Abstract
Aflibercept and ranibizumab are novel drugs for effectively treating wet age-associated macular degeneration (AMD). In the present study, the effect of aflibercept and ranibizumab on wet AMD was compared. A total of 80 AMD patients were intravitreously treated with aflibercept (2.0 mg/dose, 40 participants) or ranibizumab (0.3 mg/dose, 40 participants). The mean visual acuity and central subfield thickness (CTS) were determined at baseline and each follow-up visit (every 4 weeks). ELISA was used to detect the expression of transforming growth factor-β1 (TGF-β1), monocyte chemoattractant protein 1 (MCP-1) and interleukin 6 (IL-6). The primary outcome was the mean change in visual acuity letter score (VAS) and CTS at 1 year. The VAS was markedly improved by 13.1 in the aflibercept group and by 11.0 in the ranibizumab group. In a subgroup of patients with an initial VAS of <69, the mean improvement in the VAS was 17.7 in the aflibercept group and 13.2 in the ranibizumab group (P<0.01). The mean CTS was markedly decreased by 141 in the aflibercept group and by 134 in the ranibizumab group. In the subgroup of patients with an initial VAS of <69, the mean CTS was decreased by 171 in the aflibercept group and by 154 in the ranibizumab group (P<0.01). However, the change of VAS and CTS was similar between the ranibizumab and aflibercept groups when the initial VAS was ≥69. No significant differences in serious adverse events were identified between the aflibercept and ranibizumab groups. The levels of TGF-β1, IL-6 and MCP-1 were decreased by the aflibercept and ranibizumab treatments. The decrease in the levels of the inflammatory factors was more obvious in patients with an initial VAS of <69 in comparison with that in patients with an initial VAS of ≥69. Negative correlations between the levels of TGF-β1, MCP-1 and IL-6 and the mean change of VAS when patients were treated with aflibercept or ranibizumab were identified among all ages. Positive correlations between the levels of TGF-β1, MCP-1 and IL-6 and the mean change of CTS were observed when the initial VAS of the patients was <69. In conclusion, the efficacy of aflibercept in treating patients with AMD was better than that of ranibizumab when the initial VAS of the patients was <69. The inhibition of inflammatory factors may be a secondary effect of aflibercept and ranibizumab treatment. The present study provides a useful reference for the clinical treatment of wet AMD (Chinese Clinical Trial Registry no. ChiCTR1800017782).
Collapse
Affiliation(s)
- Jianshu Yuan
- Ophthalmology Department, Ningbo Eye Hospital, Ningbo, Zhejiang 315040, P.R. China
| |
Collapse
|
25
|
Ozkaya A, Demir G, Kirmaci A. Comparison of aflibercept and ranibizumab in diabetic macular edema associated with subretinal detachment. Eur J Ophthalmol 2019; 30:363-369. [PMID: 30757913 DOI: 10.1177/1120672119827855] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To compare the efficacy of ranibizumab and aflibercept in the treatment of diabetic macular edema associated with subfoveal retinal detachment. METHODS This is a retrospective, comparative study. The treatment-naïve diabetic macular edema patients who had diabetic macular edema associated with subfoveal retinal detachment and underwent intravitreal aflibercept or intravitreal ranibizumab treatment were included. The patients were treated on a pro re nata treatment regimen after a loading dose of 3-monthly injections and the follow-up time was 12 months. The primary outcome measure of this study was the presence of subfoveal retinal detachment after treatment at different time points. The secondary outcome measures were the change in best corrected visual acuity and central retinal thickness. RESULTS A total of 46 eyes of 46 patients were included. The aflibercept group consisted of 20 and the ranibizumab group consisted of 26 eyes. During the follow-up period of 12 months, subfoveal retinal detachment was completely resolved in 75% versus 57.7% of the eyes at month 3 (p = 0.2), 90% versus 76.9% at month 6 (p = 0.2), 90% versus 65.4% at month 9 (p = 0.05), and 100% versus 80.8% at month 12 (p = 0.03) in the intravitreal aflibercept versus intravitreal ranibizumab groups. The change in best corrected visual acuity was not statistically different between the groups at months 3, 6, 9, and 12, respectively (p > 0.05 for all). CONCLUSION Both intravitreal aflibercept and intravitreal ranibizumab were effective in regards to anatomical and functional outcomes of diabetic macular edema patients associated with subfoveal retinal detachment. Interestingly, intravitreal aflibercept seemed more effective than intravitreal ranibizumab in the resolution of subfoveal retinal detachment at month 12.
Collapse
Affiliation(s)
- Abdullah Ozkaya
- Beyoglu Eye Training and Research Hospital, Istanbul, Turkey
| | - Gokhan Demir
- Beyoglu Eye Training and Research Hospital, Istanbul, Turkey
| | - Asli Kirmaci
- Beyoglu Eye Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
26
|
Tchoe H, Shin SJ, Suh JK, Cho S, Yang J, Kang MJ, Jee D. Meta-analysis of Intravitreal Injection of Anti-vascular Endothelial Growth Factors for Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.2.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Hajin Tchoe
- Office of Economic Evaluation Research, National Evidence Based Healthcare Collaborating Agency, Seoul, Korea
| | - Sang Jin Shin
- Office of Economic Evaluation Research, National Evidence Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jae Kyung Suh
- Office of Economic Evaluation Research, National Evidence Based Healthcare Collaborating Agency, Seoul, Korea
| | - Songhee Cho
- Office of Economic Evaluation Research, National Evidence Based Healthcare Collaborating Agency, Seoul, Korea
| | - Jangmi Yang
- Office of Economic Evaluation Research, National Evidence Based Healthcare Collaborating Agency, Seoul, Korea
| | - Min Joo Kang
- Office of Economic Evaluation Research, National Evidence Based Healthcare Collaborating Agency, Seoul, Korea
| | - Donghyun Jee
- Department of Ophthalmology and Visual Science, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
27
|
Virgili G, Parravano M, Evans JR, Gordon I, Lucenteforte E. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2018; 10:CD007419. [PMID: 30325017 PMCID: PMC6517135 DOI: 10.1002/14651858.cd007419.pub6] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) can reduce oedema, improve vision and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. OBJECTIVES The 2014 update of this review found high-quality evidence of benefit with anti-VEGF modalities, compared to laser photocoagulation, for the treatment of DMO. The objective of this updated review is to compare the effectiveness and safety of the different anti-VEGF drugs using network meta-analysis methods. SEARCH METHODS We searched various electronic databases on 26 April 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham or no treatment in people with DMO. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for pair-wise meta-analysis and we augmented this evidence using network meta-analysis methods. We focused on the relative efficacy and safety of the three most commonly used drugs as interventions of direct interest for practice: aflibercept and ranibizumab, used on-label; and off-label bevacizumab.We collected data on three efficacy outcomes (gain of 15 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters; mean change in best-corrected visual acuity (BCVA); mean change in central retinal thickness (CRT)), three safety outcomes (all severe systemic adverse events (SSAEs); all-cause death; arterial thromboembolic events) and quality of life.We used Stata 'network' meta-analysis package for all analyses. We investigated the risk of bias of mixed comparisons based on the variance contribution of each study, having assigned an overall risk of bias to each study. MAIN RESULTS Twenty-four studies included 6007 participants with DMO and moderate vision loss, of which two studies randomised 265 eyes of 230 participants and one was a cross-over study on 56 participants (62 eyes) that was treated as a parallel-arm trial. Data were collected on drugs of direct interest from three studies on aflibercept (975 eyes), eight studies on bevacizumab (515 eyes), and 14 studies on ranibizumab (1518 eyes). As treatments of indirect interest or legacy treatment we included three studies on pegaptanib (541 eyes), five studies on ranibizumab plus prompt laser (557 eyes), one study on ranibizumab plus deferred laser (188 eyes), 13 studies on laser photocoagulation (936 eyes) and six studies on sham treatment (793 eyes).Aflibercept, bevacizumab and ranibizumab were all more effective than laser for improving vision by 3 or more lines after one year (high-certainty evidence). Approximately one in 10 people improve vision with laser, and about three in 10 people improve with anti-VEGF treatment: risk ratio (RR) versus laser 3.66 (95% confidence interval (CI) 2.79 to 4.79) for aflibercept; RR 2.47 (95% CI 1.81 to 3.37) for bevacizumab; RR 2.76 (95% CI 2.12 to 3.59) for ranibizumab. On average there was no change in visual acuity (VA) with laser after one year, compared with a gain of 1 or 2 lines with anti-VEGF treatment: laser versus aflibercept mean difference (MD) -0.20 (95% CI -0.22 to -0.17) logMAR; versus bevacizumab MD -0.12 (95% CI -0.15 to -0.09) logMAR; versus ranibizumab MD -0.12 (95% CI -0.14 to -0.10) logMAR. The certainty of the evidence was high for the comparison of aflibercept and ranibizumab with laser and moderate for bevacizumab comparison with laser due to inconsistency between the indirect and direct evidence.People receiving ranibizumab were less likely to gain 3 or more lines of VA at one year compared with aflibercept: RR 0.75 (95% CI 0.60 to 0.94), moderate-certainty evidence. For every 1000 people treated with aflibercept, 92 fewer would gain 3 or more lines of VA at one year if treated with ranibizumab (22 to 148 fewer). On average people receiving ranibizumab had worse VA at one year (MD 0.08 logMAR units, 95% CI 0.05 to 0.11), moderate-certainty evidence; and higher CRT (MD 39 µm, 95% CI 2 µm to 76 µm; low-certainty evidence). Ranibizumab and bevacizumab were comparable with respect to aflibercept and did not differ in terms of VA: RR of gain of 3 or more lines of VA at one year 1.11 (95% CI 0.87 to 1.43), moderate-certainty evidence, and difference in change in VA was 0.00 (95% CI -0.02 to 0.03) logMAR, moderate-certainty evidence. CRT reduction favoured ranibizumab by -29 µm (95% CI -58 µm to -1 µm, low-certainty evidence). There was no evidence of overall statistical inconsistency in our analyses.The previous version of this review found moderate-certainty evidence of good safety of antiangiogenic drugs versus control. This update used data at the longest available follow-up (one or two years) and found that aflibercept, ranibizumab and bevacizumab do not differ regarding systemic serious adverse events (SSAEs) (moderate- or high-certainty evidence). However, risk of bias was variable, loop inconsistency could be found and estimates were not precise enough on relative safety regarding less frequent events such as arterial thromboembolic events or death (low- or very low-certainty evidence).Two-year data were available and reported in only four RCTs in this review. Most industry-sponsored studies were open-label after one year. One large publicly-funded study compared the three drugs at two years and found no difference. AUTHORS' CONCLUSIONS Anti-VEGF drugs are effective at improving vision in people with DMO with three to four in every 10 people likely to experience an improvement of 3 or more lines VA at one year. Aflibercept may confer some advantage over ranibizumab and bevacizumab in people with DMO at one year in visual and anatomic terms but it is unclear whether this applies to the long-term. There is a need for more evidence on the long-term (greater than two years) comparative effects of these anti-VEGF agents. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated and under-monitored.We found no signals of differences in overall safety between the three antiangiogenic drugs that are currently available to treat DMO, but our estimates are imprecise for cardiovascular events and death.
Collapse
Affiliation(s)
- Gianni Virgili
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Mariacristina Parravano
- Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia‐IRCCSOphthalmologyVia Livenza n 3RomeItaly00198
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Iris Gordon
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Ersilia Lucenteforte
- University of FlorenceDepartment of Neurosciences, Psychology, Drug Research and Children’s Healthviale Gaetano Pieraccini, 6FlorenceItaly50139
| | | |
Collapse
|
28
|
Popescu M, Bogdan C, Pintea A, Rugină D, Ionescu C. Antiangiogenic cytokines as potential new therapeutic targets for resveratrol in diabetic retinopathy. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:1985-1996. [PMID: 30013318 PMCID: PMC6037275 DOI: 10.2147/dddt.s156941] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Diabetes mellitus (DM) affects >350 million people worldwide. With many complications that can reduce the patient’s quality of life, vision loss is one of the most debilitating disorders it can cause. Active research in the field of diabetes includes microvascular complications in diabetic retinopathy (DR). Disturbances in the balance of pro-angiogenesis and anti-angiogenesis factors can lead to the progression of DR. The retinal pigment epithelium (RPE) is the outermost layer of the retina, and it is essential in maintaining the visual function. The RPE produces and secretes growth factors as well as protective agents which maintain structural integrity of the retina. Small natural molecules, such as resveratrol, may influence neurotrophic factors of the retina. The pigment epithelium-derived factor (PEDF) and thrombospondin-1 (TSP-1) are secreted by RPE cells. These two proteins inhibit angiogenesis and inflammation in RPE cells. An alteration of their production contributes to various eye diseases. There is a critical balance between two important factors secreted on opposite sides of the RPE: at the basal side, vascular endothelial growth factor (VEGF; acts on the choroidal endothelium) and, on the apical side, PEDF (acts on neurons and photoreceptors). Resveratrol inhibits VEGF expression in human adult RPE cells and limits the development of proliferative vitreoretinopathy, by attenuating transforming growth factor-β2-induced wound closure and cell migration. Possible new mechanisms could include PEDF and TSP-1 expression alterations under physiological and pathological conditions. Resveratrol is currently of interest due to its capacity to influence the cell’s secretory activity. Some limitations arise from its low bioavailability. Several drug delivery systems are currently tested, promising to improve tissue concentrations. This article reviews biological pathways involved in the pathogenesis of DR that could be influenced by resveratrol. A study of these pathways could identify new potential targets for the reduction of diabetic complications.
Collapse
Affiliation(s)
- Mihaela Popescu
- Department of Biochemistry, University of Medicine and Pharmacy "Iuliu Haţieganu", Cluj-Napoca, Romania
| | - Cătălina Bogdan
- Department of Dermopharmacy and Cosmetics, University of Medicine and Pharmacy "Iuliu Haţieganu", Cluj-Napoca, Romania,
| | - Adela Pintea
- Department of Biochemistry, University of Agriculture Sciences and Veterinary Medicine, Cluj-Napoca, Romania
| | - Dumitriţa Rugină
- Department of Biochemistry, University of Agriculture Sciences and Veterinary Medicine, Cluj-Napoca, Romania
| | - Corina Ionescu
- Department of Biochemistry, University of Medicine and Pharmacy "Iuliu Haţieganu", Cluj-Napoca, Romania
| |
Collapse
|
29
|
Campos Polo R, Rubio Sánchez C, García Guisado DM, Díaz Luque MJ. Aflibercept for clinically significant diabetic macular edema: 12-month results in daily clinical practice. Clin Ophthalmol 2018; 12:99-104. [PMID: 29386883 PMCID: PMC5764298 DOI: 10.2147/opth.s154421] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose To assess the effectiveness and safety of intravitreal aflibercept in clinically significant diabetic macular edema (DME) in daily clinical practice. Methods Prospective, open-label, single-center study. Anti-vascular endothelial growth factor naïve patients with clinically significant DME received intravitreal injections of aflibercept 2 mg, five monthly doses followed by a fixed schedule every 2 months for 12 months. The mean change in best-corrected visual acuity (BCVA) (Early Treatment Diabetic Retinopathy Study [ETDRS] letters) was the primary outcome. Results The mean BCVA improved significantly as compared with baseline at 12 months of treatment (47.3 [14.2] vs 62.2 [13.9] ETDRS letters, P<0.001). Significant improvement in BCVA was already observed at visit 2 after the loading doses of aflibercept. At 12 months, gains in ETDRS letters were documented in all eyes (100%), with gains ≥10 letters in 89.6%, ≥15 letters in 65.5%, and ≥20 letters in 6.9% (n=2). A significant reduction in central macular thickness from a mean of 460.5 (11.8) μm at baseline to 229.0 (43.8) μm at 12 months (P<0.001) was observed. Significant reductions of central macular thickness were already observed after the loading doses and continued lowering throughout the study period. No adverse events occurred. Conclusion Aflibercept as a first-line therapy was effective and well tolerated for treating clinically significant DME in naïve patients in daily practice. Successful results in terms of improvement of visual and reduction in central macular thickness contribute to provide evidence for the positioning of aflibercept as a first-line indication of newly diagnosed clinically significant DME.
Collapse
Affiliation(s)
- Rafael Campos Polo
- Unit of Retina, Department of Ophthalmology, Hospital Virgen del Puerto, Plasencia, Cáceres, Spain
| | - Consuelo Rubio Sánchez
- Unit of Retina, Department of Ophthalmology, Hospital Virgen del Puerto, Plasencia, Cáceres, Spain
| | | | - María José Díaz Luque
- Unit of Retina, Department of Ophthalmology, Hospital Virgen del Puerto, Plasencia, Cáceres, Spain
| |
Collapse
|
30
|
Edington M, Connolly J, Chong NV. Pharmacokinetics of intravitreal anti-VEGF drugs in vitrectomized versus non-vitrectomized eyes. Expert Opin Drug Metab Toxicol 2017; 13:1217-1224. [DOI: 10.1080/17425255.2017.1404987] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Magdalena Edington
- Department of Ophthalmology, University of Oxford, Oxford, UK
- Department of Ophthalmology, Tennent Institute of Ophthalmology, Glasgow, UK
| | - Julie Connolly
- Department of Ophthalmology, Tennent Institute of Ophthalmology, Glasgow, UK
| | - Ngaihang Victor Chong
- Department of Ophthalmology, University of Oxford, Oxford, UK
- Department of Ophthalmology, Royal Free Hospital, London, UK
| |
Collapse
|
31
|
Virgili G, Parravano M, Evans JR, Gordon I, Lucenteforte E. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2017; 6:CD007419. [PMID: 28639415 PMCID: PMC6481463 DOI: 10.1002/14651858.cd007419.pub5] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) modalities can reduce oedema and thereby improve vision and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. OBJECTIVES The 2014 update of this review found high-quality evidence of benefit with antiangiogenic therapy with anti-VEGF modalities, compared to laser photocoagulation, for the treatment of DMO.The objective of this updated review is to compare the effectiveness and safety of the different anti-VEGF drugs in preserving and improving vision and quality of life using network meta-analysis methods. SEARCH METHODS We searched various electronic databases on 26 April 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham or no treatment in people with DMO. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for pair-wise meta-analysis and we augmented this evidence using network meta-analysis methods. We focused on the relative efficacy and safety of the three most commonly used drugs as interventions of direct interest for practice: aflibercept and ranibizumab, used on-label; and off-label bevacizumab.We collected data on three efficacy outcomes (gain of 15 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters; mean change in best-corrected visual acuity (BCVA); mean change in central retinal thickness (CRT)), three safety outcomes (all severe systemic adverse events (SSAEs); all-cause death; arterial thromboembolic events) and quality of life.We used Stata 'network' meta-analysis package for all analyses. We investigated the risk of bias of mixed comparisons based on the variance contribution of each study, having assigned an overall risk of bias to each study. MAIN RESULTS Twenty-four studies included 6007 participants with DMO and moderate vision loss, of which two studies randomised 265 eyes of 230 participants and one was a cross-over study on 56 participants (62 eyes) that was treated as a parallel-arm trial. Data were collected on drugs of direct interest from three studies on aflibercept (975 eyes), eight studies on bevacizumab (515 eyes), and 14 studies on ranibizumab (1518 eyes). As treatments of indirect interest or legacy treatment we included three studies on pegaptanib (541 eyes), five studies on ranibizumab plus prompt laser (557 eyes), one study on ranibizumab plus deferred laser (188 eyes), 13 studies on laser photocoagulation (936 eyes) and six studies on sham treatment (793 eyes).Aflibercept, bevacizumab and ranibizumab were all more effective than laser for improving vision by 3 or more lines after one year (high-certainty evidence). Approximately one in 10 people improve vision with laser, and about three in 10 people improve with anti-VEGF treatment: risk ratio (RR) versus laser 3.66 (95% confidence interval (CI) 2.79 to 4.79) for aflibercept; RR 2.47 (95% CI 1.81 to 3.37) for bevacizumab; RR 2.76 (95% CI 2.12 to 3.59) for ranibizumab. On average there was no change in visual acuity (VA) with laser after one year, compared with a gain of 1 or 2 lines with anti-VEGF treatment: laser versus aflibercept mean difference (MD) -0.20 (95% CI -0.22 to -0.17) logMAR; versus bevacizumab MD -0.12 (95% CI -0.15 to -0.09) logMAR; versus ranibizumab MD -0.12 (95% CI -0.14 to -0.10) logMAR. The certainty of the evidence was high for the comparison of aflibercept and ranibizumab with laser and moderate for bevacizumab comparison with laser due to inconsistency between the indirect and direct evidence.People receiving ranibizumab were less likely to gain 3 or more lines of VA at one year compared with aflibercept: RR 0.75 (95% CI 0.60 to 0.94), moderate-certainty evidence. For every 1000 people treated with aflibercept, 92 fewer would gain 3 or more lines of VA at one year if treated with ranibizumab (22 to 148 fewer). On average people receiving ranibizumab had worse VA at one year (MD 0.08 logMAR units, 95% CI 0.05 to 0.11), moderate-certainty evidence; and higher CRT (MD 39 µm, 95% CI 2 µm to 76 µm; low-certainty evidence). Ranibizumab and bevacizumab were comparable with respect to aflibercept and did not differ in terms of VA: RR of gain of 3 or more lines of VA at one year 1.11 (95% CI 0.87 to 1.43), moderate-certainty evidence, and difference in change in VA was 0.00 (95% CI -0.02 to 0.03) logMAR, moderate-certainty evidence. CRT reduction favoured ranibizumab by -29 µm (95% CI -58 µm to -1 µm, low-certainty evidence). There was no evidence of overall statistical inconsistency in our analyses.The previous version of this review found moderate-certainty evidence of good safety of antiangiogenic drugs versus control. This update used data at the longest available follow-up (one or two years) and found that aflibercept, ranibizumab and bevacizumab do not differ regarding systemic serious adverse events (SSAEs) (moderate- or high-certainty evidence). However, risk of bias was variable, loop inconsistency could be found and estimates were not precise enough on relative safety regarding less frequent events such as arterial thromboembolic events or death (low- or very low-certainty evidence).Two-year data were available and reported in only four RCTs in this review. Most industry-sponsored studies were open-label after one year. One large publicly-funded study compared the three drugs at two years and found no difference. AUTHORS' CONCLUSIONS Anti-VEGF drugs are effective at improving vision in people with DMO with three to four in every 10 people likely to experience an improvement of 3 or more lines VA at one year. There is moderate-certainty evidence that aflibercept confers some advantage over ranibizumab and bevacizumab in people with DMO at one year in visual and anatomic terms. Relative effects among anti-VEGF drugs at two years are less well known, since most studies were short term. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated and under-monitored.We found no signals of differences in overall safety between the three antiangiogenic drugs that are currently available to treat DMO, but our estimates are imprecise for cardiovascular events and death.
Collapse
Key Words
- humans
- angiogenesis inhibitors
- angiogenesis inhibitors/therapeutic use
- antibodies, monoclonal
- antibodies, monoclonal/therapeutic use
- antibodies, monoclonal, humanized
- antibodies, monoclonal, humanized/therapeutic use
- aptamers, nucleotide
- aptamers, nucleotide/therapeutic use
- bevacizumab
- diabetic retinopathy
- diabetic retinopathy/complications
- laser coagulation
- laser coagulation/methods
- macular edema
- macular edema/drug therapy
- macular edema/surgery
- randomized controlled trials as topic
- ranibizumab
- receptors, vascular endothelial growth factor
- receptors, vascular endothelial growth factor/therapeutic use
- recombinant fusion proteins
- recombinant fusion proteins/therapeutic use
- triamcinolone
- triamcinolone/therapeutic use
- vascular endothelial growth factor a
- vascular endothelial growth factor a/antagonists & inhibitors
Collapse
Affiliation(s)
- Gianni Virgili
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Mariacristina Parravano
- Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia‐IRCCSOphthalmologyVia Livenza n 3RomeItaly00198
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Iris Gordon
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Ersilia Lucenteforte
- University of FlorenceDepartment of Neurosciences, Psychology, Drug Research and Children’s Healthviale Gaetano Pieraccini, 6FlorenceItaly50139
| |
Collapse
|