Switching to Aflibercept in Diabetic Macular Edema after Unsatisfactory Response to Other Anti-vascular Endothelial Growth Factor Drugs

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

Objective

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

Methods

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

Results

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

Conclusion

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

Modified early intensive and treat-and-extend regimen of anti-vascular endothelial growth factor for diabetic macular edema in Taiwan

Given the rising prevalence of patients with diabetes and increasing treatment burden for patients with vision-threatening diabetic macular edema (DME), we aimed to explore the efficacy of modified early intensive and treat-and-extend regimen of anti-vascular endothelial growth factor (VEGF) therapy under the Taiwan National Insurance Bureau reimbursement policy. We obtained data on 69 eyes treated with initial 4-monthly intravitreal injections of aflibercept or ranibizumab, plus individualized treat-and-extend regimen. At 12 months, the mean (SD) change in LogMAR best corrected visual acuity from baseline was - 0.28 (0.31) in all eyes, while that in the aflibercept and ranibizumab groups were - 0.30 (0.34) and - 0.25 (0.28), respectively. Central retinal thickness decreased by 137.2 (122.4) in all eyes, 138.1 (134.2) in the aflibercept group, and 136.2 (110.9) in the ranibizumab group. Additionally, the aflibercept group had a lower mean number of injections than the ranibizumab group (8.5 vs. 8.7). The last extended dosing interval of > 12 weeks was 31.0% and 16.7% of the eyes in the aflibercept and ranibizumab groups, respectively. The modified anti-VEGF regimens effectively managed DME in terms of functional and anatomical outcomes, and efficiently reduced the healthcare burden by reducing the number of injections and extending treatment intervals within 12 months.

Changes in metamorphopsia following intravitreal aflibercept injection for diabetic macular edema

The aim of the present study was to investigate changes in metamorphopsia in patients with diabetic macular edema (DME) following intravitreal aflibercept injection (IVA) with the treat and extend (TAE) regimen for a year. We performed a post hoc analysis of a multicenter, open-label, single-arm, prospective study. The study included 20 patients with DME. All eyes received 3 monthly loading injections of 2 mg aflibercept, followed by a TAE regimen. Every visit, the severity of metamorphopsia and the best-corrected visual acuity (BCVA) were evaluated, and optical coherence tomography (OCT) images were obtained. The severity of metamorphopsia was measured using M-CHARTS. The metamorphopsia scores before treatment and at 1, 2, 3, 6 and 12 months following treatment were 0.25 ± 0.23, 0.21 ± 0.15, 0.19 ± 0.23, 0.14 ± 0.16, 0.17 ± 0.20 and 0.10 ± 0.17, respectively, with significant improvement from before treatment to 3 and 12 months following treatment (p < 0.05 and p < 0.005, respectively). At the time of macular edema resolution, the presence of an epiretinal membrane (ERM) was associated with the metamorphopsia score (p < 0.05). In conclusion, the metamorphopsia score in patients with DME improved following IVA with the TAE regimen for one year. The presence of ERM was associated with the metamorphopsia score.

Safety and outcomes of intravitreal aflibercept in diabetic macular edema - a systematic review

BACKGROUND

Recent evidence on the role of vascular endothelial growth factor (VEGF) in the pathogenesis of ischemia and microvascular hyperpermeability leading to macular edema has brought anti-VEGF intravitreal therapy into the limelight.

OBJECTIVE

We performed a systematic literature review focusing on the outcomes and safety of the intravitreal use of aflibercept in diabetic macular edema.

METHODS

The studies documented cases with at least three consecutive intravitreal injections of aflibercept (IVA) repeated monthly with a follow-up period of at least one year. The outcomes were evaluated in terms of reported functional and anatomical improvement of the macula, as reflected by changes in visual acuity and macular thickness measured by Optical Coherence Tomography (OCT). In addition, for safety assessment, all reported local and general adverse effects were analyzed.

RESULTS

All studies showed an overall significant anatomical and functional improvement. In patients with the 5 IVA monthly at the beginning of the therapy, the visual gain at 52 weeks varied widely between 5 and 18.9 EDRS letters, with a mean value of 9.48 letters. The higher gain was obtained in treatment naïve patients, with worse VA and increased CST at baseline. The lower gain was obtained in patients previously treated with anti-VEGF. Anti-Platelet Trialists' Collaboration-defined arterial thromboembolic events were not statistically different between the aflibercept group and the laser group.

CONCLUSIONS

Intravitreal aflibercept therapy provides significant improvement in visual acuity and a good safety profile. Randomized studies are needed to document the optimal frequency of intravitreal injections for optimal treatment.

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

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

Review of clinical studies and recommendation for a therapeutic flow chart for diabetic macular edema

Diabetic macular edema (DME), characterized by exudative fluid accumulation in the macula, is the most common form of sight-threatening retinopathy in patients with diabetes. The management of DME has changed considerably in recent years, especially following the development of intravitreal anti-vascular endothelial growth factor therapy which has emerged as a first-line therapy for center-involved DME. Laser treatment, intravitreal steroid therapy, and vitrectomy are also important treatment options for DME. We believe that it is important to choose the most appropriate treatment option for DME based on the clinical evidences, in addition to the careful consideration of individual patients' general or ocular condition, DME characteristics, patients' motivation, and compliance to the treatment in real-world clinical practice. In this review, we have summarized important clinical evidences for the main treatments for DME, presented an expert review for these evidences, and proposed a recommended therapeutic flow chart for DME. We hope that our review of the clinical evidences and the recommended therapeutic flow chart for DME will contribute to better treatment outcome for DME.

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

Background

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

Methods

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

Results

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

Conclusions

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