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Jhaveri CD, Glassman AR, Ferris FL, Liu D, Maguire MG, Allen JB, Baker CW, Browning D, Cunningham MA, Friedman SM, Jampol LM, Marcus DM, Martin DF, Preston CM, Stockdale CR, Sun JK. Aflibercept Monotherapy or Bevacizumab First for Diabetic Macular Edema. N Engl J Med 2022; 387:692-703. [PMID: 35833805 PMCID: PMC9714135 DOI: 10.1056/nejmoa2204225] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In eyes with diabetic macular edema, the relative efficacy of administering aflibercept monotherapy as compared with bevacizumab first with a switch to aflibercept if the eye condition does not improve sufficiently (a form of step therapy) is unclear. METHODS At 54 clinical sites, we randomly assigned eyes in adults who had diabetic macular edema involving the macular center and a visual-acuity letter score of 24 to 69 (on a scale from 0 to 100, with higher scores indicating better visual acuity; Snellen equivalent, 20/320 to 20/50) to receive either 2.0 mg of intravitreous aflibercept or 1.25 mg of intravitreous bevacizumab. The drug was administered at randomization and thereafter according to the prespecified retreatment protocol. Beginning at 12 weeks, eyes in the bevacizumab-first group were switched to aflibercept therapy if protocol-specified criteria were met. The primary outcome was the mean change in visual acuity over the 2-year trial period. Retinal central subfield thickness and visual acuity at 2 years and safety were also assessed. RESULTS A total of 312 eyes (in 270 adults) underwent randomization; 158 eyes were assigned to receive aflibercept monotherapy and 154 to receive bevacizumab first. Over the 2-year period, 70% of the eyes in the bevacizumab-first group were switched to aflibercept therapy. The mean improvement in visual acuity was 15.0 letters in the aflibercept-monotherapy group and 14.0 letters in the bevacizumab-first group (adjusted difference, 0.8 letters; 95% confidence interval, -0.9 to 2.5; P = 0.37). At 2 years, the mean changes in visual acuity and retinal central subfield thickness were similar in the two groups. Serious adverse events (in 52% of the patients in the aflibercept-monotherapy group and in 36% of those in the bevacizumab-first group) and hospitalizations for adverse events (in 48% and 32%, respectively) were more common in the aflibercept-monotherapy group. CONCLUSIONS In this trial of treatment of moderate vision loss due to diabetic macular edema involving the center of the macula, we found no evidence of a significant difference in visual outcomes over a 2-year period between aflibercept monotherapy and treatment with bevacizumab first with a switch to aflibercept in the case of suboptimal response. (Funded by the National Institutes of Health; Protocol AC ClinicalTrials.gov number, NCT03321513.).
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Affiliation(s)
- Chirag D Jhaveri
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Adam R Glassman
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Frederick L Ferris
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Danni Liu
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Maureen G Maguire
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - John B Allen
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Carl W Baker
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - David Browning
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Matthew A Cunningham
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Scott M Friedman
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Lee M Jampol
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Dennis M Marcus
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Daniel F Martin
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Carin M Preston
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Cynthia R Stockdale
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
| | - Jennifer K Sun
- From the Retina Consultants of Austin and the Austin Research Center for Retina - both in Austin, TX (C.D.J.); the Jaeb Center for Health Research, Tampa (A.R.G., D.L., M.G.M., C.M.P., C.R.S.), the Florida Retina Institute, Orlando (M.A.C.), and Florida Retina Consultants, Lakeland (S.M.F.) - all in Florida; Ophthalmic Research Consultants, Waxhaw (F.L.F.), and Southeast Clinical Research Associates (J.B.A.) and Charlotte Eye, Ear, Nose, and Throat Associates (D.B.), Charlotte - all in North Carolina; the Ophthalmology Group, Paducah, KY (C.W.B.); the Feinberg School of Medicine, Northwestern University, Chicago (L.M.J.); the Southeast Retina Center, Augusta, GA (D.M.M.); Cole Eye Institute, Cleveland Clinic, Cleveland (D.F.M.); and the Joslin Diabetes Center, Beetham Eye Institute, and the Department of Ophthalmology, Harvard Medical School, Boston (J.K.S.)
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5
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Baker CW, Glassman AR, Beaulieu WT, Antoszyk AN, Browning DJ, Chalam KV, Grover S, Jampol LM, Jhaveri CD, Melia M, Stockdale CR, Martin DF, Sun JK. Effect of Initial Management With Aflibercept vs Laser Photocoagulation vs Observation on Vision Loss Among Patients With Diabetic Macular Edema Involving the Center of the Macula and Good Visual Acuity: A Randomized Clinical Trial. JAMA 2019; 321:1880-1894. [PMID: 31037289 PMCID: PMC6537845 DOI: 10.1001/jama.2019.5790] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Intravitreous injections of antivascular endothelial growth factor agents are effective for treating diabetic macular edema (DME) involving the center of the macula (center-involved DME [CI-DME]) with visual acuity impairment (20/32 or worse). The best approach to treating patients with CI-DME and good visual acuity (20/25 or better) is unknown. OBJECTIVE To compare vision loss at 2 years among eyes initially managed with aflibercept, laser photocoagulation, or observation. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted at 91 US and Canadian sites among 702 adults with type 1 or type 2 diabetes. Participants had 1 study eye with CI-DME and visual acuity of 20/25 or better. The first participant was randomized on November 8, 2013, and the final date of follow-up was September 11, 2018. INTERVENTIONS Eyes were randomly assigned to 2.0 mg of intravitreous aflibercept (n = 226) as frequently as every 4 weeks, focal/grid laser photocoagulation (n = 240), or observation (n = 236). Aflibercept was required for eyes in the laser photocoagulation or observation groups that had decreased visual acuity from baseline by at least 10 letters (≥ 2 lines on an eye chart) at any visit or by 5 to 9 letters (1-2 lines) at 2 consecutive visits. MAIN OUTCOMES AND MEASURES The primary outcome was at least a 5-letter visual acuity decrease from baseline at 2 years. Antiplatelet Trialists' Collaboration adverse events (defined as myocardial infarction, stroke, or vascular or unknown death) were reported. RESULTS Among 702 randomized participants (mean age, 59 years; 38% female [n=264]), 625 of 681 (92% excluding deaths) completed the 2-year visit. For eyes with visual acuity that decreased from baseline, aflibercept was initiated in 25% (60/240) and 34% (80/236) in the laser photocoagulation and observation groups, respectively. At 2 years, the percentage of eyes with at least a 5-letter visual acuity decrease was 16% (33/205), 17% (36/212), and 19% (39/208) in the aflibercept, laser photocoagulation, and observation groups, respectively (aflibercept vs laser photocoagulation risk difference, -2% [95% CI, -9% to 5%]; relative risk, 0.88 [95% CI, 0.57-1.35; P = .79]; aflibercept vs observation risk difference, -3% [95% CI, -11% to 4%]; relative risk, 0.83 [95% CI, 0.55-1.27; P = .79]; laser photocoagulation vs observation risk difference, -1% [95% CI, -9% to 6%]; relative risk, 0.95 [95% CI, 0.64-1.41; P = .79]). Antiplatelet Trialists' Collaboration vascular events occurred in 15 (7%), 13 (5%), and 8 (3%) participants in the aflibercept, laser photocoagulation, and observation groups. CONCLUSIONS AND RELEVANCE Among eyes with CI-DME and good visual acuity, there was no significant difference in vision loss at 2 years whether eyes were initially managed with aflibercept or with laser photocoagulation or observation and given aflibercept only if visual acuity worsened. Observation without treatment unless visual acuity worsens may be a reasonable strategy for CI-DME. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01909791.
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Affiliation(s)
| | | | | | - Andrew N. Antoszyk
- Charlotte Eye, Ear, Nose, and Throat Associates PA, Charlotte, North Carolina
| | - David J. Browning
- Charlotte Eye, Ear, Nose, and Throat Associates PA, Charlotte, North Carolina
| | - Kakarla V. Chalam
- Department of Ophthalmology, Loma Linda University Health Care, Loma Linda, California
| | - Sandeep Grover
- Department of Ophthalmology, University of Florida College of Medicine, Gainesville
- Jacksonville Health Science Center, Jacksonville, Florida
| | - Lee M. Jampol
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Chirag D. Jhaveri
- Retina Consultants of Austin Retina Research Center, Austin, Texas
- Dell Medical School, University of Texas at Austin
| | | | | | | | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Department of Ophthalmology, Boston, Massachusetts
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Sahni J, Patel SS, Dugel PU, Khanani AM, Jhaveri CD, Wykoff CC, Hershberger VS, Pauly-Evers M, Sadikhov S, Szczesny P, Schwab D, Nogoceke E, Osborne A, Weikert R, Fauser S. Simultaneous Inhibition of Angiopoietin-2 and Vascular Endothelial Growth Factor-A with Faricimab in Diabetic Macular Edema: BOULEVARD Phase 2 Randomized Trial. Ophthalmology 2019; 126:1155-1170. [PMID: 30905643 DOI: 10.1016/j.ophtha.2019.03.023] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The phase 2 BOULEVARD trial compared safety and efficacy of faricimab, a novel bispecific antibody targeting angiopoietin-2 and vascular endothelial growth factor-A (VEGF-A), with ranibizumab in patients with diabetic macular edema (DME). DESIGN The BOULEVARD trial (ClinicalTrials.gov identifier, NCT02699450) was a prospective, randomized, active comparator-controlled, double-masked, multicenter, phase 2 study conducted at 59 sites in the United States. PARTICIPANTS The trial enrolled patients 18 years of age or older with center-involving DME, best-corrected visual acuity (BCVA) of 73 to 24 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and central subfield thickness (CST) of 325 μm or more. METHODS Anti-VEGF treatment-naïve patients were randomized 1:1:1 to intravitreal 6.0 mg faricimab, 1.5 mg faricimab, or 0.3 mg ranibizumab, and patients previously treated with anti-VEGF were randomized 1:1 to 6.0 mg faricimab or 0.3 mg ranibizumab. Patients were dosed monthly for 20 weeks, followed by an observation period up to week 36 to assess durability. MAIN OUTCOME MEASURES The prespecified primary outcome measure was mean change in BCVA from baseline at week 24 for faricimab versus ranibizumab in treatment-naïve patients. Key secondary and exploratory outcome measures included CST, Diabetic Retinopathy Severity Scale (DRSS) score, and durability as assessed by time to re-treatment. RESULTS The trial enrolled 229 patients (168 treatment-naïve and 61 previously treated with anti-VEGF). In treatment-naïve patients, 6.0 mg faricimab, 1.5 mg faricimab, and 0.3 mg ranibizumab resulted in mean improvements of 13.9, 11.7, and 10.3 ETDRS letters from baseline, respectively. The 6.0-mg faricimab dose demonstrated a statistically significant gain of 3.6 letters over ranibizumab (P = 0.03). In both patient populations, faricimab resulted in dose-dependent reductions in CST, improvements in DRSS score, and longer time to re-treatment during the observation period compared with ranibizumab. Faricimab showed no new or unexpected safety signals. CONCLUSIONS The BOULEVARD trial met its primary end point; faricimab demonstrated statistically superior visual acuity gains versus ranibizumab at week 24 in treatment-naïve patients. Central subfield thickness reduction, DRSS score improvement, and extended durability outcomes support the primary outcome. These findings suggest the benefit of simultaneous inhibition of angiopoietin-2 and VEGF-A with faricimab for patients with DME.
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Affiliation(s)
- Jayashree Sahni
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland.
| | | | - Pravin U Dugel
- Retinal Consultants of Arizona, Phoenix, Arizona; USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Arshad M Khanani
- Sierra Eye Associates, Reno, Nevada; Reno School of Medicine, The University of Nevada, Reno, Nevada
| | - Chirag D Jhaveri
- Retina Consultants of Austin and Retina Research Center, Austin, Texas; Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Charles C Wykoff
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
| | | | - Meike Pauly-Evers
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Shamil Sadikhov
- Roche Product Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Piotr Szczesny
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Dietmar Schwab
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Everson Nogoceke
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | | | - Robert Weikert
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Sascha Fauser
- Roche Pharma Research and Early Development, F. Hoffmann-La Roche Ltd., Basel, Switzerland
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