This article is more than 5 years old. Information may no longer be current.
Early anti-VEGF switch yields improved response in cases of refractory DME
Click Here to Manage Email Alerts
Patients with diabetic macular edema who were switched early to ranibizumab or aflibercept after not responding to bevacizumab experienced a statistically significant improvement in best corrected visual acuity.
The retrospective study included 59 eyes of 45 patients, of which 17 eyes of 14 patients were switched to Eylea (aflibercept, Regeneron) and 42 eyes of 31 patients were switched to Lucentis (ranibizumab, Genentech) after not responding to treatment with Avastin (bevacizumab, Genentech) for DME. The aflibercept cohort previously had 5.76 injections compared with 4.1 injections in the ranibizumab cohort. Patients were treated with bevacizumab for less than 9 months.
The combined aflibercept and ranibizumab cohort experienced a significant improvement in BCVA from 0.65 logMAR pre-switch to 0.54 logMAR 1 month post-switch (P < .05). The individual ranibizumab cohort experienced a statistically significant increase from 0.67 logMAR pre-switch to 0.56 logMAR 1 month post-switch (P < .05). The BCVA difference in the individual aflibercept group was not statistically significant from pre-switch to 1 month post-switch. There was no significant difference between the two drugs.
In the combined cohort, the central subfield thickness significantly decreased from 475.6 ± 118.8 µm pre-switch to 416.2 m ± 119 µm 1 month post-switch (P < .05); the two individual drugs also showed statistically significant differences, but there was no significant difference between the drugs.
“Switching to either aflibercept or ranibizumab may offer an interesting option in cases with diabetic macular edema refractory to bevacizumab. This effect seems to be independent of baseline [central subfield thickness] and previous number of injections,” the researchers wrote. – by Robert Linnehan
Disclosure: The authors report no relevant financial disclosures.
Perspective
Back to TopW. Lloyd Clark, MD
The how, when and why of switching anti-VEGF drugs for the treatment of diabetic macular edema remain elusive and rely on clinical experience and anecdotal evidence. Ashraf and colleagues identified a cohort of patients with persistent, severe DME after initial treatment with bevacizumab. The choice of ranibizumab or aflibercept as substitute therapy made no real difference in disease activity after an initial injection; they all improved.
So how do we use this observation in clinical practice? If bevacizumab is first-line in your clinical practice, then consider an alternative therapy if there is not a significant response after several monthly injections, rather than tolerating chronic DME.
This report also confirms the recent results of the Diabetic Retinopathy Clinical Research Network’s Protocol T. In this current study, there was a differential biologic effect once bevacizumab was discontinued. Taken in context with the more extensive data from Protocol T, these findings can help inform a decision for primary therapy, particularly in eyes with more severe disease.
The bottom line is anti-VEGF therapy for retinal diseases such as DME requires an individualized approach with the goal of elimination, not reduction, of macular edema.
Collapse
Ashraf M, et al. Ophthalmic Surg Lasers Imaging Retina. 2017;doi:10.3928/23258160-20170301-06.
Click Here to Manage Email Alerts