Anti-VEGF agents, corticosteroids both efficacious in DME treatment
Intravitreal injections of anti-VEGF agents and corticosteroids were found to be safe and effective in the treatment of diabetic macular edema, according to an assessment published in Ophthalmology.
“Both anti-VEGF injection and corticosteroid implant treatments result in significant functional and anatomic improvements,” Justis P. Ehlers, MD, director of the Tony and Leona Campane Center for Excellence in Image-Guided Surgery & Advanced Imaging Research at the Cole Eye Institute, and colleagues wrote. “Current literature lacks extensive robust evidence on comparative analysis between anti-VEGF and corticosteroid pharmacotherapies, combination therapies and intervention time. In the absence of such evidence, the choice of therapy must be made by the physician on a case-by-case basis, prioritizing outcomes for each individual patient.”
Ehlers and colleagues focused their assessment on level I evidence in 17 articles that evaluated one or more anti-VEGF pharmacotherapies, including ranibizumab (n = 14), aflibercept (n = 5) and bevacizumab (n = 2) alone or in conjunction with other DME treatments, and seven articles that evaluated corticosteroid implants.
The overall ocular safety profile of anti-VEGF therapeutics was tolerable across studies, while cataract formation and increased IOP were the most common significant ocular adverse effects observed with corticosteroids.
“Future research may focus on comparative efficacy among agents, long-term dosing strategies and the place of combination therapies, including the role of focal laser in selected patients,” the study authors wrote. “Further investigations with imaging modalities that include color fundus photography, OCT and OCT angiography, and ultra-widefield fluorescein angiography are needed to interpret the role of current drugs in patient-tailored approaches to DME management and prognosis.”
Perspective
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The first thing I was reminded of while reading this study was that the acronyms we use for clinical trials have gotten out of hand. RISE and RIDE seem fit for a cowboy in the morning.
This paper is a nice reference tool if one wants to do due diligence in finding major studies to verify what has become the standard of care for treatment of DME. We learn that both steroids and anti-VEGF inhibitors have level I verification of safety and efficacy. We learn that there is no level I data comparing the two treatments and that “the choice of therapy must be made by the physician on a case-by-case basis.”
At the hospital where I work, nearly every patient with DME is treated with anti-VEGF. The patients who receive steroid injections for DME are mostly pseudophakes who are nonresponsive to anti-VEGF. Very rarely is focal laser performed. It is vital to know what the standard of care is so we can pass this knowledge to our patients. But it is also important to know where that standard of care comes from.
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