Compared with intravitreous ranibizumab, the decreases in the plasma-free VEGF levels were greater with intravitreous aflibercept and bevacizumab in patients with diabetic macular edema.
Diabetic Macular Edema
Among a subset of patients in the phase IV PALADIN study, there was improved visual acuity, improved macular thickness, and reduced treatment burden among patients treated with the intravitreal fluocinolone acetonide 0.2 µg (Iluvien implant) for DME.
The addition of dexamethasone implant (Ozurdex, Allergan) to a continuing regimen of ranibizumab (Lucentis, Genentech) did not produce results in visual acuity outcomes that differed from those achieved with ranibizumab alone at 6 months. However, there was an improvement in the central macular thickness on OCT in patients.
The use of aflibercept led to greater improvement in macular perfusion status in a phase III trial with DME patients. Those with baseline nonperfusion tended to have more advanced disease.
There is subset of patients with resistant or persistent DME that forms the impetus for new treatment strategies, including next-generation anti-VEGF-A and new classes of drugs. Pravin U. Dugel, MD, outlines a list of potential treatment candidates that may lead that paradigm shift.
Results of the prospective TREX-DME study provide an evidence base for using a treat-and-extend protocol for administering anti-VEGF injections for eyes with diabetic macular edema.
Suprachoroidal triamcinolone acetonide (CLS-TA, Clearside Biomedical) injection resulted in visual and anatomic improvements in eyes with diabetic macular edema, particularly in those that were treatment-naïve. Multiple injections of the investigational treatment were well-tolerated and associated with a low incidence of IOP elevation.
The fluocinolone acetonide 0.2 mcg/day implant (Iluvien, Alimera Sciences) offers an additional option for treating diabetic macular edema that reduces the need for subsequent therapy with anti-vascular endothelial growth factor or steroid treatment.
Patients with diabetic retinopathy have a high risk of developing macular edema after cataract surgery. Intravitreal injections of aflibercept might result in fewer patients developing macular edema in this patient population.
ALG-1001 (Luminate, Allegro Ophthalmics) has a number of different mechanisms of action that benefit patients chronically treated with anti-vascular endothelial growth factor drugs and those who are treatment naïve.