How effective are VEGF inhibitors in the management of diabetic retinopathy?

Updated: Sep 02, 2021
  • Author: Abdhish R Bhavsar, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Answer

Aflibercept and ranibizumab reduced the swelling of the macula more than bevacizumab. Also, a smaller percentage of participants on aflibercept (36%) had laser treatment for persistent edema that did not resolve with anti–vascular endothelial growth factor (anti-VEGF) treatment alone, compared with participants on bevacizumab (56%) or ranibizumab (46%). [36]

Aflibercept gained US Food and Drug Administration (FDA) approval for all stages of diabetic retinopathy (NPDR) in May 2019. Approval was based on the 1-year data from the PANORAMA trial (n=402). The study enrolled patients with moderately severe to severe NPDR without DME. At week 52, 80% of patients receiving aflibercept every 8 weeks and 65% of those receiving the drug every 16 weeks improved by two or more steps from baseline on the Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale (ETDRS-DRSS), compared with 15% of placebo patients. [37, 38]

Ranibizumab intravitreal injection was initially approved for diabetic retinopathy in patients with DME. Approval was based on the RISE and RIDE studies (n = 759). The trials measured the proportions of patients who gained 15 letters or more from baseline at month 36 in the sham/0.5 mg, 0.3 mg, and 0.5 mg ranibizumab groups. Results in each group were 19.2%, 36.8%, and 40.2%, respectively, in RIDE and 22.0%, 51.2%, and 41.6%, in RISE.

In the ranibizumab arms, reductions in central foveal thickness (CFT) seen at 24 months were, on average, sustained through month 36. Visual acuity (VA) gains and improvement in retinal anatomy achieved with ranibizumab at month 24 were sustained through month 36. In the third year, sham patients, while still masked, were eligible to cross over to monthly 0.5 mg ranibizumab. After crossover to 1 year of treatment with ranibizumab, average VA gains in the sham/0.5 mg group were lower compared with gains seen in the ranibizumab patients after 1 year of treatment (2.8 vs. 10.6 and 11.1 letters). [39]

Subsequent studies have also pointed to ranibizumab's efficacy in diabetic retinopathy. A literature review by Stewart found that in a large minority of eyes, regular injections of ranibizumab resulted in improved diabetic retinopathy severity scores. In proliferative diabetic retinopathy, patients experienced less visual field loss with the drug than with laser photocoagulation. The literature also indicated that ranibizumab is superior to laser photocoagulation for the treatment of diabetic macular edema. [40]

Similarly, a literature review by Vergmann and Grausland indicated that in the treatment of proliferative diabetic retinopathy, VEGF inhibitors are less damaging to visual fields than is conventional panretinal photocoagulation (PRP). [41]


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