COMMENTARY

The Best of Retina

American Academy of Ophthalmology (AAO) 2015

Nikolas J.S. London, MD

Disclosures

January 11, 2016

In This Article

Author's Note:
Retina Subspecialty Day, held during this year's annual meeting of the American Academy of Ophthalmology, brought together thousands of retina specialists from across the globe. We were treated to a series of excellent clinical trial presentations, interactive point/counterpoint debates, surgical video discussions, and demonstrations of cutting-edge technology and surgical techniques. Below is a brief summary of some of the best presentations.

DRCR.net Protocol T

One of the hottest topics in retina is the relative effectiveness of the three available anti-vascular endothelial growth factor (VEGF) medications: bevacizumab, ranibizumab, and aflibercept. This is important not only for clinical care and optimizing outcomes for our patients, but also for financial reasons, given the dramatic cost differences between the three medications. Herein, we will focus on the doses for diabetic macular edema (DME), which cost approximately $1950 for aflibercept, $1400 for ranibizumab, and $50 for bevacizumab.

The Diabetic Retinopathy Clinical Research Network recently published the 1-year results of a large-scale comparison of these three medications for the treatment of DME. Dr John Wells[1] presented the results at the meeting.

The study included 660 eyes with decreased vision due to DME from 89 sites across the country. Patients were randomly assigned to receive one of the three medications under a standard treatment protocol. The authors evaluated visual acuity (VA) outcomes as well as changes in central subfield thickness on optical coherence tomography.

In short, the 1-year VA outcomes revealed no significant difference among the three options overall, but did suggest a greater efficacy for aflibercept in the subgroup of patients with worse baseline VA, defined as 20/50 or worse. In this group, the average 1-year VA gain was +18.9 letters for aflibercept compared with +11.8 letters for bevacizumab and +14.2 letters for ranibizumab. This is an important difference that is supported by anecdotal evidence from thought leaders.

However, a few things must be kept in mind. The groups may not have been truly similar at baseline. For one, patients could have received focal or grid macular laser treatment. As we well know, grid laser has a more substantial impact on a patient's vision. It may be inappropriate to lump these together without a better description of how the groups compared at baseline.

Moreover, all three drugs were extremely efficacious. Although the outcome differences as a whole are not significant, the cost differences between them absolutely are. Just for the purposes of this study, which included a small number of roughly 224 patients per group who were treated for only 1 year, the real-world cost of aflibercept would have been approximately $3,931,200, with nearly $1 million saved with ranibizumab (approximately $3,136,000) and nearly $4 million saved with bevacizumab ($112,000). Considering that DME affects approximately 750,000 patients in the United States, the yearly cost difference among the medications is staggering.[2]

My takeaway from this study is that most patients do well regardless of the medication used. I nearly always prefer bevacizumab at treatment initiation. If the response is suboptimal after about three injections, it is reasonable to switch to ranibizumab or aflibercept. In suboptimal responders with poor initial VA, these data will probably lead me to aflibercept. Once I achieve control of the DME, I would attempt to transition back to bevacizumab in patients who can tolerate it.

As a personal aside, focal laser or intravitreal corticosteroids can also be beneficial in certain patients.

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