Guidelines for the Management of Center-Involving Diabetic Macular Edema: Treatment Options and Patient Monitorization

Abstract

Diabetic macular edema (DME) is the main cause of visual impairment associated with diabetic retinopathy (DR) and macular laser, during approximately three decades, and was the single treatment option. More recently, intravitreous injections of anti-angiogenics and corticosteroids modified the treatment paradigm associated with significant vision improvements. Nevertheless, not all patients respond satisfactorily to anti-VEGF or corticosteroid injections, so an adequate treatment choice and a prompt switch in therapeutic class is recommended. Several algorithms and guidelines have been proposed for treating center involving DME to improve patients’ vision and quality of life. However, in Portugal, such guidelines are lacking. The present review aimed to provide guidelines for the treatment options and patient monitorization in the management of center-involving DME. We recommend anti-vascular endothelial growth factor (VEGF) as first-line therapy after a clinical evaluation accompanied by a rigorous metabolic control. Depending on the response obtained after 3–6 monthly intravitreal injections we suggest switching outside the class in case of a non-responder, maintaining the anti-VEGF-therapy in responders to anti-angiogenics. The treatment regimen for Dexamethasone intravitreal implant (DEXii) should be pro-re-nata with bi-monthly or quarterly monitoring visits (with a scheduled visit at 6–8 weeks after DEXii for intraocular pressure control). If a patient does not respond to DEXii, switch again to anti-VEGF therapy, combine therapies, or re-evaluate patients diagnose. There is a resilient need to understand the disease, its treatments, regimens available, and convenience for all involved to propose an adequate algorithm for the treatment of diabetic retinopathy (DR) and DME in an individualized regimen. Further understanding of the contributing factors to the development and progression of DR should bring new drug discoveries for more effective and better-tolerated treatments.

Keywords:

• anti-vascular endothelial growth factor
• center-involving diabetic macular edema
• dexamethasone intravitreal implant
• diabetic retinopathy

Acknowledgments

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Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

Figueira J contribute in consultancy or advisory roles from Alcon, Allergan, Alimera, Bayer, Novartis and Roche. Henriques J contribute in consultancy or advisory roles from Alcon, Allergan, Alimera, Bayer, Roche and Novartis. Carneiro A contribute in consultancy or advisory roles from Allergan, Alimera, Bayer, Novartis and Roche. Neves C contribute in consultancy or advisory roles from Allergan, Bayer and Flores R contribute in consultancy or advisory roles from Allergan, Bayer, Novartis and Roche. Castro-Sousa JP contribute in consultancy or advisory roles from Allergan, Bayer, Novartis and Roche. Meireles A contribute in consultancy or advisory roles from Alcon, Allergan, Alimera and Novartis. Gomes N contribute in consultancy or advisory roles from Allergan, Bayer and Novartis. Nascimento J contribute in consultancy or advisory roles from Allergan, Bayer and Novartis. Amaro M contribute in consultancy or advisory roles from Allergan, Bayer, Novartis and Zeiss. Silva R is a member of advisory board for Allergan, Alimera, Bayer, Novartis, NovoNordisk, Thea and Roche. The authors report no other conflicts of interest in this work.

Additional information

Funding

Allergan plc provided financial support for the work conducted to prepare this manuscript but was not involved directly in preparation of the manuscript or the decision to publish.