Update on current pharmacologic therapies for diabetic retinopathy

ABSTRACT

Introduction

Diabetic retinopathy is a major cause of visual loss worldwide. The most important clinical findings include diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR).

Areas covered

PubMed was used for our literature review. Articles from 1995 to 2023 were included. Pharmacologic treatment of diabetic retinopathy generally involves the use of intravitreal anti-vascular endothelial growth factor (VEGF) therapy for DME and PDR. Corticosteroids remain important second-line therapies for patients with DME. Most emerging therapies focus on newly identified inflammatory mediators and biochemical signaling pathways involved in disease pathogenesis.

Expert opinion

Emerging anti-VEGF modalities, integrin antagonists, and anti-inflammatory agents have the potential to improve outcomes with reduced treatment burdens.

KEYWORDS:

• Corticosteroids
• diabetic macular edema
• intravitreal injection
• proliferative diabetic retinopathy
• vascular endothelial growth factor

Article highlights

• Most patients with center-involved diabetic macular edema (CI-DME) are offered treatment with anti-vascular endothelial growth factor (anti-VEGF) monotherapy. The choice between available anti-VEGF agents is complex. The Diabetic Retinopathy Clinical Research Network (DRCR.net) Protocol T phase III trial reported very favorable results with bevacizumab, ranibizumab, and aflibercept, so the choice of which agent to use is probably less important than when an agent is initiated and continued.

• DME may respond slowly to anti-VEGF therapy, in contrast to the more rapid results seen in patients with neovascular AMD or retinal vein occlusion. It is important to treat monthly, and at least five or six injections are probably needed to assess treatment response in most patients. In patients who respond well, treatment intervals are generally extended.

• In patients unresponsive to anti-VEGF therapy, corticosteroid therapy may be considered. Initial corticosteroid treatment is generally with the FDA-approved dexamethasone delivery system (Ozurdex) or with off-label triamcinolone acetonide.

• Patients with more advanced PDR may be treated either with long-term anti-VEGF therapy or with panretinal photocoagulation or both.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript has disclosed serving for Allergan, Regeneron, Genentech, Roche, Bayer, Allegro, Ocuphire, Oxurion, Adverum, Regenix Bio, and OcuTerra. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript was partially funded by NIH Center Core Grant P30EY014801 and Research to Prevent Blindness Unrestricted Grant GR004596-1 to the University of Miami.