Anti-VEGF agents in the management of diabetic macular edema

ABSTRACT

Introduction

Diabetic macular edema (DME) is a common cause of vision loss in patients with diabetic retinopathy and occurs in a substantial proportion of patients with long-standing diabetes. Intravitreal anti-VEGF agents have revolutionized the treatment of DME and become the standard of care for managing macular edema.

Areas covered

A literature search was performed in PubMed for all articles in the past ten years that involve DME and at least one anti-VEGF agent, focusing mainly on randomized clinical trials. We provide an overview of three anti-VEGF agents – bevacizumab, ranibizumab, and aflibercept – and summarize the key evidence regarding their safety and efficacy. In addition, we discuss new anti-VEGF therapies that are currently being developed for DME and other retinal vascular diseases.

Expert opinion

There is level 1 evidence to demonstrate that intravitreal anti-VEGF agents are safe and effective for the treatment of DME. Anti-VEGF therapy improves visual acuity and decreases retinal thickness associated with DME. Novel anti-VEGF agents and alternative drug delivery systems are currently being investigated as additional therapies for DME.

KEYWORDS:

• Diabetic macular edema
• anti-VEGF
• bevacizumab
• ranibizumab
• aflibercept

Article highlights

-DME is the most common cause of vision loss in those with diabetic retinopathy and develops in approximately 30% of patients who have had diabetes for at least 20 years.

-Intravitreal anti-VEGF agents – bevacizumab, ranibizumab, and aflibercept – are the first-line treatment for DME. Ranibizumab and aflibercept are FDA approved for DME, while bevacizumab, the most cost-effective option, continues to be used off-label. Key RCTs include BOLT (bevacizumab), RESTORE/REVEAL and RISE/RIDE (ranibizumab), VIVID/VISTA (aflibercept), and DRCR Protocol T (head-on comparison of all three).

- Level 1 evidence demonstrates intravitreal anti-VEGF agents are effective and safe for the treatment of DME with improvements in visual acuity and reductions in retinal thickness. In addition, these intravitreal agents are safe and well-tolerated.

-New anti-VEGF agents being studied for DME include conbercept, faricimab, brolucizumab, and KSI-301.

Declaration of interest

Diano Do receives research funding from Genentech, Regeneron and Novartis, and is also a Consultant for Genentech, Regeneron, Novartis and Kodiak Sciences. The authors have no other 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 apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This paper is not funded