Comparison of Intravitreal Aflibercept and Ranibizumab following Initial Treatment with Ranibizumab in Persistent Diabetic Macular Edema

Abstract

Purpose To compare the visual and anatomic outcomes in patients with persistent diabetic macular edema (DME) who switched from ranibizumab to aflibercept with those who continued with previous ranibizumab therapy. Methods In this retrospective comparative study, medical records of consecutive patients with center-involved DME ≥ 350 μm who had at least three recent consecutive monthly ranibizumab injections followed by as-needed therapy with either aflibercept or ranibizumab were reviewed. Data were collected at presentation (preinjection), at the intermediary visit, and at the last visit (at the end of the follow-up period). Results Forty-three eyes of 43 patients were divided into two groups: the switch group (n = 20) and the ranibizumab group (n = 23). Though no significant improvement was found in the mean BCVA from the intermediary visit to the last visit, there was a difference in the mean CMT in the switch group and the ranibizumab group (p < 0.001 and p = 0.03, resp.). The mean CMT decreased after the intermediary visit by 188.6 ± 120.5 μm in the switch group and by 60.3 ± 117.1 μm in the ranibizumab group (p = 0.003). Conclusions Both aflibercept and ranibizumab decreased CMT in patients with persistent DME who showed a poor response to ranibizumab injections. However, switching to aflibercept provided only morphologic improvement.

Aflibercept versus Ranibizumab as a Second Line Therapy After Bevacizumab for Diabetic Macular Edema

“…To the best of our knowledge, our study is unique in comparing two commonly used anti-VEGF in refractory DME after 3 to 6 bevacizumab injection regimen. Demircan et al 12 studied the effect of continuing on ranibizumab vs switching to aflibercept injection after initial three injections of ranibizumab. In contrast to our study findings, they noted better outcomes of aflibercept treatment regimen than ranibizumab treatment regimen in term of the reduction In view of higher binding affinity to VEGF-A, aflibercept binds better to VEGF-B and placental growth factor (P1GF) compared to bevacizumab or ranibizumab and therefore has better bioavailability at the macula.…”

“…Widely-used and cost-effective bevacizumab injection regimens have shown that as high as 40–65.6% of eyes have residual DME. 11 , 12 Hence switching to alternative anti-VEGF agents is crucial and has shown promising anatomic and functional outcomes. 5 , 12 , 13 However, which anti-VEGF to select is still debatable and present study could not get sufficient evidence to recommend aflibercept or ranibizumab treatment regimen as 2nd line of treatment.…”

Visual and anatomic outcomes of sustained single agent anti-VEGF treatment versus double anti-VEGF switching in the treatment of persistent diabetic macular edema

“…In both groups, there was significant anatomical improvement, while the decrease in CRT in the switch group was significantly more pronounced. On the other hand, functional improvement was not significantly different either between the baseline and last visits in both groups or between each other [14]. However, this study did not include eyes with double anti-VEGF switch.…”

“…However, reports from the BOLT, RISE/RIDE, and DRCR.net studies have demonstrated that DR patients with DME that did not achieve immediate anatomical response may be late responders, as they still achieved further functional and anatomical improvement with sustained treatment [10][11][12][13]. This finding makes unclear whether the visual and/or anatomic improvement seen in patients that switch anti-VEGF therapies originates from the new intravitreal anti-VEGF agent or from the total number of anti-VEGF injections [14]. The scenario becomes more complicated when the patient did not respond adequately after switching anti-VEGF; in this situation, it is unclear whether a second switch would be more beneficial versus continuing the same treatment regimen.…”

Management of Refractory Diabetic Macular Edema: A Review Article

“…Demircan et al compared the outcomes in eyes with refractory DME who received intravitreal aflibercept following prior unresponsive intravitreal ranibizumab injections with eyes who continued with intravitreal ranibizumab injections. 38 In this retrospective study, 43 eyes with a CMT ≥350 µm who received at least 3 monthly intravitreal ranibizumab injections and were then treated with either ranibizumab or aflibercept with a PRN regimen were included. This study showed that the CMT decreased significantly from baseline in both groups with switching to aflibercept or continued with ranibizumab.…”