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Aflibercept Monotherapy or Bevacizumab First for Diabetic Macular Edema.

Citation
Jhaveri, C. D., et al. “Aflibercept Monotherapy Or Bevacizumab First For Diabetic Macular Edema.”. The New England Journal Of Medicine, pp. 692-703.
Center Joslin Diabetes Center
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Author Chirag D Jhaveri, Adam R Glassman, Frederick L Ferris, Danni Liu, Maureen G Maguire, John B Allen, Carl W Baker, David Browning, Matthew A Cunningham, Scott M Friedman, Lee M Jampol, Dennis M Marcus, Daniel F Martin, Carin M Preston, Cynthia R Stockdale, Jennifer K Sun, DRCR Retina Network
Abstract

BACKGROUND: In eyes with diabetic macular edema, the relative efficacy of administering aflibercept monotherapy as compared with bevacizumab first with a switch to aflibercept if the eye condition does not improve sufficiently (a form of step therapy) is unclear.

METHODS: At 54 clinical sites, we randomly assigned eyes in adults who had diabetic macular edema involving the macular center and a visual-acuity letter score of 24 to 69 (on a scale from 0 to 100, with higher scores indicating better visual acuity; Snellen equivalent, 20/320 to 20/50) to receive either 2.0 mg of intravitreous aflibercept or 1.25 mg of intravitreous bevacizumab. The drug was administered at randomization and thereafter according to the prespecified retreatment protocol. Beginning at 12 weeks, eyes in the bevacizumab-first group were switched to aflibercept therapy if protocol-specified criteria were met. The primary outcome was the mean change in visual acuity over the 2-year trial period. Retinal central subfield thickness and visual acuity at 2 years and safety were also assessed.

RESULTS: A total of 312 eyes (in 270 adults) underwent randomization; 158 eyes were assigned to receive aflibercept monotherapy and 154 to receive bevacizumab first. Over the 2-year period, 70% of the eyes in the bevacizumab-first group were switched to aflibercept therapy. The mean improvement in visual acuity was 15.0 letters in the aflibercept-monotherapy group and 14.0 letters in the bevacizumab-first group (adjusted difference, 0.8 letters; 95% confidence interval, -0.9 to 2.5; P = 0.37). At 2 years, the mean changes in visual acuity and retinal central subfield thickness were similar in the two groups. Serious adverse events (in 52% of the patients in the aflibercept-monotherapy group and in 36% of those in the bevacizumab-first group) and hospitalizations for adverse events (in 48% and 32%, respectively) were more common in the aflibercept-monotherapy group.

CONCLUSIONS: In this trial of treatment of moderate vision loss due to diabetic macular edema involving the center of the macula, we found no evidence of a significant difference in visual outcomes over a 2-year period between aflibercept monotherapy and treatment with bevacizumab first with a switch to aflibercept in the case of suboptimal response. (Funded by the National Institutes of Health; Protocol AC ClinicalTrials.gov number, NCT03321513.).

Year of Publication
2022
Journal
The New England journal of medicine
Volume
387
Issue
8
Number of Pages
692-703
Date Published
08/2022
ISSN Number
1533-4406
DOI
10.1056/NEJMoa2204225
Alternate Journal
N Engl J Med
PMID
35833805
PMCID
PMC9714135
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