JAMA Study on DR Treatment Says Anti-VEGF Agent "Noninferior" for Long-Term Use

The VEGF inhibitors have been a game-changer in treatment of ocular conditions in diabetes.

Results released late Friday in JAMA say that long-term treatment with ranibizumab was “noninferior”—or not worse than—panretinal photocoagulation (PRP), which had been the standard treatment for proliferative diabetic retinopathy (PDR) until the arrival of the vascular endothelial growth factor (VEGF) inhibitor class.

The results were presented at the American Academy of Opthalmology, meeting in Las Vegas.

In the new study, researchers from the Diabetic Retinopathy Clinical Research Network enrolled individual eyes for 305 adults—for a total of 394 study eyes. Individual eyes were randomized to receive PRP treatment, completed in 1 to 3 visits (203 eyes) or ranibizumab, completed as frequently as every 4 weeks based on the protocol (191 eyes). The authors noted that 53% of the PRP group also received ranibizumab injections for DME.

The primary outcome was mean visual acuity at 2 years. More peripheral visual field loss occurred, more vitrectomies (removal of the gel [vitreous] from within the eyeball) were performed, and DME development was more frequent in the PRP group compared with the ranibizumab group. No systemic safety concerns with ranibizumab were identified in the prespecified major safety outcomes.

"Although longer-term follow-up is needed, ranibizumab may be a reasonable treatment alternative at least through 2 years for patients with proliferative diabetic retinopathy," the authors wrote.

An accompany editorial sought to clarify the role of the 2 treatments, but had praise for anti-VEGF treatments as an option. "This important study … represents a major step forward for patients with PDR by providing the ophthalmologists who manage their retinal disease with new options," wrote Timothy W. Olsen, MD, of Emory University in Atlanta, Georgia.

"The short-term role (2 years) for using anti-VEGF agents seems to represent a viable alternative therapy for adherent patients with high-risk PDR. Nevertheless, PRP represents the standard of care for PDR and may represent the best long-term treatment option for high-risk PDR. It is certainly not time to abandon PRP in favor of exclusively treating patients with PDR using only intravitreal anti­-VEGF injections.

Olsen said physicians must use their best clinical judgment for patients with high-risk PDR. Ranibizumab, marketed as Lucentis, is one of several anti-VEGF agents on the market. Afilbercept, marketed as Eylea, has come on the market more recently; and bevacizumab, approved as the cancer therapy Avastin, has been repackaged for ocular treatment.