Step therapy without disadvantages

The impending visual deterioration in diabetic macular edema does not have to be treated first line with aflibercept. First of all, it is obviously worth trying bevacizumab. If it fails, you can switch.

The treatment of choice for diabetic macular edema consists of intravitreal injections of drugs that inhibit vascular proliferation. In the USA, this includes the active ingredient Aflibercept authorized. For financial reasons, however, more and more health insurance companies insist on one graded therapy. This stipulates that the more expensive preparations should only be used if there is no response to the cheaper bevacizumabbut only that off label can be used. This strategy has been used for patients with moderate visual loss probably no significant disadvantages with regard to vision after two years, reports Prof. Dr. Chirag Jhaveri from the Austin Research Center for Retina.

Together with other researchers, he initiated a study conducted at 54 US clinics Study. 270 diabetics were included who suffered from moderate visual impairment as a result of central diabetic macular edema (a total of 312 affected eyes). According to randomization, 158 eyes received monotherapy with aflibercept, while the researchers initially treated the remaining 154 eyes with bevacizumab. If the treatment success measured using previously defined criteria failed to materialize in this group, the injections were subsequently switched to aflibercept.

On Switch to aflibercept occurred within two years in 70% of eyes initially treated with bevacizumab. Regarding the average visual improvement as well as the central retinal thickness distinguished However, the two treatment groups ended up differing not essential.

Since diabetic macular edema endangers eyesight, one wants graded therapy well considered be, say Prof. Dr. David Musch from the University of Michigan in Ann Arbor and Dr. Emily Chew from the National Institutes of Health in Bethesda. At $50 per dose, bevacizumab is significantly cheaper than aflibercept ($1,941). However, those affected must then also consistently and closely monitored in order not to miss the right time for a change of therapy. This could be a challenge, especially for diabetics, who usually have to complete numerous other medical check-ups due to comorbidities.

1. Jhaveri CD et al. N Engl J Med 2022; 387: 692-703; DOI: 10.1056/NEJMoa2204225
2. Musch DC, Chew EY. N Engl J Med 2022; 387: 751-752; DOI: 10.1056/NEJMe2208454

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