Efficacy and Safety of Brolucizumab for Diabetic Macular Edema: The KINGFISHER Randomized Clinical Trial

Effect Modifiers and Risk Factors of Intraocular Inflammation Following Brolucizumab: A Systematic Review and Meta-analysis

PURPOSE

To identify risk factors and effect modifiers associated with intraocular inflammation (IOI) following brolucizumab injection.

METHODS

Our protocol was registered on PROSPERO (CRD42022382645). We searched six electronic databases (PubMed, Scopus, Web of Science, CENTRAL, EMBASE, and Google Scholar) to retrieve all studies that reported the occurrence of IOI following brolucizumab. Data are reported as mean difference with their corresponding 95% confidence intervals. All analyses were conducted per eye, and the risk of bias was assessed using the National Health Institute tool.

RESULTS

Our analysis included 3527 eyes of 3469 patients of 33 papers. The mean age of the patients was 74 years (SD = 10.9, Range = 62.3-80.9). There were 1793 male patients (51.7%) and 1719 female patients (49.6%). The average follow-up period was 13.9 months (SD = 9.4). The mean number of injections was 4.5 (SD = 2.9) injections per eye; 1315 (37.3%) eyes had neovascular AMD, 189 (5.4%) had diabetic macular edema, and 129 (3.7%) eyes had polypoidal choroidal vasculopathy. Post-intervention, subretinal fluid, intraretinal fluid, and pigment epithelial detachment were significantly improved (46.5-11.3% of patients, 55.7-11.3% of patients, 24.7-7.1% of patients, respectively) (p < 0.001). Regarding visual acuity, there was an improvement with a mean difference of 0.12 (95% CI = 0.18-0.07, z = 4.38, p < 0.0001, 2064 eyes). The most common reported complication is IOI (n = 196, 6%). IOI was observed more in the elderly (76.3 ± 9.2 years), females (66%), and after the second injection.

CONCLUSIONS

This systematic review provides valuable insights into risk factors and effect modifiers for IOI associated with brolucizumab treatment, aiding clinicians in optimizing patient care. Future studies should prioritize prospective, long-term investigations to further elucidate the safety profile of brolucizumab and refine its use in the management of retinal and choroidal vascular diseases.

Brolucizumab versus Aflibercept in Patients with Diabetic Macular Edema: A Meta-Analysis of Randomized Controlled Trials

Purpose

To assess efficacy and safety of brolucizumab versus aflibercept in patients with diabetic macular edema (DME).

Patients and Methods

We performed a systematic review and meta-analysis with trial sequential analysis (TSA). We searched Embase, Cochrane Central Register of Controlled Trials and PubMed databases from inception to February 16, 2024 for randomized controlled trials (RCTs) comparing brolucizumab with aflibercept in patients with DME and reporting any of the visual, anatomical and safety outcomes of interest. We conducted a TSA of safety outcomes to assess the risk of statistical errors.

Results

1253 patients (1253 eyes) from 3 RCTs were included, of whom 57% received brolucizumab and 43% received aflibercept. Mean follow-up ranged from 52 to 100 weeks. Brolucizumab was non-inferior to aflibercept when comparing the mean change of best-corrected visual acuity from baseline (least squares mean difference [LSMD] 0.29; 95% confidence interval [CI] -1.37 to 1.95; p = 0.73). Change in central subfield thickness was significantly greater in the brolucizumab group compared with aflibercept (LSMD -24.5 μm; 95% CI -48.2 to -0.7 μm; p < 0.05). Incidence of adverse events of special interest (AESIs) (risk ratio [RR] 1.7; p = 0.08) and incidence of ≥1 ocular adverse events (AEs) (RR 0.95; p = 0.45) were not significantly different between groups.

Conclusion

Brolucizumab was non-inferior in functional outcomes and was superior to aflibercept in anatomical parameters. Ocular AEs and AESIs were numerically low and not statistically significant. Our findings underscore the importance of new RCTs powered to assess safety outcomes in order to suggest brolucizumab as an alternative to the treatment of DME.

Monoclonal Antibodies for the Treatment of Ocular Diseases

Monoclonal antibodies (mAbs) have revolutionized the landscape of cancer therapy, offering unprecedented specificity and diverse mechanisms to combat malignant cells. These biologic agents have emerged as a cornerstone in targeted cancer treatment, binding to specific antigens on cancer cells and exerting their therapeutic effects through various mechanisms, including inhibition of signaling pathways, antibody-dependent cellular cytotoxicity (ADCC), complement-dependent cytotoxicity (CDC), and antibody-dependent cellular phagocytosis (ADCP). The unique ability of mAbs to engage the immune system and directly interfere with cancer cell function has significantly enhanced the therapeutic armamentarium against a broad spectrum of malignancies. mAbs were initially studied in oncology; however, today, treatments have been developed for eye diseases. This review discusses the current applications of mAbs for the treatment of ocular diseases, discussing the specificity and the variety of mechanisms by which these molecules exhibit their therapeutic effects. The benefits, drawbacks, effectiveness, and risks associated with using mAbs in ophthalmology are highlighted, focusing on the most relevant ocular diseases and mAbs currently in use. Technological advances have led to in vitro production methods and recombinant engineering techniques, allowing the development of chimeric, humanized, and fully human mAbs. Nowadays, many humanized mAbs have several applications, e.g., for the treatment of age-related macular disease, diabetic retinopathy, and uveitis, while studies about new applications of mAbs, such as for SARS-CoV-2 infection, are also currently ongoing to seek more efficient and safe approaches to treat this new ocular disease.

Real-World Experience with Brolucizumab Compared to Aflibercept in Treatment-Naïve and Therapy-Refractory Patients with Diabetic Macular Edema

Background: To report on the outcome of intravitreal brolucizumab compared to aflibercept in patients with diabetic macular edema (DME). Methods: Prospective, observational, study in 35 eyes of 24 patients with a loading dose of five injections of 6 mg brolucizumab every 6 weeks (q6w, treatment-naïve eyes) or a minimum of two injections of brolucizumab q6w after the switch (recalcitrant DME eyes), followed by a treat and extend (T&E) regimen. The results were compared with 40 eyes of 31 DME patients who were treated with aflibercept. The data were obtained from the Berlin Macula Registry. The primary outcome measure was the change in best-corrected visual acuity (BCVA) at week 36. Secondary outcome measures were the change in central retinal thickness (CRT) and the treatment intervals until week 36. Results: BCVA increased significantly in treatment-naïve DME eyes treated with either brolucizumab (+0.12 logMAR, +6.4 letters, p = 0.03) or aflibercept (+0.19 logMAR, +9.5 letters, p = 0.001). In recalcitrant DME eyes, BCVA also increased significantly after switching to brolucizumab (+0.1 logMAR, +5 letters, p = 0.006) or aflibercept (+0.11 logMAR, +5.5 letters, p = 0.02). All treatment-naïve and recalcitrant DME eyes had a significant decrease in CRT after treatment with brolucizumab (p = 0.001 and p < 0.001) or aflibercept (p = 0.0002 and p = 0.03). At week 36, the mean treatment interval for brolucizumab was 11.3 weeks, while for aflibercept, it was 6.5 weeks for treatment-naïve eyes and 9.3 weeks vs. 5.3 weeks for pretreated eyes. Conclusions: In routine clinical practice, patients with treatment-naïve and recalcitrant DME showed a favorable response to brolucizumab and aflibercept therapy, with a reduced injection frequency after brolucizumab treatment.

The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When

Diabetic macular edema (DME) is a common complication of diabetes mellitus and a leading cause of visual impairment worldwide. It is defined as the diabetes-related accumulation of fluid, proteins, and lipids, with retinal thickening, within the macular area. DME affects a significant proportion of individuals with diabetes, with the prevalence increasing with disease duration and severity. It is estimated that approximately 25-30% of diabetic patients will develop DME during their lifetime. Poor glycemic control, hypertension, hyperlipidemia, diabetes duration, and genetic predisposition are recognized as risk factors for the development and progression of DME. Although the exact pathophysiology is still not completely understood, it has been demonstrated that chronic hyperglycemia triggers a cascade of biochemical processes, including increased oxidative stress, inflammation, activation of vascular endothelial growth factor (VEGF), cellular dysfunction, and apoptosis, with breakdown of the blood-retinal barriers and fluid accumulation within the macular area. Early diagnosis and appropriate management of DME are crucial for improving visual outcomes. Although the control of systemic risk factors still remains the most important strategy in DME treatment, intravitreal pharmacotherapy with anti-VEGF molecules or steroids is currently considered the first-line approach in DME patients, whereas macular laser photocoagulation and pars plana vitrectomy may be useful in selected cases. Available intravitreal steroids, including triamcinolone acetonide injections and dexamethasone and fluocinolone acetonide implants, exert their therapeutic effect by reducing inflammation, inhibiting VEGF expression, stabilizing the blood-retinal barrier and thus reducing vascular permeability. They have been demonstrated to be effective in reducing macular edema and improving visual outcomes in DME patients but are associated with a high risk of intraocular pressure elevation and cataract development, so their use requires an accurate patient selection. This manuscript aims to provide a comprehensive overview of the pathology, epidemiology, risk factors, physiopathology, clinical features, treatment mechanisms of actions, treatment options, prognosis, and ongoing clinical studies related to the treatment of DME, with particular consideration of intravitreal steroids therapy.

Innovations in Diabetic Macular Edema Management: A Comprehensive Review of Automated Quantification and Anti-vascular Endothelial Growth Factor Intervention

Diabetic macular edema (DME) poses a significant threat to the vision and quality of life of individuals with diabetes. This comprehensive review explores recent advancements in DME management, focusing on integrating automated quantification techniques and anti-vascular endothelial growth factor (anti-VEGF) interventions. The review begins with an overview of DME, emphasizing its prevalence, impact on diabetic patients, and current challenges in management. It then delves into the potential of automated quantification, leveraging machine learning and artificial intelligence to improve early detection and monitoring. Concurrently, the role of anti-VEGF therapies in addressing the underlying vascular abnormalities in DME is scrutinized. The review synthesizes vital findings, highlighting the implications for the future of DME management. Promising outcomes from recent clinical trials and case studies are discussed, providing insights into the evolving landscape of personalized medicine approaches. The conclusion underscores the transformative potential of these innovations, calling for continued research, collaboration, and integration of these advancements into clinical practice. This review aims to serve as a roadmap for researchers, clinicians, and industry stakeholders, fostering a collective effort to enhance the precision and efficacy of DME management.