Translating evidence into practice: recommendations by a UK expert panel on the use of aflibercept in diabetic macular oedema

Ultrastructural imaging biomarkers in diabetic macular edema: A major review

Diabetic macular edema (DME) is a vision-threatening complication of diabetic retinopathy and causes significant morbidity in patients. Anti-vascular endothelial growth factor (VEGF) agents are the mainstay of treatment for DME, with steroid implants being used for the treatment of anti-VEGF resistant eyes. Over the years, several classification systems have been devised to describe the patterns of DME using optical coherence tomography (OCT). With the advent of effective treatments, it has become imperative that imaging cues are not merely used for classifying the disease but also as biomarkers for prognostication of disease activity and treatment response. In this aspect, newer imaging findings such as hyperreflective dots, photoreceptor integrity, and disorganization of retinal inner layers have been characterized in detail by several authors. Macular perfusion analysis using OCT angiography is the latest in the armamentarium for imaging DME. In this narrative review, we have summarized all relevant literature related to the ultrastructural imaging-based biomarkers of DME and their correlation to treatment.

Cost-Effectiveness of Faricimab in the Treatment of Diabetic Macular Oedema (DMO): A UK Analysis

AIM

The aim of this work was to evaluate the cost-effectiveness of faricimab against relevant therapeutic alternatives used in clinical practice for the treatment of diabetic macular oedema (DMO) in the UK.

METHODS

A state-transition (Markov) model, with health states based on visual acuity scores and treatment pathways, was developed to conduct cost-utility analysis of faricimab treat and extend (T&E) regimen versus ranibizumab pro re nata (PRN) and aflibercept PRN over a time horizon of 25 years. Comparison against bevacizumab PRN was considered in scenario analysis. Effectiveness data for faricimab was sourced from the pivotal YOSEMITE and RHINE double-blind randomised controlled trials, and from a network meta-analysis for comparators. Costs and (dis)utilities were taken from nationally published sources or literature. The base case included indirect costs (productivity gains, informal care) given the wider impacts of DMO on society. Sensitivity analyses were conducted.

RESULTS

In the base case, faricimab T&E dominated ranibizumab PRN and aflibercept PRN, being more effective and resulting in cost savings (between 0.16 and 0.36 mean QALYs gained, and £5483-9655 mean cost savings). In scenario analysis, faricimab was more effective but costlier compared with bevacizumab, with an incremental cost-effectiveness ratio (ICER) of £8898 per QALY gained. Considering only healthcare payer costs, the ICER of faricimab compared with ranibizumab PRN was £7991 per QALY gained and faricimab dominated aflibercept PRN.

CONCLUSIONS

Faricimab T&E has the potential to reduce the burden of vision loss on society, giving people living with DMO greater independence and contributing to increased healthcare system capacity. At a threshold of £20,000, faricimab T&E is cost-effective compared with relevant comparators, and potentially cost saving.

Intravitreal antivascular endothelial growth factor in diabetic macular oedema: scoping review of clinical practice guidelines recommendations

BACKGROUND

Diabetic macular oedema (DME) is a worldwide major cause of low vision and blindness. Intravitreal antivascular endothelial growth factor (anti-VEGF) constitutes an effective treatment. Clinical practice guidelines (CPGs) are synthesis documents that seek to improve patient care.

OBJECTIVES

To identify CPGs that make anti-VEGF recommendations for DME and to assess their reporting quality and their considerations when making recommendations.

ELIGIBILITY CRITERIA

CPGs published between December 2009 and December 2019 that make explicit anti-VEGF recommendations in DME.

SOURCES OF EVIDENCE

Sensitive search strategy in Embase, Google Scholar and hand-searching on 165 websites.

METHODS

We extracted information from each CPG with a previously piloted sheet. Two independent authors applied theAppraisal of Guidelines, Research and Evaluation tool (AGREE-II) assessment for each CPG.

RESULTS

The 21 included CPGs recommend anti-VEGF for DME, but there is a wide variation among the clinical aspects included, such as location of DME, visual acuity required, therapeutical alternatives or discontinuation. Most have a poor quality of reporting based on the AGREE-II tool assessment, especially those developed by ophthalmological societies, those that have an exclusive content about DME, and those where most of their authors disclose conflict of interest (COI) with pharmaceutical industry or where their authors did not report COIs. Pharmaceutical-sponsored CPGs did not use systematic reviews (SRs) to support their recommendations. Very few recommendations consider patient values and preferences, equity, acceptability and feasibility of the intervention.

CONCLUSIONS

Most of the CPGs that made recommendations of anti-VEGF for DME have poor quality of reporting, do not use SRs and do not consider patients' values and preferences.

Expert Panel Consensus for Addressing Anti-VEGF Treatment Challenges of Diabetic Macular Edema in Spain

Purpose

The treatment of diabetic macular edema (DME) has evolved rapidly in the past decade, highlighting the need to address the challenges of routine clinical practice decision-making through expert consensus agreements.

Methods

After a literature review and discussion of real-world experience on DME management, a group of ten retina specialists agreed on a consensus of recommendations for the most appropriate management of DME patients using vascular endothelial growth factor inhibitors (anti-VEGF) in Spain.

Results

The panel recommended early treatment initiation in DME patients with worse baseline visual acuity (VA) to maintain or improve outcome. For patients with good VA, an observation strategy was recommended, considering the presence of diabetic retinopathy, optical coherence tomography biomarkers, and impact on patient's quality of life. Based on the available evidence and clinical experience, the panel recommended the use of anti-VEGF intensive loading doses with the objective of achieving anatomic and visual responses as soon as possible, followed by a Treat & Extend (T&E) strategy to maintain VA improvement. Aflibercept was recommended for patients with a baseline decimal VA <0.5, followed by a T&E strategy, including the possibility to extend frequency of injections up to 16 weeks.

Conclusion

An expert panel proposes a consensus for the management of DME in Spain. Early treatment initiation with anti-VEGF in DME patients is recommended to maintain or improve VA; aflibercept is recommended for patients with a poor baseline VA.

Aflibercept in clinical practice; visual acuity, injection numbers and adherence to treatment, for diabetic macular oedema in 21 UK hospitals over 3 years

INTRODUCTION

Randomised controlled trials provide evidence that a treatment works. Real world evidence is required to assess if proven treatments are effective in practice.

METHOD

Retrospective data collection on patients given aflibercept for diabetic macular oedema over 3 years from 21 UK hospitals: visual acuity (VA); Index of multiple deprivation score (IMD); injection numbers; protocols used, compared as a cohort and between sites.

RESULTS

Complete data: 1742 patients (from 2196 eligible) at 1 year, 860 (from 1270) at 2, 305 (from 506) at 3 years. The median VA improved from 65 to 71, 70, 70 (ETDRS letters) at 1, 2 and 3 years with 6, 9 and 12 injections, respectively. Loss to follow-up: 10% 1 year, 28.8% at 3. Centres varied: baseline: mean age 61-71 years (p < 0.0001); mean IMD score 15-37 (p < 0.0001); mean VA 49-68 (p < 0.0001). Only four centres provided a loading course of five injections at monthly intervals and one 6. This did not alter VA outcome at 1 year. Higher IMD was associated with younger age (p = 0.0023) and worse VA at baseline (p < 0.0001) not total number of injections or change in VA. Lower starting VA, higher IMD and older age were associated with lower adherence (p = 0.0010).

CONCLUSIONS

The data showed significant variation between treatment centres for starting age, VA and IMD which influenced adherence and chances of good VA. Once treatment was started IMD did not alter likelihood of improvement. Loading dose intensity did not alter outcome at one year.

A Review of Aflibercept Treatment for Macular Disease

Aflibercept is a fully human recombinant fusion protein that includes the second domain of human VEGF receptor 1 and the third domain of human VEGF receptor 2. Despite the important role played by VEGF in maintaining the physiological condition of the retina under normal conditions, dysregulation of VEGF can result in pathological alterations including hyperpermeability of the retinal capillaries and migration and proliferation of retinal endothelial cells. Over the years, a number of studies have evaluated the use of intravitreal aflibercept in different retinal diseases. In this review, we aim to summarize the scientific evidence and recommendations for use of intravitreal aflibercept in neovascular age-related macular degeneration, diabetic macular oedema, macular oedema associated with retinal vein occlusion, and myopic choroidal neovascularization.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

[Neurodegenerative biomarkers of the response to diabetic macular edema treatment]

There are currently no reliable biomarkers for predicting the response to treatment of diabetic macula edema (DME).

PURPOSE

To asses the predictive role of neurodegenerative biomarker of the response to anti-VEGF therapy of DME.

MATERIAL AND METHODS

Examination and treatment was carried out on 14 patients (20 eyes) with DME. The eyes were divided into 2 groups by the type of diabetes: 6 eyes with type 1 diabetes and 14 eyes with type 2 diabetes. The duration of diabetes was 16.5±7.9 years, the level of glycated hemoglobin was 8.4±2%. A number of indicators were evaluated using optical coherence tomography (OCT) in order to determine the neurodegenerative biomarkers of the response to anti-VEGF treatment. All patients underwent standard loading course of Aflibercept (5 intravitreal injections).

RESULTS

Significant improvement in Best Corrected Visual Acuity (BCVA) and decrease of central retinal thickness (CRT) was seen after the treatment course. Data analysis revealed a correlation between functional outcomes of the treatment, and the following pathological changes in the retina: thickness of retinal nerve fiber layer (RNFL), thickness of the complex of ganglion cell and inner plexiform layers in the macular region (GCL+), thickness of the RNFL and GCL+ complex (GCL++) in the macular region, ΔCRT, as well as BCVA, patient age, and type of diabetes. Anatomical outcomes correlate with the stage of diabetic retinopathy, RNFL, GCL+, GCL++, violation of the integrity of the ellipsoid zone before treatment.

CONCLUSION

The course of intravitreal administration of the Aflibercept drug has been established to be an effective method of treating patients with clinically significant DME. Neurodegenerative biomarkers of the response to the anti-VEGF drug therapy have been determined: thickness of the peripapillary RNFL, GCL+ and GCL ++, as well as integrity of the ellipsoid zone.