'Step therapy' an effective strategy for diabetic eye disease

Clinical trial results from the DRCR Retina Network suggest that a specific step strategy, in which patients with diabetic macular edema start with a less expensive medicine and switch to a more expensive medicine if vision does not improve sufficiently, gives results similar to starting off with the higher-priced drug.

The main complication of diabetic macular edema, fluid build-up in the retina that causes vision loss, is commonly treated with anti-vascular endothelial growth factor (VEGF) drugs.

Results of the trial, which examined a stepped regimen of anti-VEGF drugs Avastin (bevacizumab) and Eylea (aflibercept), were published today in the New England Journal of Medicine.

The study enrolled 270 participants with diabetic macular edema, some of whom received treatments in both eyes. At enrollment, all had best-corrected visual acuity between 20/50 and 20/320. Half the study eyes were assigned to Eylea from the start, and half were assigned to start with Avastin.

For participants who needed treatment in both eyes, each eye started treatment with a different drug. Participants received either Avastin or Eylea injections every four weeks for 24 weeks. If eyes assigned Avastin failed to reach the preset improvement benchmarks starting at 12 weeks, the eye was switched to Eylea.

After 24 weeks, physicians could taper down the frequency of injections as appropriate to maintain visual acuity. The study collected information about participants' retinal structure and visual acuity for two years.

After two years, eyes in both groups had similar visual acuity outcomes, improving on average approximately three lines on an eye chart, compared to the trial's start. In the Avastin group, 70% of eyes switched to Eylea during the study.

Researchers concluded though most participants on Avastin eventually switched to Eylea, they still had improvement during those initial weeks, even if they didn't hit their pre-set benchmarks. There are large cost disparities between these drugs, so differences in treatment strategies may have substantial cost implications.

Reference: "A type of 'step therapy' is an effective strategy for diabetic eye disease"; NIH/NATIONAL EYE INSTITUTE; JOURNAL- New England Journal of Medicine.