Diabetic Macular Oedema
Watch Time: 4 mins

Jennifer Lim, ARVO 2023: Current therapeutic options for diabetic macular edema

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Published Online: May 24th 2023

Diabetic macular edema is characterised by exudative fluid accumulation in the macula and is the most common form of sight-threatening retinopathy in people with diabetes affecting one in 15 people with diabetes. Intraocular pharmacotherapy with anti-VEGF agents is the standard of care. It was a pleasure to speak with Dr Jennifer Lim (University of Illinois Chicago, IL, USA) around the current treatment paradigm for DME and their limitations.

The presentation entitled ‘Durable vision gains and greater fluid control with extended faricimab dosing vs aflibercept in patients with DME’ was presented at the Association for Research in Vision and Ophthalmology Annual Meeting, May 05-09, 2023

Questions:

  1. Could you give us a brief overview of the treatment paradigm for diabetic macular edema (DME)? (0:23)
  2. What are the limitations of current therapeutic options for DME? (3:35)

Disclosures: Jennifer Lim is a consultant for Genentech, Regeneron, Opthea, Cognition, Viridian, Santen, Quark, Luxa, Aura, Alimera, Unity & Eyenuk and discloses grant/research support from Genentech, Regeneron, Aldeyra, NGM, , Adverum, Regenexbio, Janssen & Spring Vision.

Support: Interview and filming supported by Touch Medical Media Ltd. Interview conducted by Shanice Allen.

Filmed in coverage of the virtual ARVO 2023.

Click here for more content on DME 

Transcript

I’m Jennifer Lim from the University of Illinois, where I serve as the Marion Schenck Chair in ophthalmology and Vice Chair of the department, as well as Director of the retina service. I’m also a UIC distinguished Professor of Ophthalmology, and it’s my pleasure to be here today.

Could you give us a brief overview of the treatment paradigm for diabetic macular edema (DME)?

Currently, the treatment paradigm for diabetic macular edema revolves around the use of anti-VEGF therapy. However, there’s still a role for laser treatment for diabetic macular edema when the edema is not involving the fovea centre. Specifically, when they’re hard exits, in an extra foveal location where you can safely treat the microaneurysms and prevent the clinically significant diabetic macular edema from progressing. Otherwise, when the edema is involving the fovea centre, we typically use anti-VEGF therapies. There are several approved treatments which include ranibizumab, aflibercept, brolucizumab and most recently, faricimab. There is also off label anti-VEGF therapy, which involves the use of bevacizumab. Protocol T showed us that for patients with visual acuity of 20/50 or worse that aflibercept was better than ranibizumab or bevacizumab. This held true for year one and year two. For patients with good visual acuity of 20/40 or better it really didn’t matter which anti-VEGF you used, you got good results with all three. Recently faricimab has been compared to aflibercept in the YOSEMITE and RHINE studies. And in these studies, it’s been shown that faricimab is non-inferior to aflibercept with regards to best corrected visual acuity. Interestingly, however, when you looked at the matched dose phase where patients were given the same number of anti-VEGF treatments, the faricimab treated eyes did better than the aflibercept treated eyes, and this remained true for the duration of year one. The total amount of visual acuity in terms of area under the curve is also better for the faricimab treated eyes and for the aflibercept treated eyes. Moreover, with the use of this new therapy, faricimab, we’re able to get more durable treatments. In fact, about 60% of patients can be treated Q16 weeks after four loading doses and 70 plus percent can be treated Q12 weeks after these four loading doses. This was found in the personalized treatment arm, which is essentially a treat and extend arm in the YOSEMITE and RHINE trials. There’s also another class of drugs known as steroids, and we do use steroids more of a second line of therapy in patients who in the past haven’t responded to anti-VEGFs. It’s also been shown in studies that the longer the duration of diabetic macular edema is, the higher the level of cytokines that are not VEGF driven. That is, these are more likely to respond to steroids. These are the eyes that have done very well with steroid therapy. But again, it’s more of a second line treatment. In the future, they’re going to be extended drug delivery platforms such as the PDS platform, which recently is undergoing phase III trials and has positive results. They’ll also probably be some gene therapies.

What are the limitations of current therapeutic options for DME?

The limitations of the current treatment options for diabetic macular edema include the fact that you must reinject these patients. So, it would be nice if we really had a long-term treatment, if you will, maybe a one and done that would be ideal. Maybe that will be achievable with genetics, but I think we can get closer to that goal when we use the port delivery system for extended drug delivery.

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