Clinical Decision-Making when Treating Diabetic Macular Edema Patients with Dexamethasone Intravitreal Implants

Abstract

Diabetes mellitus (DM) is a metabolic disease frequently associated with comorbidities that include diabetic macular edema (DME). The current medical approach to treating DME involves intravitreal injections with either anti-vascular endothelial growth factors or steroids. However, the burden associated with intravitreal injections and DM-derived complications is high, underlining the need to find optimal treatment regimens. In this article we describe the considerations we apply when treating DME patients with dexamethasone intravitreal implants (Ozurdex®), particularly those that influence the clinical decision-making process during the follow-up period. These considerations are based both on the available medical literature and on our clinical experience following the use of these implants in this type of patient, the goal being to optimize the number of injections and the clinical outcome of this therapy. We also provide a general overview of the pathophysiology of DME, highlighting the inflammatory component as a rationale to use steroids in these patients.

<p>A Real-World Study of Dexamethasone Implant in Treatment-Naïve Patients with Diabetic Macular Edema: Efficacy and Correlation Between Inflammatory Biomarkers and Treatment Outcome</p>

“…Many authors have reported a more significant improvement of morphological biomarkers in naïve patients and particularly if compared to refractory patients treated with the DexI. 14 , 43 – 47 …”

“…Currently available treatments are aimed at reducing or resolving the edema itself in order to improve or preserve visual function in DME: they are based on the use of laser therapy and intravitreal administration of drugs, such as anti-VEGF therapies (bevacizumab, ranibizumab, aflibercept) or steroids (triamcinolone acetonide, dexamethasone, fluocinolone acetonide). 14 – 16 Unfortunately, local application does not allow effective concentrations of drug to be reached near the macula, due to the limited uptake and penetration. 17 Intravitreal injections increase ocular drug delivery, but are invasive and require frequent retreatment, with consequent limitations in their use.…”

“…20 However, pre- and post-marketing studies have shown that after the third month and long before the sixth month the pharmacological efficacy is reduced and macular edema resumes. 14 , 23 …”

Real-Life Management of Diabetic Macular Edema with Dexamethasone Intravitreal Implant: A Retrospective Analysis of Long-Term Clinical Outcomes

“…Another debated issue concerning the treatment of DME with intravitreal corticosteroids is the timing of treatment initiation and the appropriateness of current treatment standards, which generally limit corticosteroid therapy to the second-line treatment [1,23,25]. A recent study investigated patterns of recurrence following a first intravitreal injection of DEX implant in patients with DME [26].…”

Association of Body Fluid Expansion With Optical Coherence Tomography Measurements in Diabetic Retinopathy and Diabetic Macular Edema

“…5,6 Based on these considerations, intravitreal anti-VEGF agents and steroid injections have been the mainstay of treatment. 7,8 While current treatment modalities address the components of the blood-retinal barrier, edema may not resolve sometimes even after repeated injections of these agents.…”