Intravitreal bevacizumab versus intravitreal triamcinolone for diabetic macular edema–Systematic review, meta-analysis and meta-regression

Abstract

Background The most frequent cause of vision loss from diabetic retinopathy is diabetic macular edema (DME). Earlier clinical trials tried to examine the role of intravitreal triamcinolone (IVT) and intravitreal bevacizumab (IVB) in DME; they either qualified IVT over IVB or IVB over IVT or did not exhibit a significant difference. Objective This paper aims to compare the efficacy and safety of IVB versus IVT alone or combined IVB+IVT in the treatment of DME. Methods We systematically searched PubMed, CENTRAL, Scopus, Embase, Science Direct, OVID, and Web of Science for randomized controlled trials of IVB versus IVT alone or combined IVB+IVT and IVT versus the combined IVB+IVT in DME patients. Results A total of 1243 eyes of 17 trials were included in our meta-analysis and regression. Repeated injections of IVB were superior at improving VA comparing with those of IVT at 12, 24, 48-weeks, and IVB+IVT at 12, 24, 48-weeks. Single injections were comparable across the three arms regarding BCVA improvement. CMT reductions were also comparable across the three arms. Meanwhile, the overall safety regarding intraocular pressure and intraocular hypertension significantly favored the IVB group. Improvement in VA was best modified with CMT reduction from 480 um to 320um. This association was significant at 12-weeks in the three arms and persisted till 24-weeks and 48-weeks exclusively in the IVB group. Conclusions and relevance Our analysis reveals that repeated successive injections associate with better BCVA compared to single injection. Current evidence affirms that IVB is superior to IVT and IVB+IVT at improving BCVA, comparable at reducing CMT, and presents a better safety profile in the treatment of DME.

The role of anti-vascular endothelial growth factor in diabetic macular edema

“…Hunt et al demonstrated a fixed protocol of 12-month intravitreal bevacizumab injections consisting of five consequent injections of 1.25 mg/0.05 mL followed by four injections every other month and showed a significant improvement in BCVA and reduction in central macular thickness 34 . Multiple injections of bevacizumab also had a (statistically significant) greater improvement in BCVA compared to intravitreal triamcinolone and a combination of intravitreal triamcinolone with bevacizumab 5 . Bevacizumab is more expensive than ranibizumab or aflibercept.…”

“…Analysis done by Bhandari et al presented that patients, on average, received four to nine injections over the year, which resulted in patients gaining better VA (7-9 letters) 33 . Multiple injections were given, with a 4-6-week interval 5 . Hunt et al demonstrated a fixed protocol of 12-month intravitreal bevacizumab injections consisting of five consequent injections of 1.25 mg/0.05 mL followed by four injections every other month and showed a significant improvement in BCVA and reduction in central macular thickness 34 .…”

“…Visual impairment could hinder daily tasks and affect the quality of life, stressing the importance of therapy in DME. Anti-vascular endothelial growth factor (anti-VEGF) has been rising as the new gold standard 5 for effectively treating DME. Many clinical trials have proven that intravitreal anti-VEGF injection is important in arresting the development of DME.…”

Triamcinolone as an adjunct to the combination of anti-VEGF for the management of diabetic macular edema

“…It is reported in a fiveyear extension of the same study that the increasement of IOP incidence was 79%, the initiation of IOP-lowering medication was 56%, 3% of cases called for glaucoma surgery, and the occurrence of cata racts was 71% [26] . In Abdel-Maboud et al's [27] Meta-analysis, at 36 and 48wk follow-up, the intravitreal bevacizumab (IVB) group was lower IOP than the IVTA group with a statistically significance. In addition, when compared with IVTA or IVB+IVTA, the group who received IVB showed a significant lower intraocular hypertension (IOH) incidence.…”

Management of retinopathy of prematurity: an updated review

“…57 Being the first suggested anti-VEGF for ROP, Bevacizumab is a recombinant monoclonal antibody used to treat several cancers such as glioblastoma, renal, colon, and lung carcinomas when given systematically; and macular degeneration or retinopathy, when given intravitreally. 58,59 Other Anti-VEGF agents include intravitreal ranibizumab (IVR) and intravitreal aflibercept (IVA). 60 After the findings of the Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity (BEAT-ROP) study, anti-VEGF agents gained more credentials in treating ROP.…”