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Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial.

Publication ,  Journal Article
Maturi, RK; Glassman, AR; Liu, D; Beck, RW; Bhavsar, AR; Bressler, NM; Jampol, LM; Melia, M; Punjabi, OS; Salehi-Had, H; Sun, JK ...
Published in: JAMA Ophthalmol
January 1, 2018

IMPORTANCE: Some eyes have persistent diabetic macular edema (DME) following anti-vascular endothelial growth factor (anti-VEGF) therapy for DME. Subsequently adding intravitreous corticosteroids to the treatment regimen might result in better outcomes than continued anti-VEGF therapy alone. OBJECTIVE: To compare continued intravitreous ranibizumab alone with ranibizumab plus intravitreous dexamethasone implant in eyes with persistent DME. DESIGN, SETTING, AND PARTICIPANTS: Phase 2 multicenter randomized clinical trial conducted at 40 US sites in 129 eyes from 116 adults with diabetes between February 2014 and December 2016. Eyes had persistent DME, with visual acuity of 20/32 to 20/320 after at least 3 anti-VEGF injections before a run-in phase, which included an additional 3 monthly 0.3-mg ranibizumab injections. Data analysis was according to intent to treat. INTERVENTIONS: Following the run-in phase, study eyes that had persistent DME and were otherwise eligible were randomly assigned to receive 700 μg of dexamethasone (combination group, 65 eyes) or sham treatment (ranibizumab group, 64 eyes) in addition to continued 0.3-mg ranibizumab in both treatment arms as often as every 4 weeks based on a structured re-treatment protocol. MAIN OUTCOMES AND MEASURES: The primary outcome was change in mean visual acuity letter score at 24 weeks as measured by the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS). The principal secondary outcome was change in mean central subfield thickness as measured with the use of optical coherence tomography. RESULTS: Of the 116 randomized patients, median age was 65 years (interquartile range [IQR], 58-71 years); 50.9% were female and 60.3% were white. Mean (SD) improvement in visual acuity from randomization was 2.7 (9.8) letters in the combination group and 3.0 (7.1) letters in the ranibizumab group, with the adjusted treatment group difference (combination minus ranibizumab) of -0.5 letters (95% CI, -3.6 to 2.5; 2-sided P = .73). Mean (SD) change in central subfield thickness in the combination group was -110 (86) μm compared with -62 (97) μm for the ranibizumab group (adjusted difference, -52; 95% CI, -82 to -22; 2-sided P < .001). Nineteen eyes (29%) in the combination group experienced increased intraocular pressure or initiated treatment with antihypertensive eyedrops compared with 0 in the ranibizumab group (2-sided P < .001). CONCLUSIONS AND RELEVANCE: Although its use is more likely to reduce retinal thickness and increase intraocular pressure, the addition of intravitreous dexamethasone to continued ranibizumab therapy does not improve visual acuity at 24 weeks more than continued ranibizumab therapy alone among eyes with persistent DME following anti-VEGF therapy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01945866.

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Published In

JAMA Ophthalmol

DOI

EISSN

2168-6173

Publication Date

January 1, 2018

Volume

136

Issue

1

Start / End Page

29 / 38

Location

United States

Related Subject Headings

  • Visual Acuity
  • Vascular Endothelial Growth Factor A
  • Tomography, Optical Coherence
  • Retrospective Studies
  • Ranibizumab
  • Middle Aged
  • Male
  • Macular Edema
  • Macula Lutea
  • Intravitreal Injections
 

Citation

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Maturi, R. K., Glassman, A. R., Liu, D., Beck, R. W., Bhavsar, A. R., Bressler, N. M., … Diabetic Retinopathy Clinical Research Network, . (2018). Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial. JAMA Ophthalmol, 136(1), 29–38. https://doi.org/10.1001/jamaophthalmol.2017.4914
Maturi, Raj K., Adam R. Glassman, Danni Liu, Roy W. Beck, Abdhish R. Bhavsar, Neil M. Bressler, Lee M. Jampol, et al. “Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial.JAMA Ophthalmol 136, no. 1 (January 1, 2018): 29–38. https://doi.org/10.1001/jamaophthalmol.2017.4914.
Maturi RK, Glassman AR, Liu D, Beck RW, Bhavsar AR, Bressler NM, et al. Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial. JAMA Ophthalmol. 2018 Jan 1;136(1):29–38.
Maturi, Raj K., et al. “Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial.JAMA Ophthalmol, vol. 136, no. 1, Jan. 2018, pp. 29–38. Pubmed, doi:10.1001/jamaophthalmol.2017.4914.
Maturi RK, Glassman AR, Liu D, Beck RW, Bhavsar AR, Bressler NM, Jampol LM, Melia M, Punjabi OS, Salehi-Had H, Sun JK, Diabetic Retinopathy Clinical Research Network. Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial. JAMA Ophthalmol. 2018 Jan 1;136(1):29–38.

Published In

JAMA Ophthalmol

DOI

EISSN

2168-6173

Publication Date

January 1, 2018

Volume

136

Issue

1

Start / End Page

29 / 38

Location

United States

Related Subject Headings

  • Visual Acuity
  • Vascular Endothelial Growth Factor A
  • Tomography, Optical Coherence
  • Retrospective Studies
  • Ranibizumab
  • Middle Aged
  • Male
  • Macular Edema
  • Macula Lutea
  • Intravitreal Injections