Efficacy of anti-VEGF and laser photocoagulation in the treatment of visual impairment due to diabetic macular edema: a systematic review and network meta-analysis

PLoS One. 2014 Jul 16;9(7):e102309. doi: 10.1371/journal.pone.0102309. eCollection 2014.

Abstract

Objective: Compare the efficacy of ranibizumab, aflibercept, laser, and sham in the first-line treatment of diabetic macular edema (DME) to inform technology assessments such as those conducted by the UK National Institute for Health and Care Excellence (NICE).

Data sources: MEDLINE, Embase, Cochrane Library, congress abstracts, ClinicalTrials.gov registry and Novartis data on file.

Inclusion criteria: Studies reporting 6- or 12-month results of randomized controlled trials (RCTs) evaluating at least two of ranibizumab 0.5 mg pro re nata, aflibercept 2.0 mg bi-monthly, laser photocoagulation or sham. Study quality was assessed based on likelihood of bias in selection, attrition, detection and performance.

Outcome measure: Improvement in best-corrected visual acuity (BCVA) measured as the proportion of patients gaining ≥10 letters on the Early Treatment Diabetic Retinopathy Study scale. The outcome was chosen following acceptance by NICE of a Markov model with 10-letter health states in the assessment of ranibizumab for DME.

Meta-analysis: Bayesian network meta-analyses with fixed and random effects adjusted for differences in baseline BCVA or central retinal thickness.

Results: The analysis included 1,978 patients from eight RCTs. The random effects model adjusting for baseline BCVA was the best model based on total residual. The efficacy of ranibizumab was numerically, but not statistically, superior to aflibercept (odds ratio [OR] 1.59; 95% credible interval [CrI], 0.61-5.37). Ranibizumab and aflibercept were statistically superior to laser monotherapy with ORs of 5.50 (2.73-13.16) and 3.45 (1.62-6.84) respectively. The probability that ranibizumab is the most efficacious treatment was 73% compared with 14% for aflibercept, 12% for ranibizumab plus laser, and 0% for laser.

Limitations: Three of the eight RCTs included are not yet published. The models did not adjust for all potential effect modifiers.

Conclusion: Ranibizumab was non-significantly superior to aflibercept and both anti-VEGF therapies had statistically superior efficacy to laser.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Antibodies, Monoclonal, Humanized / therapeutic use*
  • Bayes Theorem
  • Diabetic Retinopathy / pathology*
  • Humans
  • Laser Coagulation / methods*
  • Macular Edema / complications*
  • Macular Edema / pathology
  • Odds Ratio
  • Randomized Controlled Trials as Topic
  • Ranibizumab
  • Receptors, Vascular Endothelial Growth Factor / therapeutic use*
  • Recombinant Fusion Proteins / therapeutic use*
  • Retina / pathology
  • Vascular Endothelial Growth Factor A / antagonists & inhibitors*
  • Vision Disorders / drug therapy*
  • Vision Disorders / etiology
  • Vision Disorders / surgery*
  • Visual Acuity / drug effects

Substances

  • Antibodies, Monoclonal, Humanized
  • Recombinant Fusion Proteins
  • Vascular Endothelial Growth Factor A
  • aflibercept
  • Receptors, Vascular Endothelial Growth Factor
  • Ranibizumab

Grants and funding

This study was funded by Novartis Pharma AG. The funder provided support in the form of salaries for authors SR, WM, FA and VB, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. Novartis Pharma AG and Genentech, Inc. reviewed the manuscript before submission. Third-party medical writing assistance, but not editorial content sufficient to meet International Committee of Medical Journal Editors (ICMJE) authorship criteria, was funded by Novartis Pharma AG.