{"id":1119,"date":"2014-12-26T06:28:28","date_gmt":"2014-12-26T06:28:28","guid":{"rendered":"https:\/\/touchophthalmology.com\/2014\/12\/26\/aflibercept-setting-its-sights-on-diabetic-macular-oedema\/"},"modified":"2014-12-26T06:28:28","modified_gmt":"2014-12-26T06:28:28","slug":"aflibercept-setting-its-sights-on-diabetic-macular-oedema","status":"publish","type":"post","link":"https:\/\/touchophthalmology.com\/diabetic-macular\/journal-articles\/aflibercept-setting-its-sights-on-diabetic-macular-oedema\/","title":{"rendered":"Aflibercept \u2013 Setting its Sights on Diabetic Macular Oedema"},"content":{"rendered":"

Diabetic macular oedema (DMO) is an increasingly common visionthreatening disease that results from retinal vascular dysfunction and low-grade inflammation, developing into diabetic retinopathy (DR) and then to DMO over 10 or more years following the onset of diabetes.1<\/sup> Areas of retinal tissue lose capillary vasculature and become ischaemic, stimulating secretion of vascular endothelial growth factor (VEGF) and other cytokines.2\u20134<\/sup> Changes in paracellular and transcellular transport across the capillary endothelium and altered hydrostatic and osmotic pressure gradients result in fluid movement into retinal tissues, leading to consequent oedema and retinal damage. <\/p>\n

Effective prevention and management of DR and DMO require intensive treatment of diabetes in terms of controlling glycaemia, blood pressure and lipid levels.5<\/sup> Hyperglycaemia drives vascular dysfunction and DR, and it is important that patients understand the critical importance of controlling blood glucose levels. Treatment of DMO during the past decades has been almost entirely limited to laser photocoagulation but, recently, anti-VEGF agents have emerged as first-line agents in a subset of patients.6<\/sup> Among these, two medications have been approved for this indication: aflibercept (EYLEA\u00ae ▼<\/font><\/sub> ) and ranibizumab, (Lucentis\u00ae) and in large clinical trials, these have shown greater efficacy in central DMO than laser treatment or placebo, respectively.7\u20139<\/sup> <\/p>\n

This article reports the proceedings of a symposium that reviewed the pathophysiology of DMO and the possible approaches to its management, particularly laser, anti-VEGF agents and corticosteroids. It also discussed the results of two large ongoing phase III clinical trials that are evaluating treatment of a large population of DMO patients with the anti-VEGF agent, aflibercept. These novel trials involve two regimens of aflibercept, in a head-to-head comparison with laser therapy. They are providing much-needed data on the comparativeefficacy of these treatments in DMO in terms of visual acuity (VA) and retinal pathology and are also providing useful data on their relative safety and tolerability. <\/p>\n

Note from Publisher:<\/b> This article was temporarily removed from the website for a short period of time. This was not related to the content of the article in any way, but was a technical requirement following a recent update to the prescribing information for aflibercept. The online article carried a version of the prescribing information which was no longer valid, owing to addition of a new licensed indication for aflibercept. <\/i>

The Science Behind the Disease <\/b>
Professor Reinier Schlingemann
University of Amsterdam, The Netherlands
<\/center> <\/p>\n

DMO is an increasing threat to vision worldwide and is the leading cause of blindness in young adults in developed countries.10<\/sup> This rising prevalence is driven by the burgeoning numbers of people with type I and especially, type II diabetes. In Europe in 2013 it was estimated that 56 million people had diabetes, and this is expected to rise to 69 million by 2035 (22 % increase).11<\/sup> Globally, 382 million people were estimated to have diabetes in 2013 with a projected rise to 592 million by 2035 (55 % increase).11<\/sup> Among people with diabetes, approximately one-third have DR and approximately one-third of those have DMO. Therefore, 6.2 million people (11 % of people with diabetes) in Europe currently have DMO and 0.6\u20131.7 million have clinically significant MO.11,12<\/sup> Given this burden, effective treatments for DMO are a critical need worldwide. <\/p>\n

Main risk factors for the development of DR and DMO include: poorly controlled diabetes, chronic hyperglycaemia, dyslipidaemia, hypertension, high body mass index, low levels of physical activity and insulin resistance.13,14<\/sup> Less strongly associated potential risk factors include: sleep apnoea; nonalcoholic fatty liver disease; levels of serum prolactin, serum adiponectin and serum homocysteine; age; renal disease; and pregnancy.13,15<\/sup> <\/p>\n

The effects of diabetes on the retina are slow to manifest: signs of DR take approximately 10 years to appear after disease onset. The criteria for clinically significant DMO that will benefit from laser therapy were defined by the Early Treatment Diabetic Retinopathy Study Group during the 1980s.16<\/sup> These include thickening of the retina (\u2264500 \u03bcm of the foveal centre), possibly with hard exudates and changes in the vasculature. Early damage is seen to both vascular and neural cells. Within retinal capillaries, pericytes and endothelial cells are lost leading to the appearance of \u2018ghost\u2019 capillaries. The relationship between neuropathy and vasculopathy in DMO, however, is unclear. <\/p>\n

In DMO, there appear to be two pathological processes: a primary one causing vascular loss in small areas and a secondary one causing these areas to enlarge. The areas of vascular loss become ischaemic, stimulating growth factor secretion, which attracts inflammatory cells, and microaneurysms may occur. This creates a vicious circle of increasing vascular activation and inflammation in which areas of capillary nonperfusion tend to enlarge to sight-threatening DR (see Figure 1<\/i>).2\u20134<\/sup> <\/p>\n

Possibly the most important factor stimulated in DMO is vascular endothelial growth factor-A (VEGF-A). VEGF is secreted by all hypoxic cells and has vital roles in maintaining normal tissue function and in disease. These functions include: cell survival, permeability, angiogenesis, inflammation, mitogenicity, chemotaxis and neuroprotection.17,18<\/sup> VEGF causes blood vessels to grow but also to leak and is consequently a target for several treatments of DMO.<\/p>\n

Evidence that VEGF is involved is DMO first came from a South American tudy in which 88 patients with the disease were given intravitreal treatment with at least one injection of the anti-VEGF agent, bevacizumab (1.25 mg or 2.5 mg).19<\/sup> In just 1 month, both VA in terms of best corrected VA (BCVA) and retinal thickness were significantly improved and this was sustained during 6 months of follow-up (p<0.0001 for both parameters). Anti-VEGF agents are now widely used to successfully treat DMO in the clinic as discussed in the next section.20<\/sup><\/p>\n

Further evidence of the role of inflammation in DMO has come from analysis of vitreous fluids from patients with DMO. Two studies conducted in Japan (n=92 and n=53) revealed significantly raised inflammatory cytokines in patients with DMO versus patients without diabetes (p<0.05 for all).21,22<\/sup> In particular, levels of interleukin-6 (IL-6) IL-8, monocyte chemoattractant protein-1 (MCP-1) and intracellular adhesion molecule (ICAM-1) were elevated indicating an inflammatory state. In addition, corticosteroids such as triamcinolone acetonide have demonstrated efficacy in the treatment of DMO, reducing retinal thickness and improving VA.23,24<\/sup> Corticosteroids have multifactorial actions against various inflammatory cytokines but they also have a direct effect in restoring the blood\u2013retina barrier (BRB) in retinal endothelium, independently of inflammation. Their efficacy in DMO therefore not necessarily supports inflammation as a driver of DMO, a notion widely advocated.<\/p>\n

The accumulation of fluids in retinal tissues in DMO follows the wellestablished principles of the Starling equation.25,26<\/sup> This states that the flow of liquids between capillaries and surrounding tissues is the result of both hydrostatic pressure and osmotic pressure gradients resulting from vascular and tissue solute concentrations. In normal tissue, these forces are balanced and there is no net change in fluid volume but in DMO, they become unbalanced leading to disrupted fluid transport in and out of the tissue and fluid accumulation. The changes in hydrostatic and osmotic pressure and inflammation in DMO are mediated by multiple cellular and protein factors leading to localised breakdown of the BRB and consequent leakage into retinal tissues.27 <\/sup>The passage of plasma solutes out of retinal capillaries occurs through either a paracellular pathway via tight junctions between epithelial cells or via a transcellular pathway through the cells involving caveolae. Studies on rat retinal cells exposed to VEGF showed a transient down-regulation of some proteins such as occludin and claudin-5 that control tight junctions.28<\/sup> In addition, long-term upregulation of the vesicular transport-related genes encoding caveolin-1 and plasmalemma vesicle protein-1 (PV-1) was observed. This indicates that in DMO there is a transient induction of paracellular transport but a more important sustained activation of transcellular transport that results in BRB breakdown. These findings were supported by a study of monkey eyes in which exposure to VEGF resulted in intense retinal microvascular leakage.29<\/sup> Electron microscopy of leaky blood vessels in these tissues showed significantly increased pinocytotic vesicles (caveolae) that had moved to a luminal position indicating greatly increased transcellular transport. This increased transcellular transport of fluid in DMO is likely to decrease osmotic pressure in tissues, and as vascular hydrostatic pressure is also increased in DR, these forces result in net fluid movement to the tissues and consequent oedema. <\/p>\n

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