Aflibercept for Diabetic Macular Edema

Overseen By Andrew Yates, B.A.

Age: 18+

Sex: Any

Trial Phase: Phase 4

Sponsor: Retina Consultants of Orange County

Must be taking: Anti-VEGF therapy

Disqualifiers: Glaucoma, Uveitis, Corneal issues, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Prior Safety Data This treatment has passed at least one previous human trial

Breakthrough Therapy This drug has been fast-tracked for approval by the FDA given its high promise

Approved in 2 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 3

Duration: 12 months

15 Participants Needed

Trial Summary

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.

What data supports the effectiveness of the drug Aflibercept for treating diabetic macular edema?

Research shows that Aflibercept significantly improves vision in patients with diabetic macular edema compared to other treatments like laser therapy and similar drugs. Studies also indicate that patients experience better quality of life related to their vision after using Aflibercept. ^{1 2 3 4 5}

Is Aflibercept safe for use in humans?

Aflibercept has safety measures in place in Europe to educate doctors and patients on its safe use, indicating that its safety is monitored and managed. ^{6 7 8 9 10}

How is the drug Aflibercept unique for treating diabetic macular edema?

Aflibercept is unique because it acts as a decoy receptor for multiple growth factors, including VEGF-A, VEGF-B, and placental growth factor, which helps reduce swelling in the eye. It has a higher binding affinity compared to similar drugs like ranibizumab and bevacizumab, potentially leading to better improvements in visual acuity for patients with diabetic macular edema. ^{1 3 5 11 12}

What is the purpose of this trial?

Patients with diabetic macular edema (DME) sometimes must undergo vitrectomy surgery (PPV) for diabetic and non-diabetic related issues. Patients may have improved DME with anti-VEGF therapy and ranibizumab has been found to reduce central macular thickness (CMT) with anti-VEGF therapy following vitrectomy. Those patients still require intravitreal injections but the pharmacokinetics of a vitrectomized eye are different than those eyes that have not undergone vitrectomy. The clearance of protein molecules is quicker in vitrectomized eyes so these patients may be more refractory to standard of care anti-VEGF therapy. In rabbit models, the half-life of both bevacizumab and ranibizumab were reduced by a factor 1.8 and 1.3, respectively, after pars plana vitrectomy. In a study examining intravitreal triamcinolone acetonide in human eyes, the half-life was found to be 18.6 days in non-vitrectomized eyes and 3.2 days in vitrectomized eyes, but there was considerable intrasubject variation. Patients with various disease states, including neovascular age-related macular degeneration (nAMD) have been managed with monthly anti-VEGF therapy successfully after vitrectomy surgery. Another study performed by the DRCR net showed that patients with DME treated with anti-VEGF are not affected in the long term if they had had a previous vitrectomy. High dose aflibercept may improve anatomic and visual outcomes in this patient population. Also, high dose aflibercept may allow for longer treatment intervals in these vitrectomized eyes.

Research Team

Sean Adrean, M.D.

Principal Investigator

Retina Consultants of Orange County

Eligibility Criteria

This trial is for patients with diabetic macular edema who have had a vitrectomy surgery. It's designed to see if high doses of Aflibercept can better improve their condition, considering the faster clearance of medication from eyes that have undergone this procedure.

Inclusion Criteria

I am 18 or older with type 1 or type 2 diabetes.

Willing and able to comply with clinic visits and study-related procedures

Provide informed consent signed by study patient or legally acceptable representative

Exclusion Criteria

I have swelling in the retina not caused by diabetes.

Prior intravitreal investigational agents in the study eye (gene therapy, etc.) at any time

IOP ≥28 mmHg in the study eye

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

1 visit (in-person)

Treatment

Patients with DME and previous vitrectomy are treated with high dose aflibercept using a treat-extend-stop protocol until fluid has resolved.

12 months

Monthly visits (in-person)

Follow-up

Participants are monitored for safety and effectiveness after treatment, with visual acuity and CMT recorded at each visit.

4 weeks

2 visits (in-person)

Treatment Details

Interventions

• Aflibercept

Trial Overview The study tests whether a higher dose (8 mg) of Aflibercept, an anti-VEGF therapy, can provide better outcomes for those with diabetic macular edema after vitrectomy surgery compared to standard treatments.

Participant Groups

Group I: Patients with previous vitrectomy and diabetic macular edema treated with high dose aflibercept Active Control 1 Intervention

Identify patients that have had a previous vitrectomy and have DME that requires anti-VEGF therapy. Then using a treat-extend-stop protocol6,7 that I previously published, treat patients with DME using high dose aflibercept, until the fluid has resolved and then extend the time interval in between treatments for those patients, while maintaining a fluid-free macula.

Aflibercept is already approved in United States, European Union for the following indications:

Approved in United States as Eylea for:

• Neovascular (Wet) Age-Related Macular Degeneration (AMD)
• Macular Edema following Retinal Vein Occlusion (RVO)
• Diabetic Macular Edema (DME)
• Diabetic Retinopathy (DR)

Approved in European Union as Eylea for:

• Neovascular (Wet) Age-Related Macular Degeneration (AMD)
• Macular Edema following Retinal Vein Occlusion (RVO)
• Diabetic Macular Edema (DME)
• Diabetic Retinopathy (DR)

Approved in United States as Zaltrap for:

• Metastatic Colorectal Cancer

Who Is Running the Clinical Trial?

Retina Consultants of Orange County

Lead Sponsor

Trials

1

Recruited

20+

Regeneron Pharmaceuticals

Industry Sponsor

Trials

690

Recruited

948,000+

Founded

1988

Headquarters

Tarrytown, USA

Known For

Precision medicine

Top Products

Dupixent, EYLEA, Libtayo, Praluent

Leonard Schleifer

Regeneron Pharmaceuticals

Chief Executive Officer since 1988

MD and PhD in Medicine

George Yancopoulos

Regeneron Pharmaceuticals

Chief Medical Officer since 1997

MD from Harvard Medical School

Findings from Research

Intravitreal aflibercept significantly improved visual acuity in patients with diabetic macular oedema compared to macular laser photocoagulation and other treatments like bevacizumab and ranibizumab, particularly in those with worse baseline vision, as shown in phase III trials.

Aflibercept was generally well tolerated, making it a promising and effective new treatment option for diabetic macular oedema.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Aflibercept: A Review of Its Use in Diabetic Macular Oedema. Keating, GM.[2022]

In a study of 92 diabetic patients treated with intravitreal aflibercept for diabetic macular edema, significant improvements were observed after 12 months, with average visual acuity increasing from 59.7 to 69.6 Early Treatment Diabetic Retinopathy Study letters.

Aflibercept treatment also led to a notable reduction in central foveal thickness from 431 µm to 306 µm, indicating effective anatomical changes alongside improved vision.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Intravitreal aflibercept for diabetic macular oedema: Moorfields' real-world 12-month visual acuity and anatomical outcomes. Lukic, M., Williams, G., Shalchi, Z., et al.[2022]

In a study of 553 patients with diabetic macular edema treated with intravitreal aflibercept over 52 weeks, there was a significant improvement in vision-related quality of life, as measured by the NEI VFQ-25 total score, which increased by an average of +6.11 points.

The treatment also led to notable improvements in best-corrected visual acuity (BCVA) and a reduction in central retinal thickness (CRT), while the safety profile was consistent with known effects, with 53.6% of patients experiencing treatment-emergent adverse events, including a low incidence of serious ocular events.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Vision-Related Quality of Life in Patients with Diabetic Macular Edema Treated with Intravitreal Aflibercept: The AQUA Study. Garweg, JG., Stefanickova, J., Hoyng, C., et al.[2020]

In a study of 90 eyes from 67 patients switched from ranibizumab to aflibercept for diabetic macular edema, there was a significant improvement in visual acuity, with an average increase of 4 Early Treatment Diabetic Retinopathy Study letters after 12 months (p=0.0053).

Anatomical outcomes also showed positive trends, with a reduction in central foveal thickness by 136.8 μm, although this change was not statistically significant (p=0.69), indicating that aflibercept may be effective in improving vision in patients previously treated with ranibizumab.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

One-year real-life results on effect of intravitreal aflibercept in patients with diabetic macular oedema switched from ranibizumab. Lukic, M., Williams, G., Shalchi, Z., et al.[2021]

In a study of 26 patients with refractory diabetic macular edema (DME), ziv-aflibercept treatment led to significant improvements in visual acuity and macular thickness after switching from previous anti-VEGF therapies.

No adverse ocular or systemic side effects were reported, indicating that ziv-aflibercept is a safe option for patients who did not respond to other treatments.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Safety and Efficacy of Ziv-Aflibercept in the Treatment of Refractory Diabetic Macular Edema. Ashraf, M., Kayal, HE., Souka, AAR.[2022]

A study analyzing over 9 million adverse event reports found that glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with a significantly lower frequency of retinal adverse events compared to other glucose-lowering medications, with a rate of 2.53 per 1000 reports for GLP-1RAs versus 6.62 per 1000 for other medications.

Despite patients on GLP-1RAs having more comorbid conditions and concomitant medications, there was no evidence linking GLP-1RAs to an increased risk of retinopathy progression, suggesting they are a safer option in this regard for treating type 2 diabetes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Glucagon-like peptide-1 receptor agonists are not associated with retinal adverse events in the FDA Adverse Event Reporting System. Fadini, GP., Sarangdhar, M., Avogaro, A.[2022]

A total of 40,599 adverse events (AEs) were reported for enzalutamide (ENZ) and 13,562 for abiraterone (ABI) in the EudraVigilance database, with over 90% of these AEs classified as serious, indicating significant safety concerns for both treatments.

Older patients (over 65 years) treated with ABI or ENZ are at a higher risk for serious health issues, such as cardiac and infectious disorders, compared to younger patients, highlighting the need for careful monitoring in this age group.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adverse events related to abiraterone and enzalutamide treatment: analysis of the EudraVigilance database and meta-analysis of registrational phase III studies. De Nunzio, C., Lombardo, R., Tema, G., et al.[2021]

A study analyzing 31,542 adverse event reports from the FDA found that semaglutide, a GLP-1 analogue, has a higher potential for misuse and abuse compared to other GLP-1 receptor agonists, with significant reporting odds ratios for issues like drug abuse and withdrawal syndrome.

The findings suggest that semaglutide may be misused as a weight-loss treatment in non-obese individuals, highlighting the need for further research to fully understand its safety profile and the implications of its use outside of approved indications.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Is There a Risk for Semaglutide Misuse? Focus on the Food and Drug Administration's FDA Adverse Events Reporting System (FAERS) Pharmacovigilance Dataset. Chiappini, S., Vickers-Smith, R., Harris, D., et al.[2023]

Aflibercept, a recombinant fusion protein, effectively inhibits VEGF signaling and has been shown to significantly improve visual acuity in patients with macular edema due to central retinal vein occlusion (CRVO) when administered intravitreally at a dose of 2 mg monthly, as demonstrated in clinical trials with significant improvements over sham injections.

The treatment was generally well tolerated with minimal risk of systemic drug accumulation, making aflibercept a safe and effective option for managing CRVO-related macular edema, although optimal monitoring strategies for long-term efficacy still need further investigation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Intravitreal aflibercept (Eylea(®)): a review of its use in patients with macular oedema secondary to central retinal vein occlusion. Yang, LP., McKeage, K.[2021]

In a study of 30 eyes from 23 patients with diabetic macular edema (DME) who previously received an average of 16 injections of ranibizumab and/or bevacizumab, switching to aflibercept resulted in a significant reduction in central subfoveal thickness, improving from 374 µm to 332 µm after the first aflibercept injection (P < .001).

Visual acuity also improved after the switch to aflibercept, with a change from logMAR 0.40 (20/50) to logMAR 0.35 (20/45) (P = .044), suggesting that aflibercept may be a beneficial treatment option for patients with persistent DME.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Aflibercept for Diabetic Macular Edema in Eyes Previously Treated With Ranibizumab and/or Bevacizumab May Further Improve Macular Thickness. Shah, CP., Heier, JS.[2022]

References

1. New Zealand pubmed.ncbi.nlm.nih.gov

Aflibercept: A Review of Its Use in Diabetic Macular Oedema. [2022]

2. United States pubmed.ncbi.nlm.nih.gov

Intravitreal aflibercept for diabetic macular oedema: Moorfields' real-world 12-month visual acuity and anatomical outcomes. [2022]

3. United States pubmed.ncbi.nlm.nih.gov

Vision-Related Quality of Life in Patients with Diabetic Macular Edema Treated with Intravitreal Aflibercept: The AQUA Study. [2020]

4. United States pubmed.ncbi.nlm.nih.gov

One-year real-life results on effect of intravitreal aflibercept in patients with diabetic macular oedema switched from ranibizumab. [2021]

5. United States pubmed.ncbi.nlm.nih.gov

Safety and Efficacy of Ziv-Aflibercept in the Treatment of Refractory Diabetic Macular Edema. [2022]

6. New Zealand pubmed.ncbi.nlm.nih.gov

Physician and Patient Knowledge of Safety and Safe Use Information for Aflibercept in Europe: Evaluation of Risk-Minimization Measures. [2020]

7. England pubmed.ncbi.nlm.nih.gov

Glucagon-like peptide-1 receptor agonists are not associated with retinal adverse events in the FDA Adverse Event Reporting System. [2022]

8. England pubmed.ncbi.nlm.nih.gov

Adverse events related to abiraterone and enzalutamide treatment: analysis of the EudraVigilance database and meta-analysis of registrational phase III studies. [2021]

9. Switzerland pubmed.ncbi.nlm.nih.gov

Is There a Risk for Semaglutide Misuse? Focus on the Food and Drug Administration's FDA Adverse Events Reporting System (FAERS) Pharmacovigilance Dataset. [2023]

10. England pubmed.ncbi.nlm.nih.gov

Adverse drug reactions associated with six commonly used antiepileptic drugs in southern China from 2003 to 2015. [2020]

11. New Zealand pubmed.ncbi.nlm.nih.gov

Intravitreal aflibercept (Eylea(®)): a review of its use in patients with macular oedema secondary to central retinal vein occlusion. [2021]

12. United States pubmed.ncbi.nlm.nih.gov

Aflibercept for Diabetic Macular Edema in Eyes Previously Treated With Ranibizumab and/or Bevacizumab May Further Improve Macular Thickness. [2022]