First Author: M.Pavlidis GERMANY
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Patients with diabetic macular edema (DME) can be challenging to manage with existing therapies due to limited clinical capacity. Indeed, injection rates directly affect current practices with low injection rates being associated with sub-optimal / under treatment and high injection rates leading to increased treatment costs and appointment burden. In both scenarios Iluvien® may be a suitable treatment option provided patients have shown an insufficient response to first line therapy. To compare responses following early and late switches to Iluvien® in patients with DME from a clinical practice.
3 DME eyes were treated with Iluvien® based on these clinical criteria; persistent edema, a short response to the dexamethasone implant, an increased cardiovascular risk profile due to arterial hypertension, poor patient compliance due to the need for repeated injections and impaired quality of life due to sub-optimal driving vision.
Patient case histories (n=2; one was a bilateral case) were investigated to assess the number and type of therapies prior to administration of Iluvien®. Patient one (a bilateral case) was judged to have been switched ‘early’ to Iluvien® whereas patient two was switched ‘late.’ Prior to Iluvien®, patient one had three intravitreal injections of bevacizumab and this was followed by a single dexamethasone implant which was administered 319 days prior to Iluvien®. In contrast, patient two received ten intravitreal injections of anti-VEGF agents followed by five injections of dexamethasone over a period of approximately 3 years. In both cases the patients had been judged by the physician not to have responded adequately to the dexamethasone implant. Visual acuity (VA; in ETDRS letters), central macular thickness (CMT; in microns) and intra-ocular pressure (IOP) were measured at three phases in the therapy: (1) after last cycle of anti-VEGF agents and prior to dexamethasone; (2) after dexamethasone and prior to Iluvien®; and, (3) at the last observation for Iluvien®.
In patient one, mean VA in OD was 65, 65 and 63 ETDRS letters accompanied by concurrent, gradual improvements in CMT from 445, to 393 and 270 µm during phases (1, over 534 days), (2, over 318 days) and (3, over 634 days) and in OS was 55, 56 and 58 ETDRS letters accompanied by concurrent, gradual improvements in CMT from 343, to 234 and 213 µm, respectively. In patient two, VA was in phase 1 (146 days) stable at 35, in phase 2 (756 days) at 45 and in phase 3 (849 days) at 48 ETDRS letters. During the three phases, CMT was recorded to be 566, 492 and 257 µm, respectively. IOP was relatively stable in all three cases and remained below 25 mmHg throughout the period of monitoring.
These cases show that even after patients had a short-term response intermittent pulse therapies (anti-VEGF agents and dexamethasone), a single Iluvien® implant led to sustained improvements in VA and CMT. Moreover, comparison of the early and late switch cases suggests Iluvien® is effective but the best VA outcomes seemed to occur when switched to Iluvien® earlier. To support these observations, further analysis in a larger patient cohort and under more controlled conditions is required to assess the true impact of early and late switches to a second-line therapy such as Iluvien®.