W. Lloyd Clark, MD: Choosing Between Anti-VEGF Treatments

With the prevalence of diabetes continuing to increase without an end in sight, physicians from a wide array of fields outside of endocrinology are having to deal with the effects of this disease. 



At the 2019 American Society of Retina Specialists Annual Meeting, diabetic macular edema (DME) is one of the diseases that will be taking center stage and while some trials have shown superiority of some anti-VEGF treatments, some debate exists over which treatment is best for certain patient populations.

With 3 anti-VEGF agents (aflibercept, ranibizumab, and avastin) dominating the space, the choice would appear to be simple for physicians, but that is not always the case. W. Lloyd Clark, MD, of the Palmetto Retina Center, sat down with MD Magazine® to discuss how he goes about deciding which treatment best fits into a patient’s treatment regimen. 


MD Mag: How do you decide which anti-VEGF treatment is most appropriate for a patient’s treatment plan?

Clark: Both of these agents are outstanding agents for diabetic macular edema. We have good head-to-head data from protocol T. Protocol T was a clinical trial that was funded by the federal government instituted by the Diabetic Retinopathy Clinic Research Network and this trial established a head-to-head comparison between all 3 anti-VEGF agents: aflibercept, ranibizumab, and avastin. What was seen is that trial is when you look at patients with very good vision, 20/40 or better vision, really there appears to be minimal differences between aflibercept and ranibizumab for diabetic macular edema in terms of visual acuity improvement.

Now, there is a difference though in response in patients who have more severe disease. So, in a second subgroup of Protocol T, where patients had 20/50 or worse visual acuity it appeared that, in that case, aflibercept had a more rapid improvement in visual acuity and a higher level of visual acuity gains in patients with more severe disease. So, the take home there is: in patients with very severe disease, it looks like aflibercept is probably a better agent in terms of primary therapy for patients with severe diabetic macular edema.