Switching Drugs Effective in Treating Diabetic Macular Edema


Research examines whether a step-approach with treatment for macular edema produces positive results.

Switching from the less expensive Avastin (bevacizumab) to the more expensive Eylea (aflibercept) for diabetic macular edema produces similar results as starting off with Eylea, new research shows.

Results of the clinical trial from the DRCR Retina Network, funded by the National Institutes of Health’s (NIH) National Eye Institute (NEI) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), were published in the New England Journal of Medicine.1

Image courtesy of Chirag Jhaveri.

Image courtesy of Chirag Jhaveri.

Retinal injections of anti-VEGF drugs can restore vision lost in diabetic macular edema. Although Eylea is approved by the FDA to treat diabetic macular edema and results in better visual outcomes on average, off-label Avastin is much less expensive and is sometimes required by insurers as a first-line treatment, NIH/NEI said in a news release.2

The study included 270 participants with diabetic macular edema, some of whom received treatments in both eyes. Half of the patients were assigned to Eylea from the start, and half were assigned to start with Avastin. For participants who needed treatment in both eyes, each eye started treatment with a different drug.

Participants received either Avastin or Eylea injections every 4weeks for 24 weeks. If eyes assigned Avastin failed to reach the pre-set improvement benchmarks starting at 12 weeks, the eye was switched to Eylea.

After 2 years, eyes in both groups had similar visual acuity outcomes, improving on average approximately 3 lines on an eye chart, compared to the trial’s start. In the Avastin group, 70% of eyes switched to Eylea during the study.

Serious adverse events (in 52% of the patients in the Eylea-monotherapy group and in 36% of those in the Avastin-first group) and hospitalizations for adverse events (in 48% and 32%, respectively) were more common in the Eylea monotherapy group.

“Our study showed that switching treatments when needed is a reasonable strategy,” said Chirag Jhaveri, M.D., lead study author and ophthalmologist at Austin Research Center for Retina, Texas. “Insurance companies often require clinicians to start with the less expensive treatment, so we really wanted to see how a specific treatment strategy using this approach would affect patient care.”

Although most participants on Avastin eventually switched to Eylea, they still had improvement during the initial weeks, “even if they didn’t hit our pre-set benchmarks,” added Adam Glassman, executive director of the Jaeb Center for Health Research in Wesley Chapel, Florida, and director of the DRCR Retina Network coordinating center. “There are large cost disparities between these drugs, so differences in treatment strategies may have substantial cost implications.”


1. Jhaveri C, Glassman A, Ferris FL, et al. Aflibercept monotherapy or bevacizumab first for diabetic macular edema. N Engl J Med. 2022 Jul 14. doi: 10.1056/NEJMoa2204225. Online ahead of print.

2. A type of ‘step therapy’ is an effective strategy for diabetic eye disease. News release. NIH/National Eye Institute. July 17, 2022. Accessed July 18, 2022. https://www.eurekalert.org/news-releases/958497.

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