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Efficacy of Anti-VEGF and Laser Photocoagulation in the Treatment of Visual Impairment due to Diabetic Macular Edema: A Systematic Review and Network Meta-Analysis

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  • Stephane Régnier
  • William Malcolm
  • Felicity Allen
  • Jonathan Wright
  • Vladimir Bezlyak

Abstract

Objective: Compare the efficacy of ranibizumab, aflibercept, laser, and sham in the first-line treatment of diabetic macular edema (DME) to inform technology assessments such as those conducted by the UK National Institute for Health and Care Excellence (NICE). Data sources: MEDLINE, Embase, Cochrane Library, congress abstracts, ClinicalTrials.gov registry and Novartis data on file. Inclusion criteria: Studies reporting 6- or 12-month results of randomized controlled trials (RCTs) evaluating at least two of ranibizumab 0.5 mg pro re nata, aflibercept 2.0 mg bi-monthly, laser photocoagulation or sham. Study quality was assessed based on likelihood of bias in selection, attrition, detection and performance. Outcome measure: Improvement in best-corrected visual acuity (BCVA) measured as the proportion of patients gaining ≥10 letters on the Early Treatment Diabetic Retinopathy Study scale. The outcome was chosen following acceptance by NICE of a Markov model with 10-letter health states in the assessment of ranibizumab for DME. Meta-analysis: Bayesian network meta-analyses with fixed and random effects adjusted for differences in baseline BCVA or central retinal thickness. Results: The analysis included 1,978 patients from eight RCTs. The random effects model adjusting for baseline BCVA was the best model based on total residual. The efficacy of ranibizumab was numerically, but not statistically, superior to aflibercept (odds ratio [OR] 1.59; 95% credible interval [CrI], 0.61–5.37). Ranibizumab and aflibercept were statistically superior to laser monotherapy with ORs of 5.50 (2.73–13.16) and 3.45 (1.62–6.84) respectively. The probability that ranibizumab is the most efficacious treatment was 73% compared with 14% for aflibercept, 12% for ranibizumab plus laser, and 0% for laser. Limitations: Three of the eight RCTs included are not yet published. The models did not adjust for all potential effect modifiers. Conclusion: Ranibizumab was non-significantly superior to aflibercept and both anti-VEGF therapies had statistically superior efficacy to laser.

Suggested Citation

  • Stephane Régnier & William Malcolm & Felicity Allen & Jonathan Wright & Vladimir Bezlyak, 2014. "Efficacy of Anti-VEGF and Laser Photocoagulation in the Treatment of Visual Impairment due to Diabetic Macular Edema: A Systematic Review and Network Meta-Analysis," PLOS ONE, Public Library of Science, vol. 9(7), pages 1-10, July.
    • Handle: RePEc:plo:pone00:0102309
    DOI: 10.1371/journal.pone.0102309
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    References listed on IDEAS

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    1. Sofia Dias & Alex J. Sutton & A. E. Ades & Nicky J. Welton, 2013. "Evidence Synthesis for Decision Making 2," Medical Decision Making, , vol. 33(5), pages 607-617, July.
    2. Jansen, Jeroen P. & Naci, Huseyin, 2013. "Is network meta-analysis as valid as standard pairwise meta-analysis? It all depends on the distribution of effect modifiers," LSE Research Online Documents on Economics 55472, London School of Economics and Political Science, LSE Library.
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