title: 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.
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).
  
  
  METHODS
  MEDLINE, Embase, Cochrane Library, congress abstracts, ClinicalTrials.gov registry and Novartis data on file.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  Three of the eight RCTs included are not yet published. The models did not adjust for all potential effect modifiers.
  
  
  CONCLUSIONS
  Ranibizumab was non-significantly superior to aflibercept and both anti-VEGF therapies had statistically superior efficacy to laser.
authors.affiliation: Novartis Pharma AG, Basel, Switzerland.
authors.forename: Stephane
authors.initials: S
authors.lastname: Régnier
authors.affiliation: Novartis Pharmaceuticals UK Ltd, Frimley Business Park, Frimley, Surrey, United Kingdom.
authors.forename: William
authors.initials: W
authors.lastname: Malcolm
authors.affiliation: Novartis Pharmaceuticals UK Ltd, Frimley Business Park, Frimley, Surrey, United Kingdom.
authors.forename: Felicity
authors.initials: F
authors.lastname: Allen
authors.affiliation: Numerus Ltd, Wokingham, United Kingdom.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Wright
authors.affiliation: Novartis Pharma AG, Basel, Switzerland.
authors.forename: Vladimir
authors.initials: V
authors.lastname: Bezlyak
mesh_terms: D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D001499:Bayes Theorem; D003930:Diabetic Retinopathy / Q000473:pathology*; D006801:Humans; D017075:Laser Coagulation / Q000379:methods*; D008269:Macular Edema / Q000150:complications* / Q000473:pathology; D016017:Odds Ratio; D016032:Randomized Controlled Trials as Topic; D000069579:Ranibizumab; D040262:Receptors, Vascular Endothelial Growth Factor / Q000627:therapeutic use*; D011993:Recombinant Fusion Proteins / Q000627:therapeutic use*; D012160:Retina / Q000473:pathology; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors*; D014786:Vision Disorders / Q000188:drug therapy* / Q000209:etiology / Q000601:surgery*; D014792:Visual Acuity / Q000187:drug effects
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D011993:Recombinant Fusion Proteins; D042461:Vascular Endothelial Growth Factor A; C533178:aflibercept; D040262:Receptors, Vascular Endothelial Growth Factor; D000069579:Ranibizumab