Long-term mineralocorticoid receptor antagonists beneficial in chronic CSC
medwireNews: The majority of patients with chronic non-resolving central serous chorioretinopathy (CSC) will experience complete resolution following 2 years of treatment with a mineralocorticoid receptor antagonist (MRa), study findings indicate.
In addition, visual acuity and retinal morphological parameters improved at a steady but statistically significant rate during therapy, suggesting that “prolonged MRa treatment leads to long-term visual and anatomical improvement in long-standing forms of CSC,” write Francine Behar-Cohen (Université Sorbonne Paris Cité, France) and colleagues in the British Journal of Ophthalmology.
Behar-Cohen and team studied 16 eyes from 16 patients (mean age 53 years; 88% men) with chronic non-resolving CSC who were treated with either eplerenone or spironolactone (each at 25 or 50 mg/day) for at least 6 months (mean 21 months). Chronic non-resolving CSC was defined as the presence of foveal subretinal fluid (SRF) lasting longer than 4 months (median 11.2 months) accompanied by retinal pigment epithelium (RPE) alterations.
At baseline, half of the patients were receiving eplerenone and half were receiving spironolactone. At 24 months, the proportions on each drug were 63% and 31%, respectively, as switching was permitted. One patient had stopped treatment completely due to SRF resolution.
The researchers report that LogMAR best corrected visual acuity improved significantly during treatment, from 0.14 at baseline to 0.07 at 24 months.
There were also significant progressive improvements from baseline to 24 months in mean foveal SRF height (100 vs 27 µm), central macular thickness (346 vs 254 µm) and subfoveal choroidal thickness (431 vs 371 µm).
Of note, the change in subfoveal choroidal thickness significantly correlated with the change in SRF at 24 months (r=0.65), which Behar-Cohen et al say “supports the hypothesis of MR involvement in CSC pathogenesis.”
The mean time to complete foveal SRF resolution was 10.5 months after treatment initiation, and was achieved in 13 (81%) eyes by 24 months. The resolution rates at 6, 12 and 18 months were 31%, 44% and 69%, respectively.
Four patients receiving spironolactone and one receiving eplerenone experienced minor side effects at the higher 50 mg/day dose (one case each of dizziness, gynaecomastia, tingling arms, urinary retention and hypotension) which all resolved following a switch to the other MRa.
Behar-Cohen and co-authors say their findings indicate that “MRa agents should be administered as long-term therapy in these patients with complex CSC as they may act as disease-modifying drugs, acting on many components of its intricate pathophysiology.”
They add: “Future randomised controlled trials should evaluate the efficacy of MRa combined with other treatment modalities.”
By Laura Cowen
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Br J Ophthalmol 2018; doi:10.1136/bjophthalmol-2018-312892