High Dose Aflibercept in Diabetic Macular Edema in Patients With Previous Vitrectomy
试验速览
- 阶段
- 4 期
- 状态
- 招募中
- 发起方
- 入组人数
- 15
- 试验地点
- 1
- 主要终点
- Visual acuity changes
研究概览
简要总结
Patients with diabetic macular edema (DME) sometimes must undergo vitrectomy surgery (PPV) for diabetic and non-diabetic related issues. Patients may have improved DME with anti-VEGF therapy and ranibizumab has been found to reduce central macular thickness (CMT) with anti-VEGF therapy following vitrectomy. Those patients still require intravitreal injections but the pharmacokinetics of a vitrectomized eye are different than those eyes that have not undergone vitrectomy. The clearance of protein molecules is quicker in vitrectomized eyes so these patients may be more refractory to standard of care anti-VEGF therapy. In rabbit models, the half-life of both bevacizumab and ranibizumab were reduced by a factor 1.8 and 1.3, respectively, after pars plana vitrectomy. In a study examining intravitreal triamcinolone acetonide in human eyes, the half-life was found to be 18.6 days in non-vitrectomized eyes and 3.2 days in vitrectomized eyes, but there was considerable intrasubject variation. Patients with various disease states, including neovascular age-related macular degeneration (nAMD) have been managed with monthly anti-VEGF therapy successfully after vitrectomy surgery. Another study performed by the DRCR net showed that patients with DME treated with anti-VEGF are not affected in the long term if they had had a previous vitrectomy. High dose aflibercept may improve anatomic and visual outcomes in this patient population. Also, high dose aflibercept may allow for longer treatment intervals in these vitrectomized eyes.
详细描述
Patients with Diabetic Macular Edema (DME) and previous Pars Plana Vitrectomy (PPV) will be treated with a treat-extend-stop (TES) protocol that was previously published. Below is the description of the TES protocol published in the International Journal of Retina and Vitreous. This protocol was originally used in patients with neovascular age-related macular degeneration (nAMD) but it is being adapted for treatment of patients with DME in this study.
Patients were treated following the treat-and-extend-stop (TES) protocol, which is a variant to the treat-and-extend regimen. The TES treatment protocol required 3 loading injections at 4-to-6-week treatment interval. Upon clinical examination and on Optical Coherence Tomography (OCT), dosing interval was extended by 1 to 2 weeks in patients with dry macula. Any evidence of fluid on OCT and decreased vision was carefully monitored. If fluid or worsening of vision was detected, the dosing interval was reduced. After successful management of patients following decreased interval, patients were allowed to increase interval by 1 week for the next 2 to 4 injections. In patients with good response without worsening vision, but exhibiting presence of mild fluid during the initial 4 to 6 week treatment interval, the same interval was maintained. In patients with complete absence of fluid in the macula, dosing interval was extended by 1 to 2 weeks. Extension of dosing interval continued until 12 weeks was reached between visits. To avoid recurrence of fluid, patients were monitored carefully once the 12-week interval was reached. Patients who experienced deterioration of vision or increase in metamorphopsia were instructed to contact the office for earlier return visit.
In this study, patients that have had a previous vitrectomy and have DME will be treated with high dose aflibercept until fluid has resolved and then the time interval in between treatments for those patients will be extended, while maintaining a fluid-free macula.
- VEGF Trap, 8 mg is intended for intravitreal administration.
- VEGF Trap, 8 mg study drug will be provided in single-use vial
- The appearance of the vial will be in clear glass 2R vial with 13 mm West 4432/50 gray stopper with FluroTec® coatings and 13 mm royal blue flip-off seal.
- The formulation of the VEGF Trap, 8 mg is sterile, vialed VEGF Trap recombinant protein, 114.3mg/mL, in an aqueous buffered solution, pH 5.8, containing 50 mM arginine monohydrochloride, 10 mM histidine, 5% (w/v) sucrose, and 0.03% (w/v) polysorbate 20.
- Store refrigerated at 2°C - 8°C (36°F - 46°F) in the original carton to protect from light.
Visual acuity and CMT will be recorded prior to vitrectomy and prior to inclusion into the trial, after the PPV. Visual acuity and CMT will be recorded at each treatment visit. Diabetic retinopathy (DR) will also be assessed at the visit prior to inclusion using wide-field fundus photos (FP) and fluorescein angiography (FA). DR will also be assessed as a secondary endpoint at 6 months and at the one-year visit utilizing FP and FA
研究设计
- 研究类型
- Interventional
- 分配方式
- Na
- 干预模型
- Single Group
- 主要目的
- Treatment
- 盲法
- None
入排标准
- 年龄范围
- 21 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •A patient must meet the following criteria at both the screening and randomization visits (except where indicated) to be eligible for inclusion in the study:
- •Men or women ≥18 years of age with type 1 or type 2 diabetes mellitus
- •DME with central involvement in the study eye with CRT ≥320 μm on Spectralis.
- •BCVA early treatment diabetic retinopathy study (ETDRS) letter score of 84 to 20 (approximate Snellen equivalent of 20/25 to 20/400) in the study eye with decreased vision determined to be primarily the result of DME
- •Willing and able to comply with clinic visits and study-related procedures
- •Provide informed consent signed by study patient or legally acceptable representative
- •Have a previous history of vitrectomy surgery.
排除标准
- •A patient who meets any of the following criteria at either the screening or randomization visits will be excluded from the study:
- •Evidence of macular edema due to any cause other than diabetes mellitus in either eye
- •Prior intravitreal investigational agents in the study eye (gene therapy, etc.) at any time
- •IOP ≥28 mmHg in the study eye
- •History of glaucoma filtration surgery in the past
- •Evidence of infectious blepharitis, keratitis, scleritis , or conjunctivitis in either eye within 4 weeks (28 days) of the screening visit.
- •Any intraocular inflammation/infection in either eye within 6 weeks (42 days) of the screening visit.
- •History of idiopathic or autoimmune uveitis in the study eye
- •Vitreomacular traction or epiretinal membrane in the study eye evident on biomicroscopy or OCT that is thought to affect central vision
- •Current iris neovascularization, vitreous hemorrhage, or tractional retinal detachment visible at the screening assessments in the study eye
- •History of corneal transplant or corneal dystrophy in study eye
- •Any concurrent ocular condition in the study eye which, in the opinion of the investigator, could either increase the risk to the patient beyond what is to be expected from standard procedures of IVT injections, or which otherwise may interfere with the injection procedure or with evaluation of efficacy or safety.
- •Structural damage to the center of the macula in the study eye that is likely to preclude improvement in BCVA following the resolution of macular edema including atrophy of the retinal pigment epithelium, subretinal fibrosis or scar, significant macular ischemia, or organized hard exudates
- •Inability to obtain photographs, FA, or SD-OCT in the study eye, eg, due to media opacity, allergy to fluorescein dye, or lack of venous access
- •History of other disease, metabolic dysfunction, physical examination finding, or clinical laboratory finding giving reasonable suspicion of a disease or condition that contraindicates the use of high dose aflibercept or that might affect interpretation of the results of the study or render the patient at high risk for treatment complications
- •Uncontrolled diabetes mellitus as defined by hemoglobin A1c (HbA1c) > 14%
- •History of cerebrovascular accident or myocardial infarction within 24 weeks (168 days) of screening visit
- •Known sensitivity to any of the compounds of the study formulation
- •Participation in an investigational study within 30 days prior to screening visit that involved treatment with any drug (excluding vitamins and minerals) or device
- •Pregnant or breastfeeding women
- •Men or women of childbearing potential (WOCBP)* who are unwilling to practice highly effective contraception prior to the initial dose/start of the first treatment and during the study.
研究组 & 干预措施
Patients with previous vitrectomy and diabetic macular edema treated with high dose aflibercept
Identify patients that have had a previous vitrectomy and have DME that requires anti-VEGF therapy. Then using a treat-extend-stop protocol that I previously published, treat patients with DME using high dose aflibercept, until the fluid has resolved and then extend the time interval in between treatments for those patients, while maintaining a fluid-free macula.
干预措施: Aflibercept 8 mg (VEGF Trap-Eye, BAY86-5321) (Drug)
结局指标
主要结局
Visual acuity changes
时间窗: 12 months
Visual Acuity will be measured at each visit.
次要结局
- Central Macular Thickness(12 months)
- Time Interval(12 months)