# Abstract

 

## Purpose To examine the pooled per-protocol ocular end points from two conjunctival allergen challenge (CAC) clinical trials of the dual-action antihistamine bepotastine besilate ophthalmic solution (BBOS) 1.5%. 

## Methods Two Phase III, placebo-controlled, double-masked, randomized clinical trials were conducted at a total of six separate centers using the CAC model of allergic conjunctivitis. The same study design was employed for both clinical trials, with subjects randomly assigned to either BBOS 1.5% (n=78) or placebo (n=79) treatment. Each subject received one eye drop of the test agent bilaterally at different study visits 15 minutes, 8 hours, or 16 hours prior to a CAC. Primary ocular end points included changes in ocular itching reported at 3, 5, and 7 minutes and conjunctival hyperemia assessed at 7, 15, and 20 minutes following each CAC. Secondary ocular end points included chemosis as well as episcleral and ciliary hyperemia judged by investigators, and tearing (scored as either absent or present) and eyelid swelling judged by subjects. 

## Results A statistically significant reduction in ocular itching was observed for BBOS 1.5% treatment compared to placebo at all time points (*P*\<0.0001), while measures for onset and 8-hour persistence of action also reached clinical significance (ie, ≥1.0 unit difference) at a majority of time points. In addition, a significant reduction in conjunctival hyperemia was achieved at a majority of time points during the onset of action CAC test. Secondary end points were also significantly improved compared to placebo, most prominently for reduced tearing at all study visits and reduced eyelid swelling at the onset of action and 8-hour study visits. Adverse events were generally mild and transient. 

## Conclusion BBOS 1.5% rapidly reduced CAC-induced ocular itching with duration of effectiveness of at least 8 hours after dosing. Certain secondary signs of inflammation were also significantly reduced. # Results 

## Subject characteristics Subject demographics were well balanced between the BBOS 1.5% and placebo treatment groups ([Table 2](#)). No significant differences were found in the pair-wise comparison of the demographic characteristics between the BBOS 1.5% and placebo treatment groups. 

## Subject disposition A total of 439 subjects were screened as part of either the single-site or the multicenter trials. Of those, 202 subjects were excluded at visit 1 or visit 2 because they did not meet all of the inclusion criteria ([Figure 1](#)). A total of 237 patients were subsequently enrolled and assigned to treatment groups according to a computer-generated randomization code at visit 3A. A third treatment arm that was not included in this analysis of pooled data, BBOS 1.0%, accounted for 80 of these subjects and has been previously discussed.[33](#),[34](#) The remaining 157 subjects comprised the intent-to-treat population. Of these, 140 subjects completed the study without a significant protocol deviation, and thus this subgroup constituted the per protocol population. 

## Efficacy 

### Ocular itching For the PP population, the differences in mean ocular itching scores between the BBOS 1.5% and the placebo group were found to be statistically significant (*P*\<0.001) at all visits and time points by the Wilcoxon rank-sum test and across all time points at a study visit by ANCOVA assessments ([Table 3](#)). In addition, the onset and 8-hour persistence-of-action measures were also clinically significant at all time points. A comparison of the difference between onset and 8-hour persistence-of-action scores shows that the treatment effect remained relatively constant over this time period (differences of 1.4--1.6 units at onset, and 1.3--1.5 units at 8 hours). Differences in mean ocular itching scores for BBOS 1.5% compared to placebo for the 16-hour persistence-of-action measures were also statistically significant (*P*\<0.001) at all time points; however, the range of differences did not reach ≥1.0 unit difference at a majority of time points, the standard prospectively designated as clinically significant. [Figure 2A](#) shows the data for ocular itching scores by degree of resolution of itching (itching score =0), and demonstrates that more subjects in the BBOS 1.5% group compared to those in the placebo group experienced complete relief of CAC-induced ocular itching. BBOS 1.5% was statistically superior to placebo at all CAC visits. In addition, the majority of BBOS 1.5% subjects reported zero itching at the onset of action as early as 3 minutes after a CAC. Total itching relief was sustained at the 8-hour persistence-of-action visit for one-third of all subjects. In addition, a sizable number of subjects experienced complete relief from ocular itch even at the 16-hour persistence-of-action visit. [Figure 2B](#) shows the proportion of severely allergic subjects (baseline [visit 2] ocular itching scores ≥3) who experienced complete resolution of CAC-induced ocular itching. The data demonstrate that the extent of complete relief was significantly better for BBOS 1.5% than for placebo at all study visits and was comparable to the results of the entire PP population, as seen in [Figure 2A](#). 

### Conjunctival hyperemia [Table 4](#) shows the differences in mean conjunctival hyperemia scores for the PP population. Numerical reduction in hyperemia scores was superior for BBOS 1.5% compared to placebo at almost all time points. Statistically significant differences were seen at a majority of time points for the onset-of-action CAC test. However, the criterion for clinical significance (≥1.0 unit reduction) was not met at any study visit. 

### Secondary efficacy variables Consistent improvements in several secondary efficacy variables were seen with BBOS 1.5% compared to placebo. Data for ocular tearing were notable and are summarized in [Table 5](#). The percentage of subjects exhibiting tearing in response to a CAC ranged from 23%--39% from onset of action to 16 hours after drug instillation in placebo-treated eyes compared to 6%--15% from onset of action up to 16 hours after drug instillation in BBOS 1.5%-treated eyes. This reduction was both statistically and clinically significant for all time points measured. Additional end points, including ciliary and episcleral hyperemia, chemosis, and eyelid swelling, are summarized in [Table 6](#). All measures showed improvement for BBOS 1.5% compared to placebo based upon reduced mean scores. In particular, all of the end points showed statistically significant reductions by BBOS 1.5% at the onset-of-action CAC test for either all time points (chemosis and eyelid swelling) or the majority of the assessed time points (ciliary and episcleral hyperemia), and the results for ciliary and episcleral hyperemia were very similar to those seen for conjunctival hyperemia. Eyelid swelling was significantly reduced by BBOS 1.5% at all of the 8-hour persistence-of-action time points. 

## Safety The AEs from these studies were based upon a safety population of all subjects who received at least one instillation of BBOS 1.5% or placebo. Overall, there were a total of 24 AEs in the PP population reported for the BBOS 1.5% treatment group and ten AEs in the placebo treatment group ([Table 7](#)). AEs in the PP population were generally non-ocular and not considered related to the test agent. The most common non-ocular AEs included nasopharyngitis (n=3 for both treatment groups) and a mild taste upon instillation for the BBOS 1.5% treatment group (n=4). Among the few AEs that were ocular, the most commonly reported was eye irritation, which was seen in both the placebo (n=2) and BBOS 1.5% (n=3) treatment groups. In addition, visits throughout both CAC trials included an ocular examination by slit-lamp biomicroscopy for each subject, and there were no clinically significant findings reported in the course of these examinations. ::::table-wrap

::: caption
Demographics for per-protocol population
:::

```
                                  BBOS 1.5% (N=70)   Placebo (N=70)   All subjects (N=140)
```

______________________________________________________________________

Age (years)\
Mean (SD) 38.3 (16.9) 37.1 (13.5) 37.7 (15.2)
Median 39 39 39
Min--max 11--73 13--65 11--73
*P*-value[a](#) 0.644\
Sex, N (%)\
Female 35 (50.0) 41 (58.6) 76 (54.3)
Male 35 (50.0) 29 (41.4) 64 (45.7)
*P*-value[b](#) 0.396\
Ethnicity, N (%)\
Hispanic 3 (4.3) 4 (5.7) 7 (5.0)
Non-hispanic 67 (95.7) 66 (94.3) 133 (95.0)
*P*-value[b](#) 1.000\
Race, N (%)\
African American 5 (7.2) 5 (7.2) 10 (7.1)
American Indian or Alaska Native 0 (0.0) 0.0 (0) 0 (0.0)
Asian 6 (8.6) 6 (8.6) 12 (8.6)
Caucasian 57 (81.4) 59 (84.3) 116 (82.9)
Other 2 (2.9) 0 (0.0) 2 (1.4)
*P*-value[b](#) 0.753\
Iris color,[c](#) n (%) (n=140) (n=140) (n=140)
Blue 54 (38.6) 44 (31.4) 98 (35.0)
Brown 58 (41.4) 70 (50.0) 128 (45.7)
Green 12 (8.6) 12 (8.6) 24 (8.6)
Hazel 16 (11.4) 12 (8.6) 28 (10.0)
Other 0 (0.0) 2 (1.4) 2 (0.7)
*P*-value[b](#) 0.347

**Notes:**

*P*-value calculated using two-sample *t*-test comparing BBOS 1.5% to
placebo.

*P*-value calculated using Fisher's exact test comparing BBOS 1.5% to
placebo.

Values and percentages based upon number of eyes.

**Abbreviations:** BBOS, bepotastine besilate ophthalmic solution;
min--max, minimum--maximum; N, number of subjects; n, number of eyes;
SD, standard deviation.:::: ::::table-wrap
::: caption
Differences in mean ocular itching scores (observed data only) for
subjects in the per-protocol population instilling BBOS 1.5% or placebo
eye drops in each eye following a CAC
:::

```
                                        Time of itching grading post-CAC   Placebo mean score (n)   BBOS 1.5% mean score (n)   Difference in mean itching score (placebo -- BBOS 1.5%)[*](#)
```

______________________________________________________________________

Visit 5: 15-min onset of action 3 min 1.9 (70) 0.4 (70) 1.5
5 min 2.1 (70) 0.5 (70) 1.6\
7 min 1.9 (70) 0.5 (70) 1.4\
Visit 4: 8-hour persistence of action 3 min 2.1 (67) 0.8 (64) 1.4
5 min 2.3 (67) 0.8 (64) 1.5\
7 min 2.1 (67) 0.8 (64) 1.3\
Visit 3B: 16-hour persistence of action 3 min 2.0 (70) 1.2 (68) 0.8
5 min 2.3 (70) 1.3 (67) 1.0\
7 min 2.1 (69) 1.2 (68) 0.9

**Notes:** Itching was graded by subjects in each eye at the indicated
times post-CAC. Instillation of BBOS 1.5% or placebo occurred at 15 min,
8 hours, or 16 hours prior to a CAC for each subject.

*P*\<0.0001 by Wilcoxon rank-sum test at each time point for all study
visits and for ANCOVA analyses across all time points at a study visit.

**Abbreviations:** ANCOVA, analysis of covariance; BBOS, bepotastine
besilate ophthalmic solution; CAC, conjunctival allergen challenge; min,
minute(s); n, number of subjects providing ocular itching grades at a
study visit time point.:::: ::::table-wrap
::: caption
Differences in mean conjunctival hyperemia scores (observed data only)
for subjects in the per-protocol population instilling BBOS 1.5% or
placebo eye drops in each eye following a CAC
:::

```
                                        Time of hyperemia grading post-CAC   Placebo mean score (n)   BBOS 1.5% mean score (n)   Difference in mean hyperemia score (placebo -- BBOS 1.5%)   *P*-value[a](#) for difference
```

______________________________________________________________________

Visit 5: 15-min onset of action 7 min 1.9 (70) 1.3 (70) 0.6 \<0.0001
15 min 2.0 (70) 1.6 (70) 0.4 0.0012\
20 min 1.9 (70) 1.6 (70) 0.3 0.0382\
Visit 4: 8-hour persistence of action 7 min 1.7 (67) 1.4 (64) 0.3 0.0062
15 min 1.8 (67) 1.6 (64) 0.3 0.0716\
20 min 1.8 (67) 1.6 (64) 0.2 0.1601\
Visit 3B: 16-hour persistence of action 7 min 1.8 (70) 1.7 (68) 0.1 0.2168
15 min 1.9 (70) 1.8 (68) 0.1 0.5481\
20 min 1.8 (70) 1.8 (68) 0.0 0.9949

**Notes:** Conjunctival hyperemia was graded by the investigator for
each eye at the indicated times post-CAC. Instillation of BBOS 1.5% or
placebo occurred at 15 min, 8 hours, or 16 hours prior to a CAC for each
subject.

*P*-values were derived using the Wilcoxon rank-sum test.

**Abbreviations:** BBOS, bepotastine besilate ophthalmic solution; CAC,
conjunctival allergen challenge; min, minute(s); n, number of subjects
providing conjunctival hyperemia grades at a study visit time point.:::: ::::table-wrap
::: caption
The number and percentage of eyes in the per-protocol population for
which tearing was present at the indicated times for placebo-treated
compared to BBOS 1.5%-treated eyes
:::

```
                                        Time of tearing grading post-CAC   Number of eyes with tearing present   Difference in % of eyes with tearing (placebo -- BBOS 1.5%)   *P*-value for difference   
```

______________________________________________________________________

Placebo (n=140) (%) BBOS 1.5% (n=140) (%)\
Visit 5: 15-min onset of action 7 min 55 (39) 9 (6) 33 \<0.0001
15 min 38 (27) 11 (8) 19 \<0.0001\
20 min 38 (27) 13 (9) 18 0.0002\
Visit 4: 8-hour persistence of action 7 min 55 (39) 13 (9) 30 \<0.0001
15 min 55 (39) 9 (6) 33 \<0.0001\
20 min 38 (27) 13 (9) 18 0.0003\
Visit 3B: 16-hour persistence of action 7 min 46 (33) 21 (15) 18 0.0008
15 min 45 (32) 12 (9) 23 \<0.0001\
20 min 32 (23) 12 (9) 14 0.0016

\*\*Note:\*\**P*-values were derived using Fisher's exact test and applying
multiplicity corrections derived using the false discovery rate method.

**Abbreviations:** BBOS, bepotastine besilate ophthalmic solution; CAC,
conjunctival allergen challenge; min, minute(s); n, number of eyes.:::: ::::table-wrap
::: caption
Differences in mean secondary end point values (placebo -- BBOS 1.5%)
assessed following a CAC (per-protocol population)
:::

Mean grade differences: placebo -- BBOS 1.5% Ciliary hyperemia Episcleral hyperemia Chemosis Eyelid swelling

______________________________________________________________________

Visit 5: 15-min onset of action 7 min 0.54 (\<0.001) 0.59 (\<0.0001) 0.27 (\<0.001) 0.38 (0.0001)
15 min 0.38 (0.004) 0.43 (0.002) 0.24 (0.011) 0.37 (\<0.001)\
20 min 0.19 (0.188) 0.27 (0.057) 0.32 (0.002) 0.40 (\<0.0001)\
Visit 4: 8-hour persistence of action 7 min 0.39 (0.004) 0.37 (0.049) 0.22 (0.011) 0.39 (0.0001)
15 min 0.27 (0.073) 0.26 (0.082) 0.16 (0.058) 0.49 (\<0.001)\
20 min 0.23 (0.164) 0.16 (0.259) 0.17 (0.092) 0.43 (0.002)\
Visit 3B: 16-hour persistence of action 7 min 0.19 (0.178) 0.22 (0.060) 0.16 (0.078) 0.30 (0.008)
15 min 0.15 (0.436) 0.18 (0.277) 0.27 (0.007) 0.46 (\<0.001)\
20 min 0.15 (0.288) 0.07 (0.728) 0.25 (0.035) 0.29 (0.023)

**Notes:** Values in parentheses represent *P*-values for significance
of mean values for the BBOS 1.5% treatment group (n=70) compared to the
placebo treatment group (n=70) and were derived using observed data only
and applying the Wilcoxon rank-sum test. Measures were considered
statistically significant at a study visit if a majority of time points
exhibited *P*≤0.0125 (visit 5) or *P*≤0.00625 (visit 3B and visit 4).

**Abbreviations:** BBOS, bepotastine besilate ophthalmic solution; CAC,
conjunctival allergen challenge; min, minute(s).:::: ::::table-wrap
::: caption
AEs in the per-protocol population
:::

AEs Placebo (N=70) BBOS 1.5% (N=70)

______________________________________________________________________

Total AEs 10 24
AEs considered related to test agent 3 8
**Ocular AEs**\
Eye irritation 2 3
Foreign body sensation 1 0
Conjunctival cyst 0 1[a](#)
Trace SPK 0 1[a](#)

**Note:**

Adverse event considered unrelated to instillation of test agent.

**Abbreviations:** AE, adverse event; BBOS, bepotastine besilate
ophthalmic solution 1.5%; N, number of subjects; SPK, superficial
punctate keratitis.::::


Extracted trial result:
Outcome: ocular itching for visit 3B at 7 min (continuous)
Intervention: bepotastine besilate ophthalmic solution (BBOS) 1.5%
Comparator: placebo
Intervention group size: 70
Intervention mean: 1.2
Comparator group size: 70
Comparator mean: 2.1
Notes: Original outcome name is "ocular itching". However, due to many different visits and data from timepoints. We specified this in the outcome. Visit 3B was the first study they conducted and 7 min is the last timepoint. No SD information was given