Patent Description:
Neovascular (wet) AMD (nAMD) is a major health issue in aging populations globally. Vision loss in nAMD results from the abnormal growth and leakage of blood vessels in the macula. In elderly patients affected by nAMD, vision loss frequently has an even greater impact, as it substantially reduces the visual compensation of functional impairment by other age-related comorbidities, such as arthritis and osteoporosis.

Intravitreally (IVT) administered anti-vascular endothelial growth factor (VEGF) therapies like EYLEA® inhibit neovascular vessel growth and leakage in the retina, and they are currently the standard-of-care for patients with nAMD. They not only maintain visual function but also provide clinically meaningful visual gains. Treatment of nAMD is chronic and life-long in most patients to suppress retinal edema and recurrences of choroidal neovascularization (CNV). Although the currently approved IVT anti-VEGF therapies are efficacious and well-tolerated, the need for IVT injections every <NUM> to <NUM> weeks, specifically in the initial phase and during maintenance of treatment, represents a significant burden to physicians, patients, and caregivers. While the procedure is straightforward and relatively easy to perform, capacity issues for ensuring an appropriate injection frequency in order to achieve patient outcomes similar to those seen in the pivotal studies represent an increasing challenge to individual practices and the healthcare system, overall. Moreover, high frequency dosing leads to increased burdens on patients, e.g., to find transportation and miss work. A secondary effect of this burden is a lower probability of non-compliance with the prescribed treatment regimen.

While the efficacy and safety of currently approved VEGF antagonist therapies have been established for the treatment of nAMD, there remains an unmet medical need for the development of therapies with the potential to reduce treatment burden while providing at least similar or even improved visual outcomes over currently available standard-of-care.

EYLEA (<NUM> dose, administered at a concentration of <NUM>/mL, also called intravitreal aflibercept injection [IAI]) is currently approved in the United States (US) for the treatment of nAMD, and is also approved for the treatment of macular edema following retinal vein occlusion (RVO), diabetic macular edema (DME), and diabetic retinopathy (DR).

The following documents are also mentioned:.

The present invention provides aflibercept for use in a method for treating an angiogenic eye disorder, in a subject in need thereof, wherein the method comprises administering, intravitreally, to an eye of the subject, a single initial dose of <NUM> ± <NUM> of aflibercept, followed by one or more secondary doses of <NUM> ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose. In one embodiment, aflibercept is for such use wherein the angiogenic eye disorder is e.g., neovascular age-related macular edema (nAMD), diabetic macular edema (DME), diabetic retinopathy (DR), macular edema (ME) secondary to retinal vein occlusion (RVO) (ME-RVO, wherein the method comprises administering, intravitreally, to an eye of the subject (e.g., by intravitreal injection), e.g., in about <NUM>µl, a single initial dose of <NUM> ± <NUM> of aflibercept, followed by one or more secondary doses of <NUM> ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered <NUM> to <NUM> or <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose.

In an embodiment of the invention, wherein, e.g., while receiving such a regimen: (i) with respect to visual acuity or best corrected visual acuity (BCVA), the subject achieves: no loss in visual acuity or BCVA; a gain in visual acuity or BCVA; no loss of visual acuity or BCVA by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM>, following the initial dose wherein visual acuity or BCVA is according to ETDRS or the Snellen equivalent; no loss of visual acuity or BCVA of about <NUM> or more, about <NUM> or more, or about <NUM> or more letters by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM>, following the initial dose wherein visual acuity or BCVA is according to ETDRS or the Snellen equivalent; a gain in visual acuity or BCVA, of about <NUM> or more, about <NUM> or more or about <NUM> or more letters, by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM> following the initial dose, wherein visual acuity or BCVA is according to ETDRS or the Snellen equivalent; and/or a gain in visual acuity or BCVA of about <NUM> or <NUM> or <NUM> letters by about week <NUM> and maintaining a gain of about <NUM> or <NUM> or <NUM> letters until at least about week <NUM> wherein visual acuity or BCVA is according to ETDRS or the Snellen equivalent; (ii) with respect to central retinal thickness (CRT), the subject achieves: a decrease in central retinal thickness; a decrease in central retinal thickness by at least about <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM> micrometers (µm) by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM> following the initial dose; a decrease in central retinal thickness of about <NUM> micrometers from about week <NUM> to about week <NUM> following the initial dose; a decrease in central retinal thickness of about <NUM> micrometers from about week <NUM> to about week <NUM> following the initial dose; a decrease in central retinal thickness of about <NUM> micrometers from about week <NUM> to about week <NUM> following the initial dose; a decrease in central retinal thickness of about <NUM>, <NUM><NUM> micrometers by about week <NUM>, <NUM>, <NUM>, <NUM> or <NUM> following the initial dose and maintaining the decrease until at least about week <NUM> following the initial dose; and/or a reduction in CRT of about <NUM>, <NUM>, <NUM> or <NUM> micrometers by about week <NUM> or <NUM> or <NUM> and maintaining a reduction of about <NUM>, <NUM>, <NUM> or <NUM> micrometers until at least about week <NUM>; (iii) with respect to retinal fluid, the subject achieves: a dry retina having no intraretinal fluid and no subretinal fluid; or no intraretinal fluid; or no subretinal fluid; in the center subfield or macula as measured by spectral domain optical coherence tomography; a dry retina having no intraretinal fluid and no subretinal fluid; or no intraretinal fluid; or no subretinal fluid; in the center subfield as measured by spectral domain optical coherence tomography by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM>, following the initial dose; no SRF and IRF in the macula as measured by SD-OCT by week <NUM> or week <NUM> following the initial dose; no sub-retinal pigment epithelium (RPE) fluid until at least about week <NUM> following the initial dose as measured by spectral domain optical coherence tomography; and/or maintenance of a dry retina once achieved until at least about week <NUM> following the initial dose as measured by spectral domain optical coherence tomography; and/or (iv) the subject achieves: a reduction in total choroidal neovascularization (CNV) lesion size by at least about <NUM> or <NUM> by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM> following the initial dose; no significant increase in intraocular pressure from baseline by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM> or later following the initial dose; and/or no significant increase in systolic (S) and/or diastolic (D) blood pressure from baseline by about week <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM> or later following the initial dose. The scope of the present invention also encompasses aflibercept for use in a method of treating an angiogenic eye disorder in accordance with the present invention, wherein the method achieves any of such achievements in a subject in need thereof who is suffering from an angiogenic eye disorder, by administering the dosing regimen set forth above. For example, in an embodiment of the invention, aflibercept is provided for use in the method for treating an angiogenic eye disorder (e.g., neovascular age-related macular edema, diabetic retinopathy, diabetic macular edema or macular edema following retinal vein occlusion (RVO) ), wherein the method includes administering a single initial dose of aflibercept, followed by one or more secondary doses of aflibercept, followed by one or more tertiary doses of aflibercept; wherein each secondary dose is administered about <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose. In an embodiment of the invention, relative to a subject receiving such a dosing regimen, except that only <NUM> of VEGF antagonist is administered, the subject receiving <NUM> of VEGF antagonist exhibits a greater decrease in central retinal thickness after <NUM>, <NUM>, <NUM>, <NUM> or more weeks; a greater improvement in best corrected visual acuity after <NUM>, <NUM>, <NUM>, <NUM> or more weeks; and/or a greater likelihood of having a dry retina (e.g., lacks intraretinal fluid and/or subretinal fluid) after <NUM>, <NUM>, <NUM>, <NUM> or more weeks. In an embodiment of the invention, <NUM>-<NUM> weeks is <NUM>, <NUM> or <NUM> weeks.

Also disclosed is aflibercept for use in a method for improving best corrected visual acuity, decreasing central retinal thickness and/or achieving a dry retina, in the eye of a subject (e.g., suffering from neovascular age-related macular edema, diabetic retinopathy, diabetic macular edema or macular edema following retinal vein occlusion (RVO)) in need thereof, comprising administering to the eye of the subject, a single initial dose of <NUM> ± <NUM> aflibercept to an eye of the subject, followed by one or more secondary doses of aflibercept, followed by one or more tertiary doses of aflibercept; wherein each secondary dose is administered <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose. Also disclosed is aflibercept for use in a method for promoting retinal drying, in the eye of a subject suffering from an angiogenic eye disorder (e.g., neovascular age-related macular edema, diabetic retinopathy, diabetic macular edema or macular edema following retinal vein occlusion (RVO)), comprising administering to the eye of the subject, a single initial dose of <NUM> ± <NUM> aflibercept, followed by one or more secondary doses of <NUM> ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered about <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered about <NUM> weeks after the immediately preceding dose; for example, wherein retinal drying is characterized by no intraretinal fluid (IRF) and/or no subretinal fluid (SRF) in the eye of the subject, e.g., after the subject has received the three monthly doses of the VEGF antagonist.

In an embodiment of the invention, aflibercept is for use in a method where it is administered to the eye of the subject in a pharmaceutical formulation, for example, which is selected from the formulations comprising aflibercept from the group consisting of A-KKKK as so designated herein. In an embodiment of the invention, the aflibercept is administered to the eye from a syringe, e.g., a pre-filled syringe, (e.g., which is glass, plastic and/or sterile). In an embodiment of the invention, the syringe is characterized by the ornamental design as set forth in International Design Registration No. DM/<NUM><NUM>.

In an embodiment of the invention, a dosage of <NUM> ± <NUM> aflibercept may vary within a given range, e.g., ± about <NUM>, or ± about <NUM>. The volume in which a dose is delivered can be, for example, about <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>-<NUM> microliters and the volume may vary within a given range, e.g., ± about <NUM>, <NUM>, <NUM>, or <NUM> microliters. Doses may be delivered with a dose delivery device (DDD) which is a syringe.

Highly precise doses of aflibercept may be delivered, for example, in a volume that is device-determined. In an embodiment of the invention, aflibercept is for use wherein a dose is delivered with a syringe by a method that includes the steps: (a) withdrawing a plunger rod of the syringe to fill the syringe with the formulation; (b) priming the syringe, thereby removing air from the syringe and, thus avoiding injection of air into the eye, by advancing the plunger rod by a predetermined distance into the syringe body until advancement of the plunger rod is resisted by a stop; (c) rotating the plunger rod about a longitudinal axis; and (d) actuating the plunger rod to dispense a predetermined (device-determined) volume (e.g., about <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>-<NUM> microliters, ± about <NUM>, <NUM>, <NUM>, or <NUM> microliters) of the formulation.

Increasing the molar fraction of VEGF antagonist therapeutic protein in the dosing formulation is a potential way to bring further benefits to patients with chorioretinal vascular diseases, including nAMD. A higher dose of aflibercept administered IVT has the potential to prolong the drug's therapeutic effects and for improvement in pharmacodynamics such as better drying. The resulting extension of treatment intervals early after the initiation of treatment to every <NUM> weeks would reduce the number of injections in the first treatment year. A potential decrease in injection-related treatment burden and safety events with fewer injections could be a significant contribution to patient care and healthcare services. The present invention provides, in part, aflibercept for use in a safe and effective method for treating angiogenic eye disorders with an <NUM> ± <NUM> dose of aflibercept in a regimen calling for monthly loading doses before quarterly maintenance doses. First, patients receiving an <NUM> dose, which is four times the dose approved for Eylea, (<NUM>), were not observed in the CANDELA clinical trial (discussed herein) to develop any more hypertension treatment-emergent adverse events than patients receiving <NUM> (<FIG>). Systemic exposure to VEGF inhibitor is known to be associated with the risk of systemic blood pressure (BP) increases. Moreover, intravitreal injection of VEGF inhibitors has been associated with blood pressure effects. See, for example, <NPL> and <NPL>. In addition, in the CANDELA clinical trial, subjects receiving the <NUM> dose (HD) achieved numerically superior anatomical improvements in the eye as well as numerically superior improvements in vision relative to subjects receiving a <NUM> dose (IAI). A higher proportion of eyes treated with aflibercept <NUM> (HD) were dry (without intraretinal or subretinal fluid on OCT) in the center subfield versus aflibercept <NUM> (IAI). Treatment groups followed identical dosing regimens with the <NUM> group receiving slightly fewer PRN doses. A change from baseline in central retinal thickness (CRT) suggested better anatomic outcomes with aflibercept <NUM> versus aflibercept <NUM>; and a change from baseline in BCVA favored aflibercept <NUM> (+<NUM> vs +<NUM> letters).

The anatomical and visual improvements for the HD patients that was observed was also comparable to those of subjects in the VIEW1 and VIEW2 trials (VIEW1/<NUM>) that received a <NUM> dose every <NUM> weeks (following three monthly loading doses (2q8)). See e.g., <NPL>. The VIEW1/<NUM>2q8 subjects achieved <NUM> letters of BCVA mean improvement at <NUM> weeks following the initial dose (Heier et al. (<NUM>), <FIG>); whereas the CANDELA HD subjects herein were observed to achieve a mean improvement of <NUM> letters at <NUM> weeks (<FIG>). Moreover, the improvements in the central retinal thickness (CRT) that were observed to be achieved by CANDELA HD subjects were comparable to that observed in the VIEW1/<NUM>2q8 subjects. The VIEW1 2q8 subjects achieved a mean reduction of about <NUM> micrometers in CRT and VIEW2 2q8 subjects achieved about <NUM> micrometers mean reduction in CRT, at <NUM> weeks (Heier et al. (<NUM>), <FIG>). The CANDELA HD subjects were observed to achieve a mean reduction of <NUM> micrometers and a median reduction of <NUM> micrometers at <NUM> weeks (<FIG> & <FIG>; and Heier et al. (<NUM>), <FIG>). While the 2q8 VIEW1/<NUM> subjects and the CANDELA HD subjects were not evaluated side-by-side in the same clinical trial and the VIEW trials had a greater number of participants, these data suggest that subjects can be administered <NUM> doses of aflibercept as infrequently as every <NUM> weeks yet achieve anatomic and visual outcomes comparable to that of patients dosed every <NUM> weeks (following three monthly loading doses) with <NUM>. While the VIEW1/<NUM> subjects received only the scheduled doses within the first year, some of the CANDELA subjects received additional doses pro re nata after week <NUM> (<FIG>). Twenty eight out of <NUM> of the CANDELA HD subjects did not receive any additional doses (<FIG>). Moreover, time-domain optical coherence tomography was performed in VIEW1/<NUM> to evaluated CRT whereas, a more sensitive spectral domain optical coherence tomography (SD-OCT) was used in CANDELA.

"Isolated" VEGF antagonists and VEGF receptor fusion proteins (e.g., aflibercept), polypeptides, polynucleotides and vectors, are at least partially free of other biological molecules from the cells or cell culture from which they are produced. Such biological molecules include nucleic acids, proteins, other VEGF antagonists and VEGF receptor fusion proteins, lipids, carbohydrates, or other material such as cellular debris and growth medium. An isolated VEGF antagonist or VEGF receptor fusion protein may further be at least partially free of expression system components such as biological molecules from a host cell or of the growth medium thereof. Generally, the term "isolated" is not intended to refer to a complete absence of such biological molecules (e.g., minor or insignificant amounts of impurity may remain) or to an absence of water, buffers, or salts or to components of a pharmaceutical formulation that includes the VEGF antagonists or VEGF receptor fusion proteins.

A "subject" or "patient" is a mammal, for example a human, mouse, rabbit, monkey or non-human primate. A subject or patient may be said to be "suffering from" an angiogenic eye disorder such as nAMD, DR or DME. Such a subject has the disorder in one or both eyes. In an embodiment of the invention, a subject or patient has one or more of the following characteristics (at or before the start of treatment):.

The present invention provides aflibercept for use in treating angiogenic eye disorders. Aflibercept is a VEGF antagonist. VEGF antagonists include molecules which interfere with the interaction between VEGF and a natural VEGF receptor, e.g., molecules which bind to VEGF or a VEGF receptor and prevent or otherwise hinder the interaction between VEGF and a VEGF receptor. Specific, exemplary VEGF antagonists include anti-VEGF antibodies, anti-VEGF receptor antibodies, and VEGF receptor fusion proteins.

For purposes herein, a "VEGF receptor fusion protein" refers to a molecule that comprises one or more VEGF receptors or domains thereof, fused to another polypeptide, which interferes with the interaction between VEGF and a natural VEGF receptor, e.g., wherein two of such fusion polypeptides are associated thereby forming a homodimer or other multimer. Such VEGF receptor fusion proteins may be referred to as a "VEGF-Trap" or "VEGF Trap". VEGF receptor fusion proteins within the context of the present disclosure that fall within this definition include chimeric polypeptides which comprise two or more immunoglobulin (Ig)-like domains of a VEGF receptor such as VEGFR1 (also known as Flt1) and/or VEGFR2 (also known as Flk1 or KDR), and may also contain a multimerizing domain (for example, an Fc domain).

An exemplary VEGF receptor fusion protein is a molecule referred to as VEGF1R2-FcΔC1(a) which is encoded by the nucleic acid sequence of SEQ ID NO:<NUM> or nucleotides <NUM>-<NUM> or <NUM>-<NUM> thereof.

VEGF1R2-FcΔC1(a) comprises three components:.

If the multimerizing component (MC) of a VEGF receptor fusion protein is derived from an IgG (e.g., IgG1) Fc domain, then the MC has no fewer amino acids than are in amino acids <NUM> to <NUM> of SEQ ID NO:<NUM>. Thus, the IgG of the MC cannot be truncated to be shorter than <NUM> amino acids.

In an embodiment of the invention, the VEGF receptor fusion protein comprises amino acids <NUM>-<NUM> or <NUM>-<NUM> of SEQ ID NO: <NUM>. <IMG>
<IMG>
<IMG>.

In an embodiment of the invention, aflibercept is N-glycosylated at any one or more of Asparagines <NUM>, <NUM>, <NUM>, <NUM> and <NUM>.

Also disclosed is a VEGF receptor fusion protein that comprises.

Also disclosed is a VEGF receptor fusion protein that has the following arrangement of said domains:.

Also disclosed are high concentration formulations including, instead of a VEGF receptor fusion protein, a VEGF binding molecule or anti-VEGF antibody or antigen-binding fragments thereof or biopolymer conjugate thereof (e.g., KSI-<NUM>) and uses thereof as discussed, e.g.,.

In order to minimize repetitiveness, also disclosed are any of the formulations discussed herein that include, in place of a VEGF receptor fusion protein, an anti-VEGF antibody or antibody fragment or other VEGF binding molecule as discussed herein (e.g., substituted with an anti-VEGF DARPin) at any of the concentrations discussed herein. For example, also disclosed is a formulation having <NUM> or <NUM>/ml ranibizumab, a buffer, a thermal stabilizer, a viscosity reducing agent and a surfactant.

DARPins are Designed Ankyrin Repeat Proteins. DARPins generally contain three to four tightly packed repeats of approximately <NUM> amino acid residues, with each repeat containing a β-turn and two anti-parallel α-helices. This rigid framework provides protein stability whilst enabling the presentation of variable regions, normally comprising six amino acid residues per repeat, for target recognition.

An "anti-VEGF" antibody or antigen-binding fragment of an antibody refers to an antibody or fragment that specifically binds to VEGF.

Illustrative VEGF receptor fusion proteins include aflibercept (EYLEA®, Regeneron Pharmaceuticals, Inc. ) or conbercept (sold commercially by Chengdu Kanghong Biotechnology Co. See <CIT> or <CIT>. The terms "aflibercept" and "conbercept" include biosimilar versions thereof. A biosimilar version of a reference product (e.g., aflibercept) generally refers to a product comprising the identical amino acid sequence but includes products which are biosimilar under the U. Biologics Price Competition and Innovation Act.

The present invention provides aflibercept for use in a method for treating an angiogenic eye disorder, in a subject in need thereof, wherein the method comprises administering, intravitreally, to an eye of the subject, a single initial dose of <NUM> ± <NUM> of aflibercept, followed by one or more secondary doses of <NUM> ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose.

The present invention includes aflibercept for use in methods in which the aflibercept that is administered to the patient's eye is contained within a pharmaceutical formulation. The pharmaceutical formulation includes aflibercept along with a pharmaceutically acceptable carrier. Other agents may be incorporated into the pharmaceutical formulation to provide improved transfer, delivery, tolerance, and the like. The term "pharmaceutically acceptable" means approved by a regulatory agency of the Federal or a state government or listed in the U. Pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly, in humans. The term "carrier" refers to a diluent, adjuvant, excipient, or vehicle with which the VEGF antagonist is administered. A multitude of appropriate formulations can be found in the formulary known to all pharmaceutical chemists: <NPL>), e.g., Chapter <NUM> by Blaug, Seymour, therein.

Pharmaceutical formulations for use in the present invention can be "high concentration". High concentration pharmaceutical formulations of the present invention include aflibercept, at a concentration of greater than <NUM>/ml, at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, of at least <NUM>/ml, or of at least <NUM>/ml. "High concentration" can refer to formulations that include a concentration of aflibercept of from about <NUM>/ml to about <NUM>/ml, at least about <NUM>/ml but less than <NUM>/ml, from about <NUM>/ml to about <NUM>/ml, from about <NUM>/ml to about <NUM>/ml or from about <NUM>/ml to about <NUM>/ml. In some aspects, the aflibercept concentration in the formulation is about any of the following concentrations: <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml, <NUM>/ml, <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml, <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; <NUM>/ml; or <NUM>/ml. Other aflibercept concentrations are contemplated herein, as long as the concentration functions in accordance with embodiments herein.

In an embodiment of the invention, a pharmaceutical formulation for use in a method of the present invention is of such a concentration as to contain <NUM> ± <NUM> aflibercept, in about <NUM>µl or less, about <NUM>µl or less or about <NUM>µl or less, e.g., about <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; or <NUM>µl.

The present invention includes aflibercept for use in methods (as discussed herein), wherein the methods use any of the formulations set forth under "Illustrative Formulations" herein, but wherein the concentration of the aflibercept is substituted with a concentration which is set forth in this section ("VEGF Receptor Fusion Proteins and Other VEGF inhibitors").

Buffers for use in pharmaceutical formulations herein may refer to solutions that resist pH change by use of acid-base conjugates. Buffers are capable of maintaining pH in the range of from about <NUM> to about <NUM>, and more typically, from about <NUM> to about <NUM>, and most typically, from about <NUM> to about <NUM>. In some cases, the pH of the formulation of the present invention is about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, or about <NUM>. Example buffers for inclusion in formulations herein include histidine-based buffers, for example, histidine, histidine hydrochloride, and histidine acetate. Buffers for inclusion in formulations herein can alternatively be phosphate-based buffers, for example, sodium phosphate, acetate-based buffers, for example, sodium acetate or acetic acid, or can be citrate-based, for example, sodium citrate or citric acid. It is also recognized that buffers can be a mix of the above, as long as the buffer functions to buffer the formulations in the above-described pH ranges. In some cases, the buffer is from about <NUM> to about <NUM>, or more typically, about <NUM> to about <NUM>. Buffers can be about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, or about <NUM>.

In an embodiment of the invention, a histidine-based buffer is prepared using histidine and histidine monohydrochloride.

Surfactant for use herein refers to ingredients that protect the higher concentration of aflibercept, from various surface and interfacial induced stresses. As such, surfactants can be used to limit or minimize aflibercept aggregation and promote protein solubility. Suitable surfactants herein have been shown to be non-ionic, and can include surfactants that have a polyoxyethylene moiety. Illustrative surfactants in this category include: polysorbate <NUM>, polysorbate <NUM>, poloxamer <NUM>, polyethylene glycol <NUM>, and mixtures thereof. Surfactants in the formulations can be present at from about <NUM>% to about <NUM>% weight per volume (w/v), and more typically, about <NUM>% to about <NUM>% (w/v). In some cases, the surfactant is about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), or about <NUM>% (w/v).

Thermal stabilizers for use in pharmaceutical formulations that may be used in methods set forth herein refers to ingredients that provide thermal stability against thermal denaturation of the aflibercept, as well as protect against loss of aflibercept potency or activity. Suitable thermal stabilizers include sugars, and can be sucrose, trehalose, sorbitol or mannitol, or can be amino acids, for example L-proline, L-arginine (e.g., L-arginine monohydrochloride), or taurine. Additionally, thermal stabilizers may also include substituted acrylamides or propane sulfonic acid, or may be compounds like glycerol.

In some cases, the pharmaceutical formulations for use in a method herein include both a sugar and taurine, a sugar and an amino acid, a sugar and propane sulfonic acid, a sugar and taurine, glycerol and taurine, glycerol and propane sulfonic acid, an amino acid and taurine, or an amino acid and propane sulfonic acid. In addition, formulations can include a sugar, taurine and propane sulfonic acid, glycerol, taurine and propane sulfonic acid, as well as L-proline, taurine and propane sulfonic acid.

Embodiments herein may have thermal stabilizers present alone, each independently present at a concentration of, or present in combination at a total concentration of, from about <NUM>% (w/v) to about <NUM>% (w/v) or <NUM>% (w/v) to about <NUM>% (w/v), or about <NUM>% (w/v) to about <NUM>% (w/v), or about <NUM>% (w/v) to about <NUM>% (w/v). Thermal stabilizers in the formulation can be at a concentration of about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v), about <NUM>% (w/v) or about <NUM>% (w/v).

With respect to taurine and propane sulfonic acid, in an embodiment of the invention, these thermal stabilizers can be present in the formulations at about from <NUM> to about <NUM>, and more typically from about <NUM> to about <NUM> (as compared to the other thermal stabilizers).

Viscosity reducing agents typically are used to reduce or prevent protein aggregation. Viscosity reducing agents for inclusion herein include: sodium chloride, magnesium chloride, D- or L-arginine (e.g., L-arginine monohydrochloride), lysine, or mixtures thereof. When present herein, viscosity reducing agents can be present at from about <NUM> to about <NUM>, and more typically from about <NUM> to about <NUM>, and even more typically from about <NUM> to about <NUM>. In some cases, the viscosity reducing agent is present at about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM>, about <NUM> or about <NUM>.

Pharmaceutical formulations for use in a method as set forth herein can also have a pharmaceutically acceptable viscosity for ocular administration, for example, intravitreal injection. Viscosity generally refers to the measure of resistance of a fluid which is being deformed by either shear stress or tensile stress (typically measured by techniques known in the art, viscometer or rheometer, for example). Typical viscosities of formulations for use in a method set forth herein are from about <NUM> cP (centipoise) to about <NUM> cP, from about <NUM> cP to about <NUM> cP, from about <NUM> cP to about <NUM> cP or from about <NUM> cP to about <NUM> cP. As such, formulation viscosity herein can be about <NUM> cP, about <NUM>, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, about <NUM> cP, or about <NUM> cP (e.g., when measured at <NUM>).

Various embodiments herein do not require inclusion of an inorganic salt, or other viscosity reducing agent, to maintain these highly useful viscosities. Typically, high concentration protein solutions require viscosity reducing agents to avoid protein aggregation and higher viscosity, making the formulations difficult for intravitreal injection and reducing the potency of the aflibercept. As such, embodiments herein include methods of using formulations that have had substantially no, or no added, sodium chloride (NaCl), magnesium chloride (MgCl<NUM>), D- or L-arginine hydrochloride, lysine or other viscosity reducing agent.

Osmolality is a critical attribute for injectable pharmaceutical formulations for use in a method of the present invention. It is desirable to have products match physiological osmotic conditions. Furthermore, osmolality provides confirmation of soluble content in solution. In an embodiment of the invention, the osmolality of a formulation for use in the present invention is less than or equal to about <NUM> mmol/Kg or from about <NUM> to about <NUM> mmol/Kg. , e.g., about <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM> or <NUM> mmol/Kg. In an embodiment of the invention, the osmolality is lower than about <NUM> mmol/Kg.

Illustrative pharmaceutical formulations for use in the present invention include those of the following formulations that include aflibercept:.

In an embodiment of the invention aflibercept is for use wherein the formulation that can be administered intravitreally to a subject is an aqueous pharmaceutical formulation comprising:.

The present invention provides aflibercept for use in a method for treating an angiogenic eye disorder, in a subject in need thereof, wherein the method comprises administering, intravitreally, to an eye of the subject, a single initial dose of <NUM> ± <NUM> of aflibercept, followed by one or more secondary doses of <NUM> ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose. In one embodiment, the present invention provides aflibercept for use in treating angiogenic eye disorders, wherein the one or more secondary doses are administered every <NUM>-<NUM> weeks. For example, in an embodiment of the invention, aflibercept is provided for use in treating angiogenic eye disorders, such as diabetic retinopathy, diabetic macular edema or neovascular AMD, wherein the aflibercept is provided by administering intravitreally, sequentially, two or more (e.g., <NUM>, <NUM> or <NUM>) doses of <NUM> ± <NUM> of aflibercept about every month (or about every <NUM> days, <NUM> ± <NUM> days or about every <NUM> weeks), followed by one or more doses of <NUM> ± <NUM> of aflibercept (e.g., ≥ about <NUM>) every <NUM> weeks. Each dose of aflibercept is <NUM> ± <NUM> of aflibercept (which is <NUM> ± <NUM>% or in other words <NUM>-<NUM>). In an embodiment of the invention, a dose of aflibercept is <NUM> or <NUM>.

The terms "initial dose," "secondary doses," and "tertiary doses," refer to the temporal sequence of administration of the aflibercept. Thus, the "initial dose" is the dose which is administered at the beginning of the treatment regimen (also referred to as the "baseline dose"); the "secondary doses" are the doses which are administered after the initial dose; and the "tertiary doses" are the doses which are administered after the secondary doses. The initial dose occurs on day <NUM> for the purposes of counting or numbering days thereafter (see e.g., Tables <NUM>-<NUM> and <NUM>-<NUM> herein). The initial, secondary, and tertiary doses may all contain the same amount of aflibercept, but will generally differ from one another in terms of frequency of administration. In certain embodiments, however, the amount of aflibercept contained in the initial, secondary and/or tertiary doses will vary from one another (e.g., adjusted up or down as appropriate) during the course of treatment, provided it is <NUM> ± <NUM> of aflibercept. Thus, a dosing regimen of the present invention may be expressed as follows:.

The present invention includes aflibercept for use in methods wherein one or more additional, non-scheduled, pro re nata (PRN) doses, in addition to any of the scheduled initial, secondary and/or tertiary doses of aflibercept are administered to a subject. Such PRN doses are typically administered at the discretion of the treating physician depending on the particular needs of the subject.

optionally wherein the subject receives doses, earlier in the regimen, in one pharmaceutical formulation and additional doses, later in the regimen, in a different pharmaceutical formulation, for example, comprising a different buffer (e.g., wherein one or more of the secondary doses are in one pharmaceutical formulation and the tertiary doses are in a different pharmaceutical formulation).

Dosing every "month" refers to dosing about every <NUM> days, about every <NUM> weeks, or about every <NUM> ± <NUM> days and may encompass up to every <NUM> weeks. Dosing every "<NUM> weeks" refers to dosing about every <NUM> days, about every month or about every <NUM> ± <NUM> days, and may encompass up to every <NUM> weeks.

Dosing every "<NUM>-<NUM> weeks" refers to dosing about every <NUM> weeks, <NUM> weeks or <NUM> weeks. Dosing every "<NUM> weeks" refers to dosing about every <NUM> months, about every <NUM> days, <NUM> ± <NUM> days.

Dosing every "<NUM> weeks" refers to dosing about every <NUM> months, about every quarter year, about every <NUM>, <NUM> days, <NUM> ± <NUM> days, or <NUM> ± <NUM> days.

A dose of <NUM> ± <NUM> of aflibercept includes <NUM>; <NUM>-<NUM>; <NUM>; <NUM>; <NUM>; <NUM>; <NUM>; <NUM>; <NUM>; <NUM>; <NUM>; or <NUM> (± about <NUM>%, ± about <NUM>, or ± about <NUM> of any of the foregoing provided that the dose is still <NUM> ± <NUM> of aflibercept). In an embodiment of the invention, aflibercept is for use wherein a dosage of <NUM> ± <NUM> of aflibercept is administered in a dose having a volume of about <NUM>µl or less, about <NUM>µl or less or about <NUM>µl or less, e.g., about <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>-87µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; <NUM>µl; or <NUM>µl (± about <NUM>, <NUM>, <NUM>, or <NUM> microliters).

Any dosing frequency specified herein may, in an embodiment of the invention, be expressed as the specific frequency "± <NUM> days" (e.g., where "<NUM> weeks" is stated, the present invention also includes embodiments such as <NUM> weeks ± <NUM> days).

"Sequentially administering" means that each dose of aflibercept is administered to the eye of a patient at a different point in time, e.g., on different days separated by a predetermined interval (e.g., hours, days, weeks or months). The present invention includes aflibercept for use in methods which comprise sequentially administering, to the eye of a patient, a single initial dose of <NUM> ± <NUM> aflibercept, followed by one or more secondary doses of <NUM> ± <NUM> aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> aflibercept.

An effective or therapeutically effective dose of aflibercept, for use in treating an angiogenic eye disorder refers to the amount of VEGF antagonist sufficient to alleviate one or more signs and/or symptoms of the disease or condition in the treated subject, whether by inducing the regression or elimination of such signs and/or symptoms or by inhibiting the progression of such signs and/or symptoms. In an embodiment of the invention, an effective or therapeutically effective dose of aflibercept is <NUM> ± <NUM> of aflibercept every month followed by once every <NUM> weeks.

An "angiogenic eye disorder" means any disease of the eye which is caused by or associated with the growth or proliferation of blood vessels or by blood vessel leakage. Non-limiting examples of angiogenic eye disorders that are treatable or preventable using the present invention include:.

In an embodiment of the invention, a subject receiving a treatment for an angiogenic eye disorder as set forth herein (e.g., three monthly doses of <NUM> ± <NUM> of aflibercept followed by doses of <NUM> ± <NUM> of aflibercept every <NUM> weeks) achieves one or more of the following:.

The center subfield of the retina is a <NUM> diameter area around the macula. The macula itself is about <NUM> in diameter.

The present invention also includes aflibercept for use in methods for achieving any one or more of the foregoing in a subject (e.g., increase in VA or BCVA, or decrease in CRT) suffering from an angiogenic eye disorder, e.g., nAMD, DR or DME, comprising administering intravitreally to an eye of the subject, a single initial dose of <NUM> ± <NUM> of aflibercept, followed by one or more (e.g., <NUM>, <NUM> or <NUM>) secondary doses of <NUM> ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered about <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered about <NUM> weeks after the immediately preceding dose.

The present invention includes aflibercept for use in treating an angiogenic eye disorder (e.g., nAMD, DR, DME or ME-RVO), in a subject in need thereof, comprising administering intravitreally to an eye of the subject, a single initial dose of <NUM> ± <NUM> of aflibercept, followed by one or more secondary doses of8 mg ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose; wherein the subject achieves a change in central retinal thickness, from baseline at the initiation of treatment, as depicted in <FIG> or <FIG> (or a greater reduction), e.g., by the timepoint shown for such a change; and/or wherein the subject achieves a change in central retinal thickness, during the time period as set forth in the inset box of <FIG> (or a greater reduction),
and/or.

Best corrected visual acuity (BCVA) can be measured in various methods known in the art. First, determining the proper level of lens refraction needed to best correct the visual acuity (VA) of a subject is determined before testing best corrected visual acuity (BCVA) with a visual acuity chart.

Two separate VA charts used for testing the right and left eye (e.g., Sloan Letter ETDRS Chart <NUM> and Sloan Letter ETDRS Chart <NUM>, respectively), and a third refraction chart is used for testing appropriate refraction (e.g., Sloan Letter ETDRS Chart R). The features of the Sloan charts are high-contrast Sloan letters of equal difficulty, <NUM> letters in each of <NUM> rows, and a geometric progression of letter size (and, thus, an arithmetic progression of the logarithm of minimum angle of resolution [LogMAR]) from row to row. The charts have different letter sequences.

There are three basic components to determining refraction according to ETDRS protocol-determining spherical power, determining cylindrical axis and determining cylindrical power using methods known by practitioners in the art. For assessing refraction, if the subject wears contact lenses and has glasses, he or she should be told not to wear the contact lenses on the day of the examination or remove them <NUM>-<NUM> minutes before refraction is done. A trial frame is placed and adjusted on the subject's face so that lens cells placed in the frame are parallel to the anterior plane of the orbits and centered in front of the pupils. (It is permissible to use a phoroptor for subjective refraction. However, for testing visual acuity, the lenses from the final phoroptor refraction must be placed in a frame, and the final sphere must be rechecked).

BCVA can be measured first in one eye with a visual acuity chart, and then in the other eye with another visual acuity chart (e.g., Charts <NUM> and <NUM> as discussed herein), wherein each chart remains hidden from view until the eye in question is ready for testing. The distance from the subject's eyes to the visual acuity chart is typically <NUM> meters (<NUM> feet and <NUM> inches, or <NUM> inches). The subject should be asked to read slowly (e.g., at a rate not faster than about one letter per second). Eyes reading <NUM> or fewer letters correctly at <NUM> meters can be tested at <NUM> meter.

Two commonly used tools for testing visual acuity (VA) or BCVA include the Snellen and the Early Treatment Diabetic Retinopathy Study (ETDRS) VA charts (<NPL>; <NPL>; <NPL>; <NPL>.

(<NUM>); <NPL>). A version of the Bailey-Lovie chart (<NPL>) was modified in <NUM> based on the recommendations of the Committee on Vision of the National Academy of Sciences, National Research Council, and Working Group <NUM>, and by Dr. Rick Ferris for use in the Early Treatment Diabetic Retinopathy Study (ETDRS). The "ETDRS chart" and the protocol to test vision with the chart is commonly used in clinical trials. The ETDRS chart is typically tested from a shorter distance (<NUM> feet (or <NUM> meters) rather than <NUM> feet) than Snellen, but does not allow the use of mirrors to simulate the correct distance, has the same amount of letters in every row (five letters each), and has an equal spacing of both the letters and the rows on a logarithmic scale. The Snellen Chart uses a geometric scale to measure visual acuity, with normal vision at a distance being set at <NUM>/<NUM>. In an embodiment of the invention, VA or BCVA can be expressed in terms of ETDRS or Snellen. ETDRS VA values can be converted to a corresponding Snellen equivalent using methods known in the art. In an embodiment of the invention, VA or BCVA is measured with an ETDRS chart or with a Snellen chart.

The present invention provides aflibercept for use methods as set forth herein wherein aflibercept is delivered with a high amount of precision, e.g., with a drug delivery device (DDD) (e.g., with a <NUM> volume), whether pre-filled or capable of being filled from a vial, and delivering a volume of between <NUM> and <NUM> microliter with an average volume of about <NUM> or <NUM> or <NUM>-<NUM> microliters, e.g., with a standard deviation of about <NUM> or <NUM> or <NUM>-<NUM> microliters (e.g., about <NUM> or <NUM> microliters) or less. In an embodiment of the invention, the DDD is a syringe, e.g., with a <NUM> gauge, ½ inch needle.

One means for ensuring precision of a dose to be delivered with a device, such as a syringe, is by employing a syringe wherein the dose volume is device-determined. If the dose volume is device-determined, the device is designed only to deliver a single volume (e.g., <NUM> microliters) or a single volume with a limited amount of acceptable error (± <NUM>-<NUM> microliters). Thus, if used properly, the user cannot deliver the wrong dose (e.g., cannot deliver more than the intended volume from the device).

The present invention includes embodiments wherein aflibercept is for use wherein a precise dosage of <NUM> ± <NUM> of aflibercept (e.g. ± <NUM>, or ± <NUM>) is delivered intravitreally to a subject's eye. The volume in which a dose is delivered can be, for example, about <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>-<NUM> microliters ± about <NUM>, <NUM>, <NUM>, or <NUM> microliters. Doses may be delivered with a dose delivery device (DDD) which is a syringe.

Highly precise doses of aflibercept may be delivered, for example, in a volume that is device-determined (wherein the device is a syringe), by a method that includes the steps: (a) priming the syringe (e.g., a pre-filled syringe), thereby removing air from the syringe and, thus avoiding injection of air into the eye, by advancing the plunger rod by a predetermined distance into the syringe body until advancement of the plunger rod is resisted by a stop; (b) rotating the plunger rod about a longitudinal axis; and (c) actuating the plunger rod to dispense a predetermined (device-determined) volume (e.g., about <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>, <NUM>-<NUM> microliters, ± about <NUM>, <NUM>, <NUM>, or <NUM> microliters) of the formulation.

In an embodiment of the invention, aflibercept is for use wherein the drug delivery device (DDD), comprises:.

wherein rotation of the pinion against the rack moves at least a part of the plunger rod along the longitudinal axis of the barrel; for example, which further comprises a shaft affixed to the pinion, wherein rotation of the shaft rotates the pinion against the rack which may include a knob affixed to the shaft. In an embodiment of the invention, the DDD further includes a magnifier disposed on the distal end region of the barrel. In an embodiment of the invention, the DDD further includes a stopper inside the barrel, wherein the stopper is affixed to a distal end of the plunger rod. In an embodiment of the invention, the DDD further includes a circular ratchet disposed coaxially with the pinion, wherein the circular ratchet has a diameter smaller than a diameter of the pinion; a spring-loaded pawl disposed on an internal circumference of the pinion, wherein the pawl is configured to engage the ratchet; and a shaft affixed to the ratchet, wherein rotation of the shaft in one direction causes rotation of the pinion, and rotation of the shaft in a second direction does not cause rotation of the pinion for example wherein the ratchet is disposed inside the pinion. In an embodiment of the invention, the pinion includes a plurality of teeth having a first height, and a stopper tooth having a second height greater than the first height, for example, wherein the second height of the stopper tooth prevents the pinion from engaging the plurality of teeth of the rack, and/or wherein the second height of the stopper tooth is configured to contact one of the plunger rod and the rack to stop rotation of the pinion. In an embodiment of the invention, the plunger rod includes an inner column and an outer lumen, and wherein the rack is disposed on the inner column, e.g., wherein rotation of the pinion against the rack moves the inner column of the plunger rod independently of the outer lumen, and/or further including a shaft removably affixed to the pinion, wherein the shaft prevents movement of the outer lumen of the plunger rod relative to the barrel, and wherein removal of the shaft allows for movement of the outer lumen of the plunger rod relative to the barrel. In an embodiment of the invention, the plunger rod further includes a body and a flange, the flange extending partially along a longitudinal length of the body and having a width greater than a width of the body; wherein the barrel further comprises a plunger lock, the plunger lock including a through hole configured to allow the flange to pass through the second plunger lock in a specific orientation.

wherein rotation of the plunger rod about the longitudinal axis of the drug delivery device moves the plunger rod along the longitudinal axis. In an embodiment of the invention, the plunger rod further includes a tab protruding from the plunger rod in a first direction and located proximally from the threaded region of the plunger rod, and wherein the threaded region in the interior of the barrel further includes a slot sized and configured to allow for the tab to pass through the threaded region in the interior of the barrel, e.g., wherein the slot includes a first segment parallel to the longitudinal axis of the drug delivery device and a second segment perpendicular to the longitudinal axis of the drug delivery device-the slot may include a third segment parallel to the longitudinal axis of the drug delivery device, wherein the second segment is in between the first segment and the third segment. In an embodiment of the invention, the tab is a first tab, and wherein the plunger rod further includes a second tab protruding from the plunger rod in a second direction opposite to the first direction, and wherein the threaded region in the interior of the barrel further includes a second slot sized and configured to allow for the second tab to pass through the threaded region in the interior of the barrel.

In an embodiment of the invention, aflibercept is for use wherein the drug delivery device, includes:.

wherein rotation of the sleeve in a first direction around a longitudinal axis of the drug delivery device moves the sleeve towards the distal end region of the barrel. In an embodiment of the invention, rotation of the sleeve in the first direction moves the stopper towards the distal end region of the barrel. In an embodiment of the invention; the sleeve includes an inner passage, and the stopper has a diameter larger than a diameter of the inner passage; and/or the sleeve includes a tab disposed on an exterior of the sleeve, the tab located proximally from the threaded region of the barrel interior, and wherein the tab stops movement of the sleeve towards the distal end region of the barrel, e.g., wherein the tab is configured to stop movement of the sleeve towards the distal end region of the barrel after the drug delivery device has been primed or wherein the tab is a first tab, and wherein the sleeve further includes a second tab disposed on an exterior of the sleeve, the second tab located distally from the threaded region of the barrel interior, wherein the second tab stops movement of the sleeve towards the proximal end region of the barrel.

In an embodiment of the invention, the drug delivery device, comprises:.

For example, in an embodiment of the invention, the first plunger lock is removable and/or frangible. In an embodiment of the invention, a distance between the first plunger lock and the second plunger lock is equivalent to the distance that the stopper must travel to prime the drug delivery device; and/or the plunger rod is rotatable around a longitudinal axis of the drug delivery device.

Substances from such a DDD (e.g., a formulation including aflibercept as described herein), having a plunger rod and a barrel, may be dispensed as follows:.

Advancing the plunger rod may include the step of rotating a pinion against a rack disposed on the plunger rod, e.g., wherein the stop comprises a shaft removably affixed to the pinion, and wherein deactivating the stop comprises removing the shaft from the pinion. Deactivating the stop may include the step of rotating the plunger rod. In an embodiment of the invention, deactivating the stop includes the step of removing the lock and/or breaking the lock.

for example, wherein the teeth of the pinion are further configured to engage with the plurality of teeth of the rack disposed on the barrel. In an embodiment of the invention, the pinion is a first pinion, and further includes: a second pinion disposed coaxially with the first pinion, the second pinion having a diameter smaller than a diameter of the first pinion and a plurality of teeth configured to engage with the plurality of the teeth of the rack disposed on the barrel, wherein rotation of the first pinion results in rotation of the second pinion against the rack disposed on the barrel and in movement of the inner plunger along the longitudinal axis of the barrel.

See International patent application publication no.

In an embodiment of the invention, aflibercept is for use wherein the drug delivery device (DDD), includes:.

wherein, when the protrusion is in a first position relative to the blocking component, the blocking component restricts distal movement of the plunger rod to a first stopping point, and when the protrusion is in a second position relative to the blocking component, the blocking component restricts distal movement of the plunger rod to a second stopping point. In an embodiment of the invention, the DDD further includes: a stopper disposed in the body, wherein distal movement of the plunger rod distally moves the stopper; and a drug substance disposed in the body in between the stopper and a distal end of the body, wherein distal movement of the plunger rod to the first stopping point primes the drug delivery device, and distal movement of the plunger rod to the second stopping point dispenses a predetermined volume of the drug substance from a distal end of the device. In an embodiment of the invention, moving the protrusion from the first position to the second position includes twisting the plunger rod relative to the blocking component. In an embodiment of the invention, the DDD further includes: a cavity in a proximal side of the blocking component, the cavity sized and configured to receive a portion of the protrusion, wherein when the protrusion is in the second position relative to the blocking component, the protrusion is positioned proximally from the cavity, such that distal movement of the plunger rod moves the protrusion into the cavity; e.g., wherein the cavity is a first cavity, and further includes: a second cavity in a proximal side of the blocking component, the second cavity sized and configured to receive a portion of the protrusion, wherein the first and second cavity are located on opposite sides of a central longitudinal axis of the drug delivery device. In an embodiment of the invention, the plunger rod passes through an opening in the blocking component. In an embodiment of the invention the DDD further includes an actuation portion at a proximal end portion of the plunger rod, wherein the protrusion extends from the actuation portion, e.g., wherein the actuation portion includes a generally cylindrical shape having a diameter greater than a width of the remainder of the plunger rod, wherein the protrusion extends from a side of the generally cylindrical shape, and wherein the actuation portion further comprises: a thumb pad on a proximal end of the actuation portion; and a ring on an exterior surface on the side of the generally cylindrical shape; e.g., further including a proximal collar on the blocking component, wherein the actuation portion partially fits inside the proximal collar; e.g., wherein the plunger rod further includes a pair of extensions protruding distally from the actuation portion and the blocking component (e.g., which includes one or more indents formed along a bottom wall of the blocking component; and wherein a portion of each extension is configured to be received by the one or more indents upon distal movement of the plunger rod relative to the blocking component to allow distal movement of the plunger rod to the second stopping point; or, which includes one or more indents formed along a bottom wall of the blocking component; and wherein a portion of each extension is configured to be received by the one or more indents upon distal movement of the plunger rod relative to the blocking component to allow distal movement of the plunger rod to the second stopping point; or, which includes a pair of internal grooves formed along a sidewall of the blocking component; and wherein a portion of each extension is configured to be received by at least one of the pair of internal grooves upon rotation of the plunger rod relative to the blocking component to expand the extensions radially-outward from a compressed state to a relaxed state) includes a pair of openings; and wherein a portion of each extension is configured to be received by one of the pair of openings in the first stopping point. In an embodiment of the invention, the protrusion is a first protrusion, and further includes a second protrusion extending from the plunger rod in a direction opposite to the first protrusion. In an embodiment of the invention, the blocking component is slidably coupled to the body and includes a third cavity and a pair of ribs that extend into the third cavity, wherein the body includes a top flange and the pair of ribs are configured to engage the top flange received in the third cavity; wherein the pair of internal ribs are configured to apply a distally-directed force onto the top flange. In an embodiment of the invention, the blocking component is slidably coupled to the body and includes a pair of movable tabs that are configured to engage the body; and the pair of movable tabs are laterally deflectable upon receiving the body in the blocking component and are configured to apply a radially-inward directed force onto the body. In an embodiment of the invention, the blocking component further includes a pair of finger flanges, and each of the finger flanges includes a textured surface having a predefined pattern that increases a grip of the blocking component.

wherein, when the protrusions and the slots are in a first configuration relative to one another, the blocking component restricts distal movement of the plunger rod to a first stopping point, and when the protrusions and the slots are in a second configuration, the blocking component restricts distal movement of the plunger rod to a second stopping point, wherein, in the second configuration, the slots are configured to receive the protrusions upon distal movement of the plunger rod. In an embodiment of the invention, the protrusions and the slots are movable from the first configuration to the second configuration by rotation of the actuation portion about a longitudinal axis in relation to the blocking component, and wherein when the protrusions and the slots are in the second configuration, the protrusions and the slots are not movable to the first configuration; and/or a difference between the first stopping point and the second stopping point is equivalent to a distance that the stopper must travel to expel a predetermined volume of a drug product from a distal end of the body, and wherein the plunger rod is prevented from moving from the second stopping point to the first stopping point; and/or the plurality of protrusions includes two protrusions disposed symmetrically about the actuation portion; and/or the blocking component further comprises a pair of finger flanges; and/or the drug delivery device is a pre-filled syringe; and/or the drug delivery device is changeable: (a) from a pre-use state to a primed state, by longitudinally moving the plunger rod (e.g., wherein the plunger rod includes a neck disposed distally from the actuation portion, wherein the neck interfaces with an opening in the blocking component to prevent proximal movement of the plunger rod, for example, wherein the neck further interfaces with the opening in the blocking component to prevent movement of the drug delivery device from the delivery state to the primed state) until the plunger rod reaches the first stopping point; (b) from the primed state to a delivery state by rotating the plunger rod in relation to the blocking component until the protrusions and the blocking component are in the second configuration; and (c) from a delivery state to a used state by longitudinally moving the plunger rod until the plunger reaches the second stopping point, wherein the drug delivery device is not changeable from the used state to the delivery state, from the delivery state to the primed state, or from the primed state to the pre-use state. In an embodiment of the invention, when the plunger rod is at the second stopping point, the stopper does not contact a distal end of the body.

In an embodiment of the invention, aflibercept is for use wherein a drug delivery device includes:.

wherein the plunger rod is longitudinally movable and rotatable about a longitudinal axis relative to the blocking component, and
wherein, when the drug delivery device is in a pre-use state, the protrusions and the cavity openings are not longitudinally aligned, and when the drug delivery device is in a delivery state, the protrusions and the cavity openings are longitudinally aligned. In an embodiment of the invention, the blocking component further includes a finger flange, and further includes a ribbed surface on a side of the actuation portion. In an embodiment of the invention, the plunger rod further includes: two extensions protruding distally from the actuation portion; and a plurality of openings in the collar of the blocking component, wherein a portion of each extension is configured to be received by one of the plurality of openings upon distal movement of the plunger rod relative to the blocking component.

wherein, when the stopper is in a ready position, distal advancement of one of (a) only the sleeve, (b) only the plunger rod, or (c) both the sleeve and the plunger rod together, relative to the body advances the stopper to a primed position, and wherein, when the stopper is in the primed position, distal advancement of another of (a) only the sleeve, (b) only the plunger rod, or (c) both the sleeve and the plunger rod together, relative to the body advances the stopper to a dose completion position. For example, in an embodiment of the invention, a DDD further includes a removable blocking component (e.g., wherein the blocking component is a clip removably secured around at least a portion of the sleeve) disposed between a proximal portion of the sleeve and a proximal end of the body, the blocking component obstructing distal advancement of the sleeve relative to the body, wherein distal advancement of the sleeve relative to the body after removal of the blocking component advances the stopper to the primed position. In an embodiment of the invention, the DDD further includes a removable locking component (e.g., a pin, a tab, or a bar) that couples the plunger rod to the sleeve, wherein distal advancement of both the sleeve and the plunger rod together relative to the body advances the stopper to the primed position, wherein distal advancement of only the plunger rod relative to the body after removal of the locking component advances the stopper to the dose completion position. In an embodiment of the invention, in the dose completion position, a proximal end of the plunger rod abuts against a distal end of the sleeve, such that the plunger rod is prevented from advancing distally any further relative to the body. In an embodiment of the invention, the DDD further includes a protrusion disposed on the plunger rod; and an inner protrusion disposed on an interior wall of the sleeve distally to the protrusion of the plunger rod, wherein distal advancement of only the plunger rod relative to the body advances the stopper to the primed position and causes the protrusion of the plunger rod to contact the inner protrusion of the sleeve, and wherein distal advancement of both the plunger rod and the sleeve relative to the body, after the protrusion of the plunger rod has contacted the inner protrusion of the sleeve, advances the stopper to the dose completion position. In an embodiment of the invention, the sleeve includes a finger flange. In an embodiment of the invention, the DDD further includes a stop disposed at a proximal end of the body, the stop sized to block distal advancement of the sleeve or the plunger rod once the stopper is in the completion position.

In an embodiment of the invention, aflibercept is for use wherein a drug delivery device, includes:.

wherein displacement of the obstruction from the obstructing position permits distal advancement of the plunger rod to the dose completion position, for example, further including a collar affixed to a proximal end portion of the body, the collar surrounding the proximal portion of the plunger rod; and a collar projection extending radially inward from the collar, wherein the proximal portion of the plunger rod includes a channel into which the collar projection protrudes, the channel including a circumferential path and an axial dose completion path, wherein the obstruction comprises the collar projection, which, when disposed in the circumferential path of the channel, prevents distal advancement of the plunger rod to the dose completion position, and wherein displacement of the obstruction from the obstructing position comprises twisting the plunger rod about a longitudinal axis to align the collar projection with the axial dose completion path. For example, in an embodiment of the invention, the channel further includes an axial priming path offset from the axial dose completion path, and connected to the axial dose completion path by the circumferential path, and distal movement of the plunger rod such that the collar projection travels on the axial priming path advances the plunger rod to the primed position. In an embodiment of the invention, the DDD further includes a finger flange. In an embodiment of the invention, the proximal portion of the plunger rod includes a projection extending radially outward, and the drug delivery device further includes: a rotatable alignment component disposed in between the proximal portion of the plunger rod and the body, the alignment component including a channel, the channel sized and configured to accommodate the plunger rod projection, wherein the obstruction comprises a wall of the channel that blocks a distal axial path of the plunger rod projection when the plunger rod is in the primed position, and wherein displacement of the obstruction from the obstructing position comprises rotating the alignment component to remove the wall of the channel from the distal axial path of the plunger rod projection, e.g., further including a finger flange coupled to a proximal end portion of the body, wherein the rotatable alignment component is disposed between the finger flange and the proximal portion of the plunger rod. In an embodiment of the invention, the DDD further includes a flange piece disposed at the proximal end of the body, wherein the obstruction includes a removable cap that, when in the obstructing position relative to the plunger rod, is disposed partially in between the proximal portion of the plunger rod and the flange piece. In an embodiment of the invention, removal of the cap allows the proximal portion of the plunger rod to advance to a dose completion position, wherein, in the dose completion position, the proximal portion of the plunger rod contacts the flange piece. In an embodiment of the invention, the removable cap covers the proximal portion of the plunger rod when in the obstructing position. In an embodiment of the invention, the DDD further includes a collar disposed between the proximal end of the body and the proximal portion of the plunger rod, the collar defining an opening sized to accommodate the proximal portion of the plunger rod upon distal advancement of the plunger rod beyond a primed position, wherein the obstruction comprises a tab protruding radially outward from the proximal portion of the plunger rod, the tab preventing the proximal portion of the plunger rod from fitting into the opening of the collar, and wherein a depth of the collar opening coincides with a distance the plunger rod must travel to advance distally to the dose completion position, e.g., wherein displacement of the obstruction from the obstructing position comprises either removing the tab or compressing the tab into a side of the proximal portion of the plunger rod; and/or wherein the tab is a first tab, and wherein the obstruction further comprises a second tab protruding radially outward from the proximal portion of the plunger rod in a direction opposite the protruding direction of the first tab; and/or wherein the obstruction comprises a tab that, when in the obstructing position, is disposed between the body and the proximal portion of the plunger rod, and wherein the plunger rod includes a geometry disposed proximally from the tab, wherein the geometry cannot advance distally past the tab when the tab is in the obstructing position. For example, displacement of the obstruction may include removing the tab from the drug delivery device by pulling the tab. In an embodiment of the invention, the DDD further includes a flange piece, wherein a portion of the tab is disposed inside a cavity of the flange piece. In an embodiment of the invention, displacement of the obstruction comprises removing the tab from the drug delivery device by breaking the tab. In an embodiment of the invention, the obstruction includes a flange piece that, in the obstructing position, is disposed proximally from the proximal end of the body, between the proximal portion of the plunger rod and the body, and is spaced from the proximal end of the body by a removable blocking component, and wherein displacement of the obstruction from the obstructing position comprises: removing the blocking component; and shifting the flange piece distally towards the proximal end of the body. In an embodiment of the invention, the plunger rod includes a projection extending radially outward, wherein the obstruction includes a lever having an end that, in the obstructing position, is located distally from the projection and blocks distal movement of the projection and thereby distal movement of the plunger rod, and wherein displacement of the obstruction from the obstructing position comprises actuating the lever to remove the end of the lever from its location distal from the projection. In an embodiment of the invention, distal advancement of the plunger rod beyond the dose completion position is prevented by contact between the proximal portion of the plunger rod and a portion of a flange piece coupled to the body.

wherein the plunger rod may be distally advanced into the body from a ready position to a primed position, wherein, in the primed position, the protrusion of the plunger rod is disposed inside the opening, and further distal advancement of the plunger rod is resisted by contact between the protrusion and a wall of the opening, and wherein pressure may be exerted on the protrusion to overcome the resistance to further distal advancement of the plunger rod. In an embodiment of the invention, the opening in the sleeve is a second opening, and the sleeve further includes a first opening disposed in the circumferential wall of the sleeve proximally from the second opening, and a third opening disposed in the circumferential wall of the sleeve distally from the second opening, wherein, in the ready position, the protrusion of the plunger rod is disposed in the first opening, and further distal advancement of the plunger rod is resisted by contact between the protrusion and a wall of the first opening, and wherein, after further distal advancement of the plunger rod past the primed position, the protrusion of the plunger rod is disposed in the third opening, and further distal advancement of the plunger rod is prevented. In an embodiment of the invention, the radially-extending protrusion is a first protrusion, and wherein the plunger rod further includes a second radially-extending protrusion opposite the first protrusion, and wherein squeezing the first and second protrusions towards one another while applying axial pressure in the distal direction on the plunger rod overcomes the resistance to further distal advancement of the plunger rod. In an embodiment of the invention, the protrusion includes a distally-tapering profile to aid in distal advancement of the plunger rod.

wherein rotating the rotatable element causes distal advancement of the plunger rod to a primed position, and wherein once the plunger rod is in the primed position, further rotation of the rotatable element is resisted. In an embodiment of the invention, the DDD further includes a collar disposed at a proximal end of the body, an interior of the collar including a proximal threaded portion forming a proximal helical path, wherein the rotatable element comprises a proximal portion of the plunger rod including a protrusion, wherein the proximal portion of the plunger rod may be rotated about a longitudinal axis to cause the protrusion to travel distally along the proximal helical path, and wherein once the protrusion reaches the end of the proximal threaded portion of the collar, the plunger rod is in the primed position, e.g., wherein once the plunger rod is in the primed position, the plunger rod may be depressed axially into the body to distally advance the plunger rod to a dose completion position; and/or wherein the interior of the collar further includes a distal threaded portion, wherein threads of the distal threaded portion form a distal helical path offset from, and opposite to, the proximal helical path, wherein alignment of the protrusion with the distal helical path places the plunger rod in the primed position, and wherein rotation of the proximal portion of the plunger rod to cause the protrusion to travel distally along the distal helical path causes distal advancement of the plunger rod to a dose completion position.

A substance may be dispensed using such a DDD having a plunger rod and a body, may be done by a method including:.

wherein none of steps (a), (b), and (c) are reversible. In an embodiment of the invention, the DDD further includes a flange piece having a collar, and advancing the plunger rod and actuating the plunger rod comprise pressing an actuation portion of the plunger rod into the collar of the flange piece; for example, wherein the plunger rod comprises a protrusion, and wherein the collar of the flange piece abuts against the protrusion to resist advancement of the plunger rod. For example, in an embodiment of the invention, wherein rotating the plunger rod comprises twisting an actuation portion of the plunger rod relative to the flange piece, until a protrusion on the plunger rod becomes longitudinally aligned with a cavity in the collar of the flange piece, which may further include advancing the protrusion into the cavity until the protrusion abuts a distal side of the cavity, wherein the predetermined volume of the substance is dispensed when the protrusion abuts the distal side of the cavity.

This phase <NUM>, multi-center, randomized, single-masked study in patients with nAMD investigated the efficacy, safety, and tolerability of HD (<NUM> doses) versus IAI (<NUM> doses). The Study dosing regimen is summarized in <FIG>. The Study consisted of a screening/baseline period, a treatment period, and an end of study (EOS) visit at week <NUM>. Patients were seen monthly through week <NUM>. One hundred and six eligible patients were randomized into <NUM> groups in a <NUM>:<NUM> ratio. One group received IAI and the other received HD. The investigational product was administered intravitreally (IVT) monthly for <NUM> initial injections (baseline, week <NUM>, and week <NUM>), followed by additional doses at weeks <NUM> and <NUM>. At weeks <NUM>, <NUM>, <NUM> and <NUM>, patients were evaluated and given a dose (at their randomized dose level) if either of the following criteria are met (PRN criteria):.

The following are the portions of the protocol by which the CANDELA human clinical trial was conducted.

The study also includes a pharmacokinetic (PK) sub-study, with dense blood sampling (dense PK sub-study) for systemic drug concentrations and PK assessments for approximately <NUM> patients from each group from selected sites. Additional patients (up to approximately <NUM>% more in each treatment group) may be enrolled in the dense PK sub-study to ensure adequate data is are captured.

The dosing schedule for the IAI and HD groups are set forth below in Table <NUM>-<NUM>.

Additional visits for Dense PK Substudy:.

Week <NUM>: Additional treatment allowed after discussion with sponsor.

See also Table <NUM>-<NUM> herein. As discussed in this Example, IAI dosing regimens call for <NUM> doses given as defined in Table <NUM>-<NUM>; and HD dosing regimens call for <NUM> doses given as defined in Table <NUM>-<NUM>.

There are no secondary endpoints in this study.

The efficacy variable relevant to the primary efficacy endpoint is the assessment of retinal fluid. The efficacy variables relevant to the exploratory endpoints are:.

The safety variable relevant to the primary safety endpoint is the proportion of patients with TEAEs and SAEs. The safety variables relevant to the exploratory endpoints are:.

The PK variables are the concentrations of free and bound aflibercept in plasma at each time point using both sparse sampling and dense sampling.

The study will enroll approximately <NUM> patients to be randomized in a <NUM>:<NUM> ratio.

The study population consists of treatment-naïve patients with nAMD.

A patient must meet the following criteria at both the screening and/or the randomization visits to be eligible for inclusion in the study:.

A patient who meets any of the following criteria at either the screening or randomization visits will be excluded from the study:.

The HD will be provided as a liquid formulation in a vial. The target concentration of aflibercept is <NUM>/mL. The dose will be delivered in an injection volume of <NUM> microliters. The IAI will be provided as a liquid formulation in a vial. The target concentration of aflibercept is <NUM>/mL. The dose will be delivered in an injection volume of <NUM> microliters.

Deviation from the treatment schedule defined in the protocol is discouraged. Efforts should be made to ensure adherence to the protocol-specified dosing intervals. If, however, in the investigator's judgement, a patient cannot adhere to the protocol-specified dosing interval due to persistent or worsening disease and requires an interim injection, the patient may receive additional treatment at week <NUM>. The investigator must make reasonable efforts to consult with the study director or sponsor designee prior to additional treatment being allowed.

Patients will receive their randomized dose of aflibercept if it is determined that additional treatment will be administered. Patients who receive additional treatment will continue to receive their randomized treatment at future visits and will remain masked to treatment assignment. Data from patients receiving additional treatment will be censored from the time additional treatment is administered.

Dose modification for an individual patient is not allowed.

Any treatment administered from the time of informed consent to the final study visit will be considered concomitant medication. This includes medications that were started before the study and are ongoing during the study.

If a pretreatment concomitant medication is administered in the study eye before injection (e.g., antibiotic or anesthetic), it must be administered for fellow eye treatment as well.

Patients are not allowed to receive any standard or investigational treatment for nAMD in the study eye other than their assigned study treatment with HD or IAI, as specified in the protocol. This includes medications administered locally (e.g., IVT, topical, juxtascleral, or periorbital routes), as well as those administered systemically, with the intent of treating nAMD in the study eye or fellow eye.

If the fellow eye has nAMD, or any other approved indication, IAI (<NUM>) will be allowed and supplied through the IWRS (Interactive web response system). Patients are not allowed to receive any other anti-VEGF agent in the fellow eye. Patients enrolled in the dense PK sub-study cannot receive IAI (<NUM>) in the fellow eye before week <NUM>.

Non-ocular (systemic) standard or investigational treatments for nAMD of the study or fellow eye are not permitted. Systemic anti-angiogenic agents and anti-Ang2 inhibitors are not permitted during the study.

Any other medications that are considered necessary for the patient's welfare, and that are not expected to interfere with the evaluation of the study drug, are allowed.

BCVA=Best Corrected Visual Acuity, ECG=electrocardiogram, EOS=end of study, ETDRS=Early Treatment Diabetic Retinopathy Study, FA=fluorescein angiography, FBR=future biomedical research, FP=fundus photography, IOP=Intraocular pressure, PK=pharmacokinetics, PRN=pro re nata (as needed), SDOCT= spectral domain optical coherence tomography, UPCR=urine protein:creatinine ratio.

Intraocular Pressure. Intraocular pressure will be measured in both eyes at every visit using Goldmann applanation tonometry or Tono pen™, as specified in Table <NUM>-<NUM>. The same method of IOP measurement must be used throughout the study for each individual patient. On dosing visits, IOP will also be measured approximately <NUM> minutes post-dose (study eye).

For patients in the dense PK sub-study, IOP will also be measured <NUM> hours post-dose if the reading from approximately <NUM> minutes to <NUM> minutes post-dose remains clinically significantly higher than the pre-dose reading, and again at approximately <NUM> hours post-dose if the reading from approximately <NUM> hours post-dose remains clinically significantly higher than the pre-dose reading.

Slit Lamp Examination. Patients' anterior eye structure and ocular adnexa will be examined bilaterally pre-dose at each study visit using a slit lamp (see study procedure manual) by the investigator, as specified herein.

Indirect Ophthalmoscopy. Patients' posterior pole and peripheral retina will be examined by indirect ophthalmoscopy at each study visit pre-dose (bilateral) and post-dose (study eye) by the investigator, as specified herein. Post-dose evaluation must be performed immediately after injection.

Fundus Photography/Fluorescein Angiography. The anatomical state of the retinal vasculature will be evaluated by FP and FA as specified herein. Fundus photography and FA will be captured and transmitted to an independent reading center for both eyes. For FA, the study eye will be the transit eye.

Fundus and angiographic images will be sent to an independent reading center where images will be read by masked readers. All FPs and FAs will be archived at the site as part of the source documentation. Photographers must be certified by the reading center to ensure consistency and quality in image acquisition. A detailed protocol for image acquisition and transmission can be found in the study procedure manual. Imaging technicians should remain masked to treatment assignment.

Spectral Domain Optical Coherence Tomography. Retinal characteristics will be evaluated at every visit using SD-OCT. Images will be captured and transmitted for both eyes. Images will be sent to an independent reading center where they will be read by masked readers. All OCTs will be electronically archived at the study site as part of the source documentation. Optical coherence tomography technicians must be certified by the reading center to ensure consistency and quality in image acquisition. A detailed protocol for acceptable OCT machines and OCT image acquisition/transmission can be found in the study procedure manual. Imaging technicians should remain masked to treatment assignment.

Best Corrected Visual Acuity. Visual function of the study eye and the fellow eye will be assessed using the ETDRS protocol (Early Treatment Diabetic Retinopathy Study Research Group, <NUM>) at <NUM> meters at each study visit, as specified in Table <NUM>-<NUM>. Visual acuity examiners must be certified to ensure consistent measurement of BCVA, and must remain masked to treatment assignment, treatment schedule and study eye. Best corrected visual acuity should be done before any other ocular procedures are performed. Patients enrolled at sites participating in the optional visual function sub-study may undergo additional visual function tests.

Adverse Event. An AE is any untoward medical occurrence in a patient administered a study drug which may or may not have a causal relationship with the study drug. Therefore, an AE is any unfavorable an unintended sign (including abnormal laboratory finding), symptom, or disease which is temporally associated with the use of a study drug, whether or not considered related to the study drug (ICH E2A Guideline. Clinical Safety Data Management: Definitions and Standards for Expedited Reporting, Oct <NUM>).

Serious Adverse Event. An SAE is any untoward medical occurrence that at any dose:.

Ocular important medical event. An ocular important medical event may include the following:.

The severity of AEs will be graded according to the following scale:.

The investigator must provide causality assessment as whether or not there is a reasonable possibility that the drug caused the adverse event, based on evidence or facts, his/her clinical judgment, and the following definitions. The causality assessment must be made based on the available information and can be updated as new information becomes available. The following factors should be considered when assessing causality:.

Causality to the Injection Procedure. The relationship of AEs to the injection procedure is assessed by the investigator, and is a clinical decision based on all available information. The following question is addressed: Is there a reasonable possibility that the AE may have been caused by the injection procedure? The possible answers are:.

The concentrations of free and bound aflibercept over time will be summarized by descriptive statistics for each treatment group. No formal statistical hypothesis testing will be performed.

The PK parameters to be determined after the first dose for free and bound aflibercept may include, but are not limited to:.

After repeat dosing in the dense PK sub-study, PK parameters to be determined may include, but are not limited to, Ctrough, time to reach steady-state, and accumulation ratio. The concentrations of free and bound aflibercept over time and selected PK parameters will be summarized by descriptive statistics by treatment group. This descriptive statistical assessment will include the geometric means and ratios of the geometric means for selected PK parameters, as deemed appropriate. No formal statistical hypothesis testing will be performed.

The baseline demographics, eye characteristics, and blood pressure of "All patients" at this point in this trial are set forth in <FIG>.

After <NUM> weeks of study duration, patients receiving the <NUM> doses of aflibercept (HD dosing regimen) maintained (on average) greater vision improvements and anatomical improvements than that of patients receiving the <NUM> dose (IAI dosing regimen) (relative to baseline).

Patients (Completers) receiving the HD dosing regimen maintained a greater mean change in best corrected visual acuity (<NUM>) than the IAI patients (<NUM>) at week <NUM> (<FIG>).

Anatomical improvements were also remarkable at week <NUM>. The central retinal thickness (CRT) of patients receiving the HD dosing regimen remained below that of patients (Completers) receiving the IAI dosing regimen-a mean change of -<NUM> micrometers in HD patients vs -<NUM> micrometers in IAI patients at week <NUM> (<FIG>).

Measures of retinal dryness were also strikingly better in patients receiving the HD dosing regimen. Overall, more patients (Completers) receiving the HD regimen had complete resolution of intraretinal/subretinal fluid at week <NUM>. The proportion of HD patients with dry retinas at week <NUM> was <NUM>% whereas the proportion of IAI patients with dry retinas was just <NUM>% (<FIG>). A dry retina was regarded as a retina exhibiting no intraretinal fluid (IRF) and subretinal fluid (SRF). Conversely, a greater proportion of patients receiving the IAI dosing regimen had "not-dry" retinas at week <NUM> than that of HD patients (<NUM>% vs <NUM>%, respectively) (<FIG>). Fewer HD patients exhibited IRF (IRF only or both IRF and SRF) or SRF (SRF only or both IRF and SRF) at week <NUM> than IAI patients (<FIG>, respectively). Similar trends were apparent when the retinal fluid status (Dry, IRF only, SRF only or both IRF and SRF) of IAI and HD patients at baseline, week <NUM>, week <NUM>, week <NUM> and week <NUM> was observed (<FIG>, respectively). The number of treatments in the HD and IAI treatment groups ("All patients") was comparable (<FIG>).

The HD and IAI dosing regimens were generally well tolerated. The ocular treatment-emergent adverse events (TEAEs) (<FIG>), intraocular pressure (IOP) (<FIG>), non-ocular TEAEs (<FIG>), non-ocular SAEs (<FIG>), hypertension AEs (<FIG>), mean systolic blood pressure (<FIG>), mean diastolic blood pressure (<FIG>), mean IOP (<FIG>), mean change of IOP (<FIG>) were comparable in each treatment group.

At week <NUM>, a higher proportion of these patients in the HD aflibercept <NUM> group had no retinal or subretinal fluid (<NUM>%, n=<NUM>/<NUM>) in the center (<NUM>) subfield on optical coherence tomography compared to patients treated with IAI EYLEA <NUM> (<NUM>%, n=<NUM>/<NUM>) (p=<NUM>). During the initial <NUM> weeks of the trial, treatment emergent adverse events (TEAEs) in the study eye occurred in <NUM>% (<NUM> of <NUM>) of aflibercept <NUM> patients and <NUM>% (<NUM> of <NUM>) of EYLEA <NUM> patients. AEs that occurred more frequently in the aflibercept <NUM> group were conjunctival hemorrhage (<NUM>% aflibercept <NUM>, <NUM>% EYLEA <NUM>) and vitreous detachment (<NUM>% aflibercept <NUM>, <NUM>% EYLEA <NUM>). Serious ocular AEs (SAEs) occurred in two patients overall, one in the aflibercept <NUM> group (retinal tear) and one in the EYLEA <NUM> group (visual acuity reduced). No intraocular inflammation, occlusive vasculitis, arterial thromboembolic events (adjudicated according to the AntiPlatelet Trialists' Collaboration definitions) or death in either patient group were identified through week <NUM>.

The disposition and exposure, baseline demographics, baseline characteristics, and baseline blood pressure and medical history of patients in this analysis are set forth in <FIG>, <FIG>, <FIG> and <FIG>.

The proportion of HD patients achieving a dry retina (no IRF and no SRF in the central subfield on SD-OCT (spectral domain optical coherence tomography)) was <NUM>% whereas the proportion of IAI patients was <NUM>% (<FIG>) (last observation carried forward (LOCF) values). HD patients without IRF (dry or with SRF only) was <NUM>% (IAI patients: <NUM>%) and without SRF (dry or with IRF only) was <NUM>% (IAI patients: <NUM>%) (<FIG>) (LOCF). At week <NUM>, there was a greater median (<FIG>) and mean (<FIG>) decrease in central retinal thickness from baseline in HD patients (-<NUM> micrometers, - <NUM> micrometers, respectively) relative to IAI patients (-<NUM> micrometers, -<NUM> micrometers, respectively) (LOCF). The mean change from baseline to week <NUM> in choroidal neovascularization and total lesion size is set forth in <FIG> showing greater reductions in the HD group relative to the IAI group. Regarding best corrected visual acuity (BCVA), HD patients achieved a mean change, from baseline through week <NUM>, of <NUM> (ETDRS letters) whereas IAI patients achieved <NUM> (<FIG>) (LOCF). A smaller proportion of HD patients lost letters than IAI patients, and a greater proportion of HD patients gained letters than IAI patients at week <NUM> (<FIG>).

The proportion of HD patients receiving additional treatment at week <NUM> (<NUM>%) was smaller than that of IAI patients (<NUM>%). Also, the occurrence of ocular TEAEs through week <NUM> was <NUM>% among HD patients and <NUM>% among IAI patients (<FIG>). The occurrence of ocular serious treatment emergent adverse events and intraocular inflammation TEAEs among HD and IAI patients, through week <NUM>, was comparable (<FIG>, <FIG>). Mean intraocular pressure change from baseline, occurrence of intraocular pressure events, occurrence of APTC events or deaths, hypertension adverse events among HD and IAI patients was comparable at week <NUM> (<FIG>, <FIG>, <FIG>). Mean changes in blood pressure (systolic or diastolic) through week <NUM> among all HD and IAI patients or patients in a dense PK sub-study was comparable (<FIG> (A-B), <FIG>(A-B)).

The study ended at week <NUM> with <NUM> patients. With an identical dosing regimen and slightly fewer rescue and/or PRN doses, a higher proportion of eyes receiving <NUM> aflibercept (HD) were dry in the center subfield relative to the eyes receiving <NUM> aflibercept (IAI). In addition, a change from baseline in central subfield thickness (CST) suggested better anatomic outcomes in the <NUM> HD group relative to the <NUM> IAI group. Changes in visual acuity from baseline favored the <NUM> dosing regimen (HD) over the <NUM> regimen (IAI) (+<NUM> letters vs. +<NUM> letters).

No new safety signals were seen and the safety profile for the HD group was comparable to that of IAI. There was one case of mild iritis in the HD group that resolved with topical therapy. Changes from baseline blood pressure and intraocular pressure were similar between the groups.

Out of the <NUM> patients that started in the study, <NUM> reached the <NUM>-week point-<NUM> in the IAI group and <NUM> in the HD group (<FIG>). The baseline demographics of the patients in the study were majority white and having more females than males with an average age of about <NUM> years as set forth in <FIG>. In addition, the baseline characteristics of the study eye in patients are set forth in <FIG>. The IAI and HD groups received the same mean number of injections (<NUM>) through week <NUM> (see <FIG>) with slightly more HD patients than IAI patients not receiving additional or PRN treatments.

Patients in the HD group achieved numerically superior anatomical improvements in the eye. Retinal drying (lack of fluid in the center subfield-no intraretinal fluid (IRF) and no subretinal fluid (SRF)) at weeks <NUM> to <NUM> was higher in the HD group relative to that of the IAI group (<FIG>, <FIG>). Moreover, at weeks <NUM> and <NUM>, there was a greater proportion of eyes, in the HD group than in the IAI group, without fluid in the macula (no IRF and no SRF in the macula by SD-OCT) (<FIG>). The proportion of patients in each group without IRF (dry or SRF only) at weeks <NUM> and <NUM> is set forth in <FIG>. At weeks <NUM> and <NUM>, <NUM>% of patients in the HD group exhibited no subretinal fluid (SRF) (dry or with IRF only) whereas <NUM>% of the IAI group patients exhibited no SRF (<FIG>). Through much of the <NUM>-week trial, the HD group achieved greater mean and median reductions in central retinal thickness (CRT) from baseline (<FIG>, <FIG>).

Patients in the HD group also achieved greater gains in vision. By week <NUM>, the mean change, from baseline, in best corrected visual acuity (BCVA) was <NUM> in the HD group and <NUM> in the IAI group (<FIG>). Fewer patients in the HD group than in the IAI group lost vision (≥ <NUM>, ≥<NUM> or ≥<NUM> letters lost) by week <NUM>. Moreover, more patients in the HD group gained vision ( ≥<NUM> or ≥<NUM> letters gained) (<FIG>) by week <NUM>.

Ocular TEAEs and ocular serious TEAEs, intraocular inflammation TEAEs, intraocular pressure events, non-ocular TEAEs and non-ocular serious TEAEs were comparable between treatment groups (<FIG>, <FIG>, <FIG>, <FIG>, <FIG>). Intraocular pressure (IOP) observed between treatment groups were also comparable (<FIG>). Moreover, the administration of the <NUM> dose in the HD group was not observed to have an effect on the occurrence of hypertension TEAEs (<FIG>). One patient died during the trial due to glioblastoma (<FIG>).

This Example documents the procedure and execution results of deliverable volume characterization testing conducted to compare different presentations of a formulation including aflibercept (REGN3) at a concentration of <NUM>/ml.

Testing was conducted separately for each presentation. All samples were filled with <NUM>/mL aflibercept formulated drug substance.

Deliverable volume was calculated by collecting the dose delivered through manual injection after the syringe was manually primed and weighing the collected dose on a balance. The collected mass was then divided by the density of the FDS (<NUM>/ml) to calculate the volume delivered. <MAT> where V is the delivered volume (µL), mdose is the dose mass (g), and ρ is the solution density (g/mL). Preconditioning of samples at <NUM> was conducted for the testing in order to maintain drug product integrity.

The testing of REGN3-PFS-<NUM> demonstrated that <NUM> out of <NUM> samples were able to administer a volume with high precision with <NUM> sample delivering volume of <NUM> microliters. See the histogram of delivered doses of REGN3-PFS-<NUM> in <FIG>.

Three hundred six (<NUM>) samples delivered with the <NUM> BD (Becton Dickinson) Luer Lok syringe were utilized for data analysis. Samples <NUM>, <NUM>, <NUM> and <NUM> were removed from analysis due to operator error in dose preparation prior to collection. Testing showed that <NUM> out of <NUM> samples were <NUM> microliters -<NUM> microliters. See the histogram of delivered doses in <FIG>.

The deliverable volume data of both devices showed the difference in variability and accuracy. The <NUM> BD (Becton Dickinson) Luer Lok syringe has a lower average delivered volume at <NUM> microliters than the <NUM> PFS with <NUM> microliters. However, it has a larger spread of volumes delivered with a range of <NUM> microliters compared to <NUM> microliters for the <NUM> PFS. The increased variability depicted in the <NUM> BD (Becton Dickinson) Luer Lok syringe may be attributed to user variability in setting the dose to <NUM> microliters as well as the variability in graduation printing on the syringe. Individual delivered volumes for each device are set forth in <FIG>.

Claim 1:
Aflibercept for use in a method for treating an angiogenic eye disorder, in a subject in need thereof, wherein the method comprises administering, intravitreally, to an eye of the subject, a single initial dose of <NUM> ± <NUM> of aflibercept, followed by one or more secondary doses of <NUM> ± <NUM> of aflibercept, followed by one or more tertiary doses of <NUM> ± <NUM> of aflibercept; wherein each secondary dose is administered <NUM> to <NUM> weeks after the immediately preceding dose; and wherein each tertiary dose is administered <NUM> weeks after the immediately preceding dose.