Conditions: Retinopathy of Prematurity
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 14
Healthy volunteers: no

Brief summary:
Phase 2, open-label, randomized, multi-center studies in infants and premature infants are necessary to determine treatment and preventative strategies for ROP. This study was designed to: a) target infants at the highest risk of ROP in a large number of centers with variable rates of ROP (all stages and severe ROP or stage 3+); and b) assess whether caffeine plus systemic or ophthalmic NSAID will decrease ROP among infants most at risk for ROP. The study is designed to determine whether the novel treatment regimens are safe and potentially effective for ROP prevention and to obtain requisite data for the development of a Phase III efficacy/safety randomized blinded trial. Since caffeine is used extensively in NICUs as standard of care for ELGANs, no placebo group is included.

Detailed description:
This study will evaluate the safety, tolerability and PK-PD of, and to compare and contrast, IV Ibuprofen with Caffeine and Ketorolac eye drops with Caffeine in ELGAN infants \<28 weeks GA for 14 days duration to treat and preferably prevent ROP associated with prematurity and ELGAN. The specific aims of this trial are:

Aim 1: To establish the synergistic effect of local ophthalmic NSIADs and systemic caffeine as optimal therapies for the attenuation and/or prevention of severe ROP. Hypothesis: Ocular Ketorolac or systemic Ibuprofen potentiated with systemic Caffeine will prevent or diminish the severity of ROP. We will: a) Evaluate the safety, tolerability, and efficacy of early postnatal local ophthalmic NSIADs for prevention of severe ROP in ELGANs. b) Determine the pharmacokinetics, pharmacodymanics and pharmacogenomics of NSAIDs potentiated with caffeine for prevention of ROP.

Aim 2: To identify a "critical" number of arterial oxygen desaturations as a key risk factor for severe ROP.

Hypothesis: A "critical" number of daily arterial oxygen desaturations during the first two weeks of life is a key risk factor for severe ROP. We will: a) Further define the role of VEGF, IGF, MMPs, and ROS in ROP and correlate the levels with the number of arterial oxygen desaturations. b) Establish and identify whether increased serum VEGF in infants with severe ROP is the diffusible isoform VEGF121. This isoform is formed from VEGF proteolysis by plasmin and MMPs. MMPs also cleave Notch/Dll4, which acts as a regulator of VEGF signaling.

Aim 3: To determine whether infants at risk for severe ROP are haploinsufficient for the delta-like ligand 4 (Dll4).

Hypothesis: ELGANs at risk for severe ROP will have different pattern of gene expression specifically related to the Notch signaling pathway, as has been previously shown in animal models. We will: a) Examine cord blood, cord tissue, and placental tissue to compare the gene profile of VEGF and Notch signaling pathways among infants who develop severe ROP and those who do not; and b) Determine whether NSAIDs and/or Caffeine will confer protective benefits on Notch/Dll4 signaling and prevent the development of severe ROP.

This is a phase 2b, randomized, open label, multi-center, safety, tolerability and efficacy study comparing 3 interventions for possible prevention of ROP. The trial will be conducted in at least 8 investigational sites including the Neonatal networks (SUNY Downstate and the Brooklyn-Queens Neonatal Network sites, SUNY Stony Brook), and Miller Children's Hospital, Long Beach, CA. An independent DSMB will assess safety during the study. This study will monitor for safety while on study drug and for 7 days after last dose of drug. An exploratory study to determine the role of pharmacodynamic, drug concentrations (as surrogate of PK profile) and pharmacogenomics will also be conducted in this patient population.

One hundred and twenty preterm infants (\<28 weeks gestation; \<1250 grams) between 0 and 72 hours of life will be randomized to receive either:

1. Caffeine citrate IV (20 mg/kg loading dose followed by 5 mg/kg/day maintenance dose) plus placebo saline IV (1 ml/kg followed by 0.25 ml/kg) for 5 days plus sterile normal saline (one drop two times a day) for 14 days (n=40);
2. Caffeine citrate as described in group 1 plus Ibuprofen (10 mg/kg loading dose followed by low dose ibuprofen 2.5 mg/kg/day) for 5 days plus sterile normal saline (one drop two times a day) for 14 days (n=40); and
3. Caffeine citrate plus saline IV placebo as described in group 1, and Ketorolac (Acuvail) eye drops (one drop two times a day) for 14 days (n=40)

Arms:
arm 1: Caffeine citrate IV (20 mg/kg loading dose, 5 mg/kg/day maintenance dose) plus placebo saline IV (1 ml/kg followed by 0.25 ml/kg) for 5 days plus sterile normal saline (one drop two times a day) for 14 days (n=40); Caffeine is the intervention arm 2: Caffeine citrate as described in group 1, plus Ibuprofen (10 mg/kg loading dose followed by low dose ibuprofen 2.5 mg/kg/day) for 5 days plus sterile normal saline (one drop two times a day) for 14 days (n=40); Ibuprofen is the intervention arm 3: Caffeine citrate plus saline IV placebo as described in group 1, and Ketorolac (Acuvail) eye drops (one drop two times a day) for 14 days (n=40); Ketorolac is the intervention

Interventions: intervention 1: Caffeine citrate intervention 2: Ibuprofen intervention 3: Ketorolac
Intervention descriptions: intervention 1: Caffeine citrate IV (20 mg/kg loading dose, 5 mg/kg/day maintenance dose) intervention 2: Ibuprofen (10 mg/kg loading dose followed by low dose ibuprofen 2.5 mg/kg/day) for 5 days intervention 3: Ketorolac (Acuvail) eye drops (one drop two times a day) for 14 days

Protocol document:
Prot_SAP_000.pdf: 
Protocol: NICHD#: U54HD071594 
   Page 1 of 64 
 
 
 
CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
COVER  
 
PROTOCOL including STATISTICAL ANALYSIS PLAN 
 
 
TITLE: Synergistic Pharmacologic Intervention for Prevention of ROP (SPIPROP STUDY) 
 
NCT NUMBER:  NCT02344225 
 
DOCUMENT DATE: June 07, 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Protocol: NICHD#: U54HD071594 
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CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
Title:  
Synergistic Pharmacologic Intervention for Prevention of ROP 
(SPIPROP STUDY) 
 
 
Protocol Number: 
 
1 U54HD071594 
 
Study Drugs:   
 
Ibuprofen IV & Ketorolac (Acuvail) Ophthalmic Solution 
 
 
IND Number: 
 
122395 
 
Phase: 
 
II b 
 
 
Sponsor:   
 
NIH-NICHD 
 
Principal Investigator: 
Jacob V. Aranda MD, PhD, FRCPC, FAAP 
SUNY Downstate Medical Center 
Division of Neonatology, Dept. of Pediatrics 
450 Clarkson Ave, Box 49 
 
 
Brooklyn, NY 11203 
 
 
 
Version Date: 
 
June 07, 2017 (Amendment #8) 
 
 


Protocol: NICHD#: U54HD071594 
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CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 


Protocol: NICHD#: U54HD071594 
   Page 4 of 64 
 
 
 
CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
TABLE OF CONTENTS 
 
1.0   INTRODUCTION STATEMENT AND INVESTIGATIONAL PLAN ............................................. 6 
 
1.1 Rationale .........................................................................................................................6 
 
1.2 Number of Patients ..........................................................................................................7 
 
1.3 Ibuprofen Risks ...............................................................................................................7 
 
1.4 Ketorolac Risks ...............................................................................................................8 
2.0   PROTOCOL SYNOPSIS .................................................................................................................... 9 
3.0   ABBREVIATIONS .............................................................................................................................. 13 
4.0   FLOW CHART OF STUDY PROCEDURES ................................................................................. 16 
5.0   INTRODUCTION ................................................................................................................................ 18 
 
5.1 Retinopathy of Prematurity ............................................................................................ 18 
 
5.2 Role of Oxygen Saturation Control ................................................................................ 18 
 
5.3 Pathophysiology ............................................................................................................ 19 
 
5.4 Role of COX in ROP ...................................................................................................... 20 
 
5.5 Role of VEGF in ROP .................................................................................................... 21 
 
5.6 Notch/Dll4 Signaling and Haploinsufficiency in ROP ...................................................... 22 
 
5.7 Critical Barriers: Pharmacologic Interventions ............................................................... 22 
 
5.8 Improvement of Scientific Knowledge and Clinical Impact ............................................. 23 
6.0   STUDY OBJECTIVES ....................................................................................................................... 24 
 
6.1 Aim 1 ............................................................................................................................. 24 
 
6.2 Aim 2 ............................................................................................................................. 24 
 
6.3 Aim 3 ............................................................................................................................. 24 
7.0   INVESTIGATIONAL PLAN .............................................................................................................. 25 
 
7.1 Overall Study Design/Centers ....................................................................................... 25 
 
7.2 Table 1 .......................................................................................................................... 25 
 
7.3 Rationale for Study Design ............................................................................................ 26 
 
7.4 Rationale for Drug and Dose Selection .......................................................................... 26 
 
7.5 Baseline Study Procedures ........................................................................................... 27 
 
7.6 NIPS and N-PASS Assessment..................................................................................... 27 
 
7.7 Inclusion Criteria Selection of Study Population ............................................................. 28 
 
7.8 Exclusion Criteria for Study Population .......................................................................... 28 


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CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
7.9 Patent Ductus Arteriosus (PDA) Treatment ................................................................... 28 
 
7.9.1 Withdrawal from Study ....................................................................................... 29 
 
7.9.2 Parental/Guardian Permission ........................................................................... 29 
8.0   STUDY DRUG ADMINISTRATION ................................................................................................. 29 
 
8.1 Method of Assignment to Study Groups (Randomization) ............................................. 29 
 
8.2 Study Procedures during Study Drug Treatment ........................................................... 29 
 
8.3 Drug Supplies ................................................................................................................ 30 
 
8.4 Dosing Weight ............................................................................................................... 30 
 
8.5 Treatment Compliance .................................................................................................. 30 
 
8.6 Method for Administration of Study Drug ....................................................................... 30 
 
8.7 Storage and Disposition of Supplies .............................................................................. 30 
 
8.8 Drug Accountability........................................................................................................ 31 
 
8.9 Discontinuation of Study Drug ....................................................................................... 31 
9.0   SCHEDULE AND DESCRIPTION OF STUDY PROCEDURES ................................................ 31 
 
9.1 Baseline Study Procedures ........................................................................................... 31 
 
9.2 Study Procedures During Study Treatment (Study Days 1-14) ...................................... 32 
 
9.3 Post-Treatment/End of Study Procedures ..................................................................... 33 
 
9.4 Other Data Collection .................................................................................................... 34 
 
9.5 Oxygen Saturation Monitoring ....................................................................................... 34 
 
9.6 Specimen Collection ...................................................................................................... 35 
 
9.6.1 Blood ................................................................................................................. 35 
 
9.6.2 Urine .................................................................................................................. 35 
 
9.6.3 Mixed Cord Blood .............................................................................................. 35 
 
9.6.4 Cord and Placental Tissue ................................................................................. 36 
 
9.7 Specimen Shipping........................................................................................................ 36 
 
9.8 PD Measurements ......................................................................................................... 37 
10.0   DEFINITIONS AND DETAILED DESCRIPTIONS OF ASSESSMENTS  
 
AND ENDPOINTS ............................................................................................................................. 37 
 
10.1 Efficacy Assessment ................................................................................................... 37 
 
10.2 Safety .......................................................................................................................... 37 
 
10.3 Safety Assessments .................................................................................................... 38 
 
10.4 Safety First Plan .......................................................................................................... 38 


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CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
10.5 Data Safety and Monitoring Plan (DSMP) .................................................................... 38 
 
10.6 Data Safety and Monitoring Board (DSMB) ................................................................. 38 
11.0   ADVERSE EVENTS ........................................................................................................................ 39 
 
11.1 Adverse Events Definition ............................................................................................ 39 
 
11.2 AE Reporting ............................................................................................................... 39 
 
11.3 Procedures for Assessing, Recording and Reporting AEs ........................................... 39 
 
11.4 Follow-up of AEs ......................................................................................................... 40 
 
11.5 SAEs ........................................................................................................................... 40 
 
11.6 Procedures for Assessing, Recording and Reporting SAEs ......................................... 41 
 
11.7 Dose Interruption for SAEs .......................................................................................... 41 
 
11.8 Follow-up of SAEs ....................................................................................................... 41 
 
11.9 IRB Summary Reports ................................................................................................. 42 
 
11.9.1 Table 2: AE Reporting ...................................................................................... 42 
12.0   STATISTICAL METHODOLOGY .................................................................................................. 42 
 
12.1 Planned Sample Size .................................................................................................. 42 
 
12.2 Populations for Analysis .............................................................................................. 43 
 
12.3 Statistical Methodology ................................................................................................ 43 
 
12.4 Demographics and Baseline Characteristics ................................................................ 43 
 
12.5 Efficacy ........................................................................................................................ 44 
13.0 TERMINATION OF THE STUDY .................................................................................................... 45 
 
13.1 Protocol Deviations ...................................................................................................... 45 
14.0 ADMINISTRATIVE AND REGULATORY CONSIDERATIONS ................................................ 45 
 
14.1 Prior to Initiation of the Study ....................................................................................... 45 
 
14.2 Institutional Review Board/Independent Ethics Committee Approval ........................... 46 
 
14.3 Informed Consent and Assent ..................................................................................... 46 
 
14.4 Protection of Personal Health Information ................................................................... 47 
 
14.5 Amendments and/or Changes to Informed Consent/Authorization ............................... 47 
 
14.6 Ethical Conduct of the Trial .......................................................................................... 47 
 
14.7 Source Documents ...................................................................................................... 48 
 
14.8 Case Report Forms (CRFs) ......................................................................................... 48 
 
14.9 Steering Committee ..................................................................................................... 48 
15.0 RESPONSIBILITIES OF THE CLINICAL INVESTIGATOR ...................................................... 49 


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CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
15.1 Data Quality Control and Assurance ............................................................................ 49 
 
15.2 Site Monitoring Visits ................................................................................................... 50 
 
15.3 Quality Assurance and Regulatory Agency Audits ....................................................... 50 
 
15.4 Ensuring Confidentiality ............................................................................................... 50 
 
15.5 Record Retention......................................................................................................... 50 
16.0 USE OF INFORMATION AND PUBLICATION............................................................................ 51 
 
16.1 Use of Information ....................................................................................................... 51 
 
16.2 Data Sharing Plan ....................................................................................................... 51 
 
16.3 Publication Policy ........................................................................................................ 51 
17.0 INVESTIGATOR AGREEMENT ..................................................................................................... 51 
18.0 REFERENCES .................................................................................................................... 53 
19.0 APPENDICES .................................................................................................................................... 63 
 
Appendix I: Consent Form/HIPAA Authorization 
 
Appendix II: Specimen Collection, Processing and Shipping Methodology .............................  
 
Appendix III: Ibuprofen Package Insert 
 
Appendix IV: Ketorolac Package Insert 
 
APPENDIX V: Pain Scoring and Assessment   
Neonatal Infant Pain Score (NIPS) 
Neonatal Pain, Agitation, Sedation Scale (N-PASS)   
 
 
 
 
 
 
 


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CLINICAL TRIAL  PROTOCOL 
 
_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
1.0 
INTRODUCTORY STATEMENT AND INVESTIGATIONAL PLAN 
Retinopathy of prematurity (ROP), the most common cause of blindness in children, is a 
developmental retinal vascular disorder characterized by abnormal growth of retinal blood vessels 
in the incompletely vascularized retina of extremely low gestational age neonates (ELGANs), <28 
weeks (w); <1250 grams (g). In 2010, Brooklyn, NY had 170 of 209 (81.3%) neonates born < 
1,000 grams developed ROP (all stages), with 12/209 (5.7%) progressing to Stage 3+ treated with 
Laser or Avastin, leading to significant impairment of vision and a lifetime of darkness. The 
incidence and severity of ROP increase with decreasing birth weight and gestational age. The 
multicenter Cryotherapy for Retinopathy of Prematurity study indicated that the incidence of ROP 
increased from approximately 40% in infants with birth weights 1101 to 1200 g to more than 90% 
in those with birth weights 501 to 600 g. ROP increased from approximately 35% in infants with 
gestational age of 31 weeks to more than 95% in those with gestational age of 24 weeks. Over 
90% percent of neonates born <25 weeks gestation have been reported to develop ROP with 
over 70% who developed proliferative disease (stage ± 3) and over 60% treated with retinal 
ablation. Impaired visual acuity (< 0.33) was found in 32.6% of boys and 9.2% of girls, who were 
blind living in darkness or had severe visual handicaps. In New York, 27.3% (1839 of 6745) of 
infants with birth weight <1200 g developed ROP. The incidence of any ROP was 68% among 
infants of <1251 g with a higher rate in Brooklyn, NY. Although the overall incidence of ROP has 
decreased, it still remains high in ELGANs at some centers, with threshold ROP occurring in 5% 
of ELGANs in the US, with as much as 30% of them becoming blind. Although milder ROP (Stage 
1 & 2) regress, visual problems requiring early use of corrective lenses are common. The proven 
risk factors for the development of ROP are immature retinal vasculature, hyperoxia, and 
circulatory and respiratory instability. Other factors include extremely low birthweight (ELBW), 
early gestation, patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH), 
bronchopulmonary dysplasia (BPD)/chronic lung disease (CLD), necrotizing enterocolitis (NEC), and 
sepsis. Because ROP continues to be a major problem, and due to its multi-factorial nature, a 
better understanding of the underlying mechanisms is vital for its prevention. Current methods for 
treatment and prevention are highly invasive leading to increased pain and distress in these 
micropremies. The search for new, effective, and targeted pharmacotherapies warrants a high 
priority.  Our proposed studies will investigate whether targeted, early, locally applied non-
steroidal anti-inflammatory drugs (NSAIDs) such as Ketorolac (Acuvail) or systemic Ibuprofen 
potentiates Caffeine in preventing the cascade of events leading to severe ROP and a lifetime of 
blindness and darkness 
1.1 
Rationale: 
Caffeine and NSAIDs have already been shown to decrease the risk of severe ROP in ELGANs.  
Here we propose a novel approach of combining topical ketorolac (Acuvail) or systemic Ibuprofen 
(Neoprofen) with systemic caffeine citrate (Cafcit) to optimize their efficacy for prevention of ROP.   
The overarching goal of this proposal is to investigate the synergistic effects of NSAIDs 
potentiated with systemic Caffeine on the incidence and severity of ROP.  Our specific aims are 


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_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
three-fold: 1) To establish the synergistic effect of local ophthalmic NSIADs and systemic caffeine 
as optimal therapies for the attenuation and/or prevention of severe ROP.  We hypothesize that 
ocular Ketotolac or systemic Ibuprofen potentiated with systemic Caffeine will prevent or diminish 
the severity of ROP.  We will evaluate the safety, tolerability, and efficacy of early postnatal local 
ophthalmic NSIADs for prevention of severe ROP in ELGANs and determine the 
pharmacodymanics and pharmacogenomics of ocular NSAIDs potentiated with caffeine for 
prevention of ROP; 2) To identify a “critical” number of arterial oxygen desaturations as a key risk 
factor for severe ROP.  We hypothesize that there is a “critical” number of daily arterial oxygen 
desaturations experienced by ELGANs during the first two weeks of life that is a key risk factor for 
severe ROP.  We will further define the role of biomarkers of angiogenesis such as vascular 
endothelial growth factor (VEGF), insulin-like growth factor (IGF)-I and proteases such as matrix 
metalloproteinases (MMPs); as well as biomarkers of oxidative stress and lipid peroxidation such 
as 8-iso-prostaglandin F2α (8-iso-PGF2α) in ROP and correlate the levels with the number of 
arterial oxygen desaturations. MMPs also cleave Notch/Dll4, which acts as a regulator of VEGF 
signaling; and 3) To determine whether infants at risk for severe ROP are haploinsufficient for the 
delta-like ligand 4 (Dll4).  We hypothesize that ELGANs at risk for severe ROP will have different 
pattern of gene expression specifically related to the Notch signaling pathway, as has been 
previously shown in animal models.  We will examine cord blood, cord tissue, and placental tissue 
to compare the gene profile of VEGF and Notch signaling pathways among infants who develop 
severe ROP and those who do not, and determine whether NSAIDs and/or Caffeine will confer 
protective benefits on Notch/Dll4 signaling and prevent the development of severe ROP.   
1.2 
Number of Patients:   
Total = 120 (40 per arm) 
1.3 
Ibuprofen Risks: 
Ibuprofen has been used to prevent or treat PDA with similar efficacy and a more favorable safety profile 
than Indomethacin.  Ibuprofen has been shown to have milder effects on cerebral, renal and mesenteric 
blood flow.  However, prophylactic (within 48 hours of life) and early treatment (median 6 days) with 
Ibuprofen in infants at risk for PDA is associated with an increased risk of spontaneous intestinal 
perforation (SIP). More over a recent Cochrane Review of 27 clinical trials found that the risk of developing 
NEC was reduced for Ibuprofen, the duration of ventilatory support was reduced with Ibuprofen, the risk 
of NEC was reduced, there was less evidence of transient renal insufﬁciency in infants who received 
ibuprofen. The authors concluded that Ibuprofen is as effective as Indomethacin in closing a PDA and 
reduces the risk of NEC and transient renal insufﬁciency. Given the reduction in NEC ibuprofen currently 
appears to be the drug of choice.  Too few patients have been enrolled in studies assessing the 
effectiveness of a high dose of ibuprofen versus the standard dose and early versus expectant 
administration of ibuprofen to make recommendations.  See drug package insert (Appendix III). 
 


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_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
1.4 
Ketorolac Risks: 
Ketorolac is a (NSAID) derived from Indomethacin. Its mechanism of action is blocking the synthesis of 
prostanoids by inhibiting the cyclooxygenase (COX) enzymes in arachidonic acid (AA) metabolism. The 
reported adverse effects are linked predominantly to their inhibitory action of platelet aggregation with 
hemorrhage being the principal adverse reaction. Topically administered Ketorolac decreases 
prostaglandin concentration in aqueous humor without modifying the intraocular pressure. Ophthalmic 
Ketorolac has not been shown to be quantifiable in plasma. Ketorolac ophthalmic solution is usually used 
in older adults with retinal disorders. It is used to diminish the cystoid macular edema that complicates 
the surgery of cataracts suggesting drug effects on the inner retina. Other adverse effects of ophthalmic 
Ketorolac are occasional episodes of discomfort, ocular burning, corneal lesions and corneal haziness.  
Corneal toxic lesions have been reported with NSAIDs such as nepafenac and case reports of 
reversible toxic keratolysis in adults with prolonged ketorolac treatment. The use of ketorolac 
ophthalmic solution in pediatrics is frequent as an analgesic in corneal abrasions, and in allergic and post 
surgical conjunctivitis. The FDA recognizes its indication for allergic conjunctivitis, ocular pain, post surgical 
ocular inflammation, ocular pruritus and photophobia.  See drug package insert (Appendix IV). 


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_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
2.0 
PROTOCOL SYNOPSIS 
 
Protocol Title 
Synergistic Pharmacologic Intervention for Prevention of ROP (SPIPROP 
Study) 
Sponsor: 
NICHD 
Product 
IV Ibuprofen, Ketorolac (Acuvail) ophthalmic solution  
Objectives: 
• 
To evaluate the safety, tolerability, and efficacy of early postnatal 
local ophthalmic NSIADs potentiated with caffeine for prevention of 
severe ROP in ELGANs. Our hypothesis is that ocular ketorolac or 
systemic ibuprofen potentiated with systemic caffeine will prevent or 
diminish the severity of ROP. 
• 
To determine the number of daily arterial oxygen desaturations that is 
critical for the development of severe ROP, correlate this number 
with the levels of serum VEGF, IGF-I, 8-iso-PGF2α, and MMPs, Our 
hypothesis is that there is a “critical” number of daily arterial oxygen 
saturations experienced by extremely low gestational age neonates 
during the first two weeks of life that is a key risk factor for severe 
ROP. 
• 
To determine whether infants at risk for severe ROP are 
haploinsufficient for the Dll4.  Our hypothesis is that extremely low 
gestational age neonates at risk for severe ROP will have a different 
pattern of gene expression specifically related to the Notch signaling 
pathway, as has been shown in animal models. 
Study Design: 
Multi-center, Phase 2 open label, randomized, prospective, pharmacokinetic 
and safety study of for the prevention and treatment of ROP in extremely low 
gestational age neonates. 
Study Population: 
• 
All infants <28 weeks 
• 
All infants <1250 grams 
• 
Requiring oxygen therapy and/or ventilator support within the first 2 
days of life 
• 
All infants requiring Caffeine Citrate for Apnea of Prematurity as per 
standard of care 
Number of Infants: 
120 infants (n=40 per arm) 
Number of Centers: 
5 
Treatment: 
• 
Group 1 (n=40):  Caffeine citrate IV (20 mg/kg loading dose followed 
by 5 mg/kg/day maintenance dose) + placebo saline IV (1 ml/kg 


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_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
loading dose followed by 0.25 ml/kg) for 5 days + sterile normal 
saline (one drop 2 times per day, every 12 hours) for 14 days. 
• 
Group 2 (n=40):  Caffeine citrate IV (20 mg/kg loading dose followed 
by 5 mg/kg/day maintenance dose) + Ibuprofen IV (10 mg/kg loading 
dose followed by 2.5 mg/kg/day) for 5 days + sterile normal saline 
(one drop 2 times per day, every 12 hours) for 14 days. 
• 
Group 3 (n=40):  Caffeine citrate IV (20 mg/kg loading dose followed 
by 5 mg/kg/day maintenance dose) + placebo saline IV (1 ml/kg 
loading dose followed by 0.25 ml/kg) for 5 days + Ketorolac 
ophthalmic solution (one drop 2 times per day every 12 hours) for 14 
days. 
 
The doses of Caffeine Citrate are as per standard of care for Apnea of 
Prematurity. 
Treatment Duration 
Drug or placebo administration will be initiated between 0 to 72 hours of life 
and continue until 5 to 8 days of life (Ibuprofen), or 14 to 16 days of life, 
depending on time of initiation of the drug or placebo.  Study drug/placebo 
will be discontinued in infants with any serious adverse event (SAE).  
Monitoring for adverse events will occur until death or discharge from the 
neonatal intensive care unit (NICU). 
Specimen 
Collection 
1) Mixed Cord blood:  Mixed cord blood approximately 1.0 to 3.0 cc per 
patient 
2) Cord tissue: 6 samples per patient (approximately 5 mm thick, 200 mg) 
3) Placental tissue: 7 samples per patient (approximately 5 mm thick, 200 
mg) from maternal-fetal interface, fetal side, and intervillous space. 
4) Blood samples:  Total 5 for this study (0, 1, 7, 14, and 21 days) 
approximately 0.3 mL each 
5) Urine samples: Total 5 for this study (0, 1, 7, 14, and 21 days) 
approximately 1.0 to 3.0 mL each 
6) Mixed cord blood, cord tissue and placental tissue will be used to assess 
for haploinsufficiency of Notch/Dll4.  
Patients can still be enrolled in the study if cord and placental samples cannot 
be obtained at the time of delivery. 
 
Safety: 
The protocol will rely on three mechanisms for safety:  
1) The data safety monitory board (DSMB)  
2) Adverse event (AE) and SAE reporting  
3) The active, daily, real time oversight of the clinical staff 


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Neonates will be clinically monitored and ophthalmologic exams performed 
as per the standard of care.  Safety assessments will include but are not 
limited to: the physical examination; routine laboratory values; renal function; 
hematologic parameters; urine output; gastrointestinal function (bleeding) & 
NEC; daily examination by the neonatal staff of the cornea for haziness and 
lesions; and progression of ROP if any by the Ophthalmologists. All SAEs 
will be closely monitored throughout the course of the study.   
Statistical 
Consideration: 
The primary objective of this study is to assess the safety and potential 
efficacy of caffeine plus NSAIDs to prevent ROP. We will enroll 40 evaluable 
neonates for each group (total n=120). Evaluable subjects are those who 
fulfill inclusion and exclusion criteria and survived for 36 weeks 
postconceptional (PCA) age eye examination. The estimated rate of ROP 
(all stages) for neonates <1250 grams in the Brooklyn Queens Neonatal 
Network (BQNN) is 58% and severe (Stage 3 plus) is 5.7%. We hypothesize 
that early synergistic intervention is safe and will decrease the incidence of 
ROP in the combination therapy treated patients by 50%. Assuming an ROP 
incidence of 57% (all stages), a total of 120 evaluable neonates or 40 infants 
in each group would be needed to have a statistical power of 80% to detect 
a 50% relative reduction in the risk of ROP at an alpha =0.05 beta =0.20. 
This is a small, adequately powered phase II, safety, efficacy, 
pharmacodynamic trial which will generate requisite data needed for the 
design and implementation of a conclusive randomized phase 3 trials. 
Randomization will be done using sealed envelopes at each site in blocks of 
6.  
Inclusion Criteria 
Neonates at high risk for ROP as outlined by the American Academy of 
Pediatrics, Section on Ophthalmology; American Association for Pediatric 
Ophthalmology and Strabismus; and American Academy of Ophthalmology 
will be enrolled. Inclusion criteria are:  
1) all infants with a birth weight of less than 1250 grams;  
2) all infants with a gestational age of 28 weeks or less;  
3) all infants who required oxygen therapy and/or ventilator support within 
the first 2 days of life; and 
4) All patients on Caffeine Citrate for Apnea of Prematurity as per standard 
of care. 


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Exclusion Criteria 
Exclusion criteria are:  
1) Infants with major congenital anomalies, congenital sepsis, chromosome 
abnormalities (incl. duct-dependent cardiac anomalies). 
2) Fused eyelids 
3) Maternal antenatal NSAID exposure < 72 hours before delivery of the 
baby. 
4) Infants with cardiac conditions including cardiomyopathies, serious 
arrhythmias and congenital heart defects. 
5) Infants transferred from outside hospital after 72 hours of life. 
6) Renal failure or oliguria (defined as urine flow rate <0.5 ml/kg/hour in the 
8 hours prior to randomization).  Anuria is acceptable if less than 24 hours 
of life. 
7) Admission platelet count <50,000 mm3.  
8) Clinical bleeding such as continuous, active oozing from puncture site. 
9) Participation in other clinical trials while subjects participate in this study 
and for 7 days after the last dose of study drug. 
10) Infants with cyanotic heart disease diagnosed by fetal echocardiography 
during pregnancy or infants who show persistently low oxygen 
saturations as per attending neonatologist despite adequate ventilator 
assistance.  
 


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AA 
 Arachidonic Acid 
AE 
 Adverse Event 
ANOVA 
 Analysis of Variance 
BPD 
 Bronchopulmonary Dysplasia 
BQNN 
 Brooklyn Queens Neonatal Network 
BUN 
 Blood Urea Nitrogen 
C 
 Drug Concentration 
CBC 
 Complete Blood Count 
CC 
 Coordinating Center 
CLD 
 Chronic Lung Disease 
COX 
 Cyclooxygenase 
CRF 
 Case Report Form 
CRYOROP 
 Cryotherapy for Retinopathy of Prematurity 
Dll4 
 Delta-like ligand 4 
DNA 
 Deoxyribonucleic acid 
DOL 
 Day of Life 
DSMB 
 Data and Safety Monitoring Board 
DSMP 
 Data Safety Monitoring Plan 
ECM 
 Extracellular matrix 
ECs 
 Endothelial Cells 
ELBW 
 Extremely Low Birth Weight 
ELGANs 
 Extremely Low Gestational Age Neonates 
FDA 
 Food and Drug Administration 
3.0 
ABBREVIATIONS 


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FiO2 
 Fraction of Inspired Oxygen 
g/dL 
 Grams per Deciliter 
GA 
 Gestational Age 
GCP 
 Good Clinical Practice 
HIPAA 
 Health Insurance Portability and Accountability Act  
IEC 
 Independent Ethics Committee 
IGF-I 
 Insulin-like growth factor-I 
IND 
 Investigational New Drug 
IRB 
 Institutional Review Board 
IVH 
 Intraventricular Hemorrhage 
Kg 
 Kilogram 
LFT 
 Liver Function Tests 
mL 
 Milliliter 
MMPs 
 Matrix Metalloproteinases 
NEC 
 Necrotizing Enterocolitis 
NICHD 
 National Institute of Child Health and Disease 
NICU 
 Neonatal Intensive Care Unit 
NIH 
 National Institute of Health 
NSAIDs 
 Non-Steroidal Anti-Inflammatory Drugs 
NYPD-PRC  New York Pediatric Developmental Pharmacology Research Consortium 
OIR 
 Oxygen-Induced Retinopathy 
PCA 
 Postconceptional Age 
PD 
 Pharmacodynamic 
PDA 
 Patent Ductus Arteriosus 


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
 
PG 
 Prostaglandins 
PGF2α 
 Prostaglandin F2α  
PGI2 
 Prostaglandin I2, Prostacyclin 
PI 
 Principal Investigator 
PK 
 Pharmacokinetic 
RNA 
 Ribonucleic acid 
ROP 
 Retinopathy of Prematurity 
ROS 
 Reactive Oxygen Species 
SAE 
 Serious Adverse Event 
Shh 
 Sonic HedgeHog 
STOP-ROP  Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity 
SUNY 
 State University of New York 
TIMP-1 
 Tissue Inhibitor of Metalloproteinases 
TxA2 
 Thromboxane A2 
VEGF 
 Vascular Endothelial Growth Factor 
VEGFR-1 
 Vascular Endothelial Growth Factor-1 


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4.0  FLOW CHART OF STUDY PROCEDURES 
 
Informed consent/Privacy Acknowledgement 
Baseline 
Treatment 
Post-
Treatment 
Adverse Events 
 
X 
X 
Body Weight 
X 
X 
X 
Clinical laboratory tests (renal, liver, hemogram) 
X 
X 
 
Collect extra scavenged blood from blood gases 
X 
X 
X 
Collection of placenta, cord blood, cord tissue 
X 
 
 
Demographics (BW, GA, Apgar score, maternal 
history, diagnoses, O2 and respiratory support, blood 
gases. 
X 
 
 
Medical Baseline Conditions 
X 
 
 
Neurodevelopment Assessment 
 
 
 
Ophthalmology exam 
 
 
X 
Pain Scoring 
X 
X 
 
Pertinent Medical History 
X 
 
 
Physical examination 
X 
 
 
Plasma and urine sampling 
X 
X 
X 
Record all concomitant medications 
X 
X 
X 
Record all morbidities 
 
 
X 
Record all non-medication treatments (surgical, other 
procedures) 
X 
X 
X 
Record results of all exams (head/abdominal US, CT 
scans, MRIs, echo, etc.) 
X 
X 
X 
Recording Surgical Interventions 
X 
X 
X 
ROP Assessment 
 
 
 


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
Study Drug Dosing 
 
 
 
Vital Signs 
X 
X 
 
 
 


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5.0 
INTRODUCTION 
5.1 
Retinopathy of prematurity (ROP) 
ROP is the most common cause of blindness in children.  It is a developmental retinal vascular 
disorder characterized by abnormal growth of retinal blood vessels in the incompletely 
vascularized retina of ELGANs, <28 weeks (w); <1250 grams (g). In 2010, Brooklyn, NY had 170 
of 209 (81.3%) neonates born < 1,000 grams developed ROP (all stages), with 12/209 (5.7%) 
progressing to Stage 3+ treated with Laser or Avastin, leading to significant impairment of vision 
and a lifetime of darkness. The incidence and severity of ROP increase with decreasing birth 
weight and gestational age. The multicenter Cryotherapy for Retinopathy of Prematurity 
(CRYOROP) study indicated that the incidence of ROP increased from approximately 40% in 
infants with birth weights 1101 to 1200 g to more than 90% in those with birth weights 501 to 600 
g (1,2). ROP increased from approximately 35% in infants with gestational age of 31 weeks to 
more than 95% in those with gestational age of 24 weeks. Jacobson et al. (3) reported that 97.4% 
of 114 neonates born <25 weeks gestation had ROP, 74.6% developed proliferative disease 
(stage ± 3) and 63.2% were treated with retinal ablation. Impaired visual acuity (<0.33) was found 
in 32.6% of boys and 9.2% of girls, who were blind living in darkness or had severe visual 
handicaps (4). In New York, 27.3% (1839 of 6745) of infants with birth weight <1200 g developed 
ROP (4). The incidence of any ROP was 68% among infants of <1251 g (5) with a higher rate in 
Brooklyn, NY. Although the overall incidence of ROP has decreased, it still remains high in 
ELGANs at some centers (5), with threshold ROP occurring in 5% of ELGANs in the US, with as 
much as 30% of them becoming blind (6,7). Although milder ROP (Stage 1 & 2) regress, visual 
problems requiring early use of corrective lenses are common. The proven risk factors for the 
development of ROP are immature retinal vasculature, hyperoxia, and circulatory and respiratory 
instability (8). Other factors include low birthweight, early gestation, PDA, IVH, BPD/CLD, NEC, 
and sepsis (9). Because ROP continues to be a major problem, and due to its multi-factorial 
nature, a better understanding of the underlying mechanisms is vital for its prevention. Current 
methods for treatment and prevention are highly invasive leading to increased pain and distress in 
these micropremies. The search for new, effective, and targeted pharmacotherapies warrants a 
high priority. Our proposed studies will investigate whether targeted, early, topically applied 
NSAIDs or systemic Ibuprofen potentiates Caffeine in preventing the cascade of events leading to 
severe ROP and a lifetime of blindness and darkness 
 
5.2   
Role of Oxygen Saturation Control 
Prematurity and hypoxia/hyperoxemia are two underlying factors in the development of ROP. 
Previous studies have suggested that the incidence of ROP is lower in preterm infants with 
exposure to reduced levels of oxygenation than in those exposed to higher levels of oxygenation 
(10-15). Giving supplemental oxygen to maintain oxygen saturation 96% to 99% in the STOPROP 
study did not decrease progression of ROP but did increase exacerbation of chronic lung disease, 
use of diuretics and oxygen therapy (16). Currently, it is unclear what range of oxygen saturation 
is appropriate to minimize ROP without increasing adverse outcomes. A randomized controlled 


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trial comparing target ranges of oxygen saturation of 85 to 89% versus 91 to 95% in ELGANs 
showed more deaths before discharge in the lower-oxygen-saturation group (19.9% vs. 16.2%; 
p=0.04), whereas severe ROP among survivors occurred less often in this group (8.6% vs. 
17.9%; p<0.001) (17). The increase in mortality is a major concern, since a lower target range of 
oxygen saturation is increasingly being advocated to prevent ROP. Clearly, a balance between 
the maximum reduction in severe ROP and no increase in mortality remains a challenge for 
neonatal care givers. There are wide ranges of oxygen saturation targets in various NICUs (18) 
and the critical oxygen saturation ranges increasing the risk of ROP is still unknown. However, the 
practice of targeting O2 saturations at 88% to 92% coupled with education of neonatal staff and 
better oxygen monitoring has been associated with further reductions in severe ROP (19). This 
approach is currently in practice in our NICU’s and will be maintained in this trial. 
 
5.3   
Pathophysiology 
The retina is oxygenated from retinal and choroidal circulations. The choroidal circulation is 
formed from arteries that pierce the sclera and form smaller branches that supply the 
choriocapillaries (20,21). In humans, formation of retinal vasculature occurs in utero, where the 
arterial oxygen tension is <30 mmHg. The inner retinal vasculature, which nourishes the inner 
portion of the retina, starts developing by the 16th week of gestation and is mature at term (22). 
The retina is highly susceptible to oxidative damage for several reasons: 1) it is high in 
polyunsaturated fatty acids, which are targets for oxygen free radicals; 2) it processes light, and 
photoexcitation can initiate free radical formation and peroxidation reactions and; 3) it has a high 
metabolic rate and requires a high blood flow for oxygen consumption (23-25). The retinal cells of 
premature infants are further subjected to altered perfusion, metabolic acidosis, and respiratory 
failure. During these adverse events, the retina derives its oxygen from the choroidal circulation 
and constricts in response to oxygen tension. The choroidal circulation autoregulates in response 
to changes in oxygen tension; therefore excess oxygen passes from the choroid to the retina, 
causing it to constrict to the point of obliteration. The development of ROP is thought to occur in 
two phases: Phase 1) vaso-obliteration: when the premature newborn infant is exposed to high 
levels of oxygen, normal vasculogenesis is disturbed, causing the immature retina to constrict and 
leading to obliteration of retinal capillaries, ischemia, retardation of vessel development, and 
apoptosis of the retinal cells; and Phase 2) vaso-proliferation: this phase is initiated when the 
infant is placed in room air. It is during the second phase of ROP that retinal hemorrhages, retinal 
folds, and retinal detachment occur (26). This form of ROP may not be applicable to ELGANs 
(<1000 g) who experience frequent arterial oxygen desaturations during mechanical 
ventilation and oxygen therapy. Seventy to ninety percent of all ELGANs experience recurrent, 
clinically significant apnea during the first weeks of life. These apneic episodes last several 
seconds and result in arterial oxygen desaturations. Apneas of less than 10 seconds duration can 
result in a reduction in oxygen saturation of 40% (27). The relationship between fluctuating arterial 
oxygen saturation and the risk for severe ROP has been demonstrated in humans (15,27,28) and 
animal models (2,29-36). These studies demonstrate that the two phases of ROP occur 
simultaneously in ELGANs and suggest a “new” model for the development of the disease. 


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The mechanistic events of ROP may be activated early through constant cycling of 
hyperoxia/hypoxia, and may be irreversible. Therefore, it is vital to identify infants at most risk 
for severe ROP and identify safe, effective pharmacotherapies and dosing regimens to 
prevent severe ROP. 
5.4 
Role of COX in ROP  
Exposure to high levels of oxygen induces the formation of highly reactive oxygen species, or 
ROS (37). This free radical formation appears to play an important role in the pathophysiology of 
ROP (38-40). Prostanoids play a key role in choroidal blood flow autoregulation (41). Generation 
of ROS is also known to induce VEGF, a potent angiogenesis factor involved in ROP (42) and 
prostanoids (43,44). The COX enzyme, which exists in three isoforms, regulates the production of 
prostanoids (45,46). The constitutively expressed COX-1 is responsible for maintaining basal PG 
levels, while the inducible COX-2 is involved primarily in inflammatory processes (47,48). COX-3 
is a splice variant of COX-1 that retains the intron-1 gene sequence at the mRNA level which 
encodes a 30 amino acid sequence inserted into the N-terminal hydrophobic signal peptide of the 
enzyme protein (49). Recent data have shown that the inducible COX-2 correlates with VEGF 
expression (50) and with vascular function (51), and may contribute to angiogenesis (52,53). 
COX-2 can be expressed on ischemic stimuli in the retina (54). COX-2 exerts angiogenic effects 
in tumors (55,56) and corneal neovascularization (57). COX-2 inhibition has been shown to 
decrease retinal neovascularization in ischemic models (58). We have previously shown that 
COX-2 inhibition during hyperoxia preserves VEGF receptor (VEGFR)-1 receptor mRNA 
expression in newborn rabbit retinas (59). Increasing evidence suggests that free radicals such as 
superoxide anion are increased and contribute to tissue injury (60). Certain prostanoid 
compounds, the F-isoprostanes, are generated by oxygen free radical lipid peroxidation of 
arachidonic acid (AA), independent of the COX enzyme (61). One of these isomers, 8-isoPGF2α, 
is a potent mitogen and constrictor of vascular smooth muscle, and is highly correlated with 
oxidative stress (62). Recently, studies have demonstrated that 8-iso-PGF2α is functionally linked 
to and activates the thromboxane A2 (TxA2) receptor (63,64). TxA2, a potent product of AA 
metabolism in human platelets, is dependent on the COX enzyme and has been shown to be 
associated with oxidative injury in ROP (65,66). Prostacyclin (PGI2) appears to play a significant 
role in reversing the vasoconstrictor effects of TxA2, an effect that may be impaired in ROP (67). 
Studies by Stuart et al. (67,68) have demonstrated marked reductions in kitten retinal 6-keto 
prostaglandin F1α, (6-ketoPGF1α, the stable metabolite of PGI2) during hyperoxia and recovery in 
room air. Prostaglandin F2a (PGF2a) has been shown to cause potent vasoconstriction, and 
participates in endothelial cell death and vasoobliteration of porcine retinal vessels (68). 
Nonselective COX inhibitors inhibit subretinal neovascularization (69) and improve oxygen-
induced retinopathy (OIR) in mice (70) and rats (71), and suppress VEGF and IGF-I in the retina 
(72). The importance of the COX/PG influence in ROP provides one of the key mechanisms for 
the benefits of NSAIDs for the treatment and/or prevention of ROP (73). We have shown that 
ibuprofen decreases OIR in newborn rats but Indomethacin worsens it (Figure I). While both 
indomethacin and ibuprofen exert no effect on retinal vasoconstrictor TXB2, Ibuprofen increases 


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the vasodilator prostacylin which may partly ameliorate NSAID-induced retinal vasoconstriction 
during oxygen therapy. Higher doses of Indomethacin in preterm newborns increase risk of ROP 
(74). Thus, Ibuprofen was chosen over Indomethacin for the prevention of ROP.  An 
overwhelming majority of human and animal studies have focused on rescue treatment of ROP 
when damage to the retina has already occurred. The current proposal will evaluate the 
therapeutic benefits of prophylactic use of topical or systemic NSAIDs potentiated with Caffeine, 
thus providing a novel, safe, and effective pharmacotherapy for ROP prevention. 
 
5.5   Role of VEGF in ROP 
As the retina develops, astrocytes and neural precursors spread out and migrate away from the 
existing blood vessels. As they move further away from the blood vessels, the astrocytes, which 
are hypoxic sensors, encounter hypoxic conditions. Hypoxia stimulates astrocytes to produce 
VEGF, forming a VEGF concentration gradient that stimulates angiogenesis and growth of new 
vessels toward the VEGF-producing astrocytes. The growing blood vessels follow the astrocytes 
and continue to migrate outward. A threshold concentration of VEGF is needed to inhibit 
apoptosis of endothelial cells (ECs) and stabilize the new vessels. The soluble VEGF121 may be 
involved in maintenance and stability of the new vessels. In ROP, hyperoxic conditions cause the 
astrocytes to decrease VEGF production, leading to regression of vessels and impaired retinal 
angiogenesis. VEGF has been shown to play a key role in the development of ROP (75-84) 
Levels of VEGF in the vitreous humor correlate with the degree of neovascularization. Aiello et al. 
(82) demonstrated disease-related increase in VEGF protein in the vitreous and aqueous of 
human active neovascular retinopathies. Pierce et al. (83) showed that upregulation of the VEGF 
message in an oxygen induced retinopathy (OIR) mouse model can be reversed by placing the 
animals back in oxygen. VEGF mRNA is upregulated in tissue ischemia subsequent to oxygen-
induced retinopathy. VEGF protein results in hyperpermeability of the endothelial cells and 
mediates plasma leakage. Increased VEGF may contribute to the edema observed at the 
transition zone in retinas with OIR and ROP (76). VEGF acts as a strong (perhaps the primary) 
angiogenic stimulus for preretinal neovascularization in the oxygen-injured retina (78). Various 
proteases (plasmin and matrix metalloproteinases or MMPs) cleave membrane-bound VEGF to 
produce diffusible isoforms. This appears to be a primary and key step involved in the cascade of 
events leading to ROP. Proteolysis of VEGF increases its gradient and triggers an angiogenic 
switch (84,85). MMPs degrade extracellular matrix (ECM), making it possible for retinal vessels to 
migrate and proliferate. The type IV collagenases (MMP-2 and –9) and tissue inhibitor of 
metalloproteinase (TIMP)-1 appear to play a key role in retinal neovascularization (86). The role of 
MMPs and its co-expression with COX-2 in inflammation is well established (87,88). These 
observations enable us to hypothesize that preserving the VEGF gradient during hyperoxia may 
be more beneficial than preventing vaso-proliferation. Given the association between COX and 
VEGF, we will demonstrate the protective effects of early, locally applied NSAIDs 
potentiated with Caffeine to protect the immature retina from ROP. We will examine the 
efficacy of NSAIDs/caffeine pharmacotherapy for preserving VEGF and balancing 
MMP/TIMP. 


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5.6   
Notch/Dll4 Signaling and Haploinsufficiency in ROP 
Heterozygotes sometimes display an intermediate phenotype which can result from loss-of-
function mutation in a gene where the amount of protein is not sufficient for normal cellular 
function. Such genes are called “haploinsufficient” which indicates that one copy of the gene is 
insufficient for proper function (89). Loss of function of the Notch receptors or their ligands has 
diverse and often severe clinical, physiological and biological consequences in humans (90). 
During normal retinal vascular development, suppression of Dll4/Notch signaling markedly 
enhances angiogenic sprouting and promotes the formation of a denser primary capillary network 
(91). Therefore, Dll4 acts as a negative regulator and potent endogenous inhibitor of vascular 
sprouting. Notch activation downregulated VEGFR-2 in EC cell lines, while Dll4 haploinsufficiency 
caused upregulation of VEGFR-2 in the retina of neonatal mice (92). In contrast, Jagged1 
(another Notch ligand) is proangiogenic and down-regulates Dll4/Notch signaling (93,94). Dll4 is 
highly expressed in the embryonic eye (95) and developing retinal vasculature. Gene inactivation 
in mice shows that Notch signaling is critical for vascular development. Treatment with COX 
inhibitors down-regulated Jagged1, an effect that was restored by prostaglandin E2 or exogenous 
COX-2, demonstrating that activation of Notch1 signal pathway occurs in part through COX-2 
(96). The regulation of Notch/Dll4 signaling on VEGF and angiogenesis allow us to speculate that 
ELGANs who develop severe ROP are haploinsufficient for Dll4, causing increased 
Notch/Jagged1 signaling and enhanced retinal vascular sprouting and is a molecular target for 
drug intervention. 
 
5.7         Critical barriers: Pharmacologic Interventions 
Caffeine citrate is a methylxanthine used as first-line pharmacotherapy for reducing the frequency 
of apneic episodes. Caffeine is one of the most frequently prescribed drugs in ELGANs 
(approximately 93%) during their hospitalization. Caffeine significantly reduced the risk of severe 
ROP in ELGANs (97). The mechanism of caffeine effects on severe ROP remain to be 
determined, but may involve effects on regulators of angiogenesis such as sonic hedgehog (Shh) 
(98,99), VEGF, and MMPs (100). We have shown that caffeine increased retinal VEGF during the 
vaso-obliterative phase of OIR (Figure 2A), which may allow normal vascularization in the phase 
of oxygen induced obliterative effect: In contrast, caffeine at therapeutic doses suppressed VEGF 
during vasoproliferative phase (Figure 2B), which may lead to decrease neovascularization. 
Although low serum IGF has been associated in babies with ROP (101) caffeine probably does 
not exert its protective effect via this mechanism since serum IGF is suppressed by therapeutic 
caffeine during vasoproliferative phase. Caffeine potentiates the anti-inflammatory effects of COX 
inhibitors in activated microglia which may also occur in the retina (102). Caffeine has been used 
in combination with NSAIDs for many decades to enhance their analgesic effects, suggesting that 
caffeine may be an effective adjuvant to ibuprofen (103,104). Caffeine also has some antioxidant 
properties and prevents oxidative stress in the lens (105). NSAIDs have been shown to be 
beneficial for ROP. A retrospective chart review found that Indomethacin use for PDA was 
protective for ROP (106). These findings were corroborated by a Cochrane metanalysis (107). It is 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
suggested, but not proven, that the effect of indomethacin on ROP may be related to the infant's 
postnatal age (108). This may indicate that the exact timing of treatment may be crucial for 
efficacy of the drug. Topical application of Ketorolac also prevents severe ROP (109); however, 
this effect is controversial, since another study showed no benefit (110). Other pharmacologic 
interventions include inositol (111,112), beta blockers (113), atocopherol (114,115), and recently, 
intravitreal VEGF inhibitors (116-127). The use of intravitreal Avastin is highly invasive, and 
causes pain, distress, and discomfort. In addition, there are numerous reports of retinal 
detachment, vitreous and retinal hemorrhage, and choroidal rupture with intravitreal bevacizumab 
(117-125). Intravitreal Avastin appeared to spread via the bloodstream into the fellow eye when 
injected into an 8-year old patient (124). These adverse events suggest that the immature retina 
may be vulnerable to VEGF blockade and may cause breakdown of the blood-ocular barrier 
(127). More importantly, if Avastin, even at low doses, effectively inhibits neovascularization and 
interferes with the immature blood-ocular barrier it is possible that it may cross into the neonate’s 
brain and suppress the normal angiogenesis of the developing brain. Given the role of astrocytes 
in production of VEGF and maintaining the integrity of microvasular ECs, the use of anti- VEGF 
therapies, such as Avastin, will undoubtedly have adverse effects on other related cells such as 
astrocytes, pericytes and microglia with possible long-term neurological repercussions. Clearly, a 
fuller understanding of the biomolecular mechanisms regulating ROP, as well as the use of 
alternate pharmacologic interventions that is safer, less invasive, and as effective, is needed. 
 
5.8        Improvement of Scientific Knowledge and Clinical Impact 
Seventy to ninety percent of all ELGANs experience recurrent, clinically significant apnea during 
the first weeks of life. These apneic episodes last several seconds and result in arterial oxygen 
desaturations. Apneas of less than 10 seconds duration can result in a reduction in oxygen 
saturation of 40%. The relationship between hyperoxemia and hyperoxemia and significant 
increase in severe ROP has been established (128). What is NOT known is the number of apneic 
episodes or arterial oxygen desaturations per day that results in severe ROP. We believe that a 
“critical” number is essential for the cascade of events that lead to severe ROP. This project will 
address this issue and provide new information for identification of these infants at risk. The 
impact of these studies will be substantial. We will correlate the number of arterial oxygen 
desaturations with serum VEGF levels. This has not been previously done. Finally, we will 
examine the genetic profile of these infants to determine if the propensity for severe ROP is due 
to Dll4 haploinsufficiency, and whether pharmacologic interventions can reverse it. If our proposed 
aims are achieved and hypotheses proven, our studies will provide guidelines for identification of 
infants at risk for severe ROP long before it develops in order to implement early treatment. Our 
studies will contribute to prevention of a long life of blindness, darkness and visual impairment. 
Prevention of blindness at the beginning of life will surely impact the quality of life for these 
children.  
 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
6.0 
STUDY OBJECTIVES 
This study will evaluate the safety, tolerability and PK-PD of, and to compare and contrast, IV 
Ibuprofen with Caffeine and Ketorolac eye drops with Caffeine in ELGAN infants <28 weeks GA 
for 14 days duration to treat and preferably prevent ROP associated with prematurity and ELGAN. 
The specific aims of this trial are: 
 
6.1 Aim 1: To establish the synergistic effect of local ophthalmic NSIADs and systemic 
caffeine as optimal therapies for the attenuation and/or prevention of severe ROP. 
Hypothesis: Ocular Ketorolac or systemic Ibuprofen potentiated with systemic Caffeine will 
prevent or diminish the severity of ROP. We will: a) Evaluate the safety, tolerability, and efficacy 
of early postnatal local ophthalmic NSIADs for prevention of severe ROP in ELGANs. b) 
Determine the pharmacokinetics, pharmacodymanics and pharmacogenomics of NSAIDs 
potentiated with caffeine for prevention of ROP. 
 
6.2 Aim 2: To identify a “critical” number of arterial oxygen desaturations as a key risk 
factor for severe ROP.  
Hypothesis: A “critical” number of daily arterial oxygen desaturations during the first two weeks of 
life is a key risk factor for severe ROP. We will: a) Further define the role of VEGF, IGF, MMPs, 
and ROS in ROP and correlate the levels with the number of arterial oxygen desaturations. b) 
Establish and identify whether increased serum VEGF in infants with severe ROP is the diffusible 
isoform VEGF121. This isoform is formed from VEGF proteolysis by plasmin and MMPs. MMPs 
also cleave Notch/Dll4, which acts as a regulator of VEGF signaling. 
6.3  Aim 3: To determine whether infants at risk for severe ROP are haploinsufficient for 
the delta-like ligand 4 (Dll4).  
Hypothesis: ELGANs at risk for severe ROP will have different pattern of gene expression 
specifically related to the Notch signaling pathway, as has been previously shown in animal 
models. We will: a) Examine cord blood, cord tissue, and placental tissue to compare the gene 
profile of VEGF and Notch signaling pathways among infants who develop severe ROP and those 
who do not; and b) Determine whether NSAIDs and/or Caffeine will confer protective benefits on 
Notch/Dll4 signaling and prevent the development of severe ROP.   
 
7.0 
INVESTIGATIONAL PLAN 
7.1 
Overall Study Design/Centers 
This is a phase 2b, randomized, open label, multi-center, safety, tolerability and efficacy study 
comparing 3 interventions for possible prevention of ROP. The trial will be conducted in at least 5 
investigational sites including the Neonatal networks (SUNY Downstate and the Brooklyn-Queens 
Neonatal Network sites, SUNY Stony Brook). An independent DSMB will assess safety during the 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
study. This study will monitor for safety while on study drug and for 7 days after last dose of drug. 
An exploratory study to determine the role of pharmacodynamic, drug concentrations (as 
surrogate of PK profile) and pharmacogenomics will also be conducted in this patient population. 
One hundred and twenty preterm infants (<28 weeks gestation; <1250 grams) between 0 and 72 
hours of life will be randomized to receive either: 
1) Caffeine citrate IV (20 mg/kg loading dose followed by 5 mg/kg/day maintenance dose) 
plus placebo saline IV (1 ml/kg followed by 0.25 ml/kg) for 5 days plus sterile normal saline 
(one drop two times a day) for 14 days (n=40);  
2) Caffeine citrate as described in group 1 plus Ibuprofen (10 mg/kg loading dose followed by 
low dose ibuprofen 2.5 mg/kg/day) for 5 days plus sterile normal saline (one drop two 
times a day) for 14 days (n=40); and 
3) Caffeine citrate plus saline IV placebo as described in group 1, and Ketorolac (Acuvail)  
eye drops (one drop two times a day) for 14 days (n=40). 
 
All patients will receive Caffeine citrate for Apnea of Prematurity as per standard of care.  Therefore, 
Caffeine citrate is not a study drug.  The doses of Caffeine citrate are as per standard of care for 
Apnea of Prematurity. The final blood and urine samples will be obtained at 21 days post treatment.  
This will also be the final day of the study.  It should be noted that for Ketorolac the 21-day post 
treatment can range from 35-38 days of life depending on the day of life at the initiation of the study 
drug.  On the other hand, the 21-day post treatment for Ibuprofen can range from 26-29 depending 
on the day of life at the initiation of the study drug. 
 
7.2 
Table 1.  Study Design 
Group and 
Intervention 
Caffeine 
Ibuprofen IV 
Ketorolac eye drops 
Group 1 (n=40) 
+ 
Saline (placebo) 
sterile normal saline 
(placebo) 
Group 2 (n=40) 
+ 
+ 
sterile normal saline 
(placebo) 
Group 3 (n=40) 
+ 
Saline (placebo) 
+ 
 
Treatment with Ketorolac will last 14 days and treatment with Ibuprofen will last 5 days.  Caffeine 
will be administered as per standard of care.  Birth weight will be used for dosing of Neoprofen 
and IV Saline up to day of life 8.  The primary outcome will be measured at 36 weeks post-
conceptional age.  Each infant will be followed until death or discharge.  Discharge will be defined 
as release of the infant to go home.  For infants transferred rather than being discharged home, 
study staff will call to determine the primary outcome.  Transfer includes release of the infant to 
outside institutions or other units within the same hospital. Plasma PK will be evaluated using a 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
limited sampling scheme.  Cord blood, cord tissue and placental tissue will be used to assess 
haploinsufficiency for Notch/Dll4 signaling.  Patients can still be enrolled in the study, if cord and 
placental samples cannot be obtained at the time of delivery. 
 
7.3 
Rationale for Study Design.  
Phase 2, open-label, randomized, multi-center studies in infants and premature infants are 
necessary to determine treatment and preventative strategies for ROP. This study was designed 
to: a) target infants at the highest risk of ROP in a large number of centers with variable rates of 
ROP (all stages and severe ROP or stage 3+); and b) assess whether caffeine plus systemic or 
ophthalmic NSAID will decrease ROP among infants most at risk for ROP. The study is designed 
to determine whether the novel treatment regimens are safe and potentially effective for ROP 
prevention and to obtain requisite data for the development of a Phase III efficacy/safety 
randomized blinded trial. Since caffeine is used extensively in NICUs as standard of care for 
ELGANs, no placebo group is included. 
 
7.4 
Rationale for Drug and Dose Selection.   
Neonates at high risk for ROP as outlined by the American Academy of Pediatrics, Section on 
Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; and 
American Academy of Ophthalmology (129) will be enrolled.  We have published the first 
pharmacokinetic data on IV Ibuprofen (130) and caffeine in newborns (131,132). Our published 
data on intravenous ibuprofen suggest doses of 10 mg/kg loading dose and 5 mg/kg/day 
maintenance dose are safe for closure of PDA during the first week of life. All published data 
indicate safety of a three-day therapy. However, the safety of a longer course (2 weeks) after birth 
is not known. We will provide these data which will be extremely useful in the design of larger trial. 
Lower doses (2.5 mg/kg) for a 5-day treatment will be used to maximize safety. Ketorolac eye 
drops (0.25 mg tid) have been previously evaluated in pilot trials in a limited number of neonates 
(109). There are no data on the synergistic effects of NSAIDs and caffeine for severe ROP. No 
ibuprofen ophthalmic preparation is commercially available.  Caffeine potentiates the anti-
inflammatory effects of COX inhibitors in activated microglia which may also occur in the retina 
(102). Caffeine has been used in combination with NSAIDs for many decades to enhance their 
analgesic effects, suggesting that caffeine may be an effective adjuvant to Ibuprofen (103,104). 
Caffeine also has some antioxidant properties and prevents oxidative stress in the lens (105). 
NSAIDs have been shown to be beneficial for ROP. A retrospective chart review found that 
Indomethacin use for PDA was protective for ROP (106). These findings were corroborated by a 
Cochrane met-analysis (107). It is suggested, but not proven, that the effect of Indomethacin on 
ROP may be related to the infant's postnatal age (108). This may indicate that the exact timing of 
treatment may be crucial for efficacy of the drug. Topical application of Ketorolac also prevents 
severe ROP (109), however, this effect is controversial, since another study showed no benefit 
(110). Other pharmacologic interventions include inositol (111,112), beta blockers (113), 
atocopherol (114,115), and recently, intravitreal VEGF inhibitors (116-127). The use of intravitreal 


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_______________________________________________________________________________________________ 
 
 
Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
Avastin is highly invasive, and causes pain, distress, and discomfort. In addition, there are 
numerous reports of retinal detachment, vitreous and retinal hemorrhage, and choroidal rupture 
with intravitreal bevacizumab (117-125). Intravitreal Avastin appeared to spread via the 
bloodstream into the fellow eye when injected into an 8-year old patient (124). These adverse 
events suggest that the immature retina may be vulnerable to VEGF blockade and may cause 
breakdown of the blood-ocular barrier (127). More importantly, if Avastin, even at low doses, 
effectively inhibits neovascularization and interferes with the immature blood-ocular barrier it is 
possible that it may cross into the neonate’s brain and suppress the normal angiogenesis of the 
developing brain. 
 
7.5 
Baseline Study Procedures 
Signed and dated informed consent, record demographics (birth weight, gestational age, maternal 
history) medical history (diagnoses, and medical baseline conditions: oxygen and respiratory 
support, blood gases), physical examination will be performed within 24 hours prior to 
administration of study drug, vital signs will be recorded within 24 hours prior to administration of 
study drug. Clinical laboratory tests (renal function, liver function, hemogram) will be performed 
within 72 hours prior to the first dose of IV study drug. If these labs are obtained within 72 hours 
prior to enrollment in accordance with local standard of care, the results will be used for the 
baseline values for the study. Laboratory values closest to enrollment will be used if there are 
multiple tests. If obtaining laboratory tests is not in the best of interest of the infant, it will be 
deferred.  Infants will be assessed for pain using the Neonatal Infant Pain Scale (NIPS) by two 
independent individuals. All subsequent tests will be standard of care. 
7.6 
NIPS and N-PASS  Assessment.   
NIPS (Newborn Infant Pain Score) and N-PASS (Neonatal Pain, Agitation and Sedation Scale) 
are used as behavioral and physiological assessment tools for newborn pain. NIPS includes five 
behavioral components and one physiological component (respiration) and will be assessed by 
two independent individuals before treatment and once every day for 5 days during Ibuprofen or 
placebo treatment. NIPS is used for acute pain and N-PASS is designed for prolonged pain and 
include behavioral, facial and physiologic assessments.  Each component of the NIPS and N-
PASS will be scored as the highest level achieved by the infant every day. NIPS is widely used for 
neonatal pain assessment but N-PASS have the added capability of including crying even in 
intubated infants on mechanical ventilation (Appendix V). 
 
7.7 
Inclusion Criteria Selection of Study Population 
Neonates at high risk for ROP as outlined by the American Academy of Pediatrics, Section on 
Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; and 
American Academy of Ophthalmology (129) will be enrolled. Inclusion criteria are:  
1) all infants with a birth weight of less than 1250 grams;  
2) all infants with a gestational age of 28 weeks or less;  


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
3) all infants who required oxygen therapy and/or ventilator support within the first 2 days of 
life; and 
4) All patients receiving Caffeine citrate for Apnea of Prematurity as per standard of care. 
 
7.8 
Exclusion Criteria for Study Population 
Exclusion criteria are:  
1) Infants with major congenital anomalies, congenital sepsis, chromosome abnormalities 
(incl. duct-dependent cardiac anomalies). 
2) Fused eyelids 
3) Maternal antenatal NSAID exposure < 72 hours before delivery of the baby. 
4) Infants with cardiac conditions including cardiomyopathies, serious arrhythmias and 
congenital heart defects. 
5) Infants transferred from outside hospital, after 72 hours of life. 
6) Renal failure or oligouria (defined as urine flow rate <0.5 ml/kg/hour in the 8 hours prior to 
randomization).  Anuria is acceptable if less than 24 hours of life. 
7) Admission platelet count <50,000 mm3. 
8) Clinical bleeding such as continuous, active oozing from puncture site. 
9) Infants with cyanotic heart disease diagnosed by fetal echocardiography during pregnancy 
or infants who shows persistent low oxygen saturations as per attending neonatologist  
despite adequate ventilator assistance.  
Participation in other clinical trials while subjects participate in this study and for 7 days after the 
last dose of study drug. 
 
7.9 
Patent Ductus Arteriosus (PDA) Treatment 
About 40 to 80% of ELGANs <1250 grams will develop PDA and most will be treated with either 
Indomethacin or Ibuprofen as per standard of care.  This will contaminate the treatment group. If 
the standard of care protocol is not to treat during the first week of life, then leave the baby on 
Ibuprofen because it is not a treatment drug for PDA in this study.  If the standard of care protocol 
is to administer Indomethacin, then stop Ibuprofen for 24 hours (the t½ of Ibuprofen is 22 hours), 
administer Indomethacin as standard of care.  If the standard of care is to administer Ibuprofen, 
then increase the dose to the standard of care dose and follow the standard of care protocol.  
Since Ibuprofen treatment is for 5 days only, there will likely be no need to resume the study drug.   
 
7.9.1 Withdrawal from Study 
Infants may be withdrawn from treatment or from the study at any time. Reasons for infant 
withdrawal from the study include, but are not limited to: 
1. Infant’s parent or legal guardian chooses to withdraw the infant for any reason 


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
2. AEs, conditions, or intercurrent illnesses that preclude compliance with the protocol, 
particularly if continuation would pose a risk to the infant’s safety 
3. Clinical seizure occurring between informed consent and 1st administration of study 
drug 
4. The investigator determines that it is in the infant’s best medical interest to be 
withdrawn. 
5. Patient is transferred to another hospital during treatment. However, the patient must 
be followed up for AEs and SAEs until death or discharge. 
 
Detailed reasons for infant withdrawal because of lack of efficacy or because of pre-determined 
safety concerns are given in the appropriate sections of this protocol. Withdrawn infants will be 
followed for safety end points to the extent possible. 
 
7.9.2 
Parental/Guardian Permission 
Prior to the start of any study-related procedure, a signed and dated informed consent and Health 
Insurance Portability and Accountability Act (HIPAA) authorization must be obtained and 
documented in the infant’s medical record (Appendix I). Once it has been determined that the 
infant meets all inclusion criteria and no exclusion criteria, the infant will be assigned a subject 
identification number that will be used on the subject's CRFs and will be considered enrolled.  
 
 
8.0 
STUDY DRUG ADMINISTRATION 
8.1 
Method of Assignment to Study Groups (Randomization) 
Randomization to treatment arms will be stratified by each center.  To obtain a patient number 
and the randomized treatment randomization will be conducted by the pharmacist using sealed 
envelopes in blocks of 6.  This is an open-label study.  Twins enrolled in the study will be 
randomized together to the same treatment. 
8.2 
Study Procedures During Study Drug Treatment  
The following procedures or evaluations will be performed during the treatment phase and the 
data recorded as indicated: a) study drug dosing information; b) adverse events felt related to 
study drug (definite and probably related) and all serious adverse events; c) all concomitant 
medications, antimicrobials administered through the last dose of study drug therapy; d) 
examinations and interventions for PDA during study period; e) results of any examinations 
(head/abdominal ultrasound, CT scan, MRI, echocardiogram, ophthalmology exam, etc.) 
performed to assess the diagnosis or status of any adverse event must be documented and 
recorded in the CRF; f) any non-medication treatment (surgeries, procedures) associated with the 
patient’s underlying disease will be recorded in the CRF. 
8.3 
Drug Supplies 
The Sponsor will provide the study drugs (Ketorolac and Neoprofen) and the placebos (Saline eye 
drops and Saline I.V.) to the local pharmacies.  Caffeine will not be provided as it is not a study 
drug and is used per standard of care.   The local pharmacy at each center will distribute the 


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information contained herein is confidential and is to be used only in connection with matters authorized by 
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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
study drugs/placebos to the NICU and the drugs/placebos will be administered by the attending 
Neonatologist. 
8.4 
Dosing Weight. 
Birth weight will be used for dosing of the study drug until 8 days of life (DOL) for Neoprofen and 
IV Saline.  Adjustments for Ketorolac and saline eye drops are not necessary.   
 
8.5 
Treatment Compliance 
Treatment compliance will be evaluated by review of information documented on study drug 
administration and drug accountability forms.  Day 0 of study is the day before dosing of the 
study drug.  Pre-treatment blood and urine samples will be collected at Day 0.   A final blood 
and urine sample will be collected at 21 days post treatment or Day 21.  This is the final day of 
the study.   
8.6 
Method for Administration of Study Drug 
For administration of Ketorolac, patients will be dosed with one drop of study medication per eye 
by the site PI or sub-PIs beginning Day 1 of enrollment into the study.  The date and time will be 
recorded by the study personnel.  Approximately 15 minutes after each dose, the study personnel 
will perform the NIPS and/or N-PASS pain score.  The second dose will be administered 12 hours 
later.  For each of the doses, the right eye will receive the study medication first, immediately 
followed by the left eye.  Approximately 15 minutes after each dose, the NIPS and/or N-PASS 
pain score will be performed.  Approximately 30 minutes later vital signs will be recorded.  One 
sterile unopened vial will be used for each dosing.  The remaining opened vial will be returned to 
the site Pharmacist and discarded appropriately following documentation.  The placebo (sterile 
normal saline will be administered similarly.  Neoprofen will be administered according to the local 
pharmacy guidelines. 
 
8.7 
Storage and Disposition of Supplies 
The clinical supplies will be stored at controlled room temperature according to the manufacturer’s 
recommendations.  Ketorolac (Acuvail) and Ibuprofen (Neoprofen) will be stored at 15°- 30°C and 
protected from light in the manufacturers’ containers. Investigational products are for 
investigational use only, and are to be used only within the context of this study. Study drug will 
be maintained under adequate security. Drug accountability logs will be kept by the PI and the 
Research Pharmacist. 
  
8.8 
Drug Accountability 
The investigator or his/her designee will verify that study drug supplies are received intact and 
in the correct amounts. The investigator or his/her designee will document this verification by 
signing and dating the appropriate shipment request/receipt document. An accurate inventory of 
study drug will be kept by the site. An overall accountability of the study drug will be performed 
and verified by the clinical research associate (CRA) throughout the study and at the site close-
out visit. All used and unused supplies must be inventoried, accounted for, and according to the 
institution’s standard operating procedures (SOPs) following review by the CRA. The 
investigator agrees not to supply study medication to any persons not enrolled in the study.   


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information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
8.9 
Discontinuation of Study Drug 
If the study drug is discontinued because of safety, the patient must be followed until resolution of 
the safety event.  The study drug will be discontinued if any one of the following occurs: 
1. The patient develops severe AE (renal failure, necrotizing enterocolitis Stage 2A, Bell’s 
criteria)  
2. The patient develops an unacceptable hepatic adverse event as defined by: AST or ALT 
>3X upper limit of normal (ULN) OR conjugated hyperbilirubinemia (direct bilirubin >5.0 
mg/dL) OR other evidence of liver failure;  
3. The parents or legal guardian declines further study participation;  
4. The investigator decides it is in the patient’s best interest to discontinue treatment with 
study medication.   
Study drug may be held if a patient develops a serious adverse event related to study drug. 
 
9.0 
SCHEDULE AND DESCRIPTION OF STUDY PROCEDURES 
9.1 
Baseline Study Procedures (Before Start of Study Drug/Placebo) 
1. Obtain signed and dated informed consent/Authorization. 
2. Obtain cord blood, cord tissue and placental tissue.  Patients can still be enrolled in the 
study if cord and placental samples cannot be obtained at the time of delivery. 
3. Record demographics (BW, GA, diagnoses), medical history  
4. Medical baseline conditions (O2 and respiratory support, blood gases).  FiO2 range recorded 
at the time of delivery and continued for 2 weeks or until baby off ventilator. Number of 
desaturations and lowest saturations will be recorded. Any and all corrective actions for 
pulseox alarm (RT, nurse, attending) will be documented (i.e. saturation%, length of time of 
desat, corrective action, stable FiO2 or FiO2 required for infant to maintain normoxia, desat 
due to handling, procedure, apnea, etc., arterial blood gas parameters closest to time of 
desat).  
5. Record maternal history and medications (age, parity, use of tocolysis, antenatal steroids 
and number of courses, presence of fever, antibiotic treatment, preeclampsia, placental 
abruption, chorioamnionitis, gestational diabetes, and any other pregnancy complication) 
6. Physical examination will be performed within 24 hours prior to administration of study 
drug. 
7. Birth weight will be used for dosing of Neoprofen and IV Saline through DOL 8. 
8. Vital signs will be recorded within 24 hours prior to administration of the study drug 
9. Clinical laboratory tests within 72 hours prior to first dose of IV study drug (or standard of 
care if done at least 72 hours prior to study drug). Lab tests closest to enrolment will be 
used. The following clinical laboratories will be performed within 72 prior to the first dose of 
study drugs per standard of care.  If these labs have been processed within 72 hours prior 
to enrollment, the results will be used as baseline values for the study.  Use of laboratory 
values closest to enrolment if there have been multiple tests.  If obtaining laboratory is not 
in the best interest of the infant, they may be deferred. 


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
a) Renal function tests 
b) Liver function tests 
c) Hematology 
d) Serum chemistry 
10. Record all surgeries prior to the first dose of the study 
11. Record all procedures. Patients randomized to IV ibuprofen will have cardiac echo to rule 
out PDA-dependent cardiac abnormalities. 
12. Pain score (NIPS) 
 
9.2 
Study Procedures During Study Treatment (Study Days 1-14) 
The following procedures or evaluations will be performed during the treatment phase and the 
data recorded as indicated: 
1.  Record study drug dosing information (Neoprofen/placebo will be administered for 5 
days and Ketorolac/placebo will be administered for 14 days.  Final blood and urine 
sample will be 21 days post treatment). 
2. Assess and record AEs felt related to study drug (definite and probably related) and all 
SAEs 
3. Observe eyes patients randomized to Ketorolac for any adverse events (i.e. corneal 
haziness or cloudiness) on a daily basis at 30 minutes post treatment 
4. Record all concomitant medications administered through the last dose of the study 
drug 
5. Record all surgical procedures during the study drug therapy 
6. Birth weight will be used for dosing of Neoprofen or IV Saline until DOL 8 
7. Clinical laboratories will be performed as standard of care and are to be reported on a 
weekly basis in the case report forms (CRFs) 
8. A limited PK sampling scheme will be employed such that no more than 300 µL (total 5 
samples) of blood is obtained from each patient for PK analyses. 
9. Surviving infants will have a final blood sampling on 21 days post treatment. 
10. Results of any examinations (head/abdominal ultrasound, CT scan, MRI, 
echocardiogram, ophthalmology, etc.) must be documented and recorded in the CRFs 
11. Any non-medication treatment (surgery, procedures) associated with the infant’s 
underlying disease will be recorded in the CRFs 
12. Cord blood, cord tissue and placental tissue will be used to assess haploinsufficiency 
for Notch/Dll4 signaling. 
13. Pain score will be done daily for 5 days during Ibuprofen or IV Saline treatment. 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
14. Record FiO2 range for 14 days or until baby off ventilator, number of desaturations and 
lowest saturations, any and all corrective actions for pulseox alarm (RT, nurse, 
attending) 
 
9.3 
Post-Treatment/End of Study Procedures (21 days post treatment) 
1. 72 hours after the last dose of the study drug: Assess and record status of AEs related 
to the study drug (definitely related and probably related) 
2. 7 days after the last dose of the study drug: collect one blood and urine sample for PK 
analyses 
3. 14 days after the last dose of the study drug: collect one blood and urine sample for 
other analyses 
4. 21 days after the last dose of the study drug: collect one blood and urine sample for 
other analyses 
5. Weekly thereafter until death or discharge:  Assess and record all SAEs  
6. 36 weeks post-conceptional age:  Record ophthalmology examination results 
7. Blood and urine samples:  to be shipped to appropriate labs for processing (PK, 
proteomics, metabolomics, biochemical analyses) 
8. Record all surgical procedures during the study drug therapy through last study day 
(21 days post treatment) 
9. Record all concomitant medications administered through last study day (21 days post 
treatment) 
10. Record all non-medication treatment (surgery, procedures) associated with the infant’s 
underlying disease through last study day (21 days post treatment) 
11. Record results of any examinations (head/abdominal ultrasound, CT scan, MRI, 
echocardiogram, ophthalmology, etc.) through last study day (21 days post treatment) 
12. Death or discharge:  Morbidities of special interest will be recorded including: 
a) Necrotizing enterocolitis 
b) Spontaneous intestinal perforation 
c) Intraventricular hemorrhage 
d) Periventricular leukomalacia 
e) Retinopathy of prematurity 
f) Patent ductus arteriosus 
g) Chronic lung disease/bronchopulmonary dysplasia 
h) Sepsis 
i) Corneal toxic lesions 
j) First day of full feeds 


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
k) Length of hospitalization 
l) Drug toxicity 
 
9.4 
Other Data Collection 
Data will be collected prospectively in real time, and analyzed according to different birth weight 
categories: 1) <750 grams; 2) 751-1000 grams; and 3) 1001-1250 grams. Growth will be 
assessed in terms of body weight, length, and head circumference at birth and weekly thereafter 
(as per standard of care) until the baby is off oxygen therapy. Infant data will include race, gender, 
gestational age, Apgar score, cord gases, pre- and postnatal steroids, transfusion, indomethacin 
treatment, surfactant treatment, indication for delivery, mode of delivery, % saturation, fraction of 
inspired oxygen (FiO2), duration of oxygen use, use of diuretics, and adverse events such as 
chronic lung disease, intraventricular hemorrhage, sepsis, necrotizing enterocolitis, patent ductus 
arteriosus, infection, mortality, pulmonary status, ventilator parameters, and number of hypoxic 
episodes. For each infant who received an eye examination, the maximum stage of ROP, the 
presence or absence of “plus” disease (dilated and tortuous vessels in at least 2 quadrants), and 
the need for treatment, the rate of progression to threshold in at least one eye and final status of 
eyes at 3 months (i.e. retinal detachments or folds and macula ectopia) will be recorded. Maternal 
data will include use of tocolytics, antenatal corticosteroids and number of courses, presence of 
fever before and after delivery, antibiotic treatment, presence of preeclampsia, placental 
abruption, chorioamnionitits (temperature >38oC during labor), and any other complication. 
 
9.5 
Oxygen Saturation Monitoring 
The range of FiO2 and the lowest daily FiO2 will be recorded at the time of delivery and 
documentation will continue for two weeks or until the baby is off the ventilator, whichever comes 
first. The oxygen saturation goal limits will be standard for all centers (90%-95%) as measured 
with a pulse oximeter and electronically stored data will be downloaded weekly. Below these 
ranges will be considered de-saturation (hypoxia), and above these ranges will be considered 
hyperoxia. The number of de-saturations, as well as the duration of FiO2 increase will be 
recorded. When an infant shows a low alarm for oxygen saturation <90%), the FiO2 and monitor 
settings will be recorded. The infant and monitor will be evaluated to determine whether the alarm 
is due to:  
a) motion artifact;  
b) lines disconnected; and 
c) heart rate and respiratory effort.  
When corrective action is taken, the respiratory technician, the nurse, or the attending physician 
will document parameters such as:  
a) how low is the saturation;  
b) length of time of de-saturation;  


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
c) corrective actions such as changes in monitor settings, alarm;  
d) weaning FiO2 if oxygen saturation is high (>95%), how much and how long;  
e) stable FiO2 (FiO2 required for infant to maintain normoxia);  
f) desaturation due to handling, procedure, spontaneous, apnea.  
Arterial blood gases closest to the time of desaturation will also be recorded. 
 
9.6 
Specimen Collection 
All specimens (blood, urine, cord blood, cord tissue, placental tissue) will be collected as outlined 
in the Standard Operating Procedures (Appendix L) in the Manual of Operations.   
 
9.6.1  Blood.  To determine whether ocular ketorolac crosses the blood-ocular barrier and enters 
the systemic circulation and to determine a potential relationship between efficacy/toxicity and 
plasma ibuprofen, plasma drug levels of Ketorolac and Ibuprofen will be obtained within 24 hours 
prior to drug or placebo (0 pre), and at 1, 7, 14, and 21 days post treatment, within a 15 minute 
period before or after the initial dosing time.  For example, if the dose is administered at 9:00 am, 
then there is 15-minute window of 8:45 am to 9:15 am where the next dose can be administered, 
and blood samples can be collected.  The maximum number of samples per infant for this study 
will be 5 at 0.3 mL/sample.  The total blood volume will be 1.5 mL.  Samples will be collected in 
EDTA tubes, centrifuged and the result plasma stored at -70- to 80oC until shipment to SUNY 
Buffalo, Dr. Jun Qu’s U54 Proteomics Core Laboratory for Ketorolac and Ibuprofen levels (see 
Appendix L of the Manual of Operations).   
 
9.6.2  Urine.  For renal function, urine will be collected within 24 hours prior to drug or placebo (0, 
pre), and 1, 7, 14 and 21 days, within a 15 minute period before or after the initial dosing time.  
For example, if the dose is administered at 9:00 am, then there is 15-minute window of 8:45 am to 
9:15 am where the next dose can be administered, and urine samples can be collected.  Urine 
samples will be collected with the use of a sterile cotton ball.  The cotton ball will be placed into 
the appropriate tubes, labeled appropriately and frozen at -70 to -80oC until shipment.  Samples 
will be shipped to SUNY Downstate Medical Center, Brooklyn, NY, U54 Translational/Retinal Core 
Laboratories for ELISA and other assays (142, 143), (see Appendix L of the Manual of 
Operations).   
9.6.3  Mixed Cord Blood.  For collection of mixed cord blood samples, the discarded umbilical 
cord will be double clamped and the blood samples will be aspirated with the use of a 19 gauge 
needle attached to a 10 mL syringe. Informed consent to perform these sample collections will be 
obtained.  Mixed cord blood will be collected in non-preservative tubes, centrifuged and the 
resulting serum will be stored at -70 to -80oC until shipment to SUNY Downstate Medical Center, 
Brooklyn, NY, U54 Translational/Retinal Core Laboratories for ELISA assays, and PCR assays for 
Notch/Dll4 haploinsufficiency (see Appendix L of the Manual of Operations).   
9.6.4  Cord and placental tissue. Cord and placental tissue will be collected into sterile 
DNAse/RNAse free tubes containing RNA/DNA stabilization solution (RNA later, Qiagen). 
Placental biopsies will be taken from 3 sites in the placenta: 1) the maternal-fetal interface; 2) the 
fetal side; and 3) the intervillous space. Two samples from each site will be taken, and one 
complete section of the placenta will be taken for a total of 7 placental samples. Each sample will 


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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
be first rinsed in ice-cold sterile normal saline prior to placement in the respective tubes.  Samples 
#1 will be approximately 5 mm in size and 200 mg in weight.  This will be placed in specialized 
tubes containing ceramic beads and sterile normal saline.  Samples #2 will be approximately 5 
mm in size and 200 mg in weight.  This will be placed in specialized tubes containing ceramic 
beads and RNA Later.  The complete section will be placed in specialized containers with 10% 
phosphate buffered formalin.   
For umbilical cord samples, a total of 6 samples will be taken from 2 sites: 1) closest to the baby; 
and 2 closest to the placenta.   Samples will be first rinsed in sterile normal saline prior to 
placement in the respective tubes.  From each site, sample #1 will be approximately 5 mm in size 
or 200 mg in weight will be taken from the inner cord (vessels), rinsed, and placed in specialized 
tubes containing ceramic beads and sterile normal saline. Sample #2 will be approximately 5 mm 
in size or 200 mg in weight will be taken from the inner cord (vessels), rinsed, and placed in 
specialized tubes containing ceramic beads and RNA Later. Sample #3 will be a complete section 
of the cord approximately 1 cm in size and 1 gram in weight.  This will be placed in specialized 
containers with 10% phosphate buffered formalin. 
For each patient there will be 7 placental samples and 6 cord samples.  The tubes will then be 
appropriately labeled.  Samples in the tubes containing ceramic beads will be stored in a -70oC to 
-80oC freezer until overnight shipment on dry ice. Samples in the 10% formalin containers will 
remain at room temperature until shipment.  (See Appendix L of the Manual of Operations for 
more detailed instructions on shipping).  Cord and placental biopsies will be harvested with sterile 
disposable scalpels provided by the study site.  
 
9.7 
Specimen Shipping 
The specimen shipping form will be provided and will list all patients, and their identifying 
information, whose specimens are being sent to SUNY Downstate Medical Center or to SUNY 
Buffalo. Shipping supplies (i.e. appropriate boxes and labels) will also be supplied.  However, dry 
ice must be purchased at the site and billed to your U54 account.  The shipping forms must be 
completed by both the staff at the study site center and the staff at SUNY Downstate Medical 
Center receiving laboratory. It is used to document and identify all specimens that are shipped out 
by the center. A copy of this form will accompany the shipment from the study site to SUNY 
Downstate Medical Center or to SUNY Buffalo. This form is not entered into the computerized 
database. The following information should be completed on each shipment log. 
1. Center Number 
2. Number of cord blood, patient blood, urine, cord tissue, or placental tissue samples  
enclosed 
3. Initials of staff at the shipping center completing the form 
4. Specimen numbers of specimens contained in the shipment 
Please note that there are regulations for shipping samples on dry ice that must be followed.  
Therefore, only individuals who are certified for shipping hazardous materials must undertake this 
task.  If there are no individuals at the site, the person identified to ship the samples must take the 
required shipping certification course as mandated by the FAA.  The samples should be shipped 
on a Monday (or Tuesday after a Monday holiday) and at the end of the study.  For the week of 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
Christmas and New Year’s, the study coordinator will contact Khadija Sikriti, MD at (929) 295-
2834 (mobile); (718) 270-4657 (office); Khadija.sikriti@downstate.edu (email) who will discuss 
with the nurse coordinator and the technologist the ideal time for sample shipment. Batch the 
samples in an outer bag, and then pack in dry ice to be shipped to the SUNY Downstate Medical 
Center Clinical Research Office or SUNY Buffalo Proteomics Core Laboratory. The Specimen 
Shipment Log should be filled out and included in the shipment.  For further shipping instructions 
please refer to (see Appendix L of the Manual of Operations). 
9.8 
PD Measurements 
Measurements of VEGF, sVEGFR-1, HIF1α, Notch-1, Notch-4 Dll4, IGF-I, and MMPs will be 
conducted using enzyme immunoassays.  All EIA assays will be carried out with the use of 
commercially-available immunoassay kits in the Translational/Retina Core Laboratories at SUNY 
Downstate Medical Center, Brooklyn, NY. 
 
10.0 
DEFINITIONS AND DETAILED DESCRIPTIONS OF ASSESSMENTS AND ENDPOINTS 
10.1 Efficacy Assessment 
The primary endpoint for the study is ROP (all grades) and severe ROP (Stage 3+ disease) or 
need for laser or Avastin. Eye examinations will be done at standard of care through discharge 
and once, at 50 weeks PCA, solely for the study. Parents will bring subjects back to clinic for eye 
examination at 50 weeks PCA ±7 days. All infants will undergo routine eye examination by a 
pediatric ophthalmologist according to the International Classification for ROP (135). The rate of 
mild (stage 1), moderate (stage 2) and severe ROP (stages >3) will be calculated as the number 
of infants diagnosed with ROP over the number of infants receiving retinal examinations. ROP will 
be classified according to the three components outlined by the International Classification for 
ROP: 1) The zone in which ROP occurs; 2) the stage of ROP; and 3) the presence or absence of 
plus disease. Zone 1 is the most posterior (an area within twice the distance from the optic nerve 
head to the fovea; Zone 2 is ROP outside of zone 1; and Zone 3 is ROP only present on the 
temporal side of the eye. Stage 1 is a line of demarcation from the vascularized region of the 
retina and avascular zone. In stage 2 the line becomes a ridge that protrudes into the vitreous. In 
stage 3, the extraretinal vascular proliferation occurs when the ridge and neovascular tufts are 
seen in the posterior to the ridge. Disease occurs when the vessels posterior to the ridge become 
dilated and tortuous. Stage 4 has scarring and fibrosis when neovascularization extends into the 
vitreous, causing traction of the retina and retinal detachment. Stage 5 is total retinal detachment.  
 
 
10.2 
Safety 
The number and percentage of infants having treatment-emergent AEs will be tabulated, with a 
breakdown by group. Descriptive statistics will be provided for clinical chemistry and hematology 
data, including change from baseline. All subjects who received at least one dose of study product 
will be included in the safety analyses. AEs will be summarized and tabulated by severity, and 
relationship to therapy. Deaths and premature termination will be tabulated and summarized.  
Changes in laboratory parameters will be tabulated and summarized. Laboratory data, such as 
hematology and serum chemistry data will be tabulated by dosage and age group.  Summary 
statistics for changes from baseline will be presented. AEs will be summarized in tabular form by 
dosage and age group.  Continuous laboratory measurements will be described at each visit 


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information contained herein is confidential and is to be used only in connection with matters authorized by 
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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
using univariable descriptive statistics (mean, median, etc.); observed values and changes from 
baseline will be summarized. Lab tests reflective of liver toxicity (e.g., ALT, AST) will be further 
summarized in terms of the most extreme values and largest changes from baseline (in the 
appropriate direction) observed from start of study drug through the end-of-therapy lab. Vital signs 
and physical exam results will be listed. 
10.3 
Safety Assessments 
Secondary outcome such as renal function will be determined by: a) Urine output (ml/kg/hr) daily; 
b) serum electrolyes, creatinine and blood urea nitrogen as per standard of care; and c) daily fluid 
requirement. Gastrointestinal function will be determined by daily assessment for: a) necrotizing 
enterocolitis using Bell’s criteria; b) GI bleeding; c) trophic feeding; d) time to full feeds (100 
ml/kg/day); and e) time to discontinue total parenteral nutrition. Liver function studies done weekly 
as standard of care will include a) serum bilirubin total/direct; b) AST, ALT, alkaline phosphatase. 
Hematologic parameters: done as per standard of care include platelets, hemoglobin, hematocrit, 
white blood count. Other secondary outcomes will include Intraventricular hemorrhage (Papile’s 
criteria), Perinventricular leucomalacia by sonogram as per standard of care, and ocular 
examination for: corneal lesions. Corneal toxic lesions have been reported with NSAIDs such as 
nepafenac (136) and case reports of reversible toxic keratolysis in adults with prolonged ketorolac 
treatment (137). However, recent randomized trials on ketorolac and diclofenalac eye drops 
showed anti-inflammatory efficacy with high tolerability and no adverse effects (138,139). Daily 
examination by the neonatal staff of the cornea for haziness or other lesions confirmed by an 
ophthalmologist at least once a week or whenever an AE occurs will be done. Corneal lesions or 
haziness will require prompt discontinuation of the ophthalmic study eye drops. Pain scores will 
be determined using NIPS.  Safety assessments will include physical examination, clinical 
laboratory values as available per standard local care. 
 
10.4 
Safety First Plan  
The protocol will rely on three mechanisms for safety:  
1. The DSMB whose role is outlined below and in the DSMB charter; 
2. AE and SAE reporting mechanisms in accordance with FDA guidance outlined below 
 
10.5 
Data Safety and Monitoring Plan (DSMP) 
A DSMP will be established in compliance with NIH/NICHD policies for the protection of human 
subjects in clinical studies. The DSMP outlines procedures for reporting SAEs and AEs of Special 
Interest to the New York Pediatric Developmental Pharmacology Research Consortium (NYPD-
PRC) and dissemination of this information from the Coordinating Center (CC) to the DSMB.   
 
10.6 
Data and Safety Monitoring Board (DSMB) 
The DSMB will be empowered to monitor safety during the conduct of the study. No efficacy data 
will be provided to the board, but the board will review safety data. The DSMB will be comprised 
of independent reviewers who are not involved in the conduct of the study and will be blinded to 
study drug information. Any two members of the DSMB can ask that the study be halted at any 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
time for safety. The DSMB will meet after 10%, 25%, 50% and 75% of the subjects have been 
enrolled in the study. Safety monitoring will be done throughout the study on an ongoing basis. 
The DSMB or the investigator may terminate the study at any time based on safety concerns. The 
DSMB consists of Virginia Delaney, MD, MPH (Neonatologist-Epidemiologist), Ron Thomas, PhD 
(Biostatistician), Nadine Lahage, MD (Neonatologist and DSMB chair). 
 
11.0 
ADVERSE EVENTS  
11.1 
Adverse Events Definition 
An AE is defined as any untoward medical occurrence such as a sign(s), symptom (s), and/or 
laboratory finding(s) concurrent with the use of a drug in humans. AEs include worsening of any 
baseline symptoms. The event may/may not necessarily have a causal relationship with the 
administration of the drug. AEs may be reported by the subject, or detected by the investigator, or 
other competent observer. The investigator will also evaluate any change in laboratory values. If 
the investigator determines a laboratory abnormality to be clinically significant, it is considered a 
laboratory AE; however, if the laboratory value abnormality is consistent with a current diagnosis, 
it may be documented accordingly. Adverse events related to study drug (definite or probably 
related) will be recorded from the time of first dose of study drug until 72 hours following the last 
dose of study. All serious adverse events will be recorded from the time of first dose of study drug 
until 30 days after the last dose of study drug. Adverse events felt related to study drug and all 
serious adverse events ongoing at the time of the last dose of study drug will be followed up for as 
long as necessary to adequately evaluate the patient’s safety or until the event stabilizes. If the 
event resolves during the study or follow-up period, a resolution date should be documented on 
the case report form. All serious adverse events will be reported promptly (within 24 hours of 
knowledge) to CC by phone or fax. If the initial notification is by phone, the investigator will follow 
that notification with a written serious adverse events report form by fax within 24 hours. 
 
11.2 
AE Reporting. 
AEs will be recorded from the time of informed consent until 72 hours following the last dose of 
study drug for non SAEs and until 30 days after the last dose of study drug for SAEs.  Any AE that 
occurs between the time informed consent is obtained and the initial dose of study, that is 
considered related to a protocol specified procedure, must be reported.  An initial serious adverse 
event form must be as complete as possible, including details of the current serious adverse 
event, and provide an Investigator assessment of the causal relationship between the event and 
the investigational product. Information not available at the time of the initial report will be 
documented on a follow-up serious adverse events form and reported to the local institutional 
review board (IRB) as institutional requirement. The CC will be responsible for receiving and 
reviewing event forms, data basing events into Clintrace, coding events using the MedDRA 
dictionary, writing clinical narratives, contacting sites for missing/additional information and 
generating regulatory forms (MedWatch and CIOMS) for those events that are assessed as study 
drug related by the investigator and determined by the CC monitor to be unexpected.  


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
11.3    Procedures for Assessing, Recording and Reporting AEs  
Throughout the duration of the study, the investigator will closely monitor each subject for clinical 
evidence of drug intolerance and monitor all clinically obtained laboratory values for laboratory 
evidence of AEs. AEs not explained by the infant’s underlying illness which occur during the 
course of the study will be reported in detail on the appropriate CRFs and followed until resolution 
or until it becomes stable. All SAEs will be reported to CC within 24 hours.  The description of the 
AE will include description of event, start date, stop date, intensity, if it was serious, and 
relationship to the study drug. The investigator must verify this information.  The intensity or 
severity of AEs will be graded as follows: 
• 
Mild - awareness of sign or symptom, but easily tolerated. Not expected to have a 
clinically significant effect on the subject’s overall health and well-being. Not likely to 
require medical attention 
• 
Moderate - discomfort enough to cause interference with usual activity or affects clinical 
status. May require medical intervention 
• 
Severe - incapacitating or significantly affecting clinical status. Likely requires medical 
intervention and/or close follow-up 
 
AEs that increase in intensity will be recorded with a stop date on the AE CRF of the milder AE 
equal to the date that the condition worsened. A new AE with a start date equal to the date of 
worsening will then be reported. AEs that decrease in severity need not be reported in this way. 
The start date will be the date entered above and the date of resolution should be reported as the 
stop date. The Investigator is responsible for assessing relationship to study medication using the 
following definitions: 
• 
Not related: An AE that is due to a pre-existing illness or use of another drug, and is not 
related to the study drug. 
•    Possibly related: An AE that has little or no relationship to the study drug and there 
exists a more likely alternative cause. 
•    Probably related: An AE that is likely to be related to the administration of the study 
drug and an alternative cause less likely when compared to the study drug. 
•    Definitely Related: An AE that has a strong temporal relationship to the study drug. AE 
will recur with continued or repeated use of the study drug, and another cause is unlikely 
or less likely. 
 
11.4 
Follow-up of AEs 
AEs will be followed until resolution or until stability is reached using good clinical practices. 
11.5 
SAEs  
A serious adverse event will be any adverse event that results in any of the following outcomes: 
death, life-threatening adverse event, persistent or significant disability or incapacity, inpatient 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
hospitalization or prolongation of existing hospitalization, congenital abnormality or birth defect, 
important medical event, life-threatening means that the patient or subject was, in the view of the 
investigator, at immediate risk of death from the adverse event as it occurred. It does not include 
an adverse event that, had it occurred in a more severe form, might have caused death. 
Persistent or significant disability/incapacity means that the event resulted in permanent or 
significant and substantial disruption of the subject’s ability to carry out normal life functions. 
Important medical event is any medical event that may not result in one of the above outcomes, 
but may jeopardize the health of the study participant or require medical or surgical intervention to 
prevent one of the outcomes listed in the above definition of serious adverse events. 
 
11.6 
Procedures for Assessing, Recording and Reporting SAEs  
The Investigator will use the following definitions when assessing causality of an adverse event to 
study medication: a) “NOT RELATED”: an adverse event that has no temporal relationship to trial 
drug or has a definite alternative etiology. Only serious adverse events of this category will be 
recorded on the CRFs; b) “PROBABLY NOT RELATED”: an adverse event not commonly 
associated with the drug class; has little or no temporal relationship to trial medication; and a 
probable alternative etiology is apparent. Only serious adverse events of this category will be 
recorded on the CRFs; c) “PROBABLY RELATED”: an adverse event not commonly associated 
with this drug class; has a temporal relationship to trial medication; and a possible alternative 
etiology exists or no alternative etiology is apparent, Both adverse events and serious adverse 
events of this category will be recorded on the CRFs; d) “DEFINITELY RELATED”: an adverse 
event that has a temporal relationship to trial medication and/or reappeared on re-challenge; and 
no other etiology is apparent, Both adverse events and serious adverse events of this category 
will be recorded on the CRFs. All SAEs will be forwarded to the DSMB Chair within 1-2 business 
days. The NYPD-PRC Safety Surveillance will submit MedWatch/CIOMS forms to IRB and DCRI 
Regulatory Services for review and submission to regulatory authorities. NYPD-PRC Safety 
Surveillance will provide “Safety Alert” reports to NYPD-PRC Clinical Trials team to distribute to 
sites. 
 
11.7 
Dose Interruptions for SAEs 
If the patient experiences a serious adverse event felt to be related to study drug, the study 
product must be held at the discretion of the investigator. For a serious adverse event felt to be 
related to study drug, study drug can be held until the adverse event resolves. Resume drug at 
the original dose. If the same SAE recurs, study drug should be held and the Medical Monitor 
(phone: tbd) will be contacted. For a SAE not felt to be due to study drug, no interruption is 
necessary. 
 
11.8 
Follow-up of SAEs 
The investigator must complete and submit a follow-up SAE form when important follow-up 
information (diagnosis, outcome, results of specific investigations, etc.) becomes available after 
submission of the initial form. Follow-up forms should be submitted according to the same 
process used for reporting the initial event as described above (i.e., within 24 hours of 
knowledge). All SAEs and AEs of Special Interest will be followed until resolution, stabilization or 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
30 days after the last subject is enrolled, whichever occurs, first. The investigator will be 
responsible for reporting SAEs to the local IRBs in accordance with local guidelines. 
 
11.9 
IRB Summary Safety Reports 
As required by the NIH “Guidance of Reporting Adverse Events to Institutional Review Boards for 
NIH-Supported Multicenter Clinical Trials,” the DSMB’s summary safety reports will provide 
feedback at regular and defined intervals to the IRBs. After each meeting of the DSMB, the 
executive secretary will send a brief summary safety report to each investigator. The report will 
document that a review of data and outcomes across all centers took place on a given date and 
will summarize the Board’s review of the cumulative adverse experiences reported from all 
participating sites without specific disclosure by treatment arm.  It will also inform investigators of 
the study the Board’s conclusion with respect to progress or need for modification of the protocol. 
The clinical site investigators are required to transmit the report to their local IRB as soon as they 
are received. 
 
11.9.1 Table 2:  AE Reporting 
 
 
Record on CRF 
Report to FDA 
Report to NYPD-
PRC Safety 
Surveillance 
AE 
Related (definite or probable 
Yes 
No 
No 
AE 
Not related 
No 
No 
No 
SAE 
Related (definite or probable 
Yes 
Yes (expedited) 
Yes 
SAE 
Not related 
Yes 
Yes 
Yes 
 
 
12.0 
STATISTICAL METHODOLOGY 
12.1   Planned Sample Size  
The primary objective of this study is to assess the safety and potential efficacy of caffeine plus 
NSAIDs to prevent ROP. We will enroll 40 evaluable neonates for each group (total n=120). 
Evaluable subjects are those who fulfill inclusion and exclusion criteria and survived for 36 weeks 
PCA eye examination. The estimated rate of ROP (all stages) for neonates <1250 grams in the 
BQNN Network is 58% and severe (Stage 3 plus) is 5.7%. We hypothesize that early synergistic 
intervention is safe and will decrease the incidence of ROP in the combination therapy treated 
patients by 50%. Assuming an ROP incidence of 57% (all stages), a total of 120 EVALUABLE 
neonates or 40 infants in each group would be needed to have a statistical power of 80% to 
detect a 50% relative reduction in the risk of ROP at an alpha =0.05 beta =0.20. This is a small, 
adequately powered phase II, safety, efficacy, pharmacodynamic trial which will generate 
requisite data needed for the design and implementation of a conclusive randomized 
phase 3 trials. Randomization will be done using sealed envelopes at each site in blocks of 6. 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
The participating NICUs of the Brooklyn Neonatal Network, SUNY Stony Brook NICU admit at 
least 350 ELGANs < 1250 grams per year, all of which will be potential subjects in this study. 
 
12.2 
Populations for Analysis 
The full analysis set is defined as all randomized patients who receive at least one dose of the 
study drugs (intent to treat modality). These infants will comprise the population for the safety 
analysis, and if any PK samples are obtained, their blood, urine and/or cord blood will be 
evaluated in the PK analysis.  
12.3 
Statistical Methodology 
All data will be collected and analyzed by the Bioinformatics Core Laboratory at the State 
University of New York (SUNY) Eye Institute. Additional data analysis and ad-hoc consultations 
will be provided by Dr. Ron Thomas (Wayne State PPRU biostatistician 2004 -2010) who has 
worked closely with PI (Aranda) in previous clinical trials. Descriptive, parametric and 
nonparametric statistics will be done for the birth weight categories. Contingency tables will be 
analyzed using Chi-square. The Fisher’s exact test will be used if an individual cell has <5 
observations. Comparison of continuous variables between patients with no ROP and patients 
with ROP will be done by the Student’s t-test for normal variables and the Wilcoxon rank sum test 
for non-normal variables. For comparisons of continuous variables between >2 groups (i.e. birth 
weights), analysis of variance (ANOVA) will be used for normal variables and Kruskal-Wallis test 
will be used for non-normal variables with the appropriate adjustments for multiple comparisons. 
The analyses of the primary outcome and of all other dichotomous outcomes will be adjusted with 
the use of a logistic-regression model that will include terms for treatment and center. If no 
treatment effect, the quotient of the estimated coefficient and its standard error will be used as a 
z-test statistic for the null hypothesis. For all relevant binary outcomes, logistic regression will be 
used to include adjustments for gestational age, and other relevant variables. Odds ratios and 
confidence intervals will be calculated for all outcomes of the groups. All statistical tests will be 2-
sided. Data will be presented as mean ±SD where applicable. All p-values will be two-sided and a 
value of <0.05 will be considered significant. 
 
12.4 
Demographics and Baseline Characteristics 
Infant and maternal demographic and baseline characteristics such as age, gender, race, primary 
underlying disease, etc. will be summarized and compared among treatment groups. Descriptive 
statistics such as number of observations, mean, median, 95% confidence interval, standard 
deviation, standard error, minimum, and maximum will be presented by dosage group for 
continuous variables (such as age, weight, etc.). Other descriptive statistics such as counts, 
proportions, and/or percentages will be presented by dosage group to summarize discrete 
variables (such as race, sex, ROP stage, stage +3, mortality rates, etc.). The number of infants 
completed, and discontinued early from study, and the reasons for discontinuation, will be 
summarized by dosage. Demographic and baseline characteristics will be summarized by group 
and dosage. Variables include race, age, sex, and selected clinical variables recorded prior to 
initiation of study drug. Study drug administration will be summarized in terms of number of days 
of dosing, and reasons for final discontinuation of study drug. 
 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
12.5 
Efficacy 
The primary endpoint for the study is ROP (all grades) using International ROP Classification and 
severe ROP (Stage 3+ disease) or need for laser or Avastin.  It is estimated that approximately 
20% of the analysis population will be twins.  Therefore, a generalized estimating equation method 
will be used with a repeated statement to account for correlated data when analyzing the treatment 
effect on the primary endpoint.  Patients with missing outcomes will be treated as failures.  The 
parameters for handing missing data will be detailed in the Statistical Analysis Plan.  Eye 
examinations will be done at standard of care through discharge and once, at 50 weeks PCA, solely 
for the study. Parents will bring subjects back in to clinic for eye examination at 50 weeks PCA ± 7 
days. Ideally, an objective technique such as retinal digital photographs (RetCam) read by 2 
independent investigators would decrease variability; however, such a technique employed in 
multiple sites will substantially increase cost and may not be feasible for this study. Since this clinical 
protocol will only be implemented at year 2, participating centers will be encouraged to procure 
RetCam for their sites during year 1. Otherwise, all infants will undergo routine eye examination by 
a pediatric ophthalmologist according to the International Classification for ROP (135). The rate of 
mild (stage 1), moderate (stage 2) and severe ROP (stages >3) will be calculated as the number of 
infants diagnosed with ROP over the number of infants receiving retinal examinations. ROP will be 
classified according to the three components outlined by the International Classification for ROP: 
1) The zone in which ROP occurs; 2) the stage of ROP; and 3) the presence or absence of plus 
disease. Zone 1 is the most posterior (an area within twice the distance from the optic nerve head 
to the fovea; Zone 2 is ROP outside of zone 1; and Zone 3 is ROP only present on the temporal 
side of the eye. Stage 1 is a line of demarcation from the vascularized region of the retina and 
avascular zone. In stage 2 the line becomes a ridge that protrudes into the vitreous. In stage 3, the 
extraretinal vascular proliferation occurs when the ridge and neovascular tufts are seen in the 
posterior to the ridge. Disease occurs when the vessels posterior to the ridge become dilated and 
tortuous. Stage 4 has scarring and fibrosis when neovascularization extends into the vitreous, 
causing traction of the retina and retinal detachment. Stage 5 is total retinal detachment.  
Participating ophthalmologists will meet annually to optimize uniformity in ROP assessment.  
The secondary endpoints are as follows: 
1. 
Necrotizing enterocolitis 
2. 
Spontaneous intestinal perforation 
3. 
Intraventricular hemorrhage 
4. 
Periventricular leukomalacia 
5. 
Patent ductus arteriosus 
6. 
Chronic lung disease/bronchopulmonary dysplasia 
7. 
Sepsis 
8. 
Corneal toxic lesions 
9. 
First day of full feeds 
10. 
Length of hospitalization 
11. 
Drug toxicity 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
Treatment group comparisons will be made on the secondary efficacy endpoints as described 
above.   
 
13.0 
TERMINATION OF THE STUDY 
The clinical trial progression will be monitored by CoVeris Pharmaceutical and Clinical 
Consultants (Alex J. Coimbre, BA, MPS, CCRA 919-341-0484). The Steering Committee 
has the right to terminate the study at its discretion with written notice to the institution and 
Principal Investigator.  The investigator or institution has the right to terminate this study at its 
discretion with written notice to the Steering Committee or its designee.  The study may be 
terminated by the NYPD-PRC PI if there is evidence of an investigator failing to maintain 
adequate clinical standards or evidence of an investigator or staff failing to comply with the 
protocol.  Possible reasons for termination of the study include, but are not limited to: 
a) Unsatisfactory enrollment with respect to quantity or quality 
b) Inaccurate enrollment with respect to quantity or quality 
c) Inaccurate or incomplete data collection 
d) Falsification of records. 
e) Failure to adhere to the protocol 
 
13.1 
Protocol Deviations  
When a deviation from the protocol is deemed necessary for an individual infant, the investigator 
or other responsible physician must contact the NYPD-PRC PI or clinical monitor immediately, 
unless a delay would endanger the subject, so that a timely decision can be made as to whether 
or not the infant should be enrolled or continue in the study.  The deviation from the protocol will 
be authorized only for that particular infant.  A description of the departure from the protocol and 
the reason(s) for it must be recorded on the appropriate CRF or the provided protocol deviation 
log sheet.  Additionally, sites will adhere to local IRB reporting rules for protocol deviations.   
 
14.0 
ADMINISTRATIVE AND REGULATORY CONSIDERATIONS 
14.1   Prior to Initiation of the Study 
The following will be provided to the Steering Committee or their representative, prior to the 
shipment of the study medication and initiation of the study: 
1.  A completed US Food and Drug Administration (FDA) form 1572 or other form required by 
the local regulatory agency as appropriate 
2. Curriculum vitae for the investigator and sub-investigators signed and dated within 2 years 
of current date. 
3. The “Investigator Agreement” page of the protocol and any applicable amendment(s) 
signed and dated by the investigator. 
4. An IRB/independent ethics committee (IEC) membership list and IRB assurance number. 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
5. Written verification of IRB/IEC approval of the protocol, amendments, if applicable, and 
informed consent/authorization form (or separate authorization document) in compliance 
with US federal regulation 21 CFR Part 50 and 21 CFR Part 56 (Human subjects and 
IRBs) and for clinical sites in the US, 45 CFR Parts 160 and 164 (HIPAA Privacy Rule; 
HIPAA 1996), effective date 4/14/03. 
6. Approved copy of informed consent/authorization (or separate document). 
7. Written documentation of financial disclosure in compliance with US Federal regulation 21 
CFR Part 54. 
8. A duly executed Research Agreement, if applicable. 
9. Documentation of laboratory certification and normal reference ranges. 
 
Investigators will not be allowed to administer study drug to patients in the study prior to an 
initiation visit between appropriate investigational staff and the Steering Committee 
representative(s).  This meeting will involve a detailed review of the protocol and case report form 
(CRF). 
 
14.2 
Institutional Review Board/Independent Ethics Committee Approval 
Prior to its implementation, this protocol, including any subsequent amendments, must be 
approved by an IRB/IEC constituted according to FDA regulations.  Documentation of the 
approved IRB/IEC’s initial and continued study approval or the withdrawal of such approval will be 
immediately forwarded to the Steering Committee or its designee. 
 
14.3 
Informed Consent and Assent 
The principles of informed consent in the current edition of the Declaration of Helsinki (See 
Appendix K of Manual of Operations) should be implemented before protocol-specified 
procedures are carried out. Informed consent will be obtained and documented in accordance 
with U.S. 21 CFR Part 50.25, §§ 116, 117 and 408 of 45 CFR Part 46  and all other applicable 
regulatory requirements. Prior to any study procedures being performed, the investigator or 
his/her designee will inform the subject’s legally authorized representative (e.g., parent, guardian) 
of all aspects pertaining to study participation.  Information should be given in both oral and 
written form whenever possible and deemed appropriate by the IRB. The subject’s legally 
authorized representative (parent or guardian) must be given ample opportunity to inquire about 
details of the study. The description of the study procedures will include the purpose of the 
research and procedures, risks and benefits of the research, alternative procedures, 
confidentiality, legal rights, parental or guardian permission, the contact person and phone 
number if there are any questions, and the voluntary nature of participation. It will be emphasized 
that participation is voluntary and participants may withdraw from the study at any time without 
any effect on standard care. The investigator or his/her designee, and the subject’s legally 
authorized representative must both sign and date the informed permission form. An original 
signed informed permission form will be retained in the site study records. The subject’s legally 
authorized representative will receive a copy of the signed and dated informed permission form 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
and a copy of the signed assent (if applicable). The parental/guardian permission form generated 
by the investigator must be approved (along with the protocol) by the IRB and be acceptable to 
the Steering Committee. Permission forms must be in a language fully comprehensible to the 
subject’s legally authorized representative. Permission shall be documented by the use of a 
written consent form approved by the IRB and signed and dated by the subject’s legally 
authorized representative.  The written parental/legal guardian permission document will embody 
the elements of informed consent as described in the Declaration of Helsinki, the Code of Federal 
Regulations, and the ICH Guidelines and will comply with local regulations. This form may be read 
to the subject’s legally authorized representative, but, in any event, the investigator shall give the 
representative adequate opportunity to read it before it is signed and dated.  Permission must be 
documented by the dated signature of the subject’s legally authorized representative. The 
signature confirms the permission is based on information that has been understood. Each signed 
permission form must be kept on file by the investigators for possible inspection by Regulatory 
Authorities, and NICHD or its designees. 
 
14.4 
Protection of Personal Health Information 
Prior to any study-related procedures, the investigator or designee is obligated to obtain from 
each patient, or the patient’s legally authorized representative (i.e. parent/legal guardian), a 
signed and dated written authorization consistent with FDA regulations, and the HIPAA Privacy 
Rule, and applicable State and local laws.  In the US, HIPAA Privacy Rule Authorization language 
must be included in the Informed Consent/Authorization form (where the Informed Consent and 
Authorization are combined in one document) and it must be IRB/IEC approved. The patient 
health information (PHI) of the patients will be protected according to the HIPAA regulations. 
Measures to protect against and minimize risk of breach of confidentiality will be: Master list of 
subject’s name, medical record number and medical information will be kept under strict 
confidentiality on a password protected computer which will only be accessed by authorized 
personnel. After each sample is collected it will be placed in a labeled container with the patient’s 
medical record number to prevent breech of confidentiality. All PHI will be kept in a locked cabinet 
with only the PIs and research personnel having access. All electronic PHI will be encrypted and 
kept in password protected computers with only the PIs and research personnel having access. 
 
14.5 
Amendments and/or Changes to Informed Consent/Authorization 
Amendments to this protocol must be agreed upon in writing between the investigator and the 
Steering Committee.  Written verification of IRB/IEC approval will be obtained before any 
amendment is implemented which affects patient safety or the evaluation of safety and/or efficacy.  
Modifications of the protocol that are administration in nature do not require IRB/IEC approval but 
will be submitted to the IRB/IEC for information.  If there are changes to the Informed 
Consent/authorization, written verification of the IRB/IEC approval must be forwarded to the 
Steering Committee.  An approved copy of the new Informed Consent/Authorization must also be 
forwarded. 
 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
14.6 
Ethical conduct of the trial 
This study will be conducted according to the protocol, the applicable FDA and HHS Code of 
Federal Regulations, Good Clinical Practice, the Declaration of Helsinki, and the ICH Harmonized 
Tripartite Guideline for Good Clinical Practice. It will also adhere to the ethical principles outlined 
in The Belmont Report. 
 
14.7 
Source Documents 
Source documents are defined as original documents, data and records. They may include 
hospital records, clinical and/or office charts, laboratory data/information, pharmacy dispensing 
records, radiology procedures, CPAP and ventilator recordings.  The investigator(s)/institution(s) 
will permit study-related monitoring, audits, IRB/IEC review, regulatory inspection(s), and will 
provide direct access to source data documents. 
 
14.8 
Case Report Forms (CRFs) 
Data for individual subjects will be recorded on case report forms (CRFs) provided by the NYPD-
PRC. All entries must be complete. A CRF must be completed for each subject enrolled, including 
those removed from the study. If a subject is removed from the study, the reason for removal 
must be noted on the CRF by the investigator. The principal investigator must review and approve 
each CRF.  CRFs must be current to reflect subject status at each phase during the course of the 
study.  Subjects are not to be identified on the CRFs by name; appropriate coded identification 
and subject initials must be used. The investigator must keep a separate log of subject names 
and addresses. If requested as part of an FDA inspection, this log may be shown to the FDA 
investigator, but no copy should be provided so that confidentiality is protected.  Because of the 
potential for errors and inaccuracies in entering data onto CRFs, laboratory and other test results 
must be kept on file with the subject’s study dossier. Case report forms and copies of test results 
must be available at all times for inspection by the CRA for the site and the FDA. 
 
14.9 
Steering Committee 
The Members of the Steering Committee will include the faculty and research expertise of several 
members of the PIs’ site (or Co PIs where applicable) from subcontract sites. The NICHD Project 
Officer’s input will also be requested in special circumstances. The NICHD Project Officer will be a 
non-voting member of the Steering Committee. The Steering Committee will hold regular 
teleconferences. All Steering Committee members (or in special circumstances, their designee) 
will be required to participate in these meetings/teleconferences.  The Steering Committee will 
seek and accept advice from the NICHD, CTCC (Clinical Trials Coordinating Center) and the 
DSMB, and will receive implementation recommendations from regular study coordinators’ 
teleconference, to which it may delegate authority for minor implementation decisions.  It will 
adopt a publication policy acceptable to all sites and will supervise the publication of results.  
Should a problem at any given site arise, the PI (and Co-PIs) at that site will be contacted by one 
or more members of the Steering Committee to discuss the problem and to develop a plan for its 
resolution. A timeline and action-plan will be developed. This plan will be reported back to the 
Steering Committee. The timeline and outcome will then be monitored by the Steering Committee.  


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
 
15.0 
RESPONSIBILITIES OF THE CLINICAL INVESTIGATOR 
The investigator is obligated to conduct this study in accordance with US Federal regulation 21 
CFR 312.60-69 as specified on the signed form FDA 1572, applicable state laws, and the 
International Conference on Harmonization: Good Clinical Practice: Consolidation Guideline.  The 
investigator is responsible for informing the IRB/IEC of any safety issues related to the study and 
the study drug including reports of SAEs, if required, and all investigational new drug (IND) safety 
reports. Prior to initiation of the study, the following will be done: 
a) Approved IND for use of Ketorolac (Acuvail) in preterm newborns. IV Ibuprofen was 
approved for newborn in 2006;  
b) completed U.S. Food and Drug Administration (FDA) 1572 form or other form required by 
local regulatory agency, as appropriate;  
c) curricula vitae for the investigator and sub-investigators signed and dated within 2 years of 
current date;  
d) An IRB/IEC membership list or IRB assurance number;  
e) written verification of IRB/IEC approval of protocol, amendments, if applicable, and 
informed consent/authorization form (or separate authorization document) in compliance 
with U.S. federal regulation 21 CFR Part 50 and 21 CFR Part 56 (Human Subjects and 
IRBs) and, for Clinical sites in the U.S., 45 CFR Parts 160 and 164 (HIPAA Privacy Rule; 
HIPAA 1996), effective date 4/14/03; 
f) approved copy of informed consent/authorization (or separate document);  
g) written documentation of financial disclosure in compliance with U.S. federal regulation 21 
CFR Part 54; 
 
15.1 
Data Quality Control and Assurance  
Prior to the initiation of the study, an investigator’s meeting will be held with the BPCA-CC and 
MPODS network personnel, the investigators and their study coordinators for the study. This 
meeting will include a detailed discussion of the protocol, performance of study procedures, CRF 
completion, simulation of study procedures and specimen collection methods, as applicable. In 
addition to the investigators’ meeting, the study personnel at each site will be trained on the study 
procedures at a study initiation visit.  The CRAs will monitor each site throughout the study. At 
each visit, 100% source document review will be made against entries on the CRF and a quality 
assurance check will be performed to ensure that the investigator is complying with the protocol 
and all applicable regulations.  After completion of the entry process, computer logic checks will 
be run to check for such items as inconsistent study dates and outlying laboratory values. Any 
necessary correction will be made to the database and documented via addenda or audit trail. A 
manual review of selected line listings will also be performed at the end of the study.    
 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
15.2 
Site Monitoring Visits 
The clinical trial progression will be monitored by CoVeris Pharmaceutical and Clinical 
Consultants (Alex J. Coimbre, BA, MPS, CCRA 919-341-0484).  The Steering Committee or its 
designee will monitor the study progress, as frequently as is necessary to assure compliance of 
Good Clinical Practices and protocol procedures and to monitor completion of CRFs.  
Arrangements for monitoring visits will be agreed to in advance of planned visits, except in cases 
of emergency.  FDA or other health authority representatives reserve the right to visit sites at any 
time.  Monitoring visits to the sites will be made before, during, and at close of the study to ensure 
that all aspects of the protocol are followed. Source documents will be reviewed for verification of 
data collected on the CRFs. Participating sites and investigators will guarantee access to source 
documents and CRFs to the CRAs. The principal investigator and relevant site personnel will be 
available during the monitoring visits and will set aside sufficient time for the process. 
 
15.3 
Quality Assurance and Regulatory Agency Audits 
The study sites may also be subject to quality assurance audits by the NICHD or its designees 
and appropriate regulatory agencies. 
 
15.4 
Ensuring Confidentiality 
A study number will be assigned for each subject. Data forms will be identified by subject number 
and initials. The database will not contain any personal identifiers other than subject number and 
initials. 
 
15.5 
Record Retention 
It is the investigator’s responsibility to retain all records and documents (including electronic data 
capture materials) pertaining to the conduct of the study and the distribution of the investigational 
drug for two years after discontinuation of the IND.  It is recommended, however, that records be 
retained for at least 5 years in the event follow-up is necessary to help determine any potential 
hazards to patients who took part in these studies.  The Steering Committee will notify the 
investigator if the IND is discontinued.  The investigator agrees to obtain Steering Committee 
agreement prior to disposal, moving, or transferring of any study-related records.  Data generated 
by the methods described in the protocol will be recorded in the patient’s medical records and/or 
study progress notes.  Data may be transcribed legibly on CRFs supplied for each patient or 
directly inputted into an electronic system or any combination thereof.  The Investigator and 
Steering Committee will mutually agree upon the storage format for the retention of electronic 
data.  The investigator will agree to provide access to the office, clinic, and/or hospital records of 
all patients entered into the study.  Access inspection of these records may be required by the 
Steering Committee personnel and/or their representative(s) at the time of each monitoring visit.  
In addition, all records may be subject to inspection by officials of the FDA and other health 
authorities.  The investigator shall make accurate and adequate written progress reports to the 
IRB/IEC at appropriate intervals, not exceeding one year.  The investigator shall make and 
accurate and adequate final report to the IRB/IEC within three months after completion or 


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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
termination of the study.  The Investigator shall report to the Steering Committee or their 
representative(s) any SAEs or deaths during the study, whether regarded as drug-related or not. 
To enable evaluations and/or audits from Regulatory Authorities and NIH/NICHD or its designees, 
the investigators will keep records, including the identification of all medical charts and associated 
source documents and copies of all CRFs. The investigators will contact NIH/NICHD before 
disposing of any such materials.  
 
16.0 
USE OF INFORMATION AND PUBLICATION 
16.1 
Use of information 
After the dataset for the study is finalized and main findings have gone into publication, the data 
from this project will be made available and shared through CD-ROM and/or a website. All project 
data will be stored without subject identifiers, so that the data that are shared cannot be linked 
back to any particular subject. The dataset will cover the outcome data on children collected over 
the course of the study. 
 
16.2 
Data sharing plan 
The dataset for this study will cover course and outcome data on preterm infants collected over 
the period of study. The data sharing plan will follow guidelines as dictated by institutional rules 
and approval of local IRBs of participating research sites, local, state and federal laws and 
regulations including the Privacy Rule. The final data sharing plan that will be employed by the 
BEST protocols will be developed in conjunction with the individual site PI’s, and the NYPD-PRC.    
 
16.3 
Publication Policy 
Prior to a manuscript or abstract being submitted for possible publication or presentation, the 
Steering Committee and NICHD must review the contents of the submission. More specifically, 
manuscripts, abstracts, and poster submissions must be submitted to the Steering Committee, 
and NICHD at least 30 days prior to submission for publication or presentation. Financial support 
from the NIH-NICHD will be acknowledged in all publications.  
 
17.0 
INVESTIGATOR AGREEMENT   
 
I have received and reviewed the package insert for IV Ibuprofen & Ketorolac 
 
I have read the protocol and agree to conduct the study as outlined and in accordance with all 
applicable local, state, and federal regulation. 
 
I agree to maintain the confidentiality of all information received or developed in connection with 
this protocol.   
 
 


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Signature of Principal Investigator                                                            Date 
 
Name of Principal Investigator (printed or typed) 


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18.0 
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information contained herein is confidential and is to be used only in connection with matters authorized by 
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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
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Confidential: This document and its contents are the property of SUNY Downstate Medical Center.  The 
information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
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information contained herein is confidential and is to be used only in connection with matters authorized by 
SUNY Downstate Medical Center.  No portion of this document is to be disclosed, shared, copied or 
electronically transmitted without prior permission of SUNY Downstate Medical Center. 
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electronically transmitted without prior permission of SUNY Downstate Medical Center. 
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