Conditions: Diabetic Retinopathy Macular Edema
Keywords: Diabetes Macular Edema Diabetic Retinopathy
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 20
Healthy volunteers: no

Brief summary:
Treatment of diabetic macular edema with intravitreal aflibercept in subjects previously treated with intravitreal anti-Vascular endothelial growth factor (VEGF) agents (ranibizumab or bevacizumab)

Detailed description:
This study is an investigator initiated interventional study for subjects with diabetic macular edema (DME) that have been previously treated with bevacizumab or ranibizumab. Intravitreal aflibercept 2mg will be given until OCT (ocular coherence tomography) demonstrates an absence of fluid. Continued intravitreal aflibercept 2mg will then take place every 2 months for a total of 24 months of treatment.

This study is an interventional, single arm, investigator initiated study. Subjects will be given 2 mg (0.05 mL or 50 microliters) of intravitreal aflibercept injection (IAI) administered monthly until OCT demonstrates no evidence of fluid as defined by the protocol, followed by 2 mg (0.05 mL) once every 2 months. Each subject will be evaluated for 24 months. Thus, the study duration will be 24 months plus the recruitment period.

Subjects will be evaluated for safety, efficacy as measured by Spectral Domain Optical Coherence Tomography (SDOCT) and best corrected visual acuity (BCVA) using the Electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS) protocol. In additional, fundus photography, fluorescein angiography, and OCT angiography will be performed at baseline, month 6, month 12 and at the final visit.

Only one eye per subject may be enrolled in the study. If a subject's fellow (non-study) eye requires treatment for at study entry, or during the subject's participation in the study, the fellow eye can receive IAI for DME.

Arms:
arm 1: aflibercept 2mg given intravitreally every month until resolution of fluid in retina and then continued every 2 months for a total of 24 months of treatment

Interventions: intervention 1: aflibercept
Intervention descriptions: intervention 1: aflibercept 2mg given intravitreally every month until resolution of fluid in retina and then continued every 2 months for a total of 24 months of treatment

Protocol document:
Prot_000.pdf: 
 
May 20, 2016 Version6 
 
 
Clinical Study Protocol 
Investigator Initiated Interventional Study of Subjects With Diabetic Macular Edema 
Treated With Intravitreal Aflibercept Injection Previously Treated With Other Anti-
VEGF Agents.  
SWAP-TWO Study 
 
 
 
 
Compound: 
Intravitreal aflibercept injection 
 
 
Study Name: 
Study 
 
 
Clinical Phase: 
Phase IV 
 
 
Date of Issue: 
March 28, 2015 
Version 6 
May 20, 2016 
 
 
 
 
Confidential: This document contains confidential information that is the property of 
The Cleveland Clinic Foundation and must not be disclosed to anyone other than 
designees of each party for the conduct of the study, the recipient clinical Investigator(s) 
and their designees and members of the Institutional Review Board.  This information 
must not be used for any purpose other than the evaluation or conduct of the clinical 
investigation without the prior written consent of Cleveland Clinic. 


 
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CLINICAL STUDY PROTOCOL SYNOPSIS 
TITLE 
Investigator Initiated Interventional Study of Intravitreal 
Aflibercept Injection in Subjects with Diabetic Macular 
Edema previously treated with Ranibizumab or 
Bevacizumab. 
 
TITLE IN LAY TERMS 
Treatment of diabetic macular edema with IAI in 
subjects previously treated with other anti-VEGF agents 
SITE LOCATION(S) 
 
Principal Investigator 
 
Rishi P. Singh, MD 
Cole Eye Institute 
Cleveland Clinic 
Cleveland, Ohio 


 
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OBJECTIVE(S) 
This interventional study will examine the effects of 
patients with DME previously treated with other anti-
VEGF agents who are transitioned to IAI on a fixed 
dosing scheme. The following objectives will be 
evaluated:    
 
(1) To assess the efficacy of treatment outcomes by 
improvements in OCT central subfield thickness 
and ETDRS visual acuity from baseline 
(2) To determine safety and tolerability of IAI 
therapy by monitoring adverse events and  
(3) To evaluate perfusion changes in OCT 
angiography including area of nonperfusion and 
microaneuuersym presence before and after 
therapy. 
 
STUDY DESIGN 
This study is an interventional, single arm, investigator 
initiated study.  Subjects will be given 2 mg (0.05 mL or 
50 microliters) of IAI injection administered monthly 
until OCT demonstrates no evidence of fluid as defined 
by the protocol, followed by 2 mg (0.05 mL) once every 
2 months.  Each subject will be evaluated for 12 months. 
Thus, the study duration will be 12 months plus the 
recruitment period.  
 
Subjects will be evaluated for safety, efficacy as 
measured by SDOCT and best corrected visual acuity 
(BCVA) using the Electronic Early Treatment Diabetic 
Retinopathy Study (E-ETDRS) protocol.   In additional, 
fundus photography, fluorescein angiography, and OCT 
angiography will be performed at baseline, month 6, and 
at the final visit.   
 
Only one eye per subject may be enrolled in the study. If 
a subject’s fellow (non-study) eye requires treatment for 
at study entry, or during the subject’s participation in the 
study, the fellow eye can receive IAI injection for DME.  
 
STUDY DURATION 
12 Months 
ESTIMATED STUDY COMPLETION 
DATE 
 
March 1, 2017  
POPULATION 
 
 
Sample Size: 
20 Subjects 
 
Target Population: 
Patients presenting with foveal-involving macular edema 


 
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secondary to diabetes  
TREATMENT(S) 
IAI injection will be supplied by Regeneron 
Pharmaceuticals, Inc. and will be administered using 
standard techniques.   
 
Subjects will be given 2 mg (0.05 mL or 50 microliters) 
administered by intravitreal injection every month until 
OCT demonstrates no evidence of fluid as defined by the 
protocol followed by 2 mg (0.05 mL) via intravitreal 
injection once every 2 months. 
ENDPOINT(S) 
 
 
Primary: 
 The primary study endpoint is the mean absolute 
change from baseline central foveal thickness at 
month 12 as measured by SDOCT (defined as the 
average thickness within the central 1mm 
subfield). 
 
 
Secondary: 
Secondary endpoints would include  
 The mean change from baseline in best-corrected 
visual acuity (BCVA) scores at months 6 and 12. 
 Change in macular OCT perfusion at month 6 and 
12 by OCT angiography 
 The diabetic retinopathy severity changes from 
baseline at month 6 and 12 as measured by the 
simplified ETDRS scale.    
 Presence of microaneurysm and capillary dropout 
on OCT angiography at month 6 and month 12 by 
OCT angiography 
 The percentage of subjects that were anatomically 
‘dry’ by SDOCT at months 6 and 12, 
 The percentage of participants who gained or lost 
5, 10, and 15 letters or more of vision at months 6 
and 12 
 The percentage of patients that are 20/40 or better 
at months 6 and 12 
 The percentage of patients that are 20/200 or 
worse at months 6 and 12 
 The incidence and severity of ocular and non-
ocular adverse events (AEs) and serious AEs. 
 
 
 


 
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PROCEDURES AND ASSESSMENTS 
Ongoing assessments will include BCVA measurement, 
ophthalmic examinations and recording and evaluation of 
clinical adverse events.  Subjects will undergo SDOCT at 
each visit.  Fundus photography, fluorescein 
angiography, and OCT angiography will be performed at 
baseline, month 6, and month 12. 
 
Subjects will be given 2 mg (0.05 mL or 50 microliters) 
IAI administered by intravitreal injection every month 
until OCT demonstrates no evidence of fluid as defined 
by the protocol followed by 2 mg (0.05 mL) via 
intravitreal injection once every 2 months.  The fellow 
eye may also receive IAI as needed for DME as 
determined by the investigator. 
 
STATISTICAL PLAN 
The patients will be compared to their baseline 
measurement for the primary and secondary outcome.  
Trends and statistical significant difference will be 
reported. 
 
 
 


 
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TABLE OF CONTENTS 
Clinical Study Protocol Synopsis ..................................................................................... 2 
List of Figures .................................................................................................................... 9 
List of Abbreviations and Definitions of Terms ........................................................... 10 
1. Introduction and Rationale ..................................................................................... 11 
1.1 Introduction .............................................................................................................. 11 
1.2 Rationale .................................................................................................................. 12 
1.2.1 Rationale for Study Design ........................................................................... 12 
1.2.2 Rationale for Dose Selection ........................................................................ 13 
2. Study Objectives....................................................................................................... 14 
2.1 Primary Objective .................................................................................................... 14 
2.2 Secondary Objective(s) ............................................................................................ 14 
Study Design .................................................................................................................... 14 
2.3 Study Description and Duration............................................................................... 14 
2.4 Study Committees .................................................................................................... 14 
3. Selection, Withdrawal, and Replacement of Subjects .......................................... 15 
3.1 Number of Subjects Planned .................................................................................... 15 
3.2 Study Population ...................................................................................................... 15 
3.2.1 ........................................................................................................................... 15 
Inclusion Criteria ...................................................................................................... 15 
3.3 Premature Withdrawal from the Study .................................................................... 17 
3.4 Replacement of Subjects .......................................................................................... 17 
4. Study Treatments ..................................................................................................... 17 
4.1 Additional Treatment ............................................................................................... 18 
4.2 Dose Modification and Stopping Rules ................................................................... 18 
4.2.1 Dose Modification ........................................................................................ 18 
4.2.2 Study Drug Stopping Rules .......................................................................... 18 
4.3 Method of Treatment Assignment ........................................................................... 18 
4.3.1 Blinding/Masking ......................................................................................... 18 
4.3.2 Packaging, Labeling, and Storage ................................................................. 18 
4.3.3 Supply and Disposition of Treatments .......................................................... 19 
4.3.4 Treatment Accountability ............................................................................. 19 
4.3.5 Treatment Compliance .................................................................................. 20 


 
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4.4 Concomitant Medications and Procedures............................................................... 20 
4.4.1 Permitted Medications and Procedures ......................................................... 20 
4.4.2 Prohibited Medications and Procedures ........................................................ 20 
4.5 Post-Study Treatment............................................................................................... 20 
5. Study Schedule of Events and Visit Descriptions ................................................. 21 
5.1 Schedule of Events ................................................................................................... 21 
5.2 Study Visit Descriptions .......................................................................................... 24 
5.2.1 Screening/Baseline Visit, Day 0, .................................................................. 24 
5.2.2 Follow-up Period .......................................................................................... 24 
5.2.2.1 Month 1--Month 5 (+/- 7 Days) ............................................................. 24 
 
5.2.2.2    Early Termination Visit 
5.2.3 Additional Visits ........................................................................................... 25 
5.2.3.1 Unscheduled visit ................................................................................... 25 
5.2.4 Early Termination Visit ................................................................................ 25 
5.2.5 Unscheduled Visits ....................................................................................... 26 
5.3 Study Procedures ..................................................................................................... 26 
5.3.1 Procedures Performed only at the Screening/Baseline Visit ........................ 26 
5.3.2 Efficacy Procedures ...................................................................................... 26 
5.3.3 Safety Procedures .......................................................................................... 27 
5.3.3.1 Adverse Event Information Collection .................................................. 27 
6. Safety Definitions, Reporting, and Monitoring ..................................................... 27 
6.1 Definitions................................................................................................................ 27 
6.1.1 Adverse Event ............................................................................................... 27 
6.1.2 Serious Adverse Event .................................................................................. 27 
6.2 Recording and Reporting Adverse Events ............................................................... 28 
6.2.1 Deaths ........................................................................................................... 29 
6.2.2 Pregnancy and Other Events that Require Accelerated Reporting ............... 29 
6.2.3 Reporting Adverse Events Leading to Withdrawal from the Study ............. 30 
6.2.4 Follow-up ...................................................................................................... 30 
6.3 Evaluation of Severity and Causality ....................................................................... 30 
6.3.1 Evaluation of Severity ................................................................................... 30 
6.3.2 Evaluation of Causality ................................................................................. 31 
7. Study Variables ........................................................................................................ 31 


 
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7.1 Demographic and Baseline Characteristics ............................................................. 31 
7.2 Primary and Secondary Endpoints ........................................................................... 31 
7.3 Analysis Sets ............................................................................................................ 32 
7.3.1 Efficacy Analysis Sets .................................................................................. 32 
7.3.2 Safety Analysis Set ....................................................................................... 32 
7.4 Subject Disposition .................................................................................................. 32 
7.5 Statistical Methods ................................................................................................... 32 
7.5.1 Demography and Baseline Characteristics ................................................... 32 
7.5.2 Efficacy Analyses ......................................................................................... 32 
7.5.2.1 Primary Efficacy Analysis ..................................................................... 32 
7.5.2.2 Secondary Efficacy Analysis ................................................................. 32 
7.5.3 Safety Analysis ............................................................................................. 33 
7.5.3.1 Adverse Events ...................................................................................... 33 
8. Data Management and Electronic Systems ........................................................... 33 
8.1 Electronic Systems ................................................................................................... 34 
9. Study Monitoring ..................................................................................................... 34 
9.1 Monitoring of Study Sites ........................................................................................ 34 
9.2 Source Document Requirements .............................................................................. 34 
9.3 Case Report Form Requirements ............................................................................. 34 
10. Audits and Inspections .......................................................................................... 34 
11. Ethical and Regulatory Considerations ............................................................... 35 
11.1 Good Clinical Practice Statement .......................................................................... 35 
11.2 Informed Consent................................................................................................... 35 
11.3 Subject Confidentiality and Data Protection.......................................................... 36 
11.4 Institutional Review Board .................................................................................... 36 
12. Protocol Amendments ........................................................................................... 36 
13. Premature Termination of the Study or Close-out of a Site .............................. 37 
13.1 Premature Termination of the Study ...................................................................... 37 
14. Study Documentation ............................................................................................ 37 
14.1 Certification of Accuracy of Data .......................................................................... 37 
14.2 Retention of Records.............................................................................................. 37 
 
 


 
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List of Tables 
Table 1 
Schedule of Events ........................................................................................ 22 
 
LIST OF FIGURES 
Figure 2        Diabetic retinopathy and diabetic macular edema…………………………15 
 
 
LIST OF APPENDICES 
Appendix 1 
Injection Technique………………………………………………….......38 
Appendix 2:    References……………….........................................................................40


 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
AE 
Adverse event 
CRF 
Case report form 
EC 
Ethics Committee 
eCRF 
Electronic case report form 
FAS 
Full analysis set 
ICF 
Informed consent form 
IRB 
Institutional Review Board 
MedDRA 
Medical Dictionary for Regulatory Activities 
SAE 
Serious adverse event 
SAP 
Statistical analysis plan 
TEAE 
Treatment-emergent adverse event 
 


 
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1. 
INTRODUCTION AND RATIONALE 
1.1 
Introduction 
DR is a major cause of blindness among American adults aged 40 years and older. 
The prevalence of DR in this population is increasing; it currently affects 4.2 million 
people, and it is projected that this figure will rise to 6 million people by the year 2020. 
Vision-threatening diabetic retinopathy (VTDR) is estimated to affect 700,000 
individuals in the US. By 2020, this is expected to increase to 1.34 million people.  
Diabetic macular edema (DME) is the most common cause of vision loss from diabetic 
retinopathy.  It is characterized by macular swelling secondary to increased vascular 
permeability secondary to loss of pericytes in the macular vascular bed.  Clinically, 
microaneurysms and exudates are often seen in association with macular edema.  Foveal-
involving cystic changes and macular edema can have significant impact on visual loss.  
Extent of perfusion and ischemia also is important for visual prognosis.   
Multiple factors play a role in the evolution of diabetic macular edema.  Vascular 
endothelial growth factor has been shown to be significantly elevated in diabetic 
retinopathy and may play an important role in the evolution and pathogenesis of DME.   
Increasing VEGF levels are also seen in the setting of progressive ischemia, such as 
proliferative diabetic retinopathy when extensive peripheral nonperfusion may be present 
(Wessel et al, 2012). Additionally significant peripheral vascular perfusion abnormalities 
are often seen in other retinal vascular diseases (Singer et al, 2014).  Reducing the active 
levels of VEGF may have significant positive consequences for outcomes related to 
DME. VEGF has 2 properties that explain its important roles in normal fetal development 
and in biology: VEGF is a powerful mitogen for endothelial cells (Ferrara et al., 1991), 
thus promoting formation of new vessels that are required for normal and pathological 
tissue growth (Ferrara, 2000; Ferrara and Davis-Smyth, 1997).  
VEGF is a homodimeric protein with a molecular weight of 34 to 42 kDa 
(Thickett, 1999). VEGF binds to and activates 2 high affinity receptors, Flt-1 (VEGFR1) 
and Flk-1 (VEGFR2), which are predominantly located on the vascular endothelium.  
IAI is a recombinantly produced fusion protein consisting of portions of the 
human VEGF receptor extracellular domains fused to the Fc domain of human IgG1 
(Figure 1). IAI is comprised of portions of the extracellular domains of 2 different VEGF 
receptors. It contains sequences encoding Ig domain 2 from VEGFR1 fused to Ig domain 
3 from VEGFR2, which in turn is fused to the hinge region of the human IgG1 Fc 
domain. IAI is a dimeric glycoprotein with a protein molecular weight of 97 kDa, and 
contains ~15% glycosylation to give a total molecular weight of 115 kDa. 
 
 
 
 
 
 
 


 
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Figure 1. The IAI Molecule 
 
Figure 1. VEGFR1 and VEGFR2 are related receptors that have 7 Ig domains in the 
extracellular portion and a tyrosine kinase domain intracellularly. IAI contains 
the VEGFR1 Ig2 domain fused to the VEGFR2 Ig3 domain, which is in turn fused to the 
IgG1 Fc. 
 
IAI has several potential advantages over other VEGF blockers: it has a much 
higher affinity (~ 0.5 pM dissociation constant for VEGF165 and VEGF121) than a 
humanized monoclonal antibody. IAI also binds the related factors Placental 
Growth Factor 1 and 2 (PLGF1 and PLGF2), which may be advantageous in certain 
disease situations, including retinal neovascularization (Rakic et al 2003). 
 
 
1.2 
Rationale 
1.2.1 
Rationale for Study Design 
Multiple phase III studies (e.g., RISE, RIDE, VISTA, VIVID,), have evaluated 
intravitreal anti-VEGF agents for the management of DME.  Results from these studies 
demonstrated clinical efficacy and significant improvements in visual acuity and macular 
thickness.  There are three currently utilized anti-VEGF agents for DME used: 
bevacizumab (Avastin, Genentech/Roche), ranibizumab (Lucentis,  Genentech/Roche), 
and aflibercept (Eylea, Regeneron/Bayer).   
A head to head comparison of these agents was recently completed.  Protocol T 
was a multicenter, randomized clinical trial comparing the efficacy and safety of aflibercept 2.0 
mg, bevacizumab 1.25 mg, and ranibizumab 0.3 mg in patients with type 1 or type 2 diabetes and 
with at least 1 eye with center-involved DME and no anti-vascular endothelial growth factor 
(anti-VEGF) treatment within 12 months prior to enrollment (N=660). The mean duration of 
diabetes was 17 years; the mean visual acuity (VA) at baseline was approximately 20/50 (Table 
1). A little more than a third of patients had prior focal/grid laser photocoagulation and 11% to 
14% had prior anti-VEGF therapy for DME.  
Treatment was every 4 weeks while the eye was improving or worsening.  Treatment was 
deferred when VA was 20/20 or better, with central subfield thickness (CST) below the eligibility 
threshold (250 µm to 320 µm) or the eye was stable for 2 injections (Figure 1). The mean 
improvement in VA letter score was greater with aflibercept than with bevacizumab (13.3 vs. 9.7; 
P<.001) or ranibizumab (13.3 vs. 11.2; P=.03). The relative effect varied according to initial VA, 


 
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with the mean improvement from baseline increasing with worse initial VA letter score (<69; 
20/50 or worse at baseline). In this subpopulation (49% of cohort), mean improvement was +18.9 
for aflibercept, +11.8 for bevacizumab, and +14.2 for ranibizumab. The median number of 
injections (maximum possible 13) was 9 for aflibercept, 10 for bevacizumab, and 10 for 
ranibizumab. Laser photocoagulation, at least once between 24 and 48 weeks, was performed in 
36% of aflibercept-treated eyes, 56% of bevacizumab-treated eyes, and 46% of ranibizumab-
treated eyes (P<.001 for overall comparison). Retinal thickening was decreased to <250 µm in 
66% of aflibercept-treated eyes, 36% of bevacizumab-treated eyes, and 58% of ranibizumab-
treated eyes. Bevacizumab was statistically significantly less effective for improving CST 
outcomes than either aflibercept or ranibizumab.  
 
While all treatments demonstrated significant treatment benefit, there were clearly 
differences in the anti-VEGF agent and the anatomical and vision response in patients 
especially in those with vision 20/50 or worse. Complicating matters further, Protocol T 
does not reflect the general population of patients under treatment under retina practices.  
Protocol T required patients to not have anti-VEGF therapy for a minimum of 12 months 
prior to entry.  Thus, there is a gap in understanding on what the outcomes will be when 
patients are transitioned to IAI from other therapies.    
 
In addition, the majority of retina specialists also do not treat on a fixed dosing pattern as 
seen in registration trials and instead employ a pro re nata (PRN) treatment regimen 
based on OCT and clinical exam. Does the movement from PRN treatments to a fixed 
dosing scheme of every 2 months achieve the same visual and anatomical outcomes?  
 
Below is the schema for retreatment in Protocol T.  Because of the complexity of the 
treatment algorithm, the treatment frequency from protocol T would not likely be adopted 
to retina practices. Therefore a regimen with a fixed dosing interval may improve clinical 
efficiency and decrease clinical visits for patients with DME.   
 
Preliminary studies have suggested that there is a significant amount of retinal 
vascular changes (e.g., increased permeability, ischemia) in patients with DME ((Wessel 
et al, 2012). These global assessments of OCT angiographic features, including leakage 
and ischemia, may allow for a better characterization of the disease burden and allow for 
the development of imaging biomarkers that have implications for therapeutic response 
or resistance. This study will prospectively assess the alterations in OCT angiographic 
parameters to provide insights into the retinal vascular changes that occur during 
treatment with IAI and to examine the relationship between these features and treatment 
response. 
1.2.2 
Rationale for Dose Selection 
The dose and treatment regimen was selected based on the phase III studies and the drug 
package insert.  Specifically, subjects will be given 2 mg (0.05 mL or 50 microliters) 
administered by intravitreal injection every month until OCT demonstrates no evidence 
of fluid as defined by the protocol, followed by 2 mg (0.05 mL) via intravitreal injection 
once every 2 months. 


 
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2. 
STUDY OBJECTIVES 
2.1 
Primary Objective 
 The primary study endpoint is the mean absolute change from baseline central 
foveal thickness at month 12 as measured by SDOCT (defined as the average 
thickness within the central 1mm subfield). 
 
2.2 
Secondary Objective(s) 
 To assess the efficacy of treatment outcomes by improvements in ETDRS visual 
acuity from baseline 
 To determine safety and tolerability of IAI therapy by monitoring adverse events. 
 To determine perfusion changes in OCT angiography including area of 
nonperfusion and microanuersym presence before and after therapy.       
  
STUDY DESIGN 
2.3 
Study Description and Duration 
Subjects will be assigned to treatment with 2 mg IAI (0.05 mL or 50 microliters) 
administered monthly until OCT demonstrates no evidence of fluid as defined by the 
protocol, followed by 2 mg (0.05 mL) once every 2 months.  
The planned enrollment for the 20 subjects needed for this study is estimated to be 12 
months. The study duration for each subject is scheduled to be 12 months.  
 
Only one eye will be designated as the study eye. For subjects who meet eligibility 
criteria in both eyes, the investigator and patient will select the study eye.  
 
Subjects will be evaluated at Cole Eye Main Campus for Screening/Baseline, Visit 
Month 6 and Visit Month 12. All other visits may occur at Twinsburg Family Health 
Center- Ophthalmology or Strongsville Family Health Center- Ophthalmology if that 
office suits the subject travel needs. 
 
2.4 
Study Committees 
Appropriate action, if needed, will be taken based upon this review and in consultation 
with the principal investigator.  All events will be managed and reported in compliance 
with all applicable regulations and included in the final clinical study report. 


 
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3. 
SELECTION, WITHDRAWAL, AND REPLACEMENT OF SUBJECTS 
3.1 
Number of Subjects Planned 
The target enrollment for this study is 20 subjects.  
3.2 
Study Population 
Subjects will be recruited through clinics at the Cole Eye Institute, Cleveland OH.  The 
study will seek approval from the Cleveland Clinic Investigational Review Board (IRB) 
and all study related procedures will be performed in accordance with the Declaration of 
Helsinki and US Code 21 of Federal Regulations.   
3.2.1 
 
Inclusion Criteria 
A subject must meet the following criteria to be eligible for inclusion in the study: 
1. Signed Informed Consent. 
2. Men and women ≥ 18 years of age. 
3. Foveal-involving retinal edema secondary to DME based on investigator 
review of clinical exam and SDOCT with central subfield thickness value of 
325 microns by Zeiss Cirrus SD-OCT. 
4. E-ETDRS best-corrected visual acuity of: 20/25 to 20/400 in the study eye. 
5. History of previous treatment with anti-VEGF with at least 4 injections over 
the last 6 months.  
6. Willing, committed, and able to return for ALL clinic visits and complete all 
study related procedures. 
7. Able to read, (or, if unable to read due to visual impairment, be read to 
verbatim by the person administering the informed consent or a family 
member. See Appendix J.4) understand and willing to sign the informed 
consent form.  
 
 
Exclusion Criteria 
A subject who meets any of the following criteria will be excluded from the study: 
1. Any prior or concomitant therapy with another investigational agent to treat 
DME in the study eye. 
2. Prior panretinal photocoagulation in the study eye within the past 3 months. 
3. Prior intravitreal anti-VEGF therapy in the study eye within 30 days of 
enrollment. 
4. Prior Flucinolone implantation (Iluvein) or prior Ozurdex within 6 months of 
study entry.  Prior intravitreal steroid within 4 months of study entry.   
5. Prior systemic anti-VEGF therapy, investigational or FDA-approved, is only 
allowed up to 3 months prior to first dose, and will not be allowed during the 
study. 


 
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6. Previous treatment with intravitreal aflibercept injection 
7. Significant vitreous hemorrhage obscuring view to the macula or the retinal 
periphery as determined by the investigator on clinical exam 
8. Presence of other causes of macular edema, including pathologic myopia 
(spherical equivalent of –8 diopters or more negative, or axial length of 25 
mm or more), ocular histoplasmosis syndrome, angioid streaks, choroidal 
rupture, choroidal neovascularization, age-related macular degeneration or 
multifocal choroiditis in the study eye.  Epiretinal membranes are not 
considered an exclusion.  . 
9. Presence of macula-threatening traction retinal detachment. 
10. Prior vitrectomy in the study eye. 
11. History of retinal detachment or treatment or surgery for retinal detachment in 
the study eye. 
12. Any history of macular hole of stage 2 and above in the study eye. 
13. Any intraocular or periocular surgery within 3 months of Day 1 on the study 
eye, except lid surgery, which may not have taken place within 1 month of 
day 1, as long as it’s unlikely to interfere with the injection. 
14. Uncontrolled glaucoma at baseline evaluation (defined as intraocular pressure 
≥25 mmHg despite treatment with anti-glaucoma medication) in the study 
eye. 
15. Active intraocular inflammation in either eye. 
16. Active ocular or periocular infection in either eye. 
17. Any ocular or periocular infection within the last 2 weeks prior to Screening 
in either eye. 
18. Any history of uveitis in either eye. 
19. History of corneal transplant or corneal dystrophy in the study eye. 
20. Significant media opacities, including cataract, in the study eye which might 
interfere with visual acuity, assessment of safety, or fundus photography. 
21. Any concurrent intraocular condition in the study eye (e.g. cataract) that, in 
the opinion of the investigator, could require either medical or surgical 
intervention during the 52 week study period. 
22. Any concurrent ocular condition in the study eye which, in the opinion of the 
investigator, could either increase the risk to the subject beyond what is to be 
expected from standard procedures of intraocular injection, or which 
otherwise may interfere with the injection procedure or with evaluation of 
efficacy or safety. 
23. Participation as a subject in any clinical study within the 12 weeks prior to 
Day 1. 


 
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24. Any systemic therapy with an investigational agent in the past 3 months prior 
to Day 1. 
25. Any history of allergy to povidone iodine. 
26. Pregnant or breast-feeding women 
27. Women of childbearing potential* who are unwilling to practice adequate 
contraception during the study (adequate contraceptive measures include 
stable use of oral contraceptives or other prescription pharmaceutical 
contraceptives for 2 or more menstrual cycles prior to screening; intrauterine 
device [IUD]; bilateral tubal ligation; vasectomy; condom plus contraceptive 
sponge, foam, or jelly, or diaphragm plus contraceptive sponge, foam, or jelly) 
*Postmenopausal women must be amenorrheic for at least 12 months in order not to be 
considered of child bearing potential.  Pregnancy testing and contraception are not 
required for women with documented hysterectomy or tubal ligation. 
3.3 
Premature Withdrawal from the Study 
A subject has the right to withdraw from the study at any time, for any reason, and 
without repercussion. 
The investigator has the right to withdraw a subject from the study in the event of an 
intercurrent illness, AE, treatment failure, protocol violation, cure, and for administrative 
or other reasons.  An excessive rate of withdrawals would render the study 
uninterpretable; therefore, unnecessary withdrawal of subject should be avoided. 
Should a subject (or a subject’s legally authorized guardian or representative) decide to 
withdraw, all efforts will be made to complete and report observations as thoroughly as 
possible.  Early termination procedures should be followed, as delineated in section 5.2.4. 
3.4 
Replacement of Subjects 
Subjects prematurely discontinued from the study will not be replaced. 
4. 
STUDY TREATMENTS 
Subjects will be initially assigned to treatment with 2 mg intravitreal IAI injection (0.05 
mL or 50 microliters) administered monthly until OCT demonstrates no evidence of fluid 
as defined by the protocol, followed by 2 mg (0.05 mL) once every 2 months.  
 
No evidence of fluid is defined as: 
1. Lack of subretinal fluid 
2. Central subfield thickness of less than 300 microns  
3. Grade 2 or lower CME grade.  CME grade is defined as: 
a. Grade 0: no CME 
b. Grade 1: extrafoveal CME or foveal depression present 
c. Grade 2: foveal CME with fovea flat 


 
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d. Grade 3: CME with fovea slightly raised 
e. Grade 4: CME with fovea significantly raised 
 
4.1 
Additional Treatment 
 
 
Additional treatment with IAI can be applied if the subject experiences any of the 
following events since the last treatment: 
 Loss of 15 or more ETDRS letters from best previous measurement AND increase 
in 75 microns of retinal thickness as compared to the last previous visit.   
 
If the subject meets additional treatment criteria, the subject will be switched to monthly 
visits and assessments.   
4.2 
Dose Modification and Stopping Rules 
4.2.1 
Dose Modification 
Dose modification for an individual subject is not allowed. 
4.2.2 
Study Drug Stopping Rules 
Information on follow-up for subjects who permanently discontinue from study drug, but 
choose to remain in the study is provided in section 6.2.4. 
4.3 
Method of Treatment Assignment 
All subjects are enrolled in the same cohort to receive treatment with intravitreal 
aflibrecept injection. 
4.3.1 
Blinding/Masking 
This is a single arm treatment study and the patients and physicians will be aware of their 
current treatment assignment and schema.   
4.3.2 
Packaging, Labeling, and Storage 
2.0 mg intravitreal IAI injection is formulated as a sterile liquid to a final concentration of 
40 mg/mL intravitreal IAI injection in 5% sucrose, 10 mM sodium phosphate pH 6.3, 
0.03% polysorbate 20, and 40 mM NaCl. Intravitreal IAI injection 2.0 mg study drug will 
be supplied by Regeneron Pharmaceuticals Inc. in sealed, sterile 3 mL vials with a 
“withdrawable” volume of approximately 0.05 mL. Vials must be used only once 
(defined as entered with a needle). The volume of injection will be 0.05 mL for the 2 mg 
dose. For study drug in vials, the study drug will be withdrawn using aseptic technique.  
 


 
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Study drug will be shipped to the site via overnight shipping using cold packs to maintain 
a temperature of 2° to 8° C. The Investigator, or an approved representative (e.g. 
pharmacist), will ensure that all study drugs are stored in a secured area, under 
recommended storage conditions and in accordance with applicable regulatory 
requirements. The shipping box is to be opened and stored immediately at the site in a 
refrigerator intended for investigational products at a temperature of 2° to 8°C.  
 
When vials are removed from the refrigerator, the solution should be visually inspected 
and it should have no evidence of turbidity. If particulates, cloudiness, or discoloration 
are visible, the vial must not be used. Exposure of the material to temperatures outside 
these limits, except for warming prior to administration, is not recommended and may 
result in loss of activity. Records of actual storage conditions (i.e. temperature log) at the 
study site must be maintained; and must include a record of the dates, when the 
refrigerator was checked, the initials of person checking, and the temperature. 
4.3.3 
Supply and Disposition of Treatments 
Study drug will be shipped at a temperature of 2° to 8°C to the investigator or designee at 
regular intervals or as needed during the study. At the end of the study, and following 
drug reconciliation and documentation, all opened and unopened vials of study drug will 
be destroyed or returned to Regeneron Pharmaceuticals, Inc. or designee. 
4.3.4 
Treatment Accountability 
All drug accountability records will be kept current. 
The investigator will account for all opened and unopened vials of study drug.  These 
records will contain the dates, quantity, and study medication 
 dispensed to each patient – or - 
 disposed of at the site or returned to Regeneron Pharmaceuticals, Inc. or designee. 
All accountability records will be made available for inspection by regulatory agency 
inspectors. 


 
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4.3.5 
Treatment Compliance 
All drug compliance records must be kept current and must be made available for 
inspection by regulatory agency inspectors. 
 
4.4 
Concomitant Medications and Procedures 
Study Eye: 
Subjects may not receive any medications (approved or investigational) for their DME in 
the study eye other than the assigned study treatment (intravitreal IAI injection as 
specified in this protocol, until they have completed the end of study (12 months) or ET 
visit assessments. This includes medications administered locally (e.g., IVT, topical, 
juxtascleral or periorbital routes), as well as those administered systemically, with the 
intent of treating the study and/or fellow eye. No focal/grid laser photocoagulation can be 
performed during the study. Panretinal laser photocoagulation can be performed for the 
presence of proliferative disease with vitreous hemorrhage or other high risk 
characteristics (e.g., neovascularization of the disc) during the course of the study.  
 
Fellow Eye: 
If a subject’s fellow (non-study) eye requires treatment for DME  study entry, or during 
the subject’s participation in the study, the fellow eye can receive IAI. Intravitreal 
aflibercept injection will be provided at no cost by Regeneron for the fellow eye.  
Although the fellow eye can receive treatment, it will not be considered an additional 
study eye.  The fellow eye may also receive laser photocoagulation, as needed, at 
investigator discretion. 
4.4.1 
Permitted Medications and Procedures 
Any other medication that are considered necessary for the subject’s welfare, and that are 
not expected to interfere with the evaluation of the study drug, may be given at the 
discretion of the investigator. 
4.4.2 
Prohibited Medications and Procedures 
Systemic anti-angiogenic agents will not be permitted during the study. Patient must 
refrain from the use of oral or topical steroids for 12 months during the course of the 
study.  Patients must also refrain from the use of topical nonsteriodal agents, system 
nonsteroidal agents, intraocular anti-VEGF agents, and systemic anti-VEGF agents for 12 
months during the course of the study for treatment of the study eye.  
 
4.5 
Post-Study Treatment 
All medications are permitted post-study treatment.   


 
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5. 
STUDY SCHEDULE OF EVENTS AND VISIT DESCRIPTIONS 
5.1 
Schedule of Events 
Study assessments and procedures are presented by study period and visit in Table 1.


 
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Table 1 
Schedule of Events 
 
Treatment Period (Visit intervals after baseline are 28 days since last visit +/- 7 days) 
Additional 
Study Procedure 
Screening
& 
Baseline 
Visit 1 
2 
3 
4 
5 
6 
7* 
8 
9* 
10 
11* 
12 
End of 
Treatment 
Visit 13 
Unscheduled Follow 
up Visit or Early 
Termination 
Day/Month 
Month  
0 
M 1 
28 
days 
+/- 7 
days 
M 2 
28 
days 
+/- 7 
days 
M 3 
28 
days 
+/- 7 
days 
M 4 
28 
days 
+/- 7 
days 
M 5 
28 
days 
+/- 7 
days 
M 6 
28 
days 
+/- 7 
days 
M 7 
28 
days 
+/- 7 
days 
M 8 
28 
days 
+/- 7 
days 
M 9 
28 
days 
+/- 7 
days 
M 10 
28 
days 
+/- 7 
days 
M 11 
28 
days 
+/- 7 
days 
Month 12 
+/-10 days 
NA 
Inclusion/Exclusion 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
Concomitant 
medications 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Demographics 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
ETDRS Manifest 
Refraction/Slit 
Lamp/Tonometry/ 
Fundus Exam study 
eye  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
OCT angiography 
x 
 
 
 
 
 
 
x 
 
 
 
 
 
x 
 
SDOCT study eye  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Ultra Wide Field 
Fluorescein 
Angiography** 
x 
 
 
 
 
 
x 
 
 
 
 
 
x 
 
Ultra Wide Field 
Fundus 
Photography 
x 
 
 
 
 
 
x 
 
 
 
 
 
x 
 
Administer Study 
Drug (intravitreal 
IAI injection)* 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Adverse Events 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 


 
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* IAI will be given monthly until there is no evidence of fluid is defined as: 1. Lack of subretinal fluid 2. Central subfield thickness of less than 300 microns, 3. Grade 2 or lower 
CME grade as defined in section 4.0.  If subject meets additional treatment requirements as defined in section 4.1 of the protocol, the patient will be treated in q1 intervals.     
** In cases of fluorescein dye intolerance with severe allergic reaction, patient may be excluded from this evaluation.  


 
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5.2 
Study Visit Descriptions 
5.2.1 
Screening/Baseline Visit, Day 0,  
After the subject has provided informed consent, the following information will be 
collected: 
 Inclusion/exclusion 
 Informed consent documentation 
 Demographics 
 Medical history and concurrent illnesses 
 Concomitant medications 
The following procedures and assessments will be conducted: 
 ETDRS visual acuity with manifest refraction 
 Slit lamp examination (Including IOP measurement) 
 Fundus examination 
 Spectral Domain OCT evaluation 
 Ultra Wide Field Fundus photography 
 Ultra Wide Field Fluorescein angiography 
 OCT angiography evaluation 
 Intravitreal aflibercept injection 
 
5.2.2 
Follow-up Periods 
5.2.2.1 
Q1 month interval visit (+/- 7 Days)-month 6 and 12 are mandatory visits 
and additional tests are listed below 
The following information will be collected: 
 Concomitant medications 
 AEs 
The following procedures and assessments will be conducted: 
 ETDRS visual acuity with manifest refraction 
 Slit lamp examination (including IOP measurement) 
 Fundus examination 
 Spectral Domain OCT evaluation 
 Ultra Wide Field Fundus Photography (month 6 and 12 only) 


 
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 Ultra Wide Field Fluorescein angiography (month 6 and 12 only) 
 OCT angiography (month 6 and 12 only) 
 Intravitreal aflibercept injection (if deemed necessary based on OCT) 
 
 
5.2.2.2 
Early Termination visit 
The following information will be collected: 
 Concomitant medications 
 AEs 
The following procedures and assessments will be conducted: 
 ETDRS visual acuity with manifest refraction 
 Slit lamp examination (including IOP measurement) 
 Fundus examination 
 Spectral Domain OCT evaluation 
 
5.2.3 
Additional Visits 
5.2.3.1 
Unscheduled visit 
The following information will be collected: 
 Concomitant medications 
 AEs 
The following procedures and assessments will be conducted: 
 ETDRS visual acuity with manifest refraction 
 Slit lamp examination (including IOP measurement) 
 Fundus examination 
 Spectral Domain OCT evaluation 
 
5.2.4 
Early Termination Visit 
Subjects who are withdrawn from the study should be instructed to return to the clinic for 
end of study assessments. 


 
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5.2.5 
Unscheduled Visits 
All attempts should be made to keep subjects on the study schedule.  Unscheduled visits 
may be necessary to repeat testing following AEs, or for any other reason, as warranted. 
5.3 
Study Procedures 
5.3.1 
Procedures Performed only at the Screening/Baseline Visit 
No specific procedures other than above will be performed for the sole purpose of 
determining study eligibility or characterizing the baseline population. 
5.3.2 
Efficacy Procedures 
Vision: Visual Acuity Visual function of the study eye and the fellow eye will be 
assessed using the E-ETDRS protocol (The Early Treatment Diabetic Retinopathy Study 
Group, 1985). Visual Acuity examiners must be certified to ensure consistent 
measurement of BCVA.   
 
Spectral Domain Optical Coherence Tomography (OCT): Retinal characteristics will be 
evaluated using SDOCT on the study eye. At the Screen Visit (Visit 1) images will be 
captured and archived. The scanning protocol will consist of fast macular thickness maps 
as well as high definition 6.0 mm linear scans centered on the fovea. OCT scans will be 
recorded by scoring their morphological patterns, and by recording the foveal minimum 
and volumetric analysis for each subject (Cirrus OCT, Humphrey Zeiss Inc., San 
Leandro, CA, software version 5.0).  OCT images will read by a trained reader and also 
assessed with a computerized segmentation analysis tool. 
 
Spectral domain optical coherence tomography (OCT) is noninvasive noncontact imaging 
technique that is among the most commonly ordered diagnostic tests in ophthalmology.  
OCT allows for high-resolution visualization of eye structures including the retina, 
choroid, and optic nerve.  OCT technology uses light in a similar method to ultrasound.     
 
OCT angiography (OCT-A) utilizes OCT technology and special software to reconstruct 
the active vascular network in the area of interest.  This is a major breakthrough in 
technology because for the first time a clinician has the ability to visualize the perfused 
vascular network in a noninvasive and minimal risk way.   
 
OCT-A software is now available on various FDA-cleared OCT devices.  The software is 
currently not FDA-approved as the clinical endpoints have not been defined and 
normative validation has not been completed. (see rationale for exemption for IDE in 
research procedures below).  Utilizing OCT-A software does not impact the patient.  
Following obtaining the OCT image with the FDA-approved system, the OCT-A 
software is then used to process sequential OCT scans to reconstruct the vascular 
network.   Although this software is not approved for use in the United States, it presents 
minimal risk to the patient and the procedure for imaging is exactly the same as that of 
spectral-domain OCT. 
 
The data obtained from OCT-A may provide important information on disease activity.  


 
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Fundus Evaluation, Fundus Photography, and Fluorescein Angiography (FA): 
The anatomical state of the retinal vasculature of the study eye will be evaluated by 
funduscopic examination. Ultra-widefield fundus photography and fluorescein 
angiography will be performed at the baseline visit, month 6, and at the month 12 visit.   
OCT angiography will be performed at the baseline visit, month 6, and at the month 12 
visit.  Angiographic analysis will be performed by a trained reader and a computerized 
analysis tool. 
 
Intraocular Pressure: 
Intraocular pressure (IOP) of the study eye will be measured using applanation tonometry 
or Tonopen. The same method of IOP measurement must be used in each subject 
throughout the study. 
5.3.3 
Safety Procedures 
5.3.3.1 
Adverse Event Information Collection 
The investigator (or designee) will record all AEs that occur during the study following 
the baseline visit. Information on follow-up for AEs is provided in section 6.2.4.   
The definition of an AE and SAE, and information on the determination of severity and 
relationship to treatment are provided in section 6. 
6. 
SAFETY DEFINITIONS, REPORTING, AND MONITORING 
6.1 
Definitions 
6.1.1 
Adverse Event 
An AE is any untoward medical occurrence in a patient administered a study drug which 
may or may not have a causal relationship with the study drug.  Therefore, an AE is any 
unfavorable and unintended sign (including abnormal laboratory finding), symptom, or 
disease which is temporally associated with the use of a study drug, whether or not 
considered related to the study drug.   
An AE also includes any worsening (i.e. any clinically significant change in frequency 
and/or intensity) of a pre-existing condition that is temporally associated with the use of 
the study drug. 
6.1.2 
Serious Adverse Event 
A SAE is any untoward medical occurrence that at any dose: 
 Results in death – includes all deaths, even those that appear to be completely 
unrelated to study drug (e.g. a car accident in which a patient is a passenger). 


 
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 Is life-threatening – in the view of the investigator, the patient is at immediate 
risk of death at the time of the event.  This does not include an AE that had it 
occurred in a more severe form, might have caused death. 
 Requires in-patient hospitalization or prolongation of existing hospitalization.  
In-patient hospitalization is defined as admission to a hospital or an emergency 
room for longer than 24 hours.  Prolongation of existing hospitalization is defined 
as a hospital stay that is longer than was originally anticipated for the event, or is 
prolonged due to the development of a new AE as determined by the investigator 
or treating physician. 
 Results in persistent or significant disability/incapacity (substantial disruption of 
one’s ability to conduct normal life functions). 
 Is a congenital anomaly/birth defect. 
 Is an important medical event – Important medical events may not be 
immediately life-threatening or result in death or hospitalization, but may 
jeopardize the patient or may require intervention to prevent 1 of the other serious 
outcomes listed above (e.g., intensive treatment in an emergency room or at home 
for allergic bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization; or development of drug dependency or drug abuse).  Any 
malignancy (other than basal cell skin cancers) would be considered a medically 
important event. 
6.2 
Recording and Reporting Adverse Events 
All AEs and SAEs will be recorded in the patient’s source documents.  Laboratory values 
or vital signs will be recorded as AEs only if they are medically relevant. 
 
All SAEs, regardless of assessment of causal relationship to study drug will be reported 
to Regeneron Pharmaceuticals, Inc. 
 
The investigator will promptly report to the IRB all unanticipated problems involving 
risks to subjects.  This includes death from any cause and all SAEs related to the use of 
the study drug.  All SAEs will be reported to the IRB, regardless of assessed causality. 


 
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6.2.1 
Deaths 
Any AE that results in death is considered a SAE.  Deaths that occur from the time the 
patient signs the informed consent form (“ICF”) until 30 days after dosing will be 
reported to the appropriate IRB and to Regeneron Pharmacovigilance and Risk 
Management (or designee) within 24 hours of learning of the death.   
 
Any available autopsy reports and relevant medical reports will be sent to Regeneron 
Pharmaceuticals, Inc. as soon as possible. 
 
To report an SAE, Regeneron will be contacted at the following: 
Medical.safety@regeneron.com 
Fax 914-345-7476 
SAE hotline: 914-593-1504 
6.2.2 
Pregnancy and Other Events that Require Accelerated Reporting 
The following events will be reported to Regeneron Pharmaceuticals, Inc. within 24 
hours of learning of the event: 
 
Overdose:  Accidental or intentional overdose of the study drug or concomitant 
medication, whether or not it is considered an AE. 
 
Pregnancy:  Although it is not considered an AE, the investigator will report to 
Regeneron Pharmaceuticals, Inc., any pregnancy occurring in a female patient or female 
partner of a male patient, during the study or within 30 days following the last dose of 
study drug.  The investigator will follow the pregnancy until delivery, or longer.  If the 
pregnancy continues to term (delivery), the health of the infant will also be reported to 
Regeneron Pharmaceuticals, Inc. 
 
To report an SAE, Regeneron will be contacted at the following: 
Medical.safety@regeneron.com 
Fax 914-345-7476 
SAE hotline: 914-593-1504 


 
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6.2.3 
Reporting Adverse Events Leading to Withdrawal from the Study 
All AEs that lead to a patient’s withdrawal from the study will be reported to Regeneron 
Pharmaceuticals Inc. within 30 days. All SAEs leading to a patient’s withdrawal from the 
study will be reported. To report an SAE, Regeneron will be contacted at the following: 
Medical.safety@regeneron.com 
Fax 914-345-7476 
SAE hotline: 914-593-1504 
6.2.4 
Follow-up 
Adverse event information will be collected until the end of study visit, or the early 
termination visit, if the patient withdraws consent. 
 
The investigator must make every effort to obtain follow-up information on the outcome 
of any SAE until the event is considered chronic and/or stable. 
 
6.3 
Evaluation of Severity and Causality 
6.3.1 
Evaluation of Severity 
The severity of an AE will be graded by the investigator using a 3–point scale (mild, 
moderate, or severe) and reported in detail as indicated on the CRF and/or SAE form, as 
appropriate. 
 Mild:  Does not interfere in a significant manner with the patient’s normal 
functioning level.  It may be an annoyance.  Prescription drugs are not ordinarily 
needed for relief of symptoms, but may be given because of personality of the 
patient. 
 Moderate:  Produces some impairment of functioning but is not hazardous to 
health.  It is uncomfortable or an embarrassment.  Treatment for symptom may be 
needed. 


 
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 Severe:  Produces significant impairment of functioning or incapacitation and is a 
definite hazard to the patient’s health.  Treatment for symptom may be given 
and/or patient hospitalized. 
6.3.2 
Evaluation of Causality 
The relationship to treatment will be determined by the investigator and reported on the 
CRF and/or SAE form, as appropriate.  The following terms will be used: 
Not Related:  likely or clearly due to causes other than the study drug. 
Related:  possibly, probably, or definitely related to the study drug. 
 
7. 
STUDY VARIABLES 
7.1 
Demographic and Baseline Characteristics 
Baseline characteristics will include standard demography (e.g., age, race, etc.), disease 
characteristics including medical history, and medication history for each subject. 
7.2 
Primary and Secondary Endpoints 
Primary Endpoint: 
 The primary study endpoint is the mean absolute change from baseline central 
foveal thickness at month 12 as measured by SDOCT (defined as the average 
thickness within the central 1mm subfield). 
 
Secondary Endpoint:  
Secondary endpoints would include  
 The mean change from baseline in best-corrected visual acuity (BCVA) score at 
months 6 and 12. 
 Change in macular OCT perfusion at month 6 and 12 by OCT angiography 
 The diabetic retinopathy severity change from baseline at month 6 and 12 as 
measured by the simplified ETDRS scale.    
 Presence of microaneurysm and capillary dropout on OCT angiography at month 
6 and month 12 by OCT angiography 
 The percentage of subjects that were anatomically ‘dry’ by SDOCT at months 6 
and 12 
 The percentage of participants who gained or lost 5, 10, and 15 letters or more of 
vision at months 6 and 12 
 The percentage of patients that are 20/40 or better at months 6 and 12 
 The percentage of patients that are 20/200 or worse at months 6 and 12 
 The incidence and severity of ocular and non-ocular adverse events (AEs) and 
serious AEs. 


 
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7.3 
Analysis Sets 
7.3.1 
Efficacy Analysis Sets 
The full analysis set (FAS) includes all subjects who received any study drug.  Efficacy 
endpoints will be analyzed using the FAS. 
7.3.2 
Safety Analysis Set 
The safety analysis set (SAF) includes all subjects who received any study drug; it is 
based on the treatment received (as treated).  Treatment compliance/administration and 
all clinical safety variables will be analyzed using the SAF. 
7.4 
Subject Disposition 
The following will be provided: 
 The total number of enrolled subjects  
 The total number of subjects who discontinued the study, and the reasons for 
discontinuation 
 A listing of subjects prematurely discontinued from treatment, along with reasons 
for discontinuation 
7.5 
Statistical Methods 
7.5.1 
Demography and Baseline Characteristics 
Demographic and baseline characteristics will be summarized descriptively by treatment 
group.  Continuous variables will be summarized with mean, median, standard deviation, 
minimum, and maximum.  Categorical variables will be summarized with frequency and 
percentage. 
7.5.2 
Efficacy Analyses 
7.5.2.1 
Primary Efficacy Analysis 
 The primary study endpoint is the mean absolute change from baseline central 
foveal thickness at month 12 as measured by SDOCT (defined as the average 
thickness within the central 1mm subfield). 
 
7.5.2.2 
Secondary Efficacy Analysis 
Secondary efficacy variables include the following: 
 The mean change from baseline in best-corrected visual acuity (BCVA) score at 
months 6 and 12. 
 Change in macular OCT perfusion at month 6 and 12 by OCT angiography 


 
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 The diabetic retinopathy severity change from baseline at month 6 and 12 as 
measured by the simplified ETDRS scale.    
 Presence of microaneurysm and capillary dropout on OCT angiography at month 
6 and month 12 by OCT angiography 
 The percentage of subjects that were anatomically ‘dry’ by SDOCT at months 6 
and 12 
 The percentage of participants who gained or lost 5, 10, and 15 letters or more of 
vision at months 6 and 12 
 The percentage of patients that are 20/40 or better at months 6 and 12 
 The percentage of patients that are 20/200 or worse at months 6 and 12 
 The incidence and severity of ocular and non-ocular adverse events (AEs) and 
serious AEs. 
 
7.5.3 
Safety Analysis 
7.5.3.1 
Adverse Events 
Definitions 
For safety variables, two observation periods are defined: 
 The treatment period is defined as the day from first dose of study drug to the last 
dose of study drug.  
 The post-treatment period is defined as the time after the last dose of study drug. 
Treatment-emergent AEs (TEAEs) are defined as those that are not present at baseline or 
represent the exacerbation of a pre-existing condition during the on-treatment period. 
Analysis 
 Incidence and severity of ocular and non-ocular adverse events (AEs) and serious 
AEs 
8. 
DATA MANAGEMENT AND ELECTRONIC SYSTEMS 
A data management plan specifying all relevant aspects of data processing for the study 
(including data validation, cleaning, correcting, releasing) will be maintained and stored 
at the Cleveland Clinic. 
A medical coding plan will specify the processes and the dictionary used for coding.  All 
data coding (e.g., AEs, applicable baseline findings, medication, medical history / 
surgical history/ophthalmic history) will be done using internationally recognized and 
accepted dictionaries.   
The CRF data for this study will be collected with a paper Data Capture tool. 


 
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8.1 
Electronic Systems 
Electronic systems used to process and/or collect data in this study will include the 
following: 
 Epic– EMR system 
 Statistical Analysis Software (SAS) – statistical review and analysis 
 REDCap database system – CRF collection 
9. 
STUDY MONITORING 
9.1 
Monitoring of Study Sites 
The study coordinator will review all documentation prior to enrollment of the first 
subject, and periodically during the study.  In accordance with International Conference 
on Harmonization (ICH) guidelines, the coordinator will compare the eCRF entries with 
the appropriate source documents.  Additional review may include, but is not limited to, 
subject ICFs, documentation of subject recruitment and follow-up, AEs, SAEs, and 
concomitant therapy; as well as records of study drug dispensing, compliance, and 
accountability.  A copy of the drug dispensing log must be provided to the designee upon 
request. 
9.2 
Source Document Requirements 
Investigators are required to prepare and maintain adequate and accurate subject records 
(source documents). 
The investigator must keep all source documents on file with the CRF.  Case report forms 
and source documents must be available at all times for inspection by authorized 
representatives of the designee and regulatory authorities. 
9.3 
Case Report Form Requirements 
A CRF for each subject enrolled in the study must be completed and signed by the study 
investigator or authorized designee. The CRF must be typed or filled out using indelible 
ink.  The writing must be legible. Errors should be crossed out but not obliterated, the 
correction inserted, and the change initialed and dated by the investigator or authorized 
designee. The investigator must ensure the accuracy, completeness, legibility, and 
timeliness of the data reported to the designee in the CRFs.  Case report forms must be 
available at all times for inspection by authorized representatives of the designee and 
regulatory authorities. 
10. 
AUDITS AND INSPECTIONS 
This study may be subject to a quality assurance audit or inspection by authorities.  
Should this occur, the investigator is responsible for: 
 Informing the designee of a planned inspection by the authorities as soon as 
notification is received, and authorizing the designee’s participation in the 
inspection 


 
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 Providing access to all necessary facilities, study data, and documents for the 
inspection or audit 
 Communicating any information arising from inspection by the regulatory 
authorities to the designee immediately 
 Taking all appropriate measures requested by the designee to resolve the 
problems found during the audit or inspection 
Documents subject to audit or inspection include but are not limited to all source 
documents, CRFs, medical records, correspondence, ICFs, IRB files, documentation of 
certification and quality control of supporting laboratories, and records relevant to the 
study maintained in any supporting pharmacy facilities.  Conditions of study material 
storage are also subject to inspection.  In addition, representatives of the designee may 
observe the conduct of any aspect of the clinical study or its supporting activities both 
within and outside of the investigator's institution. 
In all instances, the confidentiality of the data must be respected. 
11. 
ETHICAL AND REGULATORY CONSIDERATIONS 
11.1 
Good Clinical Practice Statement 
It is the responsibility of both the designee and the investigator(s) to ensure that this 
clinical study will be conducted in accordance with the ethical principles that have their 
origin in the Declaration of Helsinki, and that are consistent with the ICH guidelines for 
Good Clinical Practice (GCP) and applicable regulatory requirements. 
11.2 
Informed Consent 
The principles of informed consent are described in ICH Guidelines for GCP. 
Regeneron will have the right to review and comment on the informed consent form. 
It is the responsibility of the investigator or designee (if acceptable by local regulations) 
to obtain written informed consent from each subject prior to his/her participation in the 
study and after the aims, methods, objectives, and potential hazards of the study have 
been explained to the subject in language that he/she can understand.  The ICF should be 
signed and dated by the subject and by the investigator or authorized designee who 
reviewed the ICF with the subject.   
 Subjects who can write but cannot read will have the ICF read to them before 
signing and dating the ICF. 
 Subjects who can understand but who can neither write nor read will have the ICF 
read to them in presence of an impartial witness, who will sign and date the ICF 
to confirm that informed consent was given. 
The original ICF must be retained by the investigator as part of the subject's study record, 
and a copy of the signed ICF must be given to the subject. 
If new safety information results in significant changes in the risk/benefit assessment, the 
ICF must be reviewed and updated appropriately.  All study subjects must be informed of 


 
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the new information and provide their written consent if they wish to continue in the 
study.  The original signed revised ICF must be maintained in the subject’s study record 
and a copy must be given to the subject. 
 
11.3 
Subject Confidentiality and Data Protection 
The investigator must take all appropriate measures to ensure that the anonymity of each 
study subject will be maintained.  Subjects should be identified by their initials and a 
subject identification number, only, on CRFs or other documents submitted to the 
designee.  Documents that will not be submitted to the designee (e.g., signed ICF) must 
be kept in strict confidence. 
The subject's and investigators personal data, which may be included in the investigator’s 
study database, will be treated in compliance with all applicable laws and regulations.  
The investigator shall take all appropriate measures to safeguard and prevent access to 
this data by any unauthorized third party. 
11.4 
Institutional Review Board  
An appropriately constituted IRB, as described in ICH Guidelines for GCP, must review 
and approve:  
 The protocol, ICF, and any other materials to be provided to the subjects 
(e.g., advertising) before any subject may be enrolled in the study  
 Any amendment or modification to the study protocol or ICF before 
implementation, unless the change is necessary to eliminate an immediate hazard 
to the subjects, in which case the IRB should be informed as soon as possible  
 Ongoing studies on an annual basis or at intervals appropriate to the degree of risk  
In addition, the IRB should be informed of any event likely to affect the safety of subjects 
or the continued conduct of the clinical study. 
A copy of the IRB approval letter with a current list of the IRB members and their 
functions must be received by Regeneron prior to shipment of drug supplies to the 
investigator.  The approval letter should include the study number and title, the 
documents reviewed, and the date of the review. 
Records of the IRB review and approval of all study documents (including approval of 
ongoing studies) must be kept on file by the investigator. 
12. 
PROTOCOL AMENDMENTS 
The investigator may not implement a change in the design or operation of the protocol 
or ICF without an IRB approved amendment. 


 
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13. 
PREMATURE TERMINATION OF THE STUDY OR CLOSE-OUT OF A SITE 
13.1 
Premature Termination of the Study 
Cleveland Clinic or Regeneron has the right to terminate the study prematurely.  Reasons 
may include efficacy, safety, or futility, among others.   
14. 
STUDY DOCUMENTATION 
14.1 
Certification of Accuracy of Data 
A declaration assuring the accuracy and content of the data recorded on the CRFs must 
be signed by the investigator.  This certification form accompanies each set of CRFs.  
The signed form will be provided to the designee with the final set of CRFs for each 
subject. 
14.2 
Retention of Records 
The investigator must retain all essential study documents, including ICFs, source 
documents, investigator copies of CRFs, and drug accountability records for at least 
2 years following the completion or discontinuation of the study, or longer if a longer 
period is required by relevant regulatory authorities.  The investigator must consult with 
the designee before discarding or destroying any essential study documents following 
study completion or discontinuation. Records must be destroyed in a manner that ensures 
confidentiality. 
If the investigator's personal situation is such that archiving can no longer be ensured, the 
investigator must inform the designee and the relevant records will be transferred to a 
mutually agreed-upon destination. 
 
 


 
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15.   Appendix 1:  Injection Procedure 
 
Intravitreal aflibercept injection is formulated as a sterile liquid to a final concentration of 
40 mg/mL. The volume of injection will be 50 l (0.05 mL) for the 2 mg dose of IAI.  
 
 Preparation (please see below regarding the optional use of topical antibiotic agents 
pre and post dose): 
a. Apply topical anesthetic with or without subconjunctival anesthetic  
b. Apply povidone iodine to eyelid margins, eyelashes, and conjunctival surface.  
For patients who have a known sensitivity to povidone iodine, another equally 
effective agent may be used. 
c. Place 1 or 2 drops of povidone-iodine on the ocular surface at the intended 
injection site. 
d. A sterile speculum may be used. 
e. Mark the injection site location with an empty Tb syringe. 
f. Apply additional drop of povidone-iodine to site of injection. 
 
 Study Drug (VEGF Trap-Eye) Administration: 
a. Insert needle at marked injection point.  
b. Gently inject study drug.  
c. As the needle is withdrawn, a sterile cotton tip applicator may be rolled over 
the entry site to minimize the risk of drug reflux.  
 
 Post-Injection Procedures 
Confirm that the patient has at least counting fingers vision.  See guidelines below for 
additional post-injection management procedures.   
 
Guidelines for Pre and Post-injection Management 
 Use of Topical Antibiotic Agents 
No pre or post-injection antibiotics will be used.  
 


 
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 If vision is less than Counting Fingers: 
Visualize the optic nerve to verify reperfusion of the central retinal artery in the 
immediate post-injection period.  
 
Check the IOP while maintaining a clean field.  Monitor the IOP closely until it is 
below 30 mm Hg. If a Tono-pen™ is used to check pressure, a clean Tono-pen™ 
condom should be placed on the tip before taking each measurement. If Goldmann 
applanation tonometry is used, the applanator tip should be swabbed with alcohol and 
let to dry before using it to measure IOP.  IOP may be lowered by pharmaceutical or 
surgical intervention, if required.  Treatment should be initiated whenever IOP is 
increased to the extent that the central retinal artery remains closed or the patient 
remains less than count fingers for more than 1 to 2 minutes with an IOP > 35 mm 
Hg.   
 
 Discharge 
No special precautions are required before discharge of a patient who has had an 
uneventful recovery from intravitreal injection, but patients and/or caregivers should 
be educated to avoid rubbing the eye and to recognize the signs and symptoms of 
endophthalmitis, retinal detachment, or intraocular hemorrhage; these are eye pain or 
increased discomfort, increased redness of the eye (compared to immediately after 
injection), blurred or decreased vision, and increased ocular sensitivity to light.   
 


 
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16.   Appendix 2:  Critical References 
 
1. Ferrara N, Davis-Smyth T. The biology of vascular endothelial growth factor. 
Endocr Rev. 1997 Feb;18(1):4-25. 
 
2. Ferrara N, Houck KA, Jakeman LB, Winer J, Leung DW. The vascular 
endothelial growth factor family of polypeptides. J Cell Biochem. 1991 
Nov;47(3):211-8. 
 
3. Ferrara N. Vascular endothelial growth factor and the regulation of angiogenesis. 
Recent Prog Horm Res. 2000;55:15-35; discussion 35-6. 
 
4. Rakic JM, Lambert V, Devy L, Luttun A, Carmeliet P, Claes C, Nguyen L, 
Foidart JM, Noël A, Munaut C. Placental growth factor, a member of the VEGF 
family, contributes to the development of choroidal neovascularization. Invest 
Ophthalmol Vis Sci. 2003 Jul;44(7):3186-93. 
 
5. Thickett DR, Armstrong L, Millar AB. Vascular endothelial growth factor 
(VEGF) in inflammatory and malignant pleural effusions. Thorax. 1999 
Aug;54(8):707-10. 
 
6. Wessel MM, Nair N, Aaker GD, Ehrlich JR, D'Amico DJ, Kiss S. Peripheral 
retinal ischaemia, as evaluated by ultra-widefield fluorescein angiography, is 
associated with diabetic macular oedema. Br J Ophthalmol. 2012 May;96(5):694-
8 
 

SAP_001.pdf: 
 
 
Clinical Study - Statistical Methods 
Investigator Initiated Interventional Study of Subjects With Diabetic Macular 
Edema Treated With Intravitreal Aflibercept Injection Previously Treated With 
Other Anti-VEGF Agents. 
 
SWAP-TWO Study 
NCT: 02559180 
September 18, 2016 
 
 


Statistical Analysis  
 
Demography and Baseline Characteristics 
Demographic and baseline characteristics were summarized descriptively by treatment group.  
Continuous variables were summarized with mean, median, standard deviation, minimum, and 
maximum.  Categorical variables were summarized with frequency and percentage. 
 
Outcome Measures 
 
The primary outcome of the study was the mean absolute change from baseline CST at 
month 12 as measured by SD-OCT (defined as the average thickness within the central 1 mm 
subfield).  
Secondary outcome variables include the following: 
 The mean change from baseline in best-corrected visual acuity (BCVA) score at month 
6,12, and 24 
 Change in macular OCT perfusion at month 6,12, and 24 by OCT angiography 
 The diabetic retinopathy severity change from baseline at month 6,12, and 24 as 
measured by the simplified ETDRS scale.    
 Presence of microaneurysm and capillary dropout on OCT angiography at month 6,12, 
and 24 by OCT angiography 
 The percentage of patients that were anatomically ‘dry’ by SDOCT at month 6,12, and 24 
 The percentage of participants who gained or lost 5, 10, and 15 letters or more of vision 
at month 6,12, and 24 
 The percentage of patients that are 20/40 or better at month 6,12, and 24 
 The percentage of patients that are 20/200 or worse at month 6,12, and 24 
 The incidence and severity of ocular and non-ocular adverse events (AEs) and serious 
AEs. 
Safety Analyses 


Safety assessments of both ocular and systemic events were conducted at each study visit. 
The AEs were categorized according to severity (mild, moderate, or severe) and possible or 
known relationship to the study drug. 
Analysis 
 Incidence and severity of ocular and non-ocular adverse events (AEs) and serious AEs 
 
Statistical Methods 
The study variables were summarized using standard descriptive statistics and normality 
of measures using the Shapiro–Wilk test, and distributed comparisons with and between groups 
were performed using two-sided paired t-tests. Where appropriate, sensitivity analyses using 
nonparametric Wilcoxon signed rank tests were also performed. Analyses were performed using 
SAS software (V.9.2; Cary, North Carolina, USA). A significance level of 0.05 was assumed for 
all tests. Missing data was accounted for using a linear mixed effect model.