EA046420B1 - USE OF A VEGF ANTAGONIST FOR THE TREATMENT OF ANGIOGENIC EYE DISEASES - Google Patents

Description

This application claims priority to US Provisional Application Nos. 62/593,033, filed November 30, 2017; 62/644425, filed March 17, 2018; and 62/748782, filed October 22, 2018; each of which is incorporated herein by reference in its entirety.

Field of technology to which the invention relates

The invention relates to the field of therapeutic treatment of eye diseases. More particularly, the invention relates to the administration of VEGF antagonists for the treatment of ocular diseases caused by or associated with angiogenesis.

Prerequisites for creating the invention

Some ocular diseases are associated with pathological angiogenesis. For example, the development of age-related macular degeneration (AMD) is associated with a process called choroidal neovascularization (CNV). Sweating from the CNV causes macular edema and fluid accumulation under the macula, leading to vision loss. Diabetic macular edema (DME) is another ocular disease with an angiogenic component. DME is the most common cause of mild vision loss in patients with diabetes and is a common complication of diabetic retinopathy, a disease that affects the blood vessels of the retina. Clinically significant DME occurs when fluid leaks into the center of the macula, which is the light-sensitive part of the retina responsible for central vision. Fluid in the macula can cause severe vision loss or blindness. Another ocular disease associated with abnormal angiogenesis is central retinal vein occlusion (CRVO). CRVO is caused by obstruction of the central retinal vein, which causes blood and fluid to accumulate in the retina. The retina can also become ischemic, causing unacceptable growth of new blood vessels, which can cause further vision loss and more serious complications. The release of vascular endothelial growth factor (VEGF) promotes increased vascular permeability in the eye and unacceptable growth of new vessels. Thus, inhibition of the angiogenic-promoting properties of VEGF is an effective strategy for the treatment of angiogenic ocular diseases.

FDA-approved treatments for angiogenic ocular diseases such as AMD and CRVO include administration of an anti-VEGF antibody called ranibizumab (Lucentis®, Genentech, Inc.) monthly by intravitreal injection.

Methods for the treatment of ocular diseases using VEGF antagonists are indicated, for example, in US 7303746; US 7306799; US 7300563; US 7303748; and US 2007/0190058. However, there remains a need in the art for new dosing regimens for the treatment of angiogenic ocular diseases, particularly those that allow for less frequent dosing while maintaining a high level of efficacy.

The essence of the invention

The present invention provides methods for treating angiogenic ocular diseases (eg, diabetic retinopathy, eg, nonproliferative diabetic retinopathy). The methods of the invention involve sequentially administering multiple doses of a VEGF antagonist to a patient over a period of time. In particular, the methods of the invention involve sequentially administering to a patient one initial dose of a VEGF antagonist, followed by one or more secondary doses of a VEGF antagonist, followed by one or more tertiary doses of a VEGF antagonist. The inventors of the present invention have surprisingly discovered that beneficial therapeutic effects can be achieved in patients suffering from angiogenic ocular diseases by administering a VEGF antagonist to the patient at a frequency of once every 8 weeks or more, especially when preceded by about three doses administered to the patient at a frequency of about once in 2-4 weeks. Thus, in accordance with the methods of the present invention, each secondary dose of the VEGF antagonist is administered 2-4 weeks after the immediately preceding dose, and each tertiary dose is administered at least 8 weeks after the immediately preceding dose. An example of a dosage schedule of the present invention is shown in FIG. 1. One advantage of this dosing schedule is that for the majority of the course of treatment (ie, tertiary doses), it allows for less frequent dosing (eg, once every 8 weeks) compared to previously used dosing schedules for angiogenic ocular diseases. diseases that require administration once a month throughout the course of treatment. (See, for example, prescribing information for Lucentis® [ranibizumab], Genentech, Inc.).

The methods of the present invention can be used to treat any angiogenic ocular disease, including, for example, age-related macular degeneration, diabetic retinopathy, diabetic macular edema, central retinal vein occlusion, corneal neovascularization, etc.

The methods of the present invention include administering any VEGF antagonist to a patient (eg, by intravitreal injection). In one embodiment, the VEGF antagonist includes one or more chimeric molecules based on the VEGF receptor (also referred to herein as VEGF-Trap or VEGFT). An example of a VEGF antagonist that can be used in

- 1 046420 in the text of the present invention, is a multimeric VEGF-binding protein comprising two or more chimeric molecules based on the VEGF receptor, referred to herein as VEGFR1R2-FcACl(a) or aflibercept.

Various routes of administration are contemplated for use in the methods of the present invention, including, for example, topical administration or intraocular administration (eg, intravitreal administration).

Aflibercept (EYLEA™, Regeneron Pharmaceuticals, Inc) was approved by the FDA in November 2011 for the treatment of patients with neovascular (wet) age-related macular degeneration, with a recommended dose of 2 mg administered by intravitreal injection every 4 weeks for the first three months. followed by 2 mg by intravitreal injection once every 8 weeks.

The present invention provides a method for treating diabetic retinopathy of any severity, e.g., non-proliferative diabetic retinopathy (NPDR) (e.g., moderate to severe NPDR, e.g., characterized by a Diabetic Retinopathy Severity Rating Scale level of about 47-53, e.g., 47 or 53) in a patient (for example, a person, for example, 18 years of age or older, for example, having type 1 or type 2 diabetes) in need of such treatment, wherein said method includes administering (for example, by intravitreal injection) into the eye of the patient, (i) 3 monthly doses followed by one or more booster doses every 16 weeks, with the first booster dose given 8 weeks after the third monthly dose (week 16) and then continued every 16 weeks (eg, where dose administered at weeks 32, 48, 64, etc.) (see, for example, Fig. 2), or (ii) 3 or 4 or 5 monthly doses followed by one or more secondary doses every 8 weeks, with secondary doses starting 8 weeks after the final of 3 or 4 or 5 monthly doses and then continuing every 8 weeks;

about 2 mg of a VEGF antagonist, which is, for example, a chimeric molecule based on the VEGF receptor, for example, which includes (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component comprising amino acids 232-457 of SEQ ID NO: 2. For example, in one embodiment, the VEGF antagonist is Aflibercept. In one embodiment, the VEGF antagonist comprises VEGFR1R2-FcΔCl(a) encoded by the nucleotide sequence SEQ ID NO: 1. In one embodiment, the patient is characterized as not suffering from diabetic macular edema; having a baseline best-corrected visual acuity (BCVA) ETDRS letter score of 69 or greater; having a Snellen visual acuity of 20/40 or better; does not suffer from retinal neovascularization; does not suffer from anterior segment neovascularization (ASNV); does not suffer from vitreous hemorrhage; and/or does not suffer from tractional retinal detachment. In one embodiment of the invention, treatment of NPDR in a patient, as discussed herein, refers to achieving at least a 2-step improvement on the DRSS (Diabetic Retinopathy Severity Rating Scale) from baseline (before the first administration of the VEGF antagonist), for example, by a week 24 or 48 or 52 (compared to when the first VEGF antagonist was started).

The present invention provides a method for treating or preventing proliferative diabetic retinopathy (PDR) in a patient (eg, a human) in need of such treatment or prevention; or to prevent progression of nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy, anterior segment neovascularization (ASNV), diabetic macular edema (DME), or centrally affecting diabetic macular edema (CI-DME), where the patient is first treated for nonproliferative diabetic retinopathy (eg, when the patient has type 1 or 2 diabetes; has a hemoglobin Alc of about 8.5; has an ETDRA BCVA score of about 82; has a central retinal thickness of about 247 µm; has a diabetic retinopathy severity score of 47 or 53; and/or has age approximately 56 years), which method involves administering to the patient's eye (eg, by intravitreal injection) (i) 3 monthly doses followed by one or more secondary doses every 16 weeks, with the first secondary dose being administered over 8 weeks after the third monthly dose (week 16), or (ii) 3 or 4 or 5 monthly doses followed by one or more booster doses every 8 weeks;

about 2 mg of a VEGF antagonist, for example, which includes (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component comprising amino acids 232-457 of SEQ ID NO: 2 (eg, aflibercept). For example, in one embodiment of the invention, the patient is treated for at least about 24 weeks, 52 weeks, or 100 weeks, for example, the patient takes from about 3 to

- 2 046420 approximately 5 injections over a 24 week period. In one embodiment of the invention, the patient is treated, for example, for about 24 weeks or more, and one or more of the following positive results is achieved:

(i) an improvement of at least 2 grades from baseline in the Diabetic Retinopathy Severity Scale (DRSS) score;

(ii) improvement of at least 3 grades from baseline on the Diabetic Retinopathy Severity Score (DRSS);

(iii) improvement in best-corrected visual acuity of at least about 1.9 letters;

(iv) does not experience a decrease in best corrected visual acuity of more than 4 letters;

(v) diabetic macular edema does not develop;

(vi) central diabetic macular edema does not develop;

(vii) does not experience a vision-threatening complication;

(viii) proliferative diabetic retinopathy does not develop;

(ix) neovascularization of the anterior segment of the eye does not develop; and/or (x) there is a decrease in the thickness of the central part of the retina by about 19 μm. Thus, the present invention also provides methods for ensuring that a patient with nonproliferative diabetic retinopathy achieves one or more of the following benefits (i) an improvement of at least 2 grades from baseline on the Diabetic Retinopathy Severity Score (DRSS);

(ii) improvement of at least 3 grades from baseline on the Diabetic Retinopathy Severity Score (DRSS);

(iii) improvement in best-corrected visual acuity of at least about 1.9 letters;

(iv) does not experience a decrease in best corrected visual acuity of more than 4 letters;

(v) diabetic macular edema does not develop;

(vi) central diabetic macular edema does not develop;

(vii) does not experience a vision-threatening complication;

(viii) proliferative diabetic retinopathy does not develop;

(ix) neovascularization of the anterior segment of the eye does not develop;

and/or (x) there is a decrease in the thickness of the central part of the retina by about 19 μm; by administering a VEGF antagonist according to the dosing schedule described above.

For example, the present invention provides a method that causes a reduction or prevention of an increase in the level of the Diabetic Retinopathy Severity Score (DRSS) (see, for example, FIG. 18) (for example, by at least 2 or 3 levels) of non-proliferative diabetic retinopathy in a patient comprising administering, to the patient's eye (eg, by intravitreal injection), (i) 3 monthly doses followed by one or more booster doses every 16 weeks, with the first booster dose administered 8 weeks after the third monthly dose ( week 16), or (ii) 3 or 4 or 5 monthly doses followed by one or more booster doses every 8 weeks;

about 2 mg of a VEGF antagonist, for example, which includes (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component comprising amino acids 232-457 of SEQ ID NO: 2 (eg, aflibercept).

The present invention also provides a method for treating or preventing the occurrence or reoccurrence of a vision-threatening complication or blindness in the eye of a subject (e.g., a human) whose eye has nonproliferative diabetic retinopathy, comprising administering (e.g., by intravitreal injection) to the eye of the subject (e.g., by intravitreal injection), (i) 3 monthly doses followed by one or more booster doses every 16 weeks, with the first booster dose given 8 weeks after the third monthly dose (week 16), or (ii) 3 or 4 or 5 monthly doses followed by one or more booster doses every 8 weeks; about 2 mg of a VEGF antagonist, which is a chimeric molecule based on the VEGF receptor. Optionally, the subject's other eye is also administered a VEGF antagonist, even if it is not similarly affected, is affected with a lower level of DRSS, or is affected by another angiogenic ocular disease. For example, in one embodiment, the VEGF antagonist is a chimeric VEGF receptor molecule that (i) includes (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component, including

- 3 046420 amino acids 232-457 SEQ ID NO: 2; (ii) includes (1) immunoglobulin-like (Ig) domain 2 of the first VEGF receptor and (2) Ig domain 3 of the second VEGF receptor and (3) a multimerizing component; (iii) is aflibercept; or (iv) is conbercept.

One aspect of the invention is a package including:

container with medicine; and instructions for the use of the drug for the treatment or prevention of diabetic retinopathy in a patient requiring such treatment, wherein the instructions specify the use of the drug by administering the drug to the patient's eye (i) 3 monthly doses followed by one or more booster doses every 16 weeks, with the first booster dose administered 8 weeks after the third monthly dose (week 16), or (ii) 3 or 5 monthly doses followed by one or more booster doses every 8 weeks; about 2 mg of a VEGF antagonist, which is a chimeric molecule based on the VEGF receptor.

Another aspect of the invention is a package wherein the VEGF antagonist (i) comprises (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component comprising amino acids 232-457 SEQ ID NO: 2;

(ii) includes (1) immunoglobulin-like (Ig) domain 2 of the first VEGF receptor and (2) Ig domain 3 of the second VEGF receptor, and (3) a multimerizing component;

(iii) is aflibercept; or (iv) is Conbercept.

Another aspect of the invention is packaging wherein the instructions indicate that the drug is administered by intravitreal injection.

Another aspect of the invention is a package wherein the instructions indicate administration of 3 or 5 monthly doses of the drug followed by one or more doses every 8 weeks.

Another aspect of the invention is a package wherein the instructions indicate administration of 3 monthly doses of the drug followed by one or more booster doses every 16 weeks, with the first booster dose administered 8 weeks after the third monthly dose (week 16).

Another aspect of the invention is the packaging, where the instructions indicate that one dose of the drug is administered once every 8 weeks.

One aspect of the invention is a package including:

container with medicine; and instructions for the use of the drug for the treatment or prevention of proliferative diabetic retinopathy in a patient requiring such treatment, wherein the instructions specify the use of the drug by administering the drug to the patient's eye (i) 3 monthly doses followed by one or more secondary doses doses every 16 weeks, with the first booster dose administered 8 weeks after the third monthly dose (week 16), or (ii) 3 or 5 monthly doses followed by one or more booster doses every 8 weeks; about 2 mg of a VEGF antagonist, which is a chimeric molecule based on the VEGF receptor.

Another aspect of the invention is a package wherein the VEGF antagonist (i) comprises (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component comprising amino acids 232-457 SEQ ID NO: 2;

(ii) includes (1) immunoglobulin-like (Ig) domain 2 of the first VEGF receptor and (2) Ig domain 3 of the second VEGF receptor, and (3) a multimerizing component;

(iii) is aflibercept; or (iv) is Conbercept.

Other embodiments of the present invention will become apparent upon consideration of the following detailed description.

Brief description of drawings

Fig. 1 shows an exemplary dosage schedule of the present invention. In this regimen, a single initial dose of a VEGF antagonist (VEGFT) is administered at the start of the therapy regimen (i.e., week 0), two secondary doses are administered at weeks 4 and 8, respectively, and thereafter at least six tertiary doses are administered once at 8 weeks, i.e. in weeks 16, 24, 32, 40, 48, 56, etc.). This VEGF antagonist administration regimen forms part of the present invention.

Fig. 2 shows a second exemplary dosage schedule of the present invention. IN

- 4 046420 In this regimen, three monthly doses (Q4wk dose) of the VEGF antagonist are administered at the beginning of the treatment regimen (i.e., weeks 0, 4 and 8), then a single dose is administered 8 weeks after the last Q4wk dose (Q8wk dose) (t i.e. at week 16), followed by three or more additional doses given 16 weeks after the Q8wk dose and once every 16 weeks thereafter (Q16wk dose) (i.e. at weeks 32, 48, 64, etc.) d.). This VEGF antagonist administration regimen forms part of the present invention.

Fig. 3 summarizes the design of the phase 3 double-blind randomized controlled trial of PANORAMA. Patients with moderate to severe NPDR received (i) a sham injection (sham), (ii) 3 monthly doses followed by one or more secondary doses every 16 weeks, with the first secondary dose administered 8 weeks after the third monthly dose (week 16) (Group 1), or (iii) 5 monthly doses followed by one or more booster doses every 8 weeks (Group 2).

Fig. 4 summarizes the dose schedule in the PANORAMA study for the sham, Group 1 and Group 2 groups. X = Active substance injection; O=simulated injections.

Fig. 5 describes the distribution and basic demographics of the study population in PANORAMA in each dose group including: sham, Group 1, Group 2, and the combination of Group 1 and Group 2 (All IAI). [L[=Intravitreal injection of aflibercept.

Fig. 6 describes the main disease characteristics of the study population in PANORAMA in each dose group, including: sham, Group 1, Group 2, and the combination of Group 1 and Group 2 (All IAI).

Fig. 7 represents the number of injections received by subjects in PANORAMA in each dose group (sham, Group 1, Group 2, and combination of Group 1 and Group 2: All IAF).

Fig. Figure 8 shows the proportion (%) of patients in each PANORAMA dose group (sham, Group 1, Group 2, and All IAI (combined Group 1 and 2) achieving >2 grade improvement from baseline on the Diabetic Retinopathy Severity Score (DRSS).

Fig. Figure 9 shows the proportion (%) of patients in each PANORAMA dose group (sham, Group 1, Group 2, and All IAI (combined Group 1 and 2) achieving >3 grade improvement from baseline on the Diabetic Retinopathy Severity Score (DRSS).

Fig. 10 shows the proportion (%) of patients in each PANORAMA dose group (sham, Group 1, Group 2 and All IAI (combined Group 1 and 2) having vision-threatening complications (VTC; proliferative diabetic retinopathy (PDR)/anterior segment neovascularization ( ASNV))) and/or central diabetic macular edema (CI-DME) up to week 24.

Fig. 11 summarizes the mean change in best-corrected visual acuity (BCVA) score (Early Treatment Diabetic Retinopathy Study (ETDRS), letters) for each PANORAMA dose group (sham, Group 1, Group 2, and combination of Group 1 and Group 2: All IAI) up to 24 weeks.

Fig. 12 summarizes the mean change in central retinal thickness (CRT, µm) for each PANORAMA dose group (sham, Group 1, Group 2, and All IAI (combined Group 1 and 2) through week 24.

Fig. 13 summarizes study treatment-emergent ocular events (TEAEs) in the Sham and All IAI (combined Groups 1 and 2) PANORAMA groups up to week 24. FAS/SAF=full analysis set/analysis set for safety.

Fig. 14 summarizes treatment-emergent serious adverse ocular events (TEAEs) in the Sham and All IAI (combined Groups 1 and 2) PANORAMA groups through week 24. FAS/SAF=full analysis set/data set for safety analysis.

Fig. 15 summarizes the study of intraocular inflammation in the test eye in the Sham and All IAI groups (combined Group 1 and 2) in PANORAMA up to week 24.

Fig. 16 summarizes the results of the combined analysis of antiplatelet therapy (ART) in the Sham and All IAI groups (combined Groups 1 and 2) in PANORAMA up to week 24.

Fig. 17 summarizes subject mortality data in PANORAMA up to week 24.

Fig. 18 provides a detailed table of the International Diabetic Retinopathy Severity Score (DRSS).

Fig. 19 presents summary results from the PANORAMA study at 52 weeks—the percentage of subjects in each treatment group experiencing at least a 2-step improvement in the DRSS and the percentage of subjects who developed vision-threatening complications (VTC) and/or central diabetic macular edema (CI-DME).

Fig. 20 summarizes the number of injections of active substance received

- 5,046,420 subjects in the sham, 2q16 (of 6) and 2q8 (of 9) groups through week 52.

Fig. 21 summarizes the proportion of patients in the sham, 2q16 and 2q8 groups with at least a 2-step improvement from baseline on the DRSS at week 52. LOCF=using last documented value at week 52.

Fig. 22 summarizes the percentage of subjects in each treatment group (sham, 2q16, and 2q8) with at least a 2-step improvement from baseline on the DRSS at weeks 8, 12, 24, 40, and 52.

Fig. 23 summarizes the percentage of patients in each treatment group (sham, 2q16 and 2q8) who developed vision-threatening complications (VTC) and/or central diabetic macular edema (CI-DME) by week 52.

Fig. 24 presents a Kaplan-Meier plot of the probability of developing a vision-threatening complication over time for subjects in each treatment group (sham, 2q16 and 2q8). VTE=VEGF Trap eye. VGS=vision-threatening complication.

Fig. 25 summarizes the time to development of CI-DME for subjects in each treatment group (sham, 2q16, and 2q8).

Fig. 26 summarizes the mean change in best-corrected visual acuity (ETDRS letters) for subjects in each treatment group (sham, 2q16 and 2q8) over 52 weeks.

Fig. 27 summarizes central retinal thickness (µm) data for subjects in each treatment group (sham, 2q16 and 2q8) over 52 weeks.

Fig. 28 summarizes data on treatment-emergent ocular adverse events (TEAEs) experienced by subjects in the treated eye in each treatment group (sham, 2q16 and 2q8) at 52 weeks.

Fig. 29 summarizes data on treatment-emergent adverse ocular events (TEAEs) experienced by subjects in the treated eye in each treatment group (sham, 2q16 and 2q8) at 52 weeks.

Fig. 30 summarizes data on the incidence of ocular inflammation experienced by subjects in the treated eye in each treatment group (sham, 2q16 and 2q8) at 52 weeks.

Fig. 31 summarizes data, based on the antiplatelet therapy (APT) conjoint analysis, on events experienced by subjects in the treated eye in each treatment group (sham, 2q16 and 2q8) at 52 weeks.

Fig. 32 summarizes the proportion of patients with an improvement of three steps or more in each treatment group (sham, 2q16, and 2q8) at 52 weeks.

Detailed Description of the Invention

The present invention includes an extremely effective method for preventing the progression of non-proliferative diabetic retinopathy without diabetic macular edema in a patient to more severe and vision-threatening disorders such as proliferative diabetic retinopathy, diabetic macular edema and/or anterior segment neovascularization. Indeed, patients with moderate to severe nonproliferative diabetic retinopathy treated with aflibercept according to the dosing schedule of the present invention reversed disease progression, achieving an improvement of two steps or more in DRSS levels. Eyes of subjects receiving treatment in accordance with the dosing schedule of the present invention also experienced a reduction in the occurrence of vision-threatening complications compared to eyes not treated. Such prevention is achieved by administering a VEGF antagonist, such as aflibercept, to the patient's eye using the dosing regimens described herein.

Before the present invention is described, it should be clarified that the present invention is not limited to the specific methods and experimental conditions described, since such methods and conditions may vary. It should also be understood that the terminology used is intended to describe specific embodiments only and is not intended to be limiting, as the scope of the present invention is to be limited only by the appended claims.

Unless otherwise specified, all technical and scientific terms used in this application have the same meaning as commonly understood by those skilled in the art to which this invention relates. As used herein, the term about, when used in connection with a particular reported numerical value, means that the value may differ from the reported value by no more than 1%. For example, as used herein, the expression about 100 includes 99 and 101 and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.).

Although any methods and materials similar or equivalent to those described herein may be used in the practice or testing of the present invention, preferred methods and materials are described below.

- 6 046420

The subject or patient may be a mammal, such as a human (eg, a person aged 50, 55, 60, 65 or 70 years or older), rabbit, mouse, non-human primate, monkey or rat. In one embodiment of the invention, the subject or patient has previously received another DR treatment, such as PDR (eg, panretinal photocoagulation (laser) therapy). In one embodiment of the invention, previous treatment was not effective enough to treat DR. In one embodiment of the invention, the patient or subject does not suffer from DME and/or CI-DME. In one embodiment of the invention, the subject or patient has diabetes (eg, type 1 or type 2).

Dose schedules

The present invention provides methods for treating angiogenic ocular diseases such as diabetic retinopathy of any severity, such as proliferative or non-proliferative diabetic retinopathy (NPDR), such as moderately severe NPDR or severe NPDR. The methods of the invention involve sequentially administering multiple doses of a VEGF antagonist (eg, aflibercept) to the eye of a subject or patient (eg, a human, such as a person 18 years of age or older). In one embodiment of the invention, the patient has diabetes (eg, type 1 or type 2). As used herein, sequential administration means that each dose of the VEGF antagonist is administered to the patient's eye at different times, for example on different days at a predetermined interval (eg, several hours, days, weeks or months). The present invention includes methods that include sequentially administering to a patient's eye one initial dose of a VEGF antagonist, followed by one or more secondary doses of a VEGF antagonist, followed by one or more tertiary doses of a VEGF antagonist.

The present invention provides methods for treating or preventing angiogenic ocular disease (eg, NPDR); preventing the progression of DR (eg, NPDR) to a more severe form or complication, for example, to PDR, ASNV, DME and/or CI-DME; decrease in NPDR score on the DRSS scale; treating or preventing the occurrence or recurrence of VTC or blindness in a subject, comprising administering, to the eye of the subject, three or four or five initial monthly doses of a VEGF antagonist (eg, aflibercept) followed by one or more booster doses every eight weeks . In one embodiment of the invention, an antagonist is administered to the eye suffering from the disorder and, optionally, the other eye is also treated using the same or a different dosing schedule, even if the disorder has not manifested in that eye, or if a less severe form of the disorder has manifested, or if the other eye is affected by another angiogenic ocular disease. The present invention thus provides methods comprising administering a 0.5 or 2 mg dose of a VEGF antagonist (e.g., by intravitreal injection) to the eye of a subject (e.g., a human) in 3 or 4 or 5 doses once a month, followed by doses every 8 weeks, counting from the last of the initial 3 or 4 or 5 monthly doses. In one embodiment of the invention, an antagonist is administered to the eye suffering from the disorder and, optionally, the other eye is also treated using the same or a different dosing schedule, even if the disorder has not manifested in that eye, or if a less severe form of the disorder has manifested, or if the other eye is affected by another angiogenic ocular disease. In one illustrative embodiment of the present invention, one initial dose of a VEGF antagonist (e.g., 2 mg) is administered to the patient's eye (e.g., by intravitreal injection) on the first day of the therapy regimen (i.e., week 0), followed by two booster doses, each administered four weeks after the immediately preceding dose (i.e., week 4 and week 8), followed by at least 5 tertiary doses, each administered eight weeks after the immediately preceding dose (i.e., week 16, 24, 32, 40 and 48). Tertiary doses may be continued (at intervals of 8 weeks or more) indefinitely during the course of treatment. This exemplary administration scheme is graphically represented in FIG. 1.

The present invention also includes methods for treating or preventing angiogenic ocular disease (eg, NPDR); preventing the progression of DR (eg, NPDR) to a more severe form or complication, for example, to PDR, ASNV, DME and/or CI-DME; decrease in NPDR score on the DRSS scale; treating or preventing the occurrence or reoccurrence of VTC or blindness in a subject, the methods comprising administering (eg, by intravitreal injection) to the eye of the subject:

(A) three initial, monthly doses (eg, once every 4 weeks or Q4wk) of a VEGF antagonist (eg, 2 mg); followed by (B) administration to the subject's eye of a single dose (eg, 2 mg) of a VEGF antagonist 8 weeks after the immediately preceding dose (Q8wk); followed by (C) administration to the subject's eye of one or more additional (maintenance) doses (eg, 2 mg) of a VEGF antagonist (eg, aflibercept) 16 weeks after the immediately preceding dose and once every 16 weeks (Q16wk) thereafter (on weeks 32, 48 and 64, etc., counting from the first of the initial monthly doses). See, for example, FIG. 2. The method of the present invention comprises administering a VEGF antagonist in the form of (i) 3 monthly doses followed by one or

- 7 046420 with multiple secondary doses every 16 weeks, with the first secondary dose administered 8 weeks after the third monthly dose (week 16). In one embodiment of the invention, said antagonist is administered to the eye suffering from the disorder and, optionally, the other eye is also treated using the same or a different dosing schedule, even if the disorder has not manifested itself in that eye, or if a less severe form of the disorder has manifested itself, or if the other eye is affected by another angiogenic eye disease.

In one illustrative embodiment of the present invention, after the initial primary dose, each secondary dose is administered 2-4 (e.g., 2, 2½, 3, 3½, or 4) weeks after the immediately preceding dose, and each tertiary dose is administered at least 8 (e.g., 8, 8½ 9, 9½ 10, 10½ 11, 11½ 12, 12½ 13, 13½ 14, 14½ or more) weeks after the immediately preceding dose. Alternatively, after secondary doses, the VEGF antagonist is administered as needed/pro re nata (PRN) based on the results of a visual and/or anatomical assessment by the treating physician or other qualified health care provider.

The present invention also includes methods for treating or preventing angiogenic ocular disease (eg, NPDR); preventing the progression of DR (eg, NPDR) to a more severe form or complication, for example, to PDR, ASNV, DME and/or CI-DME; decrease in NPDR score on the DRSS scale; treating or preventing the occurrence or reoccurrence of VTC or blindness in a subject, the methods comprising administering (eg, by intravitreal injection) to the eye of the subject:

(A) three initial monthly doses (eg, once every 4 weeks or Q4wk) of a VEGF antagonist (eg, aflibercept or conbercept, eg, 0.5 mg or 2.0 mg); followed by (B) administration to the subject's eye of one or more doses of a VEGF antagonist 3 months after the immediately preceding dose (or every 12 weeks or quarterly); or by administering a VEGF antagonist to the subject's eye as needed/pro re nata (PRN) based on a visual and/or anatomical assessment by a physician or other qualified health care professional.

The terms initial dose, secondary doses and tertiary doses refer to the time sequence of administration of the VEGF antagonist. Thus, the starting dose is the dose that is administered at the beginning of the therapy regimen (also referred to as the starting dose); secondary doses are doses that are administered after the initial dose; and tertiary doses are doses that are administered after secondary doses. The initial, secondary and tertiary doses may all contain the same amount of VEGF antagonist, but will generally differ from each other in the frequency of administration. In some embodiments, however, the amount of VEGF antagonist contained in the initial, secondary and/or tertiary doses will vary (eg, adjusted up or down as needed) during the course of treatment.

The phrase immediately preceding dose as used herein means, in a sequence of multiple administrations, the dose of VEGF antagonist that is administered to the patient's eye before the administration of the exact next dose in the sequence, without any intervening doses.

In one embodiment of the invention, administration of the VEGF antagonist according to the described administration schedule is carried out over 24, 48, 52, 96 or 100 weeks (or more).

In one embodiment, patients (eg, those suffering from NPDR) treated with such an administration regimen demonstrate at least a 2-grade improvement in the eye on the DRSS (Diabetic Retinopathy Severity Rating Scale) from baseline (pre-treatment) by week 24 or 48 or 52. In one embodiment of the invention, the eye experiences a 3-step improvement.

The methods of the invention may include administering any number of secondary and/or tertiary doses of a VEGF antagonist to the patient's eye. For example, in some embodiments, only one secondary dose is administered to the patient's eye. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8, or more) secondary doses are administered to the patient's eye. Likewise, in some embodiments, only one tertiary dose is administered to the patient's eye. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) tertiary doses are administered to the patient's eye.

In embodiments involving multiple secondary doses, each secondary dose may be administered at the same frequency as the other secondary doses. For example, each secondary dose may be administered to the patient's eye 4 weeks after the immediately preceding dose. Likewise, in embodiments involving multiple tertiary doses, each tertiary dose can be administered at the same frequency as the other tertiary doses. For example, each tertiary dose may be administered to the patient's eye 8 weeks after the immediately preceding dose. Alternatively, the frequency with which secondary and/or tertiary doses are administered to the patient's eye may vary throughout the therapy regimen. For example, the present invention includes methods that include administering to a patient's eye one initial dose of a VEGF antagonist, followed by one or more secondary doses of a VEGF antagonist, followed by at least 5 tertiary doses.

- 8 046420 doses of a VEGF antagonist, where the first four tertiary doses are administered 8 weeks after the immediately preceding dose, and where each subsequent tertiary dose is administered after 8-12 (for example, 8, 81/2, 9, 91/2, 10, 101 /2, 11, 111/2, 12) weeks after the immediately preceding dose. The frequency of administration may also be adjusted during the course of treatment by the attending physician depending on the needs of the individual patient after clinical examination.

In one embodiment, a VEGF antagonist is administered to a subject according to a dosing schedule of the present invention in combination with another therapeutic agent (eg, a vitamin or dietary supplement) or therapeutic procedure (eg, laser therapy or a surgical procedure). For example, in one embodiment of the invention, the subject receives laser therapy, such as panretinal photocoagulation (laser) therapy, in combination with a VEGF antagonist. In one embodiment of the invention, the subject had previously received laser therapy, for example, to treat DR (eg, PDR), but was switched to a VEGF antagonist regimen in accordance with the present invention.

The term in combination with indicates that the VEGF antagonist components together with another therapeutic agent may be formulated in one composition, for example for simultaneous delivery, or separately formulated in two or more compositions (eg, a kit). Each component may be administered to a subject at a time different from the time of administration of the other components; for example, each administration may be administered non-simultaneously (eg, separately or sequentially) at intervals over a period of time. In addition, the individual components may be administered to a subject by the same or different routes of administration.

VEGF antagonists

The methods of the present invention include administering a VEGF antagonist to a patient's eye according to the specific administration regimens described herein. As used herein, the expression VEGF antagonist means any molecule that blocks, reduces or interferes with the normal biological activity of VEGF.

VEGF antagonists include molecules that interfere with the interaction between VEGF and the natural VEGF receptor, for example, molecules that bind to VEGF or the VEGF receptor and prevent or otherwise interfere with the interaction between VEGF and the VEGF receptor. Specific examples of VEGF antagonists include anti-VEGF antibodies and antigen binding fragments thereof (eg, Fab or F(ab)2), anti-VEGF receptor antibodies and antigen binding fragments thereof, single chain anti-VEGF and anti-VEGF receptor antibodies, bispecific anti-VEGF and anti-VEGF receptor antibodies VEGF and antigen-binding fragments thereof, anti-VEGF and anti-VEGF receptor DARPins (engineered ankyrin repeat proteins) and VEGF receptor chimeric molecules (also referred to herein as VEGF-Traps).

VEGF receptor-based chimeric molecules include chimeric polypeptides that include two or more VEGF receptor immunoglobulin-like domains, such as VEGFR1 (also referred to as Flt1) and/or VEGFR2 (also referred to as Flk1 or KDR), and may also contain multimerizing domain (e.g., an Fc domain that promotes multimerization [e.g., dimerization] of two or more chimeric polypeptides). SEQ ID NO: 1. VEGFR1R2-FcΔCl(a) includes three components: (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 of SEQ ID NO: 2; and (3) a multimerization component ('ΤοΔΟ(α)) comprising amino acids 232-457 of SEQ ID NO: 2 (the C-terminal amino acid of SEQ ID NO: 2 [i.e., K458], which may or may not be included a VEGF antagonist used in the methods of the invention; see, for example, US Patent No. 7396664). Amino acids 1-26 SEQ ID NO: 2 represent the signal sequence.

The VEGF antagonist used in the Examples described below is a molecule comprising a VEGFR1R2-FcΔCl(a) molecule (eg, a homodimer thereof) and is referred to herein as VEGFT. Additional chimeric molecules based on the VEGF receptor that can be used in the context of the present invention are disclosed in US 7396664, 7303746 and WO 00/75319.

In one embodiment of the invention, the VEGF antagonist is a chimeric molecule based on the VEGF receptor, which is a polypeptide (or homodimer thereof) that includes:

(1) immunoglobulin-like (Ig) domain 2 of the first VEGF receptor (eg, VEGFR1);

(2) Ig domain 3 of the second VEGF receptor (eg, VEGFR2); and (3) a multimerizing component (eg, Fc or a variant thereof).

In one embodiment of the invention, the VEGF antagonist is a chimeric molecule based on the VEGF receptor, which is a polypeptide (or homodimer thereof) that includes:

(1) immunoglobulin-like (Ig) domain 2 of the first VEGF receptor (eg, VEGFR1);

- 9 046420 (2) Ig domain 3 of the second VEGF receptor (for example, VEGFR2);

(3) immunoglobulin-like (Ig) domain 4 of the second VEGF receptor (eg, VEGFR2); and (4) a multimerizing component (eg, Fc or a variant thereof).

Examples of VEGF antagonists that can be used in the context of the present invention include, for example, VEGF mini-Trap (see for example US7087411), aflibercept, anti-VEGF DARPin such as Abicipar Pegol DARPin), single chain (for example VL-VH) an anti-VEGF antibody such as brolucizumab (RTH258), a monospecific, multispecific or bispecific anti-VEGF antibody or an antigen-binding fragment thereof, for example, that also binds to ANG2, such as RG7716, ranibizumab (LUCENTIS) or bevacizumab (AVASTIN), and conbercept.

Angiogenic eye diseases

The methods of the present invention can be used to treat or prevent any angiogenic ocular disease by administering a therapeutically effective amount of a VEGF antagonist (eg, 2 mg of aflibercept) to the eye of a subject according to the dosing schedule that is described herein. The expression angiogenic ocular disease as used herein means any eye disease that is caused by or associated with the growth or proliferation of blood vessels or the sweating of blood vessels. Non-limiting examples of angiogenic ocular diseases that can be treated using the methods of the present invention include age-related macular degeneration (eg, wet AMD, exudative AMD, etc.), retinal vein occlusion (RVO), central retinal vein occlusion (CRVO) ; eg, post-CRVO macular edema), branch retinal vein occlusion (BRVO), diabetic macular edema (DME), choroidal neovascularization (CNV; eg, myopic CNV), iris neovascularization, neovascular glaucoma, postoperative glaucoma fibrosis, proliferative vitreoretinopathy ( PVR), optic disc neovascularization, corneal neovascularization, retinal neovascularization, vitreal neovascularization, pannus, pterygium, vascular retinopathy and diabetic retinopathy such as non-proliferative diabetic retinopathy and proliferative diabetic retinopathy.

Diabetic retinopathy is a progressive condition that can occur in people with diabetes. It typically causes progressive damage to the retina, the light-sensitive layer at the back of the eye. Diabetic retinopathy is a serious sight-threatening complication of diabetes. Over time, diabetes damages the blood vessels in the retina, and diabetic retinopathy occurs when blood and other fluids leak through these tiny blood vessels. The condition usually affects both eyes. The longer a person has diabetes, the greater the likelihood of developing diabetic retinopathy. If left untreated, diabetic retinopathy can cause blindness. Symptoms of diabetic retinopathy may include:

spots or floaters before the eyes, blurred vision, a dark or empty spot in the center of vision, difficulty seeing well at night.

Thus, to preserve vision, it is important to stop or prevent the progression of diabetic retinopathy to more sight-threatening advanced stages, such as proliferative diabetic retinopathy, diabetic macular edema, and/or anterior segment neovascularization (ASNV). Klein et al., Changes in Retinal Vessel Diameter and Incidence and Progression of Diabetic Retinopathy, Arch. Opthamol. 130(6): 749-755 (2012).

Neovascularization of the anterior segment of the eye represents neovascularization of the iris and/or characteristic neovascularization of the iridocorneal angle.

As diabetic retinopathy progresses, it reaches more advanced stages, including the following:

1. Mild form of non-proliferative retinopathy. This stage is characterized by small areas of balloon-like swelling in the tiny blood vessels of the retina, called microaneurysms. These microaneurysms can leak fluid into the retina; then

2. Moderate non-proliferative retinopathy. As the disease progresses, the blood vessels that supply the retina may become swollen and distorted. They may also lose their ability to transport blood. Both conditions cause characteristic changes in the appearance of the retina and may contribute to diabetic macular edema; then

3. Severe non-proliferative retinopathy. At this stage, many other blood vessels become blocked, depriving the retinal area of blood supply. These areas secrete growth factors that transmit signals to the retina that cause new blood vessels to grow; and then

4. Proliferative diabetic retinopathy (PDR). See below. Nonproliferative diabetic retinopathy (NPDR) is an early-onset retinopathy in patients with diabetes that is not characterized by neovascularization and can also be staged according to the Diabetic Retinopathy Severity Score (DRSS). The stages of NPDR include, for example, early, moderate, moderately severe and severe. In an embodiment of the invention, NPDR from the mind

- 10 046420 Renno severe to severe corresponds to a severity level from 47 to 53 (for example, 47 or 53). In an embodiment of the invention, a patient with moderate to severe NPDR (e.g., a person, e.g., 18 years of age or older with type 1 or type 2 diabetes) is characterized by one or more of the following:

without macular edema (for example, threatening the center of the macula);

can safely delay panretinal photocoagulation for at least 6 months;

has a baseline ETDRS letter chart best-corrected visual acuity (BCVA) score of 69 or better (eg, Snellen visual acuity of 20/40 or better);

without retinal neovascularization;

without anterior segment neovascularization (ASNV);

without vitreous hemorrhage; and/or without traction retinal detachment.

Proliferative diabetic retinopathy (PDR) is a more severe form of diabetic retinopathy. At this stage, new, fragile blood vessels may begin to grow in the retina and in the vitreous humor, the gel-like fluid that fills the back of the eye. The new blood vessel can allow blood to leak into the vitreous, blurring your vision.

Thus, the present invention includes methods for treating or preventing diabetic retinopathy in the eye of a subject, whether the eye of the subject is affected by moderately severe NPDR (non-proliferative diabetic retinopathy) or severe NPDR (for example, moderate to severe NPDR) or PDR (proliferative diabetic retinopathy), for example, where the subject's DRSS diabetic retinopathy score is 47 or 53, by administering a VEGF antagonist (eg, 2 mg aflibercept) to the eye of the subject according to the dosing schedule described herein. In one embodiment of the invention, the subject does not suffer from diabetic macular edema (DME) and/or centrally affecting diabetic macular edema (CI-DME). For a patient with non-proliferative diabetic retinopathy, the administration regimens described herein can be used to prevent progression to the more severe form of NPDR or to proliferative diabetic retinopathy, ASNV, DME and/or CIDME. Indeed, the dosing regimens of the present invention can be used to reverse a tendency toward an increase (or prevent an increase) in a DRSS score in a patient suffering from NPDR (e.g., who does not suffer from DME and/or CI-DME), for example, by 2 levels or more, for example 3 levels.

The International Clinical Diabetic Retinopathy Severity Score (DRSS), including its levels, is detailed in the table in FIG. 18.

Subjects suffering from NPDR are at risk for developing various vision-threatening complications or events (VTCs) and blindness (eg, blindness secondary to such VTCs). Vision-threatening complications are defined as the combined outcome of PDR (including patients with vitreous hemorrhage or tractional retinal detachment, which are thought to be associated with PDR) and ARNV. ASNV is defined as iris neovascularization (at least 2 cumulative full hours) and/or characteristic iridocorneal angle neovascularization. The proposed administration regimens reduce the incidence of such VTC and/or blindness in subjects suffering from NPDR. Thus, the present invention provides methods for preventing the occurrence or reoccurrence (after one or more initial occurrences) of VTC and/or blindness in a subject who, for example, suffers from NPDR or PDR, by administering, to the eye of the subject, a VEGF antagonist (aflibercept, for example 2.0 mg) in accordance with the dosing schedule described in this application. Such methods may include not only the step of treating one eye suffering from VTC, but also treating the other eye, even if the other eye did not have VTC and/or blindness, to prevent VTC and/or blindness.

Pharmaceutical compositions

The present invention includes methods in which a VEGF antagonist that is administered to the eye of a patient is contained in a pharmaceutical composition. The pharmaceutical composition may contain a VEGF antagonist together with at least one inactive ingredient, such as, for example, a pharmaceutically acceptable carrier. Other substances may be included in the pharmaceutical composition to provide improved transport, delivery, tolerability, and the like. The term pharmaceutically acceptable means approved by a regulatory agency of the federal or state government or listed in the United States Pharmacopoeia or other generally accepted pharmacopoeia for use in animals and, in particular, in humans. The term carrier refers to the diluent, adjuvant, excipient or excipient with which the antibody is administered. Many suitable compositions can be found in a reference book known to all pharmaceutical chemists: Remington's Pharmaceutical Sciences (15th ed., Mack Publishing Company, Easton, PA, 1975), especially Chapter 87 of Blaug, Seymour. These compositions include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, lipid-containing (cationic or anionic) vesicles (such as LIPOFECTIN™), DNA conjugates, anhydrous absorption pastes, oil-in-water emulsions and water -in-oil, carbowax emulsions (various polyethylene glycols

- 11 046420 molecular weight), semi-solid gels and semi-solid mixtures containing carbowax. Any of the above mixtures may be suitable in the context of the methods of the present invention, provided that the VEGF antagonist is not inactivated by the composition and the composition is physiologically compatible and tolerated by the route of administration. See also Powell et al. PDA (1998) J Pharm Sci Technol. 52:238-311 and references contained therein for additional information related to excipients and carriers well known to pharmaceutical chemists.

Pharmaceutical compositions suitable for administration by injection in the context of the present invention can be prepared by dissolving, suspending or emulsifying the VEGF antagonist in a sterile aqueous or oily medium commonly used for injection. As the aqueous injection medium, for example, physiological saline solution, isotonic solution containing glucose and other auxiliary agents, etc. can be mentioned, which can be used in combination with a suitable solubilizing agent such as alcohol (eg ethanol), polyalcohol (eg propylene glycol, polyethylene glycol), nonionic surfactant [eg polysorbate 80, HCO-50 (polyoxyethylene (50 mol) hydrogenated castor oil adduct)], etc. As the oil medium, for example, sesame oil, soybean oil, etc. can be used, which can be used in combination with a solubilizing agent such as benzyl benzoate, benzyl alcohol, etc. The injectable composition thus obtained can be filled into a suitable ampoule if desired.

In an embodiment of the invention, the pharmaceutical composition administered to a subject includes aflibercept, for example, about 40 mg/ml aflibercept, in 10 mM sodium phosphate, 40 mM sodium chloride, 0.03% polysorbate 20 and 5% sucrose, pH 6.2.

In an embodiment of the invention, the pharmaceutical composition administered to a subject includes a VEGF antagonist (for example, aflibercept or conbercept, for example, at 40 mg/ml) and:

(a) pyrophosphate (eg 5-250 mM). In an embodiment of the invention, the composition further includes NaCl, sodium citrate, citric acid, mannitol and polysorbate 80, for example, pH 5.2;

(b) a buffer such as a histidine salt, eg histidine-HCl or histidine-acetate (eg at 10 mM to 50 mM), eg pH 5.7-6.2; sugar such as sucrose, trehalose, mannitol or glucose (eg more than 6% but not more than 10%, eg 2.5-10%); and a surfactant such as polysorbate 20 and polysorbate 80 (eg, 0% or 0.01-0.03%);

(c) a histidine-containing buffer such as L-histidine/histidine hydrochloride; a nonionic surfactant such as polysorbate 20 (eg 0.03%), an inorganic salt such as NaCl (eg 40 mM), and a carbohydrate such as sucrose (eg 5%), eg pH 6, 0-6.5 (for example, 6.2 or 6.5);

(d) a buffer consisting of a histidine salt (eg, where the histidine salt is histidine-HCl or histidine-acetate, for example, 10-50 mm) and having a pH in the range of 5.7 to 6.2; a sugar selected from the group consisting of sucrose, trehalose, mannitol and glucose (eg, more than 6% but not more than 10%); a surfactant selected from the group consisting of polysorbate 20 and polysorbate 80 (eg, 0% to 0.1%);

(e) citric acid (e.g. 5 mM, 10 mM, 15 mM, 20 mM, 25 mM or 30 mM), sucrose (e.g. 1%, 2%, 3%, 4%, 5%, 6%, 7 %, 8%, 9% or 10%), arginine (for example, 5 mM, 10 mM, 15 mM, 20 mM, 25 mM, 30 mM, 35 mM, 40 mM, 45 mM or 50 mM or 100 mM) and polysorbate 20 (e.g. 0.01%, 0.02%, 0.03%, 0.04%, 0.05%, 0.06%, 0.07%, 0.08%, 0.08%, 0.09% or 0.10%);

(f) a buffer such as phosphate, histidine, acetate, succinate, citrate, glutamate and/or lactate (eg, at 5-20 or 5-50 mM); a nonionic surfactant such as polysorbate (eg PS20 or PS80), polyethylene glycol dodecyl ether, poloxamer, 4-(1,1,3,3-tetramethylbutyl)phenylpolyethylene glycol, alkyl saccharide or alkyl glycoside, tonicity regulator such as a polyol or amino acid , for example, sucrose, trehalose, sorbitol, mannitol, glycerol, proline, arginine, methionine, glycine or lysine, where the final osmolality of the composition is about 300 mOsm/kg, and where the chloride anion concentration is less than about 10 mM; pH 5.0-6.5;

(g) sodium acetate (eg 10-15 mM); sucrose (eg 7%) or trehalose (eg 8%); and polysorbate 20 (eg 0.03%), pH 5.5; or (h) any of: 10 mM sodium phosphate, 40 mM sodium chloride, 5% (w/v) sucrose, 0.03% (w/v) polysorbate 20, pH 6.2; 10 mM sodium phosphate, 9% (w/v) sucrose, 0.03% (w/v) polysorbate 20, pH 6.2; 10 mM sodium phosphate, 40 mM sodium chloride, 2% (w/v) proline, 0.03% (w/v) polysorbate 20, pH 6.2; 10 mM sodium phosphate, 3% (w/v) proline, 0.03% (w/v) polysorbate 20, pH 6.2; 10 mM sodium phosphate, 9% (w/v) trehalose, 0.03% (w/v) polysorbate 20, pH 6.2; 10 mM histidine, 3% (w/v) proline, 0.03% (w/v) polysorbate 20, pH 6.2; 10 mM histidine, 9% (w/v) sucrose, 0.03% (w/v) polysorbate 20, pH 6.2; or 10 mM acetate, 9% (w/v) sucrose, 0.03% (w/v) polysorbate 20, pH 5.2.

Methods of administration

The VEGF antagonist (or a pharmaceutical composition comprising a VEGF antagonist) can be administered to a patient using any known delivery system and/or route of administration. In neko

- 12 046420 In other embodiments, the VEGF antagonist is administered to the patient by ocular, intraocular, intravitreal or subconjunctival injection. In other embodiments, the VEGF antagonist can be administered to a patient by topical administration, for example, in the form of eye drops or other liquid, gel, ointment or liquid that contains the VEGF antagonist and which can be applied directly to the eye. Ocular administration to a patient or subject refers to any suitable method of delivering a VEGF antagonist (eg, aflibercept) to the ocular tissue of a patient or subject (eg, intravitreal injection). In an embodiment of the invention, administration to the eye of a subject or patient refers to delivery of a VEGF antagonist to an eye suffering from an angiogenic ocular disease (eg, as discussed herein), such as NPDR, and optionally to delivery to the other eye, even if it does not amazed in a similar way. In one embodiment of the invention, the administration is an intravitreal injection using a syringe with a 30G 1/2 inch injection needle. For example, in an embodiment of the invention, about 50 μL is administered intravitreally to deliver about 2 mg of a VEGF antagonist (e.g., aflibercept; e.g., in a pharmaceutical composition comprising aflibercept, e.g., about 40 mg/mL aflibercept, in 10 mM sodium phosphate, 40 mM chloride sodium, 0.03% polysorbate 20 and 5% sucrose, pH 6.2). In an embodiment of the invention, 0.5 or 2.0 mg of conbercept is administered to the eye in a pharmaceutical composition comprising conbercept, citric acid, sucrose, arginine and polysorbate 20.

Other possible routes of administration include, for example, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural and oral. If this route of administration is used, delivery is not to the eye, but to another tissue such as skin, muscle tissue, peritoneum, vein, subcutaneous tissue, nasal passage, dura mater, or mouth.

Amount of VEGF antagonist administered

Each dose of a VEGF antagonist (eg, 0.5 mg or 2 mg, such as aflibercept) administered to a patient's eye throughout the therapy regimen may contain the same or substantially the same amount of VEGF antagonist. Alternatively, the amount of VEGF antagonist contained in individual doses may vary throughout the therapy regimen. For example, in some embodiments, a first amount of VEGF antagonist is administered in an initial dose, a second amount of VEGF antagonist is administered in secondary doses, and a third amount of VEGF antagonist is administered in tertiary doses. The present invention provides dosing regimens in which the amount of VEGF antagonist contained in individual doses is increased over time (eg, each subsequent dose contains more VEGF antagonist than the previous one), decreased over time (eg, each subsequent dose contains less VEGF antagonist than the previous one), first increases, then decreases, first decreases, then increases, or remains the same throughout the course of treatment.

The amount of VEGF antagonist administered to the patient's eye at each dose (eg, 0.5 mg or 2 mg, eg, aflibercept or conbercept) is, in most cases, a therapeutically effective amount. As used herein, the phrase a therapeutically effective amount means a dose of a VEGF antagonist that results in a detectable improvement in one or more symptoms or signs of an angiogenic ocular disease, or a dose of a VEGF antagonist that inhibits, prevents, reduces, or slows the progression of an angiogenic ocular disease. In the case of an anti-VEGF antibody or a chimeric molecule based on the VEGF receptor, such as VEGFR1R2-FcAC.'l(a). a therapeutically effective amount may be from about 0.05 mg to about 5 mg, for example, about 0.05 mg, about 0.1 mg, about 0.15 mg, about 0.2 mg, about 0.25 mg, about 0 .3 mg, about 0.35 mg, about 0.4 mg, about 0.45 mg, about 0.5 mg, about 0.55 mg, about 0.6 mg, about 0.65 mg, about 0.7 mg, about 0.75 mg, about 0.8 mg, about 0.85 mg, about 0.9 mg, about 1.0 mg, about 1.05 mg, about 1.1 mg, about 1.15 mg, about 1.2 mg, about 1.25 mg, about 1.3 mg, about 1.35 mg, about 1.4 mg, about 1.45 mg, about 1.5 mg, about 1.55 mg, about 1 .6 mg, about 1.65 mg, about 1.7 mg, about 1.75 mg, about 1.8 mg, about 1.85 mg, about 1.9 mg, about 2.0 mg, about 2.05 mg, about 2.1 mg, about 2.15 mg, about 2.2 mg, about 2.25 mg, about 2.3 mg, about 2.35 mg, about 2.4 mg, about 2.45 mg, about 2.5 mg, about 2.55 mg, about 2.6 mg, about 2.65 mg, about 2.7 mg, about 2.75 mg, about 2.8 mg, about 2.85 mg, about 2 .9 mg, about 3.0 mg, about 3.5 mg, about 4.0 mg, about 4.5 mg, or about 5.0 mg of an antibody or chimeric receptor-based molecule.

The amount of VEGF antagonist contained in individual doses can be expressed in milligrams of antibody per kilogram of patient body weight (ie, mg/kg). For example, a VEGF antagonist can be administered to a patient at a dose of from about 0.0001 to about 10 mg/kg of the patient's body weight.

Population and treatment effectiveness

The methods of the present invention are useful for the treatment of angiogenic ocular diseases in patients who have been diagnosed with or who are at risk of developing angiogenic ocular disease. Typically, the methods of the present invention demonstrate effectiveness within 104 weeks of starting the treatment regimen (with the initial dose administered at week 0), e.g., by the end of week 16, by the end of week 24, by the end of week 32, by the end of week 40, by end of week 48, end of week 52, end of week 56, etc.

- 13 046420

In one embodiment of the invention, in the context of methods for treating angiogenic ocular diseases such as DR, PDR, NPDR, AMD, CRVO and DME, effectiveness means that, from the start of treatment, the patient demonstrates:

loss of 15 or fewer (eg, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, or 1) letters on the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart ;

an improvement of one or more (eg, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 or more) letters in the ETDRS table;

maintaining or improving the DRSS score, for example, reducing the DRSS by 2 or 3 steps;

reducing the incidence of or preventing vision-threatening complications (VTC) and/or blindness and/or central diabetic macular edema; and/or reducing or maintaining the thickness of the central part of the retina;

for example, when one or more such goals are achieved within approximately 24 or 52 weeks after the start of treatment.

Packaging

One aspect of the invention is a package including:

container with medicine; and instructions for the use of the drug for the treatment or prevention of diabetic retinopathy in a patient requiring such treatment, wherein the instructions specify the use of the drug by administering to the patient's eye (i) 3 administered doses once a month followed by one or more booster doses every 16 weeks, with the first booster dose administered 8 weeks after the third monthly dose (week 16), or (ii) 3 or 5 monthly doses followed by one or more booster doses every 8 weeks;

about 2 mg of a VEGF antagonist, which is a chimeric molecule based on the VEGF receptor.

Another aspect of the invention is a package wherein the VEGF antagonist (i) comprises (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component comprising amino acids 232-457 SEQ ID NO: 2;

(ii) includes (1) immunoglobulin-like (Ig) domain 2 of the first VEGF receptor and (2) Ig domain 3 of the second VEGF receptor, and (3) a multimerizing component;

(iii) is aflibercept; or (iv) is conbercept.

Another aspect of the invention is packaging wherein the instructions indicate that the drug is administered by intravitreal injection.

Another aspect of the invention is the packaging, where the instructions indicate that 3 or 5 monthly doses of the drug are administered, followed by one or more doses every 8 weeks.

Another aspect of the invention is packaging wherein the instructions indicate that 3 monthly doses of the drug are administered followed by one or more secondary doses every 16 weeks, with the first secondary dose administered 8 weeks after the third monthly dose (week 16).

Another aspect of the invention is the packaging, where the instructions indicate that one dose of the drug is administered once every 8 weeks.

An aspect of the invention is a package including:

container with medicine; and instructions for the use of the drug for the treatment or prevention of proliferative diabetic retinopathy in a patient requiring such treatment, wherein the instructions specify the use of the drug by administration to the patient's eye (i) 3 administered doses once a month followed by one or more booster doses once a month at 16 weeks, with the first booster dose administered 8 weeks after the third monthly dose (week 16), or (ii) 3 or 5 monthly doses followed by one or more booster doses every 8 weeks;

about 2 mg of a VEGF antagonist, which is a chimeric molecule based on the VEGF receptor.

Another aspect of the invention is a package wherein the VEGF antagonist (i) comprises (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerization component comprising amino acids 232-457 SEQ ID NO: 2;

(ii) includes (1) immunoglobulin-like (Ig) domain 2 of the first VEGF receptor and (2) Ig domain 3

- 14 046420 second VEGF receptor, and (3) a multimerizing component;

(iii) is aflibercept; or (iv) is conbercept.

Examples

The following examples are provided to provide those skilled in the art with a complete disclosure and description of the provision and use of the methods and compositions of the invention, and are not intended to limit the scope of what the inventors believe to be their invention. The inventors have made efforts to ensure accuracy as regards the numbers used (eg quantities, temperature, etc.), but some experimental errors and deviations should be taken into account. Unless otherwise noted, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Celsius, and pressure is at or near atmospheric pressure.

The exemplary VEGF antagonist used in all of the following examples is (unless otherwise indicated) a dimeric molecule having two functional VEGF binding units. Each functional binding unit consists of Ig domain 2 of VEGFR1 fused to Ig domain 3 of VEGFR2, which in turn is fused to the hinge region of the Fc domain of human IgG1 (VEGFR1R2-FcAC'l(a); encoded by SEQ ID NO: 1). This VEGF antagonist is referred to in the examples below as VEGFT. For the purposes of the following examples, administration once a month is equivalent to administration once every four weeks.

Example 1: Phase I Clinical Trial of an Intravitreally Administered VEGF Receptor Chimeric Molecule (VEGFT) in Subjects with Neovascular AMD

In this Phase I study, 21 subjects with neovascular AMD received a single intravitreal (IVT) dose of VEGFT. Each of five groups of three subjects received either 0.05, 0.15, 0.5, 2, or 4 mg of VEGFT, and a sixth group of six subjects received 1 mg. There were no serious adverse events related to the study drug and no detectable intraocular inflammation reported. Preliminary results showed that following VEGFT injection, there was a rapid reduction in foveal thickness and macular volume that was maintained for 6 weeks. By Day 43, across all dose groups, mean excess retinal thickness [excess retinal thickness = (retinal thickness -179 µm)] on optical coherence tomography (OCT) had decreased from 119 µm to 27 µm, as assessed by rapid macular scan, and from 194 µm to 60 µm, as assessed using a single scan of the posterior pole. The mean increase in best-corrected visual acuity (BCVA) was 4.75 letters, and BCVA was stable or improved in 95% of subjects. In the 2 highest dose groups (2 and 4 mg), the mean increase in BCVA was 13.5 letters, with 3 of 6 subjects showing >3 lines improvement.

Example 2: Phase II Clinical Trial of Repeated Doses of an Intravitreally Administered VEGF Receptor Chimeric Molecule (VEGFT) in Subjects with Neovascular AMD

This study was a double-blind, randomized study of 3 doses (0.5, 2, and 4 mg) of VEGFT tested at 4-week and/or 12-week intervals between administrations. There were 5 treatment groups in this study: 1) 0.5 mg every 4 weeks, 2) 0.5 mg every 12 weeks, 3) 2 mg every 4 weeks, 4) 2 mg every 12 weeks, and 5 ) 4 mg every 12 weeks. Subjects were dosed at a fixed interval for the first 12 weeks, after which they were assessed every 4 weeks for 9 months, during which additional doses were administered based on pre-established criteria. All subjects were then followed for one year after the last dose of VEGFT. Preliminary data from a preplanned interim analysis showed that VEGFT met the primary endpoint of a statistically significant reduction in retinal thickness at 12 weeks compared with baseline (all groups combined, 135 μm reduction, P < 0.0001). The mean change from baseline in visual acuity, a key secondary endpoint of the study, also showed a statistically significant improvement (all groups combined, 5.9 letter increase, P < 0.0001). Additionally, patients in the single-dose only groups experienced an average reduction in excess retinal thickness (p < 0.0001) and improvement in visual acuity (p = 0.012) at 12 weeks. There were no serious drug-related side effects, and VEGF antagonist treatment was generally well tolerated. The most common adverse events were those typically associated with intravitreal injections.

Example 3: Phase I Clinical Trial of Systemic Administration of a Chimeric VEGF Receptor-Based Molecule (VEGFT) in Subjects with Neovascular AMD

This study was a placebo-controlled, sequential group, dose-escalating study of the tolerability and bioeffects of VEGFT when administered by intravenous infusion in subjects with neovascular AMD. A group of 8 subjects meeting study inclusion criteria for subfoveal choroidal neovascularization (CNV) was associated with

- 15046420 patients with AMD were administered 4 intravenous injections of VEGFT or placebo at dose levels of 0.3, 1, or 3 mg/kg over an 8-week period.

Most adverse events that were associated with VEGFT were mild to moderate in severity, but 2 of 5 patients receiving 3 mg/kg experienced dose-limiting toxicity (DLT) (one with grade 4 hypertension and one with grade 2 proteinuria); therefore, all subjects in the 3 mg/kg dose group were not included in the study. The mean percentage changes in excess retinal thickness were: -12%, -10%, -66% and -60% for placebo, 0.3, 1 and 3 mg/kg dose groups on day 15 (ANOVA p < 0.02) and -5.6%, +47.2% and -63.3% for placebo, 0.3 and 1 mg/kg dose groups on day 71 (ANOVA p < 0.02). There was a quantitative improvement in BCVA in subjects treated with VEGFT. As would be expected in such a small study, the results were not statistically significant.

Example 4: Phase III Clinical Trial of the Efficacy, Safety and Tolerability of Repeated Doses of Intravitreal VEGFT Injection in Subjects with Neovascular Age-Related Macular Degeneration

A. Goals, hypotheses and endpoints

Two parallel phase III clinical trials were conducted to investigate the use of VEGFT for the treatment of patients with neovascular age-related macular degeneration (Study 1 and Study 2). The primary objective of these studies was to evaluate the effectiveness of intravitreal VEGFT compared with ranibizumab (Lucentis®, Genentech, Inc.), in a non-inferiority control paradigm, to prevent moderate visual loss in subjects with all subtypes of neovascular AMD.

Secondary objectives were (a) to evaluate the safety and tolerability of repeated intravitreal VEGFT in subjects with all subtypes of neovascular AMD for periods up to 2 years; and (b) assessing the effect of repeated intravitreal VEGFT administration on vision-related quality of life (QOL) in patients with all subtypes of neovascular AMD.

The primary hypothesis of these studies was that the proportion of subjects treated with VEGFT with stable or improved BCVA (<15 letter loss) is similar to the proportion of subjects treated with ranibizumab who have stable or improved BCVA, thereby demonstrating noninferiority to control .

The primary endpoint for these studies was prevention of vision loss greater than or equal to 15 ETDRS letters from baseline at 52 weeks. Secondary endpoints were as follows: (a) change from baseline to Week 52 ETDRS letter score; (b) a Week 52 gain from baseline of 15 letters or more on the ETDRS chart; (c) change from baseline to Week 52 NEI VFQ-25 total score; and (d change from baseline to Week 52 in CNV area.

B. Study Design

For each study, subjects were randomly assigned in a 1:1:1:1 ratio to be treated with 1 of 4 dosing schedules: (1) 2 mg VEGFT administered every 4 weeks (2Q4); (2) administration of 0.5 mg VEGFT every 4 weeks (0.5Q4); (3) administration of 2 mg VEGFT every 4 weeks until week 8 and then every 8 weeks (with a sham injection at the 4-week interim visits when study drug was not administered (2Q8); and (4) administration of 0. 5 mg ranibizumab every 4 weeks (RQ4) Subjects allocated to (2Q8) received a 2 mg injection every 4 weeks until week 8, and then a sham injection at the 4 week interim visits (when study drug was not administered) at during the first 52 weeks of the study (No sham injection at week 52).

Each subject had a planned study duration of 96 weeks plus study enrollment period. During the first 52 weeks (Year 1), subjects received an intravitreal (IVT) injection or sham injection in the study eye every 4 weeks. (No mock injections in week 52). During the second year of the study, subjects should be assessed every 4 weeks and given an IVT injection of study drug at intervals determined according to specific dosing criteria, but at least once every 12 weeks. (No sham injections will be administered during the second year of the study.) During this period, injections may be administered at a frequency of every 4 weeks, but not less than every 12 weeks, according to the following criteria: (i) increase in central retinal thickness >100 µm from the lowest previous value, as measured by optical coherence tomography (OCT); or (ii) loss, from the best previous letter grade, of at least 5 ETDRS letters in combination with recurrent fluid, as demonstrated by OCT; or (iii) new or persistent fluid as demonstrated by OCT; or (iv) new classic neovascularization or new or persistent leakage determined by fluorescein angiography (FA); or (v) new macular hemorrhage; or (vi) 12 weeks have passed since the previous injection. Under this protocol, subjects must receive an injection at least once every 12 weeks.

Subjects were assessed at 4-week intervals for safety and best visual acuity with

- 16 046420 correction (BCVA) using the ETDRS protocol with a distance of 4 meters. Quality of life (QOL) was assessed using the NEI VFQ-25 questionnaire. OCT and FA examinations were performed periodically.

Approximately 1,200 subjects were enrolled in the study, with a target enrollment of 300 subjects per treatment arm.

To be eligible to participate in this study, subjects were required to have subfoveal choroidal neovascularization (CNV) secondary to AMD. Subfoveal CNV was defined as the presence of subfoveal neovascularization documented by FA or the presence of a lesion that is perifoveal as demonstrated by angiography but involves the foveal zone. Subject eligibility was confirmed based on angiographic criteria prior to randomization.

Only one eye was designated as the study eye. For subjects who met the eligibility criteria in both eyes, the eye with worse visual acuity (VA) was selected as the study eye. If both eyes had the same VA, the eye with the clearest lens and ocular media and the least amount of subfoveal scar or geographic atrophy was selected. If there was no objective basis for selecting the study eye, factors such as ocular dominance, other ocular pathology, and subject preference were considered in the selection.

Inclusion criteria for both studies were as follows: (i) signed informed consent; (ii) at least 50 years of age; (iii) active primary subfoveal CNV lesions in the setting of AMD, including perifoveal lesions that involve the foveal zone as evidenced by FA in the study eye; (iv) CNV of at least 50% of the total lesion size; (v) Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity: 20/40 to 20/320 (letter score 73 to 25) in the study eye; (vi) willingness, commitment, and ability to return for all clinic visits and completion of all study-related procedures; and (vii) can read, understand, and is willing to sign the informed consent form (or, if unable to read due to visual impairment, have it read to him by a person supervising the signing of the informed consent form or by a family member).

Exclusion criteria for both studies were as follows: 1. Any previous ocular (in the study eye) or systemic treatment or surgery for neovascular AMD, excluding dietary supplements or vitamins. 2. Any prior or concomitant therapy with another investigational drug for the treatment of neovascular AMD in the study eye, excluding dietary supplements or vitamins. 3. Previous treatment with anti-VEGF agents, as follows: (a) prior treatment with anti-VEGF therapy in the study eye was not allowed; (b) Prior treatment using anti-VEGF therapy in the other eye with an investigational agent (non-FDA approved, e.g., bevacizumab) was permitted at least 3 months before the first dose in the study, and such treatment was not permitted during the study. Previous treatment with approved anti-VEGF therapy in the other eye was allowed; (c) Prior systemic anti-VEGF therapy investigational or approved by the FDA/Health Canada was only authorized up to 3 months prior to the first dose and was not permitted during the study. 4. Total lesion size > 12 disc areas (30.5 mm ² including blood, scarring, and neovascularization) as determined by FA in the study eye. 5. Subretinal hemorrhage representing 50% or more of the total area of the lesion, or if the blood is located under the fovea and is 1 or more in size than the disc area in the eye being examined. (If blood is subfoveal, then the fovea should be surrounded by 270 degrees of visible CNV.) 6. Scar or fibrosis accounting for >50% of the total lesion in the eye being examined. 7. Scar, fibrosis or atrophy affecting the center of the foveal zone. 8. The presence of perforations or breaks in the retinal pigment epithelium affecting the macula in the eye being examined. 9. History of any vitreous hemorrhage within 4 weeks prior to Visit 1 in the study eye. 10. Presence of other causes of CNV, including pathological myopia (spherical equivalent -8 diopters or more negative, or axial length 25 mm or more), ocular histoplasmosis syndrome, angioid streaks, choroidal disruption, or multifocal choroiditis in the eye being examined. 11. History or clinical evidence of diabetic retinopathy, diabetic macular edema, or any other vascular disease affecting the retina other than AMD in either eye. 12. Previous vitrectomy in the study eye. 13. History of retinal detachment or treatment or surgery for retinal detachment in the study eye. 14. Any history of stage 2 or higher retinal perforation in the study eye. 15. Any intraocular or periocular surgery within 3 months before Day 1 on the study eye, except eyelid surgery, which may not have been performed 1 month before Day 1, provided it is unlikely to interfere with the injection. 16. Previous trabeculectomy or other filtration surgery in the eye being examined. 17. Uncontrolled glaucoma (defined as intraocular pressure greater than or equal to 25 mm Hg despite treatment with a glaucoma drug) in the test eye. 18. Active intraocular inflammation in either eye. 19. Active ocular or periocular infection in either eye. 20. Any ocular or periocular infection within the last 2 weeks before screening in either eye. 21. Any history of uveitis in either eye. 22. Active scleritis

- 17 046420 or episcleritis in either eye. 23. Presence or history of scleromalacia in either eye. 24. Aphakia or pseudophakia with absence of the posterior capsule (unless due to posterior capsulotomy using a yttrium aluminum garnet [YAG] laser) in the test eye. 25. Previous radiation therapy in the area of the eye being examined. 26. History of corneal transplantation or corneal dystrophy in the eye under study. 27. Significant media opacities, including cataracts, in the test eye that may affect visual acuity, safety assessment, or fundus imaging. 28. Any underlying intraocular condition in the study eye (eg, cataract) that, in the opinion of the investigator, may require medical or surgical intervention during the 96-week study period. 29. Any concomitant ocular disease in the study eye that, in the opinion of the investigator, may either increase the risk to the subject beyond what would be expected from standard intraocular injection procedures or may otherwise interfere with the injection procedure or the evaluation of efficacy or safety. 30. History of another medical condition, metabolic dysfunction, physical examination findings, or clinical laboratory findings that raise suspicion of a disease or condition for which study drug use is contraindicated, or that may affect the interpretation of study results or lead to a high risk of treatment complications subject. 31. Participation as a subject in any clinical trial within 12 weeks before Day 1. 32. Any systemic or ocular treatment with an investigational drug during the last 3 months before Day 1. 33. Use of long-acting steroids, either systemically or intraocularly, 6 months before Day 1. 34. Any history of allergy to povidone-iodine. 35. Severe allergy to fluorescein sodium angiography injection is known. 36. Presence of any contraindications listed on the FDA-approved labeling for ranibizumab (Lucentis®). 37. Pregnant or lactating women, or women of childbearing potential who are unwilling to use adequate contraceptive methods for the duration of the study. Adequate contraceptive measures include oral contraceptives (stable use for 2 or more cycles before screening); intrauterine contraceptive; Depo-Provera®; Norplant® system implants; bilateral tubal ligation; vasectomy; a condom or contraceptive cap plus a contraceptive sponge, foam or jelly.

Subjects were not allowed to take any standard or investigational drugs for the treatment of AMD in the study eye other than their assigned study treatment with VEGFT or ranibizumab as specified in the protocol until the last visit/early termination of the study. This includes drugs administered locally (eg, IVT, topical, mucoscleral, or periorbital routes) as well as those administered systemically for the purpose of treating the test eye and/or the other eye.

The research procedures in general are as follows:

Best Corrected Visual Acuity: Visual function of the test eye and the other eye was assessed using the ETDRS (Early Treatment Diabetic Retinopathy Study Group) protocol at a distance of 4 meters. Visual acuity assessors are certified to ensure correct BCVA measurement. VA evaluators were required to remain blind to treatment assignment.

Optical coherence tomography: Retina and damage were assessed using OCT in the study eye. At the screening visit (Visit 1), images were obtained and transmitted for both eyes. All OCT images were acquired using Zeiss Stratus OCT™ with software version 3 or higher. The OST images were sent to an independent image interpretation center, where the images were read as anonymized data during visits where OSTs were required. All OSTs were electronically archived at the study site as part of the original documentation. A subset of OCT images was read. OST technicians were required to be certified by a transcription center to ensure they were performing image acquisition work correctly and efficiently. Every effort was made to ensure that on-site OCT technicians remained unaware of treatment assignments.

Fundus photography and fluorescein angiography (FA): The anatomical status of the retinal vasculature of the study eye was assessed using funduscopy, fundus photography and FA. At the screening visit (Visit 1), fundoscopy, fundus photography, and FA data were obtained and transmitted for both eyes. Fundus films and angiographic images were sent to an independent image interpretation center where the images were read as anonymized data. The imaging center confirmed subject eligibility for study participation based on angiographic criteria prior to randomization. All FA and fundus images have been archived on the website as part of the original documentation. Specialist photographers were required to be certified by a transcription center to ensure that they were performing the work involved in acquiring images correctly and efficiently. Every effort was made to ensure that all photography specialists on site remained unaware of the treatment assignment.

- 18 046420

Vision-related quality of life: Vision-related quality of life was assessed using the National Eye Institute 25-Item Visual Function Questionnaire (NEIVFQ-25) in an interviewer-administered format. The NEIVFQ-25 survey was administered by qualified personnel at a contracted call center. At the screening visit, the study site assisted the subject and initiated the first call to the call center to collect all of the subject's contact information and complete the first NEIVFQ-25 over the phone prior to randomization and intravitreal (IVT) injection. For all follow-up visits, the call center telephoned the subject prior to the IVT injection to complete the questionnaire.

Intraocular pressure: Intraocular pressure (IOP) of the study eye was measured using applanation tonometry or Tonopen. The same IOP measurement method was used for each subject throughout the study.

C. Summary of results (data for week 52)

The primary endpoint (prevention of moderate to severe vision loss as defined above) was met by all three VEGFT arms (2Q4, 0.5Q4, and 2Q8) in this study. The results of both studies are shown in table. 1.

Table 1

Ranibizumab 0.5 mg once monthly (RQ4) VEGFT 0.5 mg once a month (0.5Q4) VEGFT 2 mg once a month (2Q4) VEGFT 2 mg every 8 weeks ^[a] (2Q8) Vision maintenance* (% of patients with <15 letter loss) at week 52 compared to baseline Study 1 94.4% 95.9%** 95.1%** 95.1%** Study 2 94.4% 96.3%** 95.6%** 95.6%** Mean visual improvement* (letters) at 52 weeks compared to baseline (p-value vs RQ4)*** Study 1 8.1 6.9 (NS) 10.9 (p<0.01) 7.9 (NS) Study 2 9.4 9.7 (NS) 7.6 (NS) 8.9 (NS

^[a] After three initial monthly doses *Visual acuity was measured as the total number of letters read correctly on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart.

**Statistically noninferior based on a 10% noninferiority margin using confidence intervals (95.1% and 95% for Study 1 and Study 2, respectively) ***Test of benefit

N S=not significant

In Study 1, patients receiving VEGFT 2 mg once monthly (2Q4) achieved a more statistically significant mean improvement in visual acuity at week 52 compared with baseline (secondary endpoint) compared with ranibizumab 0.5 mg once monthly ( RQ4); patients receiving VEGFT 2 mg once monthly gained an average of 10.9 letters compared with an average gain of 8.1 letters with ranibizumab 0.5 mg once monthly (p < 0.01). All other VEGFT dose groups in Study 1 and all dose groups in Study 2 were not statistically different from ranibizumab in this secondary endpoint.

An overall favorable safety profile was observed for both VEGFT and ranibizumab. In both studies, the incidence of ocular treatment-emergent adverse events was balanced across all four treatment groups, with the most common events related to the injection procedure, underlying disease, and/or the aging process. The most common ocular side effects were conjunctival hemorrhage, macular degeneration, eye pain, retinal hemorrhage, and vitreous floaters. The most common serious non-ophthalmic adverse events were typical of those reported in this elderly population receiving intravitreal treatment for wet AMD; the most common events were falls, pneumonia, myocardial infarction, atrial fibrillation, breast cancer, and acute coronary syndrome. There were no significant differences among the study groups.

Example 5: Phase II Clinical Trial of VEGFT in Subjects with Diabetic Macular Edema (DME)

In this study, 221 patients with clinically significant DME involving the central

- 19 046420 part of the macula, were randomly assigned to treatment groups, and 219 patients were treated in a proportional allocation to five groups. The control group received laser treatment for macular edema at baseline, and patients were eligible for repeat laser treatment, but not more frequently than at 16-week intervals. The remaining four groups received VEGFT by intravitreal injection as follows: two groups received 0.5 or 2 mg VEGFT once every four weeks for a 12-month period (0.5Q4 and 2Q4, respectively). The two groups received three initial doses of 2 mg VEGFT once every four weeks (i.e. at baseline and weeks 4 and 8), then up to week 52 administered either once every 8 weeks (2Q8) or as needed very strict reintroduction criteria (PRN). The mean improvement in visual acuity from baseline was as shown in Table 1. 2:

table 2

η Mean change from baseline in visual acuity at week 24 (letters) Average change visual acuity at week 52 compared to baseline (letters) Laser 44 2.5 -1.3 VEGFT 0.5 mg once a month (0.5Q4) 44 8.6** 11.0** VEGFT 2 mg once a month (2Q4) 44 11 4** 13.1** VEGFT 2 mg every 8 weeks ^[a] (2Q8) 42 8.5** 2 7** VEGFT 2 mg as needed AND (PRN) 45 10.3** 12.0**

^[a] After three initial monthly doses ** p < 0.01 compared to laser

In this study, the improvement in visual acuity achieved with VEGFT at week 24 was maintained or quantitatively improved through study completion at week 52 in all arms of the VEGFT study, including the 2 mg bimonthly group.

As demonstrated in the Examples presented above, administration of VEGFT to patients suffering from angiogenic ocular diseases (eg, AMD and DME) at a frequency of once every 8 weeks, after one initial dose and two secondary doses administered four weeks apart, resulted in significant preventing moderate to severe vision loss or improving visual acuity.

Example 6: Randomized, multicenter, double-blind trial of previously untreated patients with macular edema due to CRVO

In this randomized, double-blind, Phase 3 study, patients received 6 once-monthly injections of either 2 mg intravitreal VEGFT (114 patients) or sham injections (73 patients). From Week 24 to Week 52, all patients received 2 mg VEGFT as needed (PRN) according to retreatment criteria. Thus, patients receiving sham injection means that patients received sham injections once every four weeks from Week 0 through Week 20, followed by intravitreal VEGFT as needed from Week 24 through Week 52. patients means patients received intravitreal VEGFT injections once every four weeks, starting in Week 0 through Week 20, followed by intravitreal VEGFT as needed from Week 24 through Week 52. The primary endpoint was the proportion of patients with gains >15 ETDRS letters from baseline to Week 24. Visual, anatomical, and Quality of Life NEI VFQ-25 secondary outcomes were also assessed at Weeks 24 and 52.

At Week 24, 56.1% of VEGFT-treated patients had gained >15 ETDRS letters from baseline vs. 12.3% of sham-treated patients (P<0.0001). Similarly, by Week 52, 55.3% of VEGFT-treated patients had gained >15 letters vs. 30.1% of sham-injected patients (P<0.01). By Week 52, VEGFT-treated patients gained an average of 16.2 letters vs. 3.8 letters in sham-treated patients (P<0.001). The mean number of injections was 2.7 for patients receiving VEGFT vs 3.9 for patients receiving sham injection. The mean change in central retinal thickness was -413.0 µm for those receiving VEGFT

- 20,046,420 patients vs -381.8 µm for patients receiving sham injection. The proportion of patients with ocular neovascularization at Week 24 was 0% for VEGFT-treated patients and 6.8% for sham-treated patients, respectively; by Week 52, after receiving VEGFT PRN, the proportion of patients was 0% and 6.8% for those receiving VEGFT and sham injection, respectively. At Week 24, mean change from baseline in VFQ-25 total score was 7.2 vs 0.7 for the VEGFT and sham injection groups; at Week 52, estimates were 7.5 vs 5.1 for the VEGFT and sham groups.

This Example confirms that administration of a monthly 2 mg intravitreal VEGFT injection resulted in a statistically significant improvement in visual acuity at Week 24, which was maintained through Week 52 with PRN administration, compared with sham-PRN treatment. VEGFT was generally better tolerated and had a generally favorable safety profile.

Example 7: Dosing Schedules

Specific non-limiting examples of dosage regimens within the scope of the present invention are as follows:

VEGFT 2 mg (0.05 ml), administered by intravitreal injection once every 4 weeks (once a month).

VEGFT 2 mg (0.5 mL) administered by intravitreal injection once every 4 weeks for the first 8 weeks, followed by 2 mg (0.05 mL) by intravitreal injection once every 8 weeks.

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 8 weeks, followed by 2 mg (0.05 ml) by intravitreal injection less frequently based on visual and/or anatomical assessment (as determined by the attending physician or other qualified health care provider).

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 8 weeks, followed by 2 mg (0.05 ml) by intravitreal injection administered pro re nata (PRN), based on results of visual and/or anatomical assessment (determined by the attending physician or other qualified healthcare professional).

VEGFT 2 mg (0.5 mL) administered by intravitreal injection once every 4 weeks for the first 12 weeks, followed by 2 mg (0.05 mL) by intravitreal injection once every 8 weeks.

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 12 weeks, followed by 2 mg (0.05 ml) by intravitreal injection less frequently based on visual and/or anatomical assessment (as determined by the attending physician or other qualified health care provider).

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 12 weeks, followed by 2 mg (0.05 ml) by intravitreal injection administered pro re nata (PRN), based on results of visual and/or anatomical assessment (determined by the attending physician or other qualified healthcare professional).

VEGFT 2 mg (0.5 mL) administered by intravitreal injection once every 4 weeks for the first 16 weeks, followed by 2 mg (0.05 mL) by intravitreal injection once every 8 weeks.

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 16 weeks, followed by 2 mg (0.05 ml) by intravitreal injection less frequently based on visual and/or anatomical assessment (as determined by the attending physician or other qualified health care provider).

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 16 weeks, followed by 2 mg (0.05 ml) by intravitreal injection administered pro re nata (PRN), based on results of visual and/or anatomical assessment (determined by the attending physician or other qualified healthcare professional).

VEGFT 2 mg (0.5 mL) administered by intravitreal injection once every 4 weeks for the first 20 weeks, followed by 2 mg (0.05 mL) by intravitreal injection once every 8 weeks.

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 20 weeks, followed by 2 mg (0.05 ml) by intravitreal injection less frequently based on visual and/or anatomical assessment (as determined by the attending physician or other qualified health care provider).

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 20 weeks, followed by 2 mg (0.05 ml) by intravitreal injection administered pro re nata (PRN), based on results of visual and/or anatomical assessment (determined by the attending physician or other qualified healthcare professional).

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 24 weeks, followed by 2 mg (0.05 ml) by intravitreal injection once

- 21 046420 at 8 weeks.

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 24 weeks, followed by 2 mg (0.05 ml) by intravitreal injection less frequently based on visual and/or anatomical assessment (as determined by the attending physician or other qualified health care provider).

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 24 weeks, followed by 2 mg (0.05 ml) by intravitreal injection administered pro re nata (PRN), based on results of visual and/or anatomical assessment (determined by the attending physician or other qualified healthcare professional).

VEGFT 2 mg (0.5 mL) administered by intravitreal injection once every 4 weeks for the first 28 weeks, followed by 2 mg (0.05 mL) by intravitreal injection once every 8 weeks.

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 28 weeks, followed by 2 mg (0.05 ml) by intravitreal injection less frequently based on visual and/or anatomical assessment (as determined by the attending physician or other qualified health care provider).

VEGFT 2 mg (0.5 ml) administered by intravitreal injection once every 4 weeks for the first 28 weeks, followed by 2 mg (0.05 ml) by intravitreal injection administered pro re nata (PRN), based on results of visual and/or anatomical assessment (determined by the attending physician or other qualified health care professional).

VEGFT 2 mg (0.05 mL) administered by intravitreal injection as a single initial dose, followed by additional doses administered pro re nata (PRN) based on visual and/or anatomical assessment (as determined by the treating physician or other qualified physician). medical worker).

Variations to the dosage regimens described above will be apparent to those skilled in the art and are also within the scope of the present invention. For example, the amount of VEGFT and/or volume of the composition administered to a patient may vary depending on patient characteristics, disease severity, and other diagnostic assessments, as determined by the attending physician or other qualified health care professional.

Any of the above administration regimens can be used to treat, for example, age-related macular degeneration (eg, wet AMD, exudative AMD, etc.), retinal vein occlusion (RVO), central retinal vein occlusion (CRVO; eg, macular edema due to CRVO), branch retinal vein occlusion (BRVO), diabetic macular edema (DME), choroidal neovascularization (CNV; eg, myopic CNV), iris neovascularization, neovascular glaucoma, postoperative glaucoma fibrosis, proliferative vitreoretinopathy (PVR), disc neovascularization optic nerve, corneal neovascularization, retinal neovascularization, vitreal neovascularization, pannus, pterygium, vascular retinopathy, etc.

Example 8: Phase 3 Double-Blind, Randomized Study of the Efficacy and Safety of Intravitreal IAI in Patients with Moderate to Severe NPDR (PANORAMA) - Results at Weeks 24 and 52

This was a phase 3, double-blind, randomized trial of the efficacy and safety of IVT (intravitreal injection) aflibercept (IAI) for the relief of moderate to severe nonproliferative diabetic retinopathy (NPDR). These data refer to results achieved at 24 weeks and 52 weeks.

Eligible patients were assigned to 1 of 3 treatment arms in a 1:1:1 randomization design and stratified based on Diabetic Retinopathy Severity Score (DRSS) score (level 47 vs. level 53) (see Fig. 5 and Fig. 6 ). Only 1 eye was selected as the study eye.

Study plan

The primary efficacy endpoint in the study is the proportion of patients who had an improvement of >2 grades from baseline in the DRSS in the combined 2Q8 and 2Q16 arms by Week 24, and in each arm separately by Week 52.

Patients are assessed for effectiveness (best corrected visual acuity [BCVA] using the Early Treatment Diabetic Retinopathy Study [ETDRS] protocol at 4 meters, spectral domain optical coherence tomography [SD OCTA], and fluorescein angiography [FA]/fundus imaging [ FP]), as well as for visual and systemic safety (including ophthalmologic examination, visual field testing, and laboratory tests) up to week 100.

Secondary efficacy criteria are also tested by Week 52 and are as follows:

(1) Proportion of patients who developed vision-threatening complications (VTC) as a result of diabetic retinopathy up to week 52. Vision-threatening complications are defined as

- 22 046420 combined result of PDR (including patients with vitreous hemorrhage or tractional retinal detachment considered to be a result of PDR) and ASNV. ASNV is defined as iris neovascularization (at least 2 cumulative full hours) and/or characteristic iridocorneal angle neovascularization;

(2) Proportion of patients who developed CI DME up to week 52;

(3) Time to development of a vision-threatening complication up to week 52;

(4) Time to development of CI DME (affecting central DME) up to week 52;

(5) Proportion of patients who received PRP (panretinal photocoagulation) up to week 52, including patients undergoing vitrectomy with endolaser photocoagulation;

(6) Area under the curve (AUC) for change in BCVA from baseline to Week 52.

Study schedule

Day -21 to -1: Screening visit (visit 1)

Day 1: Baseline visit (visit 2)

Week 24: Primary Performance Measure (2Q8 & 2Q16 combined) (Visit 7)

Week 52: Primary Performance Criteria (2Q8 & 2Q16 separately) and all Secondary Performance Criteria (Visit 11)

Week 100: Completion of Study (Visit 18)

Exclusion Criteria: Patients who met any of the following criteria either at the screening visit or on Day 1 were excluded from the study:

(1) The presence of DME threatening the center of the macula (within 1000 microns of the foveal center) in the eye being examined;

(2) Confirmation of retinal neovascularization by clinical examination or FA (fluorescein angiography);

(3) Any previous focal or sectoral laser photocoagulation (within 1000 microns of the foveal center) or any previous PRP in the eye being examined;

(4) Any previous systemic anti-VEGF administration or IVT anti-VEGF administration in the study eye;

(5) Any previous intraocular steroid administration to the eye being examined; periocular steroid injection into the study eye 120 days before Day 1;

(6) History of vitreoretinal surgical procedure in the eye being studied;

(7) Intraocular pressure (IOP) >25 mm Hg. in the eye being examined;

(8) Evidence of active infectious blepharitis, keratitis, scleritis, or conjunctivitis in either eye;

(9) Any intraocular inflammation or infection in either eye within 3 months before the screening visit;

(10) The presence of ASNV, vitreous hemorrhage, or tractional retinal detachment observed during screening evaluations in the study eye;

(11) Ocular media of insufficient quality to obtain fundus images and optical coherence tomography (OCT) in the eye being examined; allergy to fluorescein, excluding the possibility of fluorescein angiography;

(12) Hemoglobin Alc (HbAlc) >12% or, if HbAlc is <12%, diabetes mellitus is not controlled in the opinion of the investigator;

(13) uncontrolled blood pressure (defined as systolic >160 mmHg or diastolic >95 mmHg when the patient is sitting);

(14) History of cerebrovascular complication or myocardial infarction within 180 days before day 1;

(15) Renal failure, dialysis, or history of kidney transplantation;

(16) Women who are breastfeeding or have a positive serum hCG/urine pregnancy test at the screening or baseline visit;

(17) Any concomitant ocular disease in the study eye that, in the opinion of the investigator, may either increase the risk to the subject beyond what would be expected from standard intraocular injection procedures or may otherwise interfere with the injection procedure or the evaluation of efficacy or safety;

(18) History of another medical condition, metabolic dysfunction, physical examination findings, or clinical laboratory findings that suggest a disease or condition for which study drug use is contraindicated, or that may affect the interpretation of study results or lead to a high risk of complications associated with treatment, in the subject;

(19) Participation as a patient in any interventional clinical trial within 12 weeks prior to Day 1 of the trial;

(20) Sexually active men* or women of childbearing potential** who are not

- 23 046420 bark to use adequate contraception before the initial dose/start of the first treatment, during the study and for at least 3 months after the last dose. Adequate contraceptive measures include consistent use of oral contraceptives or other prescription pharmaceutical contraceptives for 2 or more menstrual cycles before screening; intrauterine device; bilateral tubal ligation; vasectomy; a condom plus a contraceptive sponge, foam or jelly, or a contraceptive cap plus a contraceptive sponge, foam or jelly.

*Contraception is not required for men with a documented vasectomy.

* * Postmenopausal women must be amenorrheic for at least 12 months to not be considered of childbearing potential. Pregnancy testing and contraception are not required for women with a documented hysterectomy or tubal ligation.

(21) Patients who are receiving systemic anti-VEGF treatment (ie, bevacizumab, zivaflibercept) for cancer treatment (if a patient requires systemic anti-VEGF treatment during the study, the patient should be excluded).

Treatment Schedule: For the 3 treatment groups, the following dosing schedules were used from day 1 to week 48:

2Q8: aflibercept 2 mg Q8 before week 48 (after 5 initial monthly doses), followed by a flexible regimen with aflibercept 2 mg after week 52;

2Q16: aflibercept 2 mg Q16 until week 96 (after 3 initial monthly doses and 1 Q8 interval);

Sham: sham injections every 4 weeks (Q4) until week 16, followed by sham injections Q8 until week 96.

Data presented may relate to the 2Q16 dose group listed as Group 1; 2Q8 dose group, indicated as Group 2, and the sham administration group, indicated as Sham.

See fig. 3 and fig. 4.

The number of injections received by each dose group after 24 weeks is shown in FIG. 7, and the number of injections after 52 weeks is shown in FIG. 20.

To maintain blinding, sham injection studies are performed for the 2Q8 and 2Q16 groups at treatment visits during which patients will not receive an injection of active substance until week 96, and at all treatment visits for the sham group from the baseline visit to week 96. 96. Blinding of the study is maintained until completion of the study (week 100).

Adjuvant Treatment in the Study Eye: Patients who develop PDR, ASNV, or centrally affecting DME (CI DME) in the study eye are treated, if deemed appropriate, by a physician unaware of the study treatment assignment. For any of these complications, FP (fundus imaging) is performed before adjuvant treatment.

Patients who develop CI DME receive IVT aflibercept or laser photocoagulation and no longer receive the randomly assigned treatment. Adjuvant treatment is provided by a physician who is knowledgeable or unaware of the study treatment.

Patients who develop PDR and/or ASNV receive PRP or vitrectomy with endolaser photocoagulation if necessary but remain on the randomly assigned treatment regimen. Panretinal photocoagulation or surgery is performed by a physician knowledgeable or unaware of the study treatment. In addition, 1 injection of aflibercept is administered, which should be administered by a physician knowledgeable about the treatment.

If DME, ASNV, or PDR are being treated, patient data are censored from the time of treatment for the primary analysis.

Study population

402 patients were enrolled in the study.

The patient population included men or women with type 1 or 2 diabetes mellitus who had moderate to severe NPDR (without DME threatening the macular center) in whom PRP can be safely delayed for at least 6 months. See fig. 5 and fig. 6. About 75% of patients had DRSS 47, and about 25% had DRSS 53.

For patients who meet the eligibility criteria in both eyes, the eye with the most severe DRSS score is selected as the study eye. If both eyes have the same scores, factors such as eye dominance and patient preference are considered in the selection.

Ophthalmological procedures (efficacy and safety)

Best Corrected Visual Acuity (BCVA): Visual function of the test eye and the other eye is assessed using the ETDRS (Early Treatment Diabetic Retinopathy Study Group 1985) protocol at a distance of 4 meters at each study visit. Visual acuity testers were certified to ensure correct BCVA measurements. The VA reviewer remains unaware of the treatment assignment. Maximum corrected visual acuity is checked before any other ophthalmic procedures are performed.

- 24 046420

Intraocular Pressure (IOP): The intraocular pressure of the test eye is measured at each visit using Goldmann or Tonopen™ applanation tonometry. The same method of measuring IOP is used throughout the study for each individual patient. Intraocular pressure is measured before drug administration (bilaterally) by a physician (or designee) unaware of the treatment assignment, and approximately 30 minutes after drug administration (test eye) by a physician (or designee) aware of the treatment assignment.

Slit-lamp examination: Examination of the patient's anterior chamber structure and ocular adnexation is performed bilaterally before drug administration at each slit-lamp examination visit by an examiner blinded to treatment assignment.

Gonioscopy. Patients are assessed for the development of neovascularization of the iridocorneal angle by gonioscopy combined with slit-lamp biomicroscopy. The examination is carried out only on the eye being examined before the use of mydriatic agents or in the presence of obvious rubeosis.

Inverse ophthalmoscopy: Examination of the patient's posterior pole and peripheral retina is performed by inverse ophthalmoscopy at each study visit before drug administration (bilateral) by an investigator blinded to treatment and after drug administration (test eye) by an investigator knowledgeable about treatment. Post-administration assessment is carried out immediately after injection (active drug or sham).

Fundus Imaging (FP)/Fluorescein Angiography (FA): The anatomical status of the retinal vasculature and the level of DRSS are assessed by FA and FP.

Spectral domain optical coherence tomography (SD-OCT): Retinal characteristics are assessed at each visit using SD-OCT. Images are received and sent for both eyes. The images are sent to an independent image transcription center where they are read as anonymized data. All OSTs are electronically archived at the study sites as part of the original documentation. Optical coherence tomography technicians must be certified by an interpretation center to ensure they perform image acquisition work correctly and efficiently. Every effort is made to ensure that technical OST specialists at the study site remain unaware of treatment assignments.

Visual Field Testing: Visual field is assessed in the test eye using a Humphrey Visual Field Analyzer at centers for which this device is available. Technicians must be certified to ensure consistency and quality implementation of testing procedures. Every effort is made to ensure that the technicians at the study site assessing the visual field remain unaware of the treatment assignment.

Adverse events (AE)

Overall safety was assessed by assessing treatment-emergent adverse events (TEAEs), physical examination, electrocardiograms (ECGs), vital signs, and clinical safety laboratory tests (hematology, blood chemistry, hemoglobin A1c [HbA1c], and urinalysis) at various time points. time.

A TEAE is defined as an event (or exacerbation of a pre-existing event during the treatment period) that is observed or reported after the first study drug administration and no later than 30 days after the last study drug administration (active substance injection or sham injection). .

The investigator (or a person designated by him) records all AEs that occur from the moment of signing the informed consent until the end of the study. All serious adverse events (SAEs), regardless of assessment of causality to the study drug, must be reported within 24 hours.

Other events that must be reported within 24 hours include symptomatic study drug overdose (accidental or intentional overdose of at least 2 times the intended dose of study drug within the intended therapeutic window if associated with AE) and pregnancy .

The severity of adverse events will be graded according to the following scale:

Mild: Does not have a significant effect on the patient's normal level of functioning. It could be irritation. Prescription drugs are not usually needed to relieve symptoms but may be prescribed according to the individual patient's needs.

Moderate: Causes some impairment of function but does not pose a health hazard. This is an inconvenience or a hindrance. Treatment of symptoms may be necessary.

Severe: Causes significant impairment or disability and is

- 25 046420 a clear threat to the patient’s health. Symptoms may be treated and/or the patient may be hospitalized.

Results and conclusions

The proportion of patients with >2 grade improvement in DRSS was significantly greater in the IAI groups compared with the sham groups. See fig. 8, 19, 21 and 22. Patients also achieved >3 grade improvement in the IAI vs sham groups. See fig. 9 and 32.

IAI reduced the number of patients who developed VTC and CI-DME. The proportion of patients with VTC and/or DME at weeks 24 and 52 is shown in Fig. 10 and 23. Kaplan-Meier analysis of the likelihood of developing VTC or CI-DME in patients in each treatment group over time is shown in FIG. 24 and 25. A vision-threatening complication (VTC) is progression to proliferative diabetic retinopathy (PDR) and anterior segment neovascularization (ASNV).

Changes in best-corrected visual acuity (BCVA) for patients in each treatment group at weeks 24 and 52 are shown in FIG. 11 and 26. Changes in central retinal thickness in each treatment group are shown in FIG. 12 and 27.

Efficacy results were similar between groups 2Q16 (Group 1) and 2Q8 (Group 2).

Treatment-emergent ocular events at weeks 24 and 52 (TEAE) (Figs. 13 and 28, respectively), serious ocular TEAEs at weeks 24 and 52 (Figs. 14 and 29, respectively), and intraocular inflammation at week 24 are presented. and 52 (Figs. 15 and 30, respectively), and events determined from the antiplatelet therapy (ART) co-analysis results at weeks 24 and 52 (Figs. 16 and 31, respectively), and deaths at week 24 (Figs. 17). By week 52, there were a total of 7 deaths (7 in the sham treatment group and 1 in the q8w treatment group). (ARTS: see Antithrombotic Trialists' Collaboration. Collaborative overview of randomized trial of antiplatelet therapy - II: Maintenance of vascular graft or arterial patency by antiplatelet therapy. Br Med J 1994; 308:168-171; and Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Br Med J 2002;324:71-86).

- 26 046420

Sequences

SEQ Ш NO:1 (DNA sequence containing 1377 nucleotides): ATGGTCAGCTACTGGGACACCGGGGTCCTGCTGTGCGCGCTGCTCAGCTGTCTGCTT CTCACAGGATCTAGTTCCGGAAGTGATACCGGTAGACCTTTCGTAGAGATGTACAGT GAAATCCCCGAAATTATACACATGACTGAAGGAAGGGAGCTCGTCATTCCCTGCCG GGTTACGTCACCTAACATCACTG TTACTTTAAAAAAGTTTCCACTTGACACTTTGATC CCTGATGGAAAACGCATAATCTGGGACAGTAGAAAGGGCTTCATCATATCAAATGC AACGTACAAAGAAATAGGGCTTCTGACCTGTGAAGCAACAGTCAATGGGCATTTGT ATAAGACAAACTATCTCACACATCGACAAACCAATACAATCATAGATGTGGTTCTG AGTCCGTCTCATGGAATTGAACTATCTGTTGGAGAAAAGCTTGTCTT AAATTGTACA GCAAGAACTGAACTAAATGTGGGGATTGACTTCAACTGGGAATACCCTTCTTCGAA GCATCAGCATAAGAAACTTGTAAACCGAGACCTAAAAACCCAGTCTGGGAGTGAGA TGAAGAAATTTTTTGAGCACCTTAACTATAGATGGTGTAACCCGGAGTGACCAAGGA TTGTACACCTGTGCAGCATCCAGTGGGCTGATGACCAAGAAGAACAGCACATTTGTC AGGGTCCATGAAAAGGAC AAAACTCACACATGCCCACCGTGCCCAGCACCTGAACT CCTGGGGGGACCGTCAGTCTTCCTCTTCCCCCCAAAACCCAAGGACACCCTCATGAT CTCCCGGACCCCTGAGGTCACATGCGTGGTGGTGGACGTGAGCCACGAAGACCCTG AGGTCAAGTTCAACTGGTACGTGGACGGCGTGGAGGTGCATAATGCCAAGACAAAG CCGCGGGAGGAGCAGTACAACAGCACGTACCGTGTGG AT GGGCAGCCGGAGAACAACTACAAGACCACGCCTCCCGTGCTGGACTCCGACGGC TCCTTCTTCCTCTACAGCAAGCTCACCGTGGACAAGAGCAGGTGGCAGCAGGGGAA CGTCTTCTCATGCTCCGTGATGCATGAGGCTCTGCACAACCACTACACGCAGAAGAG CCTCTCCCTGTCTCCGGGTAAATGA

SEQ Ш NO:2 (polypeptide sequence containing 458 amino acids):

MVSYWDTGVLLC ALLSCLLLTGS S SGSDTGRPFVEMYSEIPEIIHMTEGRELVIPC RVTSPNITVTLKKFPLDTLIPDGKRIIWDSRKGFIISNATYKEIGLLTCEATVNGHLYKTNY LTHRQTNTIID VVLSPSHGIELSVGEI<LVLNCTARTELNVGIDFNWEYPSSI<HQHI<I<LVN RDL1<TQSGSEMI<I<FL STLTIDGVTRSDQGLYTCAASSGLMTI<I<NSTFVRVHEI<DI<THT CPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEV HNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQ PREPQVYTLPPSRDELTKNQVSLTC LVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSD GSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

The scope of the present invention is not limited to the specific embodiments described in this application. Indeed, various modifications of the invention in addition to those described herein will be apparent to those skilled in the art from the foregoing description and accompanying drawings. It is intended that such modifications be covered within the scope of the appended claims.

-

Claims (12)

CLAIM 1. A method of treating diabetic retinopathy, without central diabetic macular edema, in a patient requiring such treatment, comprising administering 5 monthly doses to the patient's eye, followed by one or more secondary doses every 8 weeks of 2 mg of a VEGF antagonist, which is a chimeric VEGF receptor-based molecule containing (a) VEGFR1 immunoglobulin-like (Ig) domain 2 and (b) VEGFR2 Ig domain 3 and (c) a multimerizing component. 2. Method according to claim 1, where: (a) the VEGF antagonist (i) contains (1) a VEGFR1 component comprising amino acids 27-129 of SEQ ID NO: 2; (2) a VEGFR2 component comprising amino acids 130-231 SEQ ID NO: 2; and (3) a multimerizing component comprising amino acids 232-457 SEQ ID NO: 2; (ii) is aflibercept; or (iii) is conbercept, and/or (b) the VEGF antagonist is administered by intravitreal injection. 3. The method according to claim 1 or 2, where the patient suffers from non-proliferative diabetic retinopathy. 4. The method according to any one of claims 1 to 3, wherein the patient suffers from moderate to severe non-proliferative diabetic retinopathy. 5. The method according to any one of claims 1 to 4, wherein the patient suffers from non-proliferative diabetic retinopathy, which is characterized by a diabetic retinopathy severity level (DRSS) of 47 or 53. 6. The method of any one of claims 1 to 5, wherein the patient, before treatment, has a best-corrected visual acuity (BCVA) according to an Early Treatment Diabetic Retinopathy Study (ETDRS) letter score of 69 or higher. 7. The method according to any one of claims 1 to 6, wherein the patient's vision is characterized by a Snellen visual acuity of 20/40 or better before treatment. 8. Method according to any one of claims 1 to 7, where the patient is a human. 9. Method according to any one of claims 1 to 8, wherein the patient is a person aged 18 years or older. 10. Method according to any one of claims 1-9, where the patient does not suffer: (a) neovascularization of the retina; (b) anterior segment neovascularization (ASNV); (c) vitreous hemorrhage; and/or (d) tractional retinal detachment. 11. Method according to any one of claims 1-10, where the patient: (i) has diabetes; (ii) has a hemoglobin Alc of 8.5; (iii) has an ETDRS BCVA score of 82; (iv) has a central retinal thickness of 247 µm; (v) has a diabetic retinopathy severity score of 47 or 53; and/or (vi) is 56 years of age. 12. The method according to any one of claims 1 to 11, wherein the patient/patient is administered a VEGF antagonist for at least 24 weeks and: (a) achieves at least a 2-step improvement over baseline as measured by the DRSS; (b) achieves at least a 3-step improvement over baseline as measured by the DRSS; (c) achieves an improvement in BCVA of at least 1.9 letters as measured by the ETDRS letter grade; (d) does not experience a decrease in BCVA of more than 4 letters as measured by the ETDRS letter grade; (e) diabetic macular edema does not develop; (f) does not experience vision-threatening complications; (g) proliferative diabetic retinopathy does not develop; (h) neovascularization of the anterior segment does not develop; and/or (i) experiences a decrease in central retinal thickness of 19 µm. -