1. Phase 2 Evaluation of Intravitreal Bevacizumab for DME Sponsored by the National Eye Institute, National Institutes of Health, U.S. Department of Health and Human Services.

2. Study Objectives  Assess the dose and dose interval related effects of intravitreal bevacizumab on central retinal thickness and VA in subjects with DME  Assess the effects of intravitreal bevacizumab combined with focal photocoagulation in DME  Assess the safety of intravitreal bevacizumab in subjects with DME

3. 5 Treatment Groups Laser (0) Focal photocoagulation at baseline Bev 1.25 (0,6) 1.25 mg intravitreal bevacizumab at baseline and at 6 wks Bev 2.5 (0,6) 2.5 mg intravitreal bevacizumab at baseline and at 6 wks Bev 1.25 (0) 1.25 mg intravitreal bevacizumab at baseline with sham injection at 6 wks Bev 1.25 (0,6) + Laser (3) 1.25 mg intravitreal bevacizumab at baseline, focal photocoagulation at 3 wks, and 1.25 mg intravitreal bevacizumab at 6 wks

4. Efficacy Outcomes Central subfield thickness on OCT

5. Electronic-ETDRS Visual Acuity (EVA) Efficacy Outcomes

6. Study Phases  Weeks 0-12: no other treatment was to be given for DME in the study eye (study visits every 3 weeks)  Weeks 13-24: treatment depended on response to treatment given during the first 12 wks (study visits every 6 weeks)  After 24 weeks: follow-up for safety (study visits at 41 and at 70 weeks)

7. Study Results  Enrollment completed in 2 months 121 eyes of 121 subjects randomized 109 eyes included in efficacy analyses oExclusions:  5 baseline CSF <275 um  1 nongradable baseline OCT  1 hx of laser 3 mos prior to randomization  2 CNV with diabetic retinopathy  2 no follow-up  1 endophthalmitis 19-24 subjects in each group

8. Baseline Characteristics  Median age: 65 yrs  Women: 39%  Caucasian: 76%  Diabetes type: 1 – 7%, 2 – 93%  Median duration of diabetes: 17 yrs  No prior DME treatment: 31%

9. Baseline Characteristics  Visual Acuity Median (quartiles) letter score: 64 (71,56) approx. Snellen equivalent 20/50 (20/40,20/80)  Central Subfield Thickness Median (quartiles) microns : 411 (334, 505)

10. 1. Does 1.25 mg bevacizumab have a positive effect on DME?  Compare Laser (0) vs. Bevacizumab 1.25 mg (0,6) at 3, 6, 9, and 12 weeks

11. OCT Central Subfield Thickness Median Change (microns) from Baseline Laser (0) N=19 Bev 1.25 (0,6) N=22 P value 3w+21-35.009 6w-40-35.22 9w-53-74.14 12w-40-56.32

12. OCT Central Subfield Thickness 50% Decrease in Thickening Laser (0) N=19 Bev 1.25 (0,6) N=22 3w11%37% 6w17%30% 9w19%38% 12w21%33%

13. Visual Acuity Letter Score Median Change from Baseline Laser (0) N=19 Bev 1.25 (0,6) N=22 P value 3w-2+5.06 6w+1+5.09 9w+3+7.07 12w+5.01

14. Visual Acuity Letter Score Increase > 10 from Baseline Laser (0) N=19 Bev 1.25 (0,6) N=22 3w6%19% 6w11%32% 9w18%29% 12w16%33%

15. 2. Does 2.5 mg bevacizumab have a positive effect on DME?  Compare Laser (0) vs. Bevacizumab 2.5 mg (0,6) at 3, 6, 9, and 12 weeks

16. OCT Central Subfield Thickness Median Change (microns) from Baseline Laser (0) N=19 Bev 2.5 (0,6) N=24 P value 3w+21-86<.001 6w-40-42.08 9w-53-56.43 12w-40-47.26

17. OCT Central Subfield Thickness 50% Decrease in Thickening Laser (0) N=19 Bev 2.5 (0,6) N=24 3w11%38% 6w17%22% 9w19%22% 12w21%33%

18. Visual Acuity Letter Score Median Change from Baseline Laser (0) N=19 Bev 2.5 (0,6) N=24 P value 3w-2+6.003 6w+1+6.03 9w+3+8.02 12w+7.003

19. Visual Acuity Letter Score Increase > 10 from Baseline Laser (0) N=19 Bev 2.5 (0,6) N=24 3w6%17% 6w11%29% 9w18%39% 12w16%25%

20. 3. Does 2.5 mg bevacizumab produce a greater short-term reduction in DME than 1.25 mg?  Compare Bevacizumab 1.25 mg (0,6) vs. Bevacizumab 2.5 mg (0,6) at 3, 6, 9, and 12 weeks

21. OCT Central Subfield Thickness Median Change (microns) from Baseline Bev 1.25 (0,6) N=22 Bev 2.5 (0,6) N=24 P value 3w-35-86.66 6w-35-42.49 9w-74-56.45 12w-56-47.90

22. OCT Central Subfield Thickness 50% Decrease in Thickening Bev 1.25 (0,6) N=22 Bev 2.5 (0,6) N=24 3w37%38% 6w30%22% 9w38%22% 12w33%

23. Bev 1.25 (0,6) N=22 Bev 2.5 (0,6) N=24 P value 3w+5+6.42 6w+5+6.67 9w+7+8.48 12w+5+7.82 Visual Acuity Letter Score Median Change from Baseline

24. Bev 1.25 (0,6) N=22 Bev 2.5 (0,6) N=24 3w19%17% 6w32%29% 9w29%39% 12w33%25% Visual Acuity Letter Score Increase > 10 from Baseline

25. 4. What is the duration of effect of the initial injection?  Among eyes with a decrease in CSF thickness of >11% (the reliability limit for real change) from baseline to 3 weeks, evaluate change from 3 weeks to 6 weeks

26. Duration of Initial Injection Pooling 1.25 mg Groups [Bev 1.25 (0,6) and Bev 1.25 (0)] OCT CSF% Change 0w to 3w >11% decrease (N=14) Within +11% (N=22) >11% increase (N=2) % Change 3w to 6w >11% decrease121 Within +11%11161 >11% increase240

27. Duration of Initial Injection Bevacizumab 2.5 mg (0,6) Group OCT CSF% Change 0w to 3w >11% decrease (N=13) Within +11% (N=10) >11% increase (N=0) % Change 3w to 6w >11% decrease000 Within +11%990 >11% increase410

28. 5. What is the duration of effect of the second injection?  Among eyes with a decrease in CSF thickness of at least 11% from 6w to 9w, evaluate change from 9 weeks to 12 weeks

29. Duration of Second Injection Bevacizumab 1.25 mg (0,6) Group OCT CSF% Change 6w to 9w >11% decrease (N=7) Within +11% (N=9) >11% increase (N=2) % Change 9w to 12w >11% decrease010 Within +11%462 >11% increase320

30. Duration of Second Injection Bevacizumab 2.5 mg (0,6) Group OCT CSF% Change 6w to 9w >11% decrease (N=3) Within +11% (N=17) >11% increase (N=2) % Change 9w to 12w >11% decrease021 Within +11%2141 >11% increase110

31. 6. Is there a greater effect with bevacizumab followed by focal laser compared with bevacizumab alone?  Compare (at 12 weeks) bevacizumab 1.25 mg alone vs. bevacizumab 1.25 mg plus laser

32. Effect of Combining Focal Photocoagulation with Bevacizumab at 12 Weeks Bev 1.25 (0,6) + Laser (3) Baseline to 12w OCT CSF 50% 33%25% VA Letter Score increase > 10 33%20%

33. Subgroup Analyses at 3 Weeks pooling all bevacizumab groups Baseline CSF <400 (N=43) Baseline CSF >=400 (N=41) P value Mean CSF microns change -3-102<0.0001 Mean CSF % change in thickening -2%-26%0.12

34. Subgroup Analyses at 3 Weeks pooling all bevacizumab groups Baseline VA <65 (N=44) Baseline VA >=65 (N=43) P value Mean VA letters change +3+10.006 Mean VA % reduction in deficit +11%+7%0.40

35. Subgroup Analyses at 3 Weeks pooling all bevacizumab groups Chg in CSF thickness (microns) Chg in VA (letters) N Median P Prior treatment No Yes 26 58 0.16 -40 -29 26 61 0.04 +5 +2 Subretinal fluid Definite/Questionable No evidence 21 63 0.52 -35 -29 21 66 0.06 +6 +1

36. Subgroup Analyses at 3 Weeks pooling all bevacizumab groups  Change in CSF thickness and change in VA from baseline to 3 weeks did not significantly vary according to: Age, gender, baseline retinopathy severity, baseline clinical characterization of DME as focal or diffuse

37. Outcome during weeks 13-24  Among eyes meeting deferral criteria at 12 weeks, deferral criteria were also met at 18 weeks in: 2 of 4 eyes in Laser (0) Group 5 of 7 eyes in Bev 1.25 (0,6) Group 1 of 8 eyes in Bev 2.5 (0,6) Group 2 of 3 eyes in Bev 1.25 (0) Group 3 of 5 eyes in Bev 1.25 (0,6) + Laser (3) Group

38. Ocular Adverse Events  1 eye in the Bev 1.25 (0,6) + Laser (3) Group with endophthalmitis

39. Cardiovascular Adverse Events  Fatal MI at 16 wks (1.25 inj at 0, 6 wks)  Non-fatal MI at 1 wk (2.5 inj at 0 wks)  CHF at 12 wks (1.25 inj at 0, 7 wks)

40. Other Systemic Adverse Events  Of the 107 subjects treated with bevacizumab Death due to cancer (N=1) Peripheral vascular disease (N=1) Syncope (N=1) Elevated BP (N=3) Worsening renal function (N=3) Anemia (N=4)  Of the 12 subjects receiving only focal photocoagulation Peripheral vascular disease (N=2) Elevated BP (N=1) Worsening renal function (N=1) Anemia (N=1)

41. Comparison of APTC events in Protocols H and B (IVT Study)  B: 11 of 693 (1.6%) subjects reported an APTC event over the first 24 weeks of follow-up  H: 2 of 107 (1.9%) subjects treated with bevacizumab reported an APTC event during the first 24 weeks of follow-up

42. Conclusions 1.There is an apparent effect of 1.25 mg and 2.5 mg of bevacizumab when compared with focal photocoagulation, although the effect appears to be modest 2.It does not appear that 2.5 mg of bevacizumab has an appreciably larger effect on DME than 1.25 mg

43. Conclusions 3.Injection intervals of 4 weeks are probably more appropriate than intervals of 6 weeks 4.A study arm with combination treatment (bevacizumab plus focal photocoagulation) is feasible from a logistical standpoint

44. Conclusions The study was designed to evaluate short term effect. No conclusions should be made regarding clinical benefit. A large phase 3 randomized clinical trial is needed for this purpose.