Diabetic Retinopathy Clinical Research Network Comparative Effectiveness Study of Aflibercept, Bevacizumab, or Ranibizumab for DME Supported through a cooperative agreement from the National Eye Institute; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health, Department of Health and Human Services EY14231, EY14229, EY018817  1

Disclosure Funding/Support: Cooperative Agreement with NEI and NIDDK of NIH, U.S. Department of Health and Human Services. Additional Contributions: Regeneron Pharmaceuticals, Inc. provided the aflibercept; Genentech Inc. provided the ranibizumab. Genentech Inc. also provided funding for blood pressure cuffs and collection of plasma and urine that are not part of the main study reported herein. A complete list of all DRCR.net investigator financial disclosures can be found at www.drcr.net.

Background Intravitreous anti-vascular endothelial growth factor (anti-VEGF) injections of either aflibercept (Eylea), bevacizumab (Avastin), or ranibizumab (Lucentis) are effective in treating DME. The relative efficacy and safety of these agents within a head-to-head study were unknown prior to the results of this trial Medicare allowable charges: Aflibercept (2.0 mg): $1961 Bevacizumab (repackaged 1.25mg): $67 Ranibizumab (0.3 mg): $1189

Primary Objective For eyes with center involved DME with decreased visual acuity, compare one year efficacy and safety of, intravitreous aflibercept (Eylea®), intravitreous bevacizumab (Avastin®) and intravitreous ranibizumab (Lucentis®) Can we change to intravitreous? I know we wrote intravitreal in the protocol, but . . . Removed period

Randomized, multi-center clinical trial (N = 89 Sites) Study Design Randomized, multi-center clinical trial (N = 89 Sites) Participants meeting all of the following criteria: At least 18 years old Type 1 or type 2 diabetes Study eye meeting all of the following criteria: ~Snellen equivalent visual acuity 20/32 or worse and 20/320 or better Central-involved DME on clinical exam Central subfield (CSF) thickness ≥ protocol-defined gender and optical coherence tomography (OCT) machine-specific thresholds No history of an anti-VEGF treatment for DME in the past 12 months or any other DME treatment in the past 4 months Hyphen between protocol and defined. Hyphen between machine and specific. Primary Outcome: Change in visual acuity at one year adjusted for baseline visual acuity using the intent-to-treat principle

Treatment Schedule Through 1 Year (q4 weeks) Repeat injections at every 4-week visit if eye “improved”* or “worsened”* Otherwise, defer injections if either: Visual acuity 20/20 or better and OCT CST “normal” or, At or after 24 weeks, visual acuity and OCT stable after 2 consecutive injections Resume injections if VA or OCT worsened* *Improved/worsened defined as: ≥ 5 letter change (~1 Snellen line) from last injection, or, ≥ 10% CST change on OCT from last injection Hyphen between 4 and week CST, not CSF thickness Uncapitalized AND since it was next to OCT in all caps.

Treatment Schedule Through 1 Year Focal/grid laser: initiated at or after 24 weeks only if persistent DME not improving after at least 2 injections Edited and cut this next line and kept in notes only: Note: If fellow eye needed anti-VEGF treatment, it received same study agent as the study eye. Frequency of non-study eye treatment was at investigator discretion.

Randomization Randomly Assigned Eyes (one per participant): N = 660 Aflibercept (2.0 mg) N = 224 Bevacizumab (1.25 mg) N = 218 Ranibizumab (0.3 mg) N = 218 Baseline N = 208 (93%) N = 206 (94%) N = 206 (94%) One Year One Year Excluding Deaths 94% 97% 96%

Ocular Baseline Characteristics Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab Mean visual acuity letter score (~Snellen Equivalent) 69 (20/40) 68 (20/50) Mean OCT CST (µm) 387 376 390 Any Prior Focal/Grid Laser 36% 39% 37% Any Prior Treatment with anti-VEGF 11% 14% 13% Phakic 74% 73% 79% Changed to CST

Treatment for Diabetic Macular Edema

DME Treatment Through 1 Year: anti-VEGF and Laser Aflibercept N = 208 Bevacizumab N = 206 Ranibizumab P-Value # of Injections (Max = 13) Mean 9.2 9.7 9.4 Median (25th, 75th percentile) 9 (8, 11) 10 (8, 12) 10 (8, 11)  0.045† At least one focal/grid laser 37% 56% 46% <0.001‡ Italicized Space before and after = sign. †Global (overall 3 group comparison) P-value. Pairwise comparisons (adjusted for multiple comparisons): aflibercept-bevacizumab: P = 0.045, aflibercept-ranibizumab: P = 0.19, bevacizumab-ranibizumab: P = 0.22. ‡Global (overall 3 group comparison) P-value. Pairwise comparisons (adjusted for multiple comparisons): aflibercept-bevacizumab: P<0.001, aflibercept-ranibizumab: P = 0.058, bevacizumab-ranibizumab: P = 0.061.

Efficacy

Mean Change in Visual Acuity Letter Score, Full Cohort 52 Week Treatment Group Comparison*: Aflibercept vs. Bevacizumab P<0.001 Aflibercept vs. Ranibizumab P = 0.034 Ranibizumab vs. Bevacizumab P = 0.12 +13 +11 +10 Changed animation to Fade Primary Analysis: Markov chain Monte Carlo method of multiple imputation (100 imputations) used to estimate missing 1 year change in visual acuity * P-values adjusted for baseline visual acuity and multiple comparisons

Mean Change in Visual Acuity Letter Score Baseline Visual Acuity 20/32 to 20/40 ~50% of Cohort ~+8

Mean Change in Visual Acuity Letter Score Baseline Visual Acuity 20/50 or Worse ~ 50% of Cohort +19 +14 +12 1-Year Treatment Group Comparison*: Aflibercept vs. Bevacizumab P<0.001 Aflibercept vs. Ranibizumab P = 0.0031 Ranibizumab vs. Bevacizumab P = 0.21 Capitalized P No space after P for < Made fade * P-values adjusted for baseline visual acuity and multiple comparisons

Subgroup Analysis Baseline Best-corrected Visual Acuity 20/32-20/40 ~+8 20/50 or worse +19 +14 +12 Added 52 week score Aflibercept Bevacizumab Ranibizumab

Visual Acuity Outcomes Baseline = 20/50 or Worse >10 Letter Improvement Treatment Group Comparisons Difference CI P- Value Aflibercept vs Bevacizumab +17% +2% to +31% 0.018 Aflibercept vs Ranibizumab +10% -4% to +23% 0.20 Ranibizumab vs Bevacizumab +7% -6% to +20% 0.28

Mean (µm) Change in OCT CST Baseline visual acuity 20/32 to 20/40 -67 -119 -129 1-Year Treatment Group Comparison*: Aflibercept vs. Bevacizumab P <0.001 Aflibercept vs. Ranibizumab P = 0.057 Ranibizumab vs. Bevacizumab P = <0.001 Thinner is decreased DME * P-values adjusted for baseline visual acuity, OCT central subfield thickness, and multiple comparisons

Mean (µm) Change in OCT CST Baseline visual acuity 20/50 or Worse 1-Year Treatment Group Comparison*: Aflibercept vs. Bevacizumab P < 0.001 Aflibercept vs. Ranibizumab P = 0.22 Ranibizumab vs. Bevacizumab P = <0.001 -135 -176 -210 Thinner is decreased DME * P-values adjusted for baseline visual acuity, OCT central subfield thickness, and multiple comparisons

Safety

Ocular Adverse Events through 1 Year (Study Eye) Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab P-Value No. of injections prior to 1 year 1991 2055 2011 Endophthalmitis Inflammation† <1% 1.0 Retinal detachment/tear 0.55 Vitreous hemorrhage 2% 4% 3% 0.35 Injection related cataract IOP elevation‡ 14% 9% 11% 0.18 Changed vitreal to vitreous. No. of study eye injections prior to 1 year† 1991 2055 2011‡ † 1 year visit (If the 1 year visit was not completed, then 365 days was used.) ‡ Seven study eyes received 1 injection and 2 eyes received 2 injections of 0.5 mg of ranibizumab prior to the FDA approving a 0.3mg †Includes anterior chamber cell/flare, choroiditis, episcleritis, iritis, vitreous cells. ‡Includes intraocular pressure increase ≥10mmHg from baseline at any visit, intraocular pressure ≥30 mmHg at any visit, or initiation of intraocular pressure-lowering medications not in use at baseline. There were no glaucoma surgeries. IOP= Intraocular Pressure

Systemic Adverse Events APTC* through 1-Year Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab Non-fatal MI 2% <1% 1% Non-fatal stroke Vascular death Any APTC Event 3% 4% 5% Put P value with specific row Global P = 0.56 * Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ 1994;308:81-106.

Post Hoc Analysis: Cardiovascular Events Through 1 Year Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab Global P-Value unadjusted/ adjusted* Any Cardiovascular Event,† excluding Hypertension 9% 17% 0.0121 0.0242 Any Cardiovascular Event† 19% 16% 26% 0.0383 0.0814 * Adjusted for potential confounders: gender, age at baseline, Hemoglobin A1c at baseline, diabetes type, diabetes duration at baseline, insulin use, prior coronary artery disease, prior myocardial infarction, prior stroke, prior transient ischemic attack, prior hypertension, smoking status † Events with a MedDRA system organ class of cardiac disorder or vascular disorder OR considered by the medical monitor as related to a cardiac or vascular event (cardiac murmur, cardiac pacemaker insertion/replacement, coronary arterial stent insertion, heart rate irregular, and stent placement) Pairwise comparisons (adjusted for multiple comparisons): A-B: P=1.0, A-R: P=0.015, B-R: P = 0.014 A-B: P=0.68, A-R: P=0.040, B-R: P = 0.024 A-B: P=0.53, A-R: P=0.087, B-R: P = 0.038 A-B: P=0.37, A-R: P=0.19, B-R: P = 0.081 † Includes events with a Medical Dictionary for Regulatory Activities system organ class of cardiac disorder or vascular disorder as coded by the medical monitor. The following additional events not coded under these systems but related to a cardiac or vascular event or intervention are also included in the cardiovascular definition: cardiac murmur, cardiac pacemaker insertion/replacement, coronary arterial stent insertion, heart rate irregular, and stent placement. Participants with multiple events are only included once in the overall tabulation but could be included in more than one of the subcategories. ‡Global (overall 3 group comparison) P-value from Fisher’s Exact Test. Pairwise comparisons from Fisher’s Exact Test (adjusted for multiple comparisons by taking the maximum of the global and pairwise comparison P-values): aflibercept-bevacizumab: P=1.0, aflibercept-ranibizumab: P=0.015, bevacizumab-ranibizumab: P=0.014. Global P-value from Poisson model with robust variance estimation using the log link,4 adjusting for gender, age at baseline, Hemoglobin A1c at baseline, diabetes type, diabetes duration at baseline, insulin use, prior coronary artery disease, prior myocardial infarction, prior stroke, prior transient ischemic attack, prior hypertension, smoking status: P=0.024. Pairwise comparisons from this model (adjusted for multiple comparisons by taking the maximum of the global and pairwise comparison P-values): bevacizumab-aflibercept: P=0.68, ranibizumab-aflibercept: P=0.040, ranibizumab-bevacizumab: P=0.024. §Global (overall 3 group comparison) P-value from Fisher’s Exact Test. Pairwise comparisons from Fisher’s Exact Test (adjusted for multiple comparisons by taking the maximum of the global and pairwise comparison P-values): aflibercept-bevacizumab: P=0.53, aflibercept-ranibizumab: P=0.087, bevacizumab-ranibizumab: P=0.038. Global P-value from Poisson model with robust variance estimation using the log link,4 adjusting for gender, age at baseline, Hemoglobin A1c at baseline, diabetes type, diabetes duration at baseline, insulin use, prior coronary artery disease, prior myocardial infarction, prior stroke, prior transient ischemic attack, prior hypertension, smoking status: P=0.081. Pairwise comparisons from this model (adjusted for multiple comparisons by taking the maximum of the global and pairwise comparison P-values): bevacizumab-aflibercept: P=0.37, ranibizumab-aflibercept: P=0.19, ranibizumab-bevacizumab: P=0.081.

Discussion All three anti-VEGF agents, on average, produced substantial visual acuity improvement by 1 month, sustained through 1 year. On average, greater improvement occurred with aflibercept, but relative effect varied by initial visual acuity. Mild initial vision loss (20/32-20/40, 50% of study eyes): little difference in mean visual acuity at 1 year Worse initial vision loss: aflibercept had an advantage over the other agents Statistically significant: Mean improvement of 18.9 for aflibercept vs. 11.8 for bevacizumab (P<0.001) and vs. 14.2 with ranibizumab (P = 0.003) Clinically meaningful: For example, relative improvement ≥15 letters (>3 Snellen lines) in 63% more aflibercept-treated eyes than bevacizumab-treated eyes, and 34% more than ranibizumab-treated eyes Added on average to first bullet.

Discussion Bevacizumab had a lesser effect on reducing macular edema than the other two agents, regardless of starting acuity. Few eyes in any group had substantial visual acuity loss. Median number of injections: 9 to 10 in all three groups. Fewer eyes in the aflibercept group received focal/grid laser for DME after 24 weeks, presumably because a greater % of eyes in the aflibercept group had resolution of central DME (which drives decision to apply laser). Edits

Discussion Serious adverse event, death, and hospitalization rates appeared similar among treatment groups. Significant differences in frequencies of major cardiovascular events were not identified However, post-hoc analysis combining MedDRA system organ classes of cardiac and vascular resulted in more participants in the ranibizumab group reporting these adverse events. This is inconsistent with prior studies and may be due to chance. Endophthalmitis was rare: 0.02% of injections. No differences in intraocular inflammation.

Conclusion All three anti-VEGF agents are effective treatments for DME causing vision impairment. When initial visual acuity loss is mild, on average there is little difference in visual acuity at 1-year. At worse levels of initial visual acuity aflibercept is more effective at improving vision. Made last bullet one sentence

Thank You on Behalf of Diabetic Retinopathy Clinical Research Network (DRCR.net) A complete list of all DRCR.net investigator financial disclosures and these slides can be found at www.drcr.net. Full protocol available on clinicalTrials.gov (NCT01627249) Reference: DOI: 10.1056/NEJMoa1414264 Diabetic Retinopathy Clinical Research Network. Aflibercept, ranibizumab, or bevacizumab for diabetic macular edema. NEJM 2015;372:xxx-xxx. Need to add page numbers. 28