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    Clinical Trial Results:
    Prospective, randomized, multicentre, open label, phase II / III study to assess efficacy and safety of ranibizumab 0.5 mg intravitreal injections plus panretinal photocoagulation (PRP) versus PRP in monotherapy in the treatment of subjects with high risk proliferative diabetic retinopathy. (PROTEUS)

    Summary
    EudraCT number
    2013-003640-23
    Trial protocol
    GB   PT  
    Global end of trial date
    27 May 2016

    Results information
    Results version number
    v1(current)
    This version publication date
    05 Jul 2018
    First version publication date
    05 Jul 2018
    Other versions
    Summary report(s)
    Study Report Synopsis

    Trial information

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    Trial identification
    Sponsor protocol code
    ECR-RET-2013-05
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT01941329
    WHO universal trial number (UTN)
    -
    Sponsors
    Sponsor organisation name
    AIBILI
    Sponsor organisation address
    Azinhaga de Santa Comba, Celas, 3000-548 Coimbra – Portugal , Coimbra, Portugal, 3000-548
    Public contact
    4C- Coimbra Coordinating Centre for Clinical Research , AIBILI - Association for Innovation and Biomedical Research on Light and Image, +351 2394801131, 4c@aibili.pt
    Scientific contact
    4C- Coimbra Coordinating Centre for Clinical Research , AIBILI - Association for Innovation and Biomedical Research on Light and Image, +351 2394801131, 4c@aibili.pt
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    21 Oct 2016
    Is this the analysis of the primary completion data?
    Yes
    Primary completion date
    27 May 2016
    Global end of trial reached?
    Yes
    Global end of trial date
    27 May 2016
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    To compare the efficacy of ranibizumab 0.5 mg intravitreal injections plus panretinal photocoagulation versus panretinal photocoagulation alone on the regression of the neovascularization area in patients with high-risk proliferative diabetic retinopathy over a 12-month treatment period.
    Protection of trial subjects
    All the measures were taken to ensure subject safety. Study medication was dispensed to the subjects of the Study Group according to the study protocol. The Principal Investigator and all clinical study staff conducted the clinical study in compliance with the protocol. The Principal Investigator ensured that all personnel involved in the conduct of the study were qualified to perform their assigned responsibilities through relevant education, training and experience. To ensure data confidentiality each subject was uniquely identified by a subject identification code. Only the Investigator was able to identify the subject based on the subject identification code.
    Background therapy
    -
    Evidence for comparator
    -
    Actual start date of recruitment
    28 Mar 2014
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    No
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Portugal: 33
    Country: Number of subjects enrolled
    United Kingdom: 19
    Country: Number of subjects enrolled
    France: 14
    Country: Number of subjects enrolled
    Italy: 21
    Worldwide total number of subjects
    87
    EEA total number of subjects
    87
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    68
    From 65 to 84 years
    18
    85 years and over
    1

    Subject disposition

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    Recruitment
    Recruitment details
    The study population was recruited by each Investigator from his/her clinical practice and the planned study population was 94 patients. The recruitment started on 28/03/2014, the FPFV was on 04/04/2014 and the LPLV was on 31/03/2015 (1 year of recruitment period).

    Pre-assignment
    Screening details
    Subjects who signed the informed consent form participated in a screening period, lasting 1 to 30 days, to evaluate eligibility (inclusion and exclusion criteria). 122 patients were screened (87 enrolled and 35 screening failures).

    Period 1
    Period 1 title
    Loading Phase
    Is this the baseline period?
    Yes
    Allocation method
    Randomised - controlled
    Blinding used
    Not blinded
    Blinding implementation details
    This is an open-label study. Blinding/unblinding procedures are not applicable.

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Study Group
    Arm description
    The study subjects received between Month-0 and Month-2 (3-months Loading Phase) 3 ranibizumab ITV injections in Month-0, Month-1 and Month-2 combined with the standard Panretinal Photocoagulation (PRP) treatment, i.e., with 1 mandatory laser session 2 ± 1 weeks after the 1st ITV injection (Month-0) and a maximum of 2 laser sessions, one 2 ± 1 weeks after the 2nd ITV injection (Month-1) and another 2 ± 1 weeks after the 3rd ITV injection (Month-2) to complete the PRP treatment.
    Arm type
    Experimental

    Investigational medicinal product name
    Ranibizumab
    Investigational medicinal product code
    S01LA04
    Other name
    Lucentis
    Pharmaceutical forms
    Solution for injection
    Routes of administration
    Intravitreal use
    Dosage and administration details
    Intravitreal injection of ranibizumab (0.5mg)

    Arm title
    Control Group
    Arm description
    The control subjects received between Month-0 and Month-2 (3-months Loading Phase) the standard Panretinal Photocoagulation (PRP) treatment, with 1 mandatory laser session in Month-0 and more laser sessions as needed until Month-2 to complete the PRP treatment.
    Arm type
    Active comparator (surgical procedure)

    Investigational medicinal product name
    No investigational medicinal product assigned in this arm
    Number of subjects in period 1
    Study Group Control Group
    Started
    41
    46
    Completed
    41
    45
    Not completed
    0
    1
         Lost to follow-up
    -
    1
    Period 2
    Period 2 title
    Treatment Phase/Follow-up Visits
    Is this the baseline period?
    No
    Allocation method
    Not applicable
    Blinding used
    Not blinded
    Blinding implementation details
    This is an open-label study. Blinding/unblinding procedures are not applicable.

    Arms
    Are arms mutually exclusive
    Yes

    Arm title
    Study Group
    Arm description
    From Month-3 to Month-11 (9-months Follow-Up/ Treatment Phase), combination treatment composed of 1 ranibizumab ITV injection plus 1 Panretinal Photocoagulation (PRP) session (2 ± 1 weeks after the injection) could be performed respecting always at least 1 month of interval between ITV injections. In every visit, the Investigator evaluated whether treatment should be repeated. Treatment was repeated if NV was still present (due to lack of regression or due to recurrence) and if the Investigator considered that a new treatment may bring benefit to the subject and reduce the NV area. In the Follow-up PRP treatments were performed using fill-in techniques.
    Arm type
    Experimental

    Investigational medicinal product name
    Ranibizumab
    Investigational medicinal product code
    S01LA04
    Other name
    Lucentis
    Pharmaceutical forms
    Solution for injection
    Routes of administration
    Intravitreal use
    Dosage and administration details
    Intravitreal injection of ranibizumab (0.5mg)

    Arm title
    Control Group
    Arm description
    From Month-3 to Month-11 (9-months Follow-Up/ Treatment Phase) patients received Panretinal Photocoagulation (PRP) as needed.
    Arm type
    Active comparator (surgical procedure)

    Investigational medicinal product name
    No investigational medicinal product assigned in this arm
    Number of subjects in period 2
    Study Group Control Group
    Started
    41
    45
    Completed
    39
    38
    Not completed
    2
    7
         Adverse event, non-fatal
    1
    6
         Lost to follow-up
    -
    1
         Lack of efficacy
    1
    -

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    Study Group
    Reporting group description
    The study subjects received between Month-0 and Month-2 (3-months Loading Phase) 3 ranibizumab ITV injections in Month-0, Month-1 and Month-2 combined with the standard Panretinal Photocoagulation (PRP) treatment, i.e., with 1 mandatory laser session 2 ± 1 weeks after the 1st ITV injection (Month-0) and a maximum of 2 laser sessions, one 2 ± 1 weeks after the 2nd ITV injection (Month-1) and another 2 ± 1 weeks after the 3rd ITV injection (Month-2) to complete the PRP treatment.

    Reporting group title
    Control Group
    Reporting group description
    The control subjects received between Month-0 and Month-2 (3-months Loading Phase) the standard Panretinal Photocoagulation (PRP) treatment, with 1 mandatory laser session in Month-0 and more laser sessions as needed until Month-2 to complete the PRP treatment.

    Reporting group values
    Study Group Control Group Total
    Number of subjects
    41 46 87
    Age categorical
    Units: Subjects
        Adults (18-64 years)
    29 39 68
        From 65-84 years
    11 7 18
        85 years and over
    1 0 1
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    58.83 ( 13.32 ) 52.02 ( 11.86 ) -
    Gender categorical
    Units: Subjects
        Female
    13 19 32
        Male
    28 27 55
    Neovascularization Total area
    Units: Disc area
        arithmetic mean (standard deviation)
    1.93 ( 2.21 ) 3.07 ( 5.66 ) -
    Neovascularization in the Disc area
    Units: Disc area
        arithmetic mean (standard deviation)
    0.41 ( 1.13 ) 0.58 ( 2.00 ) -
    Neovascularization Elsewhere area
    Units: Disc area
        arithmetic mean (standard deviation)
    1.51 ( 1.96 ) 2.49 ( 4.63 ) -
    Best-Corrected Visual Acuity
    Units: Letters
        arithmetic mean (standard deviation)
    76.12 ( 10.39 ) 75.13 ( 10.67 ) -
    Retinal Thickness in the Central Subfield
    Units: Micrometer
        arithmetic mean (standard deviation)
    292.59 ( 37.52 ) 300.41 ( 38.12 ) -
    Retinal Thickness in the Inner Ring Inferior
    Units: Micrometer
        arithmetic mean (standard deviation)
    341.80 ( 37.20 ) 354.24 ( 37.87 ) -
    Retinal Thickness in the Inner Ring Nasal
    Units: Micrometer
        arithmetic mean (standard deviation)
    354.88 ( 34.99 ) 361.83 ( 30.77 ) -
    Retinal Thickness in the Inner Ring Superior
    Units: Micrometer
        arithmetic mean (standard deviation)
    350.37 ( 35.00 ) 362.58 ( 47.57 ) -
    Retinal Thickness in the Inner Ring Temporal
    Units: Micrometer
        arithmetic mean (standard deviation)
    342.44 ( 40.08 ) 358.17 ( 44.43 ) -
    Retinal Thickness in the Outer Ring Inferior
    Units: Micrometer
        arithmetic mean (standard deviation)
    303.63 ( 30.23 ) 311.80 ( 31.79 ) -
    Retinal Thickness in the Outer Ring Nasal
    Units: Micrometer
        arithmetic mean (standard deviation)
    329.00 ( 27.05 ) 338.40 ( 33.80 ) -
    Retinal Thickness in the Outer Ring Superior
    Units: Micrometer
        arithmetic mean (standard deviation)
    320.00 ( 42.07 ) 331.29 ( 49.08 ) -
    Retinal Thickness in the Outer Ring Temporal
    Units: Micrometer
        arithmetic mean (standard deviation)
    312.68 ( 50.39 ) 328.67 ( 51.00 ) -
    Subject analysis sets

    Subject analysis set title
    Full Analysis Set (FAS)
    Subject analysis set type
    Full analysis
    Subject analysis set description
    The Full Analysis Set (FAS), consistently with ICH Guideline E9, Statistical Principles for Clinical Trials, include all randomized subjects receiving at least one study treatment and having a baseline and at least one post-baseline measurements on the primary outcome (85 patients). Subjects with major entry violations likely to affect outcome were excluded by blind review. The carrying forward of the last observation, an imputation technique, was used to compensate for missing data on the primary outcome.

    Subject analysis set title
    Per Protocol (PP)
    Subject analysis set type
    Per protocol
    Subject analysis set description
    The Per Protocol (PP) population defines a subset of the subjects in the FAS who are more compliant with the protocol and is characterised by the availability of measurements of the primary variable and the absence of any major protocol violations (57 patients). Only observed data was used in the PP population; i.e. missing data was not imputed.

    Subject analysis set title
    Safety Analysis
    Subject analysis set type
    Safety analysis
    Subject analysis set description
    The safety analysis population consists of subjects who received at least one treatment (ITV injections plus PRP or PRP alone).

    Subject analysis sets values
    Full Analysis Set (FAS) Per Protocol (PP) Safety Analysis
    Number of subjects
    85
    57
    87
    Age categorical
    Units: Subjects
        Adults (18-64 years)
    66
    43
    68
        From 65-84 years
    18
    13
    18
        85 years and over
    1
    1
    1
    Age continuous
    Units: years
        arithmetic mean (standard deviation)
    55.54 ( 12.83 )
    56.7 ( 12.32 )
    55.23 ( 12.95 )
    Gender categorical
    Units: Subjects
        Female
    32
    19
    32
        Male
    53
    38
    55
    Neovascularization Total area
    Units: Disc area
        arithmetic mean (standard deviation)
    2.55 ( 4.45 )
    2.32 ( 4.71 )
    2.53 ( 4.4 )
    Neovascularization in the Disc area
    Units: Disc area
        arithmetic mean (standard deviation)
    0.51 ( 1.66 )
    0.43 ( 1.13 )
    0.50 ( 1.64 )
    Neovascularization Elsewhere area
    Units: Disc area
        arithmetic mean (standard deviation)
    2.04 ( 3.68 )
    1.89 ( 4.17 )
    2.03 ( 3.64 )
    Best-Corrected Visual Acuity
    Units: Letters
        arithmetic mean (standard deviation)
    75.69 ( 10.43 )
    76.14 ( 10.20 )
    75.60 ( 10.49 )
    Retinal Thickness in the Central Subfield
    Units: Micrometer
        arithmetic mean (standard deviation)
    297.54 ( 37.88 )
    299.02 ( 37.81 )
    296.72 ( 37.83 )
    Retinal Thickness in the Inner Ring Inferior
    Units: Micrometer
        arithmetic mean (standard deviation)
    348.82 ( 38.15 )
    346.47 ( 39.38 )
    348.31 ( 37.85 )
    Retinal Thickness in the Inner Ring Nasal
    Units: Micrometer
        arithmetic mean (standard deviation)
    358.89 ( 33.10 )
    357.16 ( 33.80 )
    358.55 ( 32.82 )
    Retinal Thickness in the Inner Ring Superior
    Units: Micrometer
        arithmetic mean (standard deviation)
    357.48 ( 42.16 )
    353.72 ( 41.84 )
    356.76 ( 42.26 )
    Retinal Thickness in the Inner Ring Temporal
    Units: Micrometer
        arithmetic mean (standard deviation)
    351.75 ( 42.60 )
    349.12 ( 44.27 )
    350.76 ( 42.93 )
    Retinal Thickness in the Outer Ring Inferior
    Units: Micrometer
        arithmetic mean (standard deviation)
    308.61 ( 31.10 )
    307.47 ( 31.57 )
    307.91 ( 31.15 )
    Retinal Thickness in the Outer Ring Nasal
    Units: Micrometer
        arithmetic mean (standard deviation)
    334.55 ( 31.03 )
    334.74 ( 32.62 )
    333.92 ( 30.95 )
    Retinal Thickness in the Outer Ring Superior
    Units: Micrometer
        arithmetic mean (standard deviation)
    326.70 ( 46.19 )
    327.47 ( 51.05 )
    325.91 ( 45.96 )
    Retinal Thickness in the Outer Ring Temporal
    Units: Micrometer
        arithmetic mean (standard deviation)
    322.27 ( 50.92 )
    318.21 ( 50.53 )
    321.05 ( 51.05 )

    End points

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    End points reporting groups
    Reporting group title
    Study Group
    Reporting group description
    The study subjects received between Month-0 and Month-2 (3-months Loading Phase) 3 ranibizumab ITV injections in Month-0, Month-1 and Month-2 combined with the standard Panretinal Photocoagulation (PRP) treatment, i.e., with 1 mandatory laser session 2 ± 1 weeks after the 1st ITV injection (Month-0) and a maximum of 2 laser sessions, one 2 ± 1 weeks after the 2nd ITV injection (Month-1) and another 2 ± 1 weeks after the 3rd ITV injection (Month-2) to complete the PRP treatment.

    Reporting group title
    Control Group
    Reporting group description
    The control subjects received between Month-0 and Month-2 (3-months Loading Phase) the standard Panretinal Photocoagulation (PRP) treatment, with 1 mandatory laser session in Month-0 and more laser sessions as needed until Month-2 to complete the PRP treatment.
    Reporting group title
    Study Group
    Reporting group description
    From Month-3 to Month-11 (9-months Follow-Up/ Treatment Phase), combination treatment composed of 1 ranibizumab ITV injection plus 1 Panretinal Photocoagulation (PRP) session (2 ± 1 weeks after the injection) could be performed respecting always at least 1 month of interval between ITV injections. In every visit, the Investigator evaluated whether treatment should be repeated. Treatment was repeated if NV was still present (due to lack of regression or due to recurrence) and if the Investigator considered that a new treatment may bring benefit to the subject and reduce the NV area. In the Follow-up PRP treatments were performed using fill-in techniques.

    Reporting group title
    Control Group
    Reporting group description
    From Month-3 to Month-11 (9-months Follow-Up/ Treatment Phase) patients received Panretinal Photocoagulation (PRP) as needed.

    Subject analysis set title
    Full Analysis Set (FAS)
    Subject analysis set type
    Full analysis
    Subject analysis set description
    The Full Analysis Set (FAS), consistently with ICH Guideline E9, Statistical Principles for Clinical Trials, include all randomized subjects receiving at least one study treatment and having a baseline and at least one post-baseline measurements on the primary outcome (85 patients). Subjects with major entry violations likely to affect outcome were excluded by blind review. The carrying forward of the last observation, an imputation technique, was used to compensate for missing data on the primary outcome.

    Subject analysis set title
    Per Protocol (PP)
    Subject analysis set type
    Per protocol
    Subject analysis set description
    The Per Protocol (PP) population defines a subset of the subjects in the FAS who are more compliant with the protocol and is characterised by the availability of measurements of the primary variable and the absence of any major protocol violations (57 patients). Only observed data was used in the PP population; i.e. missing data was not imputed.

    Subject analysis set title
    Safety Analysis
    Subject analysis set type
    Safety analysis
    Subject analysis set description
    The safety analysis population consists of subjects who received at least one treatment (ITV injections plus PRP or PRP alone).

    Primary: Neovascularization area reduction

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    End point title
    Neovascularization area reduction
    End point description
    The primary endpoint was defined as the regression of neovascularization (NV) from baseline to the 12-month visit, measured in disc area units based on Color Fundus Photography and Fluorescein Angiography. Regression of NV was defined as any decrease of the area of neovascularization.
    End point type
    Primary
    End point timeframe
    From Baseline to the 12-month visit
    End point values
    Study Group Control Group Full Analysis Set (FAS)
    Number of subjects analysed
    41
    44
    85
    Units: 85
        Yes
    38
    31
    69
        No
    3
    13
    16
    Statistical analysis title
    Primary efficacy analysis with ITT population
    Statistical analysis description
    The null (H0) and alternative (H1) hypotheses to be tested in the primary efficacy analysis are: H0: there is no difference between groups for the number of subjects with neovascularization reduction (at Month-12). H1: there is a difference between groups for the number of subjects with neovascularization reduction (at Month-12). This hypothesis will be tested using Chi-square test with two-sided Alpha = 0.05.
    Comparison groups
    Control Group v Study Group
    Number of subjects included in analysis
    85
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    ≤ 0.05
    Method
    Chi-squared
    Confidence interval

    Primary: Neovascularization area reduction

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    End point title
    Neovascularization area reduction
    End point description
    The primary endpoint was defined as the regression of neovascularization (NV) from baseline to the 12-month visit, measured in disc area units based on Color Fundus Photography and Fluorescein Angiography. Regression of NV was defined as any decrease of the area of neovascularization.
    End point type
    Primary
    End point timeframe
    From baseline to Month-12
    End point values
    Study Group Control Group Per Protocol (PP)
    Number of subjects analysed
    29
    28
    57
    Units: 57
        Yes
    27
    18
    45
        No
    2
    10
    12
    Statistical analysis title
    Primary efficacy analysis with PP population
    Statistical analysis description
    The null (H0) and alternative (H1) hypotheses to be tested in the primary efficacy analysis are: H0: there is no difference between groups for the number of subjects with neovascularization reduction (at Month-12). H1: there is a difference between groups for the number of subjects with neovascularization reduction (at Month-12). This hypothesis will be tested using Chi-square test with two-sided Alpha = 0.05.
    Comparison groups
    Study Group v Control Group
    Number of subjects included in analysis
    57
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    ≤ 0.05
    Method
    Chi-squared
    Confidence interval

    Secondary: Best-Corrected Visual Acuity difference

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    End point title
    Best-Corrected Visual Acuity difference
    End point description
    Best-Corrected Visual Acuity changes from baseline to Month-12.
    End point type
    Secondary
    End point timeframe
    From baseline to Month-12
    End point values
    Study Group Control Group Full Analysis Set (FAS)
    Number of subjects analysed
    41
    44
    85
    Units: Letters
        arithmetic mean (standard deviation)
    -0.90 ( 12.08 )
    -5.81 ( 15.08 )
    -3.42 ( 13.84 )
    Statistical analysis title
    BCVA changes
    Statistical analysis description
    Best-Corrected Visual Acuity changes from baseline to Month-12 were tested using Student’s T test
    Comparison groups
    Control Group v Study Group
    Number of subjects included in analysis
    85
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    ≤ 0.05
    Method
    t-test, 2-sided
    Confidence interval

    Secondary: Time to complete neovascularization regression

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    End point title
    Time to complete neovascularization regression
    End point description
    Survival analysis was carried out to compare time to complete neovascularization regression between groups.
    End point type
    Secondary
    End point timeframe
    One year
    End point values
    Study Group Control Group Full Analysis Set (FAS)
    Number of subjects analysed
    41
    44
    85
    Units: 85
        At month 3
    29
    5
    34
        At month 7
    3
    2
    5
        At month 12
    1
    4
    5
    Statistical analysis title
    Time to complete neovascularization regression
    Statistical analysis description
    Survival analysis (log-rank test) was carried out to compare Time to complete NV regression between groups.
    Comparison groups
    Study Group v Control Group
    Number of subjects included in analysis
    85
    Analysis specification
    Pre-specified
    Analysis type
    other
    P-value
    ≤ 0.05
    Method
    Logrank
    Confidence interval

    Secondary: Recurrence of neovascularization

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    End point title
    Recurrence of neovascularization
    End point description
    Recurrence of neovascularization during the follow-up period.
    End point type
    Secondary
    End point timeframe
    One year
    End point values
    Study Group Control Group Full Analysis Set (FAS)
    Number of subjects analysed
    41
    44
    85
    Units: 85
        Yes
    27
    20
    47
        No
    13
    15
    28
    Statistical analysis title
    Recurrence of neovascularization
    Statistical analysis description
    Recurrence of neovascularization was tested using Fisher's exact test.
    Comparison groups
    Study Group v Control Group
    Number of subjects included in analysis
    85
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    ≤ 0.05
    Method
    Fisher exact
    Confidence interval

    Secondary: Macular retinal thickness, assessed by OCT, difference

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    End point title
    Macular retinal thickness, assessed by OCT, difference
    End point description
    Macular retinal thickness changes from baseline to Month-12, in the central subfield, in the inner ring inferior, nasal superior and temporal, and in the outer ring inferior, nasal superior and temporal.
    End point type
    Secondary
    End point timeframe
    From baseline to Month-12
    End point values
    Study Group Control Group Full Analysis Set (FAS)
    Number of subjects analysed
    41
    44
    85
    Units: μm
    arithmetic mean (standard deviation)
        In the Central Subfield
    7 ( 33.49 )
    21.68 ( 75.26 )
    14.6 ( 59.06 )
        In the Inner Ring Inferior
    4.07 ( 61.55 )
    18.6 ( 57.35 )
    11.51 ( 59.53 )
        In the Inner Ring Nasal
    7.93 ( 65.12 )
    21.32 ( 56.32 )
    14.86 ( 60.73 )
        In the Inner Ring Superior
    0.66 ( 19.94 )
    11.51 ( 45.24 )
    6.21 ( 35.46 )
        In the Inner Ring Temporal
    0.73 ( 32.08 )
    8.23 ( 52.1 )
    4.61 ( 43.52 )
        In the outer ring inferior
    -1.32 ( 18.98 )
    13.6 ( 41.92 )
    6.32 ( 33.45 )
        in the outer ring nasal
    4.15 ( 27.11 )
    14.4 ( 52.46 )
    9.39 ( 42.11 )
        in the outer ring superior
    4.93 ( 45.23 )
    5.72 ( 38.12 )
    5.33 ( 41.49 )
        in the outer ring temporal
    -0.73 ( 35.63 )
    6.88 ( 37.96 )
    3.17 ( 36.82 )
    Statistical analysis title
    Macular retinal thickness changes
    Statistical analysis description
    Macular retinal thickness changes from baseline to Month-12 for the study and control groups were tested using Student’s T test.
    Comparison groups
    Study Group v Control Group
    Number of subjects included in analysis
    85
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    ≤ 0.05
    Method
    t-test, 2-sided
    Confidence interval

    Secondary: Need of treatment for Diabetic Macular Edema

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    End point title
    Need of treatment for Diabetic Macular Edema
    End point description
    Subjects that needed treatment for DME in the control group and in the study group.
    End point type
    Secondary
    End point timeframe
    One year.
    End point values
    Study Group Control Group Safety Analysis
    Number of subjects analysed
    41
    44
    87
    Units: 85
        Yes
    0
    2
    2
        No
    41
    42
    85
    Statistical analysis title
    Need of treatment for DME
    Statistical analysis description
    Need of treatment for DME was tested using Fisher's exact test.
    Comparison groups
    Study Group v Control Group
    Number of subjects included in analysis
    85
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    ≤ 0.05
    Method
    Fisher exact
    Confidence interval

    Secondary: Need of vitrectomy

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    End point title
    Need of vitrectomy
    End point description
    Need of vitrectomy due to the occurrence of vitreous hemorrhage, tractional retinal detachment or other complications of Diabetic Retinopathy.
    End point type
    Secondary
    End point timeframe
    One year.
    End point values
    Study Group Control Group Safety Analysis
    Number of subjects analysed
    41
    44
    87
    Units: 85
        Yes
    1
    5
    6
        No
    40
    39
    81
    Statistical analysis title
    Need of vitrectomy
    Statistical analysis description
    Need of vitrectomy due to the occurrence of vitreous haemorrhage, tractional retinal detachment or other complications of Diabetic Retinopathy was tested using Fisher's exact test.
    Comparison groups
    Control Group v Study Group
    Number of subjects included in analysis
    85
    Analysis specification
    Pre-specified
    Analysis type
    superiority
    P-value
    ≤ 0.05
    Method
    Fisher exact
    Confidence interval

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    All Adverse Events reported by the subject (spontaneously or via study interview) were collected from the first day until 30 days after discontinuation/completion of study participation even if the event was not considered to be related to study drug.
    Adverse event reporting additional description
    In case of Serious Adverse Events (SAEs), the Investigator immediately reported to the Sponsor all SAEs with the exception of those that were identified as not requiring immediate reporting in protocol. The Investigator filled in a SAE Form within 24 hours of learning of its occurrence.
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    18.1
    Reporting groups
    Reporting group title
    Study Group
    Reporting group description
    Patients received Ranibizumab and Standard PRP (Panretinal Photocoagulation) (2±1 weeks after ITV).

    Reporting group title
    Control Group
    Reporting group description
    Patients received Standard PRP (panretinal photocoagulation)

    Serious adverse events
    Study Group Control Group
    Total subjects affected by serious adverse events
         subjects affected / exposed
    5 / 41 (12.20%)
    7 / 46 (15.22%)
         number of deaths (all causes)
    0
    0
         number of deaths resulting from adverse events
    Surgical and medical procedures
    Back surgery
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Below knee amputation
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Stem cell transplant
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Cardiac disorders
    Myocardial infarction
         subjects affected / exposed
    0 / 41 (0.00%)
    2 / 46 (4.35%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Nervous system disorders
    Hypoglycaemic coma
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Ischaemic stroke
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Sciatica
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Subarachnoid haemorrhage
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Eye disorders
    Subretinal haemorrhage
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Vitreous haemorrhage
         subjects affected / exposed
    1 / 41 (2.44%)
    3 / 46 (6.52%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 3
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Skin and subcutaneous tissue disorders
    Diabetic foot
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Foot ulcer
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Musculoskeletal and connective tissue disorders
    Slipped disc
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Infections and infestations
    Epididymitis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Orchitis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Metabolism and nutrition disorders
    Food intolerance
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences causally related to treatment / all
    0 / 0
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Ketoacidosis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences causally related to treatment / all
    0 / 1
    0 / 0
         deaths causally related to treatment / all
    0 / 0
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 0%
    Non-serious adverse events
    Study Group Control Group
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    21 / 41 (51.22%)
    21 / 46 (45.65%)
    Vascular disorders
    Hypertension arterial
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Peripheral vascular disease
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Surgical and medical procedures
    Coronary stent placement
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Eye operation NOS
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Intraocular lens implant
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Phacoemulsification
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Vitrectomy
         subjects affected / exposed
    2 / 41 (4.88%)
    1 / 46 (2.17%)
         occurrences all number
    2
    1
    General disorders and administration site conditions
    Fever
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Immune system disorders
    Allergic reaction
         subjects affected / exposed
    1 / 41 (2.44%)
    1 / 46 (2.17%)
         occurrences all number
    1
    1
    Reproductive system and breast disorders
    Benign prostatic hypertrophy
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Investigations
    Blood urea nitrogen abnormal
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Gamma GT raised
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Intraocular pressure high
         subjects affected / exposed
    2 / 41 (4.88%)
    4 / 46 (8.70%)
         occurrences all number
    3
    4
    Serum creatinine increased
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Injury, poisoning and procedural complications
    Corneal abrasion
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Wound dehiscence
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Cardiac disorders
    Arrhythmia
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Nervous system disorders
    Phantom limb pain
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Tingling feet/hands
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Blood and lymphatic system disorders
    Anaemia
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    2
    0
    Leukocytosis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Pancytopenia
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Ear and labyrinth disorders
    Ear ache
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Eye disorders
    Allergic conjunctivitis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Anterior uveitis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Cataract
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Cataract cortical
         subjects affected / exposed
    0 / 41 (0.00%)
    2 / 46 (4.35%)
         occurrences all number
    0
    3
    Cataract nuclear
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Diabetic macular edema
         subjects affected / exposed
    1 / 41 (2.44%)
    2 / 46 (4.35%)
         occurrences all number
    1
    2
    Dry Eyes
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Hypertension ocular
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Macular fibrosis
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Panuveitis
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Proliferative diabetic retinopathy
         subjects affected / exposed
    2 / 41 (4.88%)
    0 / 46 (0.00%)
         occurrences all number
    2
    0
    Retinal detachment
         subjects affected / exposed
    0 / 41 (0.00%)
    2 / 46 (4.35%)
         occurrences all number
    0
    2
    Rubeosis iridis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Subretinal haemorrhage
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Uveitis
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Visual acuity decreased
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Vitreous floater
         subjects affected / exposed
    0 / 41 (0.00%)
    2 / 46 (4.35%)
         occurrences all number
    0
    2
    Vitreous haemorrhage
         subjects affected / exposed
    9 / 41 (21.95%)
    4 / 46 (8.70%)
         occurrences all number
    10
    6
    Gastrointestinal disorders
    Diarrhoea
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Vomiting
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Hepatobiliary disorders
    Fatty liver
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Gallstones
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Skin and subcutaneous tissue disorders
    Blister
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Rash pruritic
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Musculoskeletal and connective tissue disorders
    Arthritis
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Fistula
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Infections and infestations
    Abscess on buttock
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    2
    Abscesses of skin
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Chest infection
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    2
    0
    Cold
         subjects affected / exposed
    1 / 41 (2.44%)
    1 / 46 (2.17%)
         occurrences all number
    1
    2
    Conjunctivitis
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Ear, nose and throat infection
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Flu
         subjects affected / exposed
    4 / 41 (9.76%)
    1 / 46 (2.17%)
         occurrences all number
    4
    1
    Foot ulcer
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Lower respiratory tract infection
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    3
    0
    Unspecified suppurative otitis media
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1
    Urinary tract infection
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Viral conjunctivitis
         subjects affected / exposed
    1 / 41 (2.44%)
    0 / 46 (0.00%)
         occurrences all number
    1
    0
    Metabolism and nutrition disorders
    Hypercholesterolaemia
         subjects affected / exposed
    0 / 41 (0.00%)
    1 / 46 (2.17%)
         occurrences all number
    0
    1

    More information

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    23 Oct 2013
    Changes requested by the Voluntary Harmonization Procedure in sections: Type / Design of the Study; Exclusion Criteria; Treatment arms and Study Treatment Procedure; Instructions for Prescribing and Performing / Taking the Study Treatment / Medication; and Safety Monitoring.

    Interruptions (globally)

    Were there any global interruptions to the trial? No

    Limitations and caveats

    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported

    Online references

    http://www.ncbi.nlm.nih.gov/pubmed/29395119
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