TREATMENTS OF DIABETIC MACULAR EDEMA AND IMPAIRED VISUAL ACUITY

Abstract

The present invention relates to treatments of diabetic macular edema (DME) and impaired visual acuity, comprising intravitreally administering the compound of formula (A) (or a pharmaceutically acceptable salt and/or solvate thereof): Formula (A).

##STR00001##

Claims

1. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use in treating diabetic macular edema (DME) or impaired visual acuity comprising: intravitreally administering a pharmaceutical composition, wherein the pharmaceutical composition is a solution comprising the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof), to a patient in need thereof, ##STR00040## wherein the patient has previously had anti-VEGF (vascular endothelial growth factor) treatment.

2. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the pharmaceutical composition is an aqueous solution comprising the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof).

3. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein intravitreal administration comprises intravitreal injection.

4. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the pharmaceutical composition is intravitreally administered into at least one of the patient's eye; optionally wherein the pharmaceutical composition is intravitreally administered into both of the patient's eyes.

5. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the solution further comprises at least one non-ionic tonicity agent and/or histidine; preferably wherein the at least one non-ionic tonicity agent is trehalose; preferably wherein the trehalose is provided as trehalose dihydrate.

6. (canceled)

7. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the pharmaceutical composition comprises an aqueous solution of the compound of formula A (or a pharmaceutically acceptable salt and/or solvate thereof), histidine and trehalose dihydrate.

8. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the pharmaceutical composition has a pH from about 2 to about 10, preferably from about 5 to about 7.5, preferably from about 5.3 to about 6, and preferably from about 5.4 to about 5.8; preferably wherein the pharmaceutical composition has a pH of about 5.5.

9. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 10 μg/mL and about 200 μg/mL based on the concentration of the free base of the compound of Formula A in solution; optionally wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 20 μg/mL and about 200 μg/mL based on the concentration of the free base of the compound of Formula A in solution; optionally wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 20 μg/mL and about 160 μg/mL based on the concentration of the free base of the compound of Formula A in solution; optionally wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 20 μg/mL and about 120 μg/mL based on the concentration of the free base of the compound of Formula A in solution; optionally wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 20 μg/mL and about 100 μg/mL based on the concentration of the free base of the compound of Formula A in solution.

10. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 30 μg/mL and about 100 μg/mL based on the concentration of the free base of the compound of Formula A in solution; optionally wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 60 μg/mL and about 100 μg/mL based on the concentration of the free base of the compound of Formula A in solution; or wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is about 30 μg/mL based on the concentration of the free base of the compound of Formula A in solution; or, wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is about 60 μg/mL based on the concentration of the free base of the compound of Formula A in solution; or, wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is about 100 μg/mL based on the concentration of the free base of the compound of Formula A in solution; or wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is about 120 μg/mL based on the concentration of the free base of the compound of Formula A in solution; or, wherein the concentration of the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is about 200 μg/mL based on the concentration of the free base of the compound of Formula A in solution.

11-12. (canceled)

13. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein about 10 μL to about 100 μL of the solution is administered per intravitreal administration; optionally wherein about 50 μL to about 100 μL of the solution is administered per intravitreal administration; or wherein about 100 μL of the solution is administered per intravitreal administration; or wherein about 50 μL of the solution is administered per intravitreal administration.

14. (canceled)

15. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein prior to administration of the compound of Formula A, the patient has a baseline visual acuity score (BCVA) of between 19 and 73 letters in at least one eye, measured using the standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart.

16. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the patient is in the early stages of DME; optionally wherein a patient in the early stages of DME is defined by having a baseline visual acuity score (BCVA), prior to administration of the compound of Formula A, of between 56 and 73 letters in at least one eye, measured using the standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart.

17. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the treatment is a monotherapy for DME.

18. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the anti-VEGF treatment is selected from aflibercept (Eylea®), bevacizumab, ranibizumab, and pegaptanib; preferably wherein the anti-VEGF is aflibercept (Eylea®).

19. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the patient received anti-VEGF treatment for no more than 36 months before commencing treatment with the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof); and/or wherein the patient received anti-VEGF treatment no less than 8 weeks before commencing treatment with the compound of formula A (or a pharmaceutically acceptable salt and/or solvate thereof); and/or wherein the patient does not receive anti-VEGF treatment concurrent to administration of the compound of Formula A.

20. (canceled)

21. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the treatment is administered over a time period of at least about 12 weeks; or wherein the treatment is administered between about once every 4 weeks and about once every 12 weeks; or wherein the treatment is administered about once every 4 weeks.

22. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the treatment is administered at a first dosing frequency over a first time period, followed by a second dosing frequency over a second time period, wherein the second dosing frequency is lower than the first dosing frequency.

23. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 22, wherein the first time period is greater than about 8 weeks; optionally wherein the first time period is greater than about 12 weeks; and/or wherein the first dosing frequency is between about once every three weeks and about once every five weeks.

24. (canceled)

25. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 22, wherein the second time period is greater than about 8 weeks; or, wherein the second time period is between about 8 weeks and about 12 weeks; or, wherein the second time period is about 12 weeks; and/or wherein the second dosing frequency is lower than about once every six weeks.

26-28. (canceled)

29. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use in treating diabetic macular edema (DME) or impaired visual acuity comprising: intravitreally administering a pharmaceutical composition, wherein the pharmaceutical composition is a solution comprising the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof), to a patient in need thereof, ##STR00041## wherein the patient is in the early stages of DME or impaired visual acuity.

30. (canceled)

31. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 29, wherein a patient in the early stages of DME or impaired visual acuity is defined by having a baseline visual acuity score (BCVA), prior to administration of the compound of Formula A, of between 56 and 73 letters in at least one eye, measured using the standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart.

32. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 29, wherein the concentration of the compound of formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 30 μg/mL and 100 μg/mL based on the concentration of the free base of the compound of formula A in solution; or, wherein the concentration of the compound of formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 60 μg/mL and 100 μg/mL based on the concentration of the free base of the compound of formula A in solution; or wherein the concentration of the compound of formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is about 60 μg/mL based on the concentration of the free base of the compound of formula A in solution.

33. (canceled)

34. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use in treating diabetic macular edema (DME) or impaired visual acuity comprising: intravitreally administering a pharmaceutical composition, wherein the pharmaceutical composition is a solution comprising the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof), to a patient in need thereof, ##STR00042## wherein the treatment is administered at a first dosing frequency over a first time period wherein the concentration of the compound of formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is greater than about 30 μg/mL based on the concentration of the free base of the compound of formula A in solution, followed by a second dosing frequency over a second time period, wherein the second dosing frequency is lower than the first dosing frequency.

35. (canceled)

36. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 34, wherein the treatment is administered at a first dosing frequency over a first time period; wherein the concentration of the compound of formula A (or a pharmaceutically acceptable salt and/or solvate thereof) when administered is between about 60 μg/mL and about 100 μg/mL based on the concentration of the free base of the compound of formula A in solution.

37. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 34, wherein the first time period is greater than about 8 weeks; or, wherein the first time period is greater than about 12 weeks; and/or wherein the second time period is greater than about 8 weeks; or wherein the second time period is between about 8 weeks and about 12 weeks; or, wherein the second time period is about 12 weeks.

38. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 34, wherein the first dosing frequency is between about once every three weeks and about once every five weeks; and/or wherein the second dosing frequency is lower than about once every six weeks.

39-40. (canceled)

41. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the previous anti-VEGF treatment was for treating impaired visual acuity or DME.

42. The compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) for use according to claim 1, wherein the treatment with the solution comprising the compound of Formula A (or a pharmaceutically acceptable salt and/or solvate thereof) slows the progression of impaired visual acuity or DME.

Description

BRIEF DESCRIPTION OF DRAWINGS

[0690] FIG. 1 is a graphical representation of the change in BCVA letters versus sham over time for 3 μg of compound of Formula A and 6 μg of compound of Formula A; and

[0691] FIG. 2 is a graphical representation of the change in BCVA letters versus sham over time for early stage compared with all subjects on the dose of 6 μg of compound of Formula A.

MODES FOR CARRYING OUT THE INVENTION

[0692] The invention is further illustrated by the following examples. It will be appreciated that the examples are for illustrative purposes only and are not intended to limit the invention as described above. Modification of detail may be made without departing from the scope of the invention. In the following examples, the following abbreviations and definitions are used:

TABLE-US-00001 AE Adverse event ANCOVA Analysis of covariance Aq Aqueous solution ASNV Anterior segment neovascularization BCVA Best corrected visual acuity BMI Body mass index BP Blood pressure C1-INH C1-esterase Inhibitor ciDME Center-involving diabetic macular edema CIRC Central Image Reading Center CST Central subfield thickness DBP Diastolic blood pressure DRSS Diabetic Retinopathy Severity Scale DM Diabetes Mellitus DME Diabetic macular edema DRL Drug Reference List ED Early discontinuation ETDRS Early Treatment Diabetic Retinopathy Study FAS Full analysis set FE Fellow eye GCP Good Clinical Practice HgA1c Glycosylated haemoglobin HMWK High-molecular-weight kininogen Hrs Hours IB Investigator's Brochure ICF Informed consent form IEC Independent Ethics Committee IOP Intraocular pressure IPA iso-propanol IRB Institutional review board IRT Interactive response technology ITT Intention-to-treat IVT Intravitreal LOCF Last observation carried forward Me Methyl MeCN Acetonitrile MedDRA Medical Dictionary for Regulatory Activities MeOH Methanol Min Minutes NOAEL No-observed adverse effect level NSAID Nonsteroidal anti-inflammatory drug OCT Optical coherence tomography PDR Proliferative diabetic retinopathy Ph Phenyl PKal Plasma kallikrein PPS Per protocol set PR Pulse rate QS Quantum satis (sufficient quantity) RRT Relative retention time rt room temperature RVP Retinal vascular permeability SAE Serious adverse event SAF Safety set SAP Statistical analysis plan SBP Systolic blood pressure SD-OCT Spectral-domain optical coherence tomography SD Standard deviation SE Study eye SUSAR Serious unexpected suspected adverse reaction SWFI Sterile water for injection TEAE Treatment-emergent adverse event US United States VA Visual acuity VEGF Vascular endothelial growth factor WHO World Health Organisation

[0693] Osmolality was determined using a calibrated osmometer in compliance with USP<785> (freezing point depression). (See United States Pharmacopeia (USP) 37, NF 32).

[0694] Particulate matter in the pharmaceutical compositions was measured using the microscopic particle count test described in USP <789> (Particulate matter in ophthalmic solutions) (See United States Pharmacopeia (USP) 37, NF 32).

Synthetic Examples

[0695] The compound of Formula A may be prepared according to the method described in Evans et al. (“Benzylamine derivatives as inhibitors of plasma kallikrein” WO2013/005045). N—[(R)-1-[(S)-1-(4-Aminomethyl-benzylcarbamoyl)-2-phenyl-ethylcarbamoyl]-2-(4-ethoxy-phenyl)-ethyl]-benzamide hydrochloride, the hydrochloride salt of the compound of Formula A, can be manufactured using methods disclosed in WO2014/006414. The structure of the compound of Formula A is shown below:

##STR00039##

Solid Forms and Concentrations

[0696] Concentrations and dose levels defined in the examples below are based on the amount of free base of the compound of Formula A.

[0697] As outlined below, the compound of Formula A is prepared as a solution formulation. Therefore, any solid form of the compound of Formula A may be used in preparing the solution formulation.

[0698] It would readily understood that the invention is not limited to the use of specific solid forms and any other solid form could also be used to prepare solution formulations of the compound of Formula A.

Preparative Compositions of 10, 30, 100 and 300 μg/mL Solution Formulations of the Compound of Formula a

[0699] A 9.8% w/w trehalose and 2 mM histidine buffer solution is prepared by dissolving L-histidine (1.09 g) and trehalose dihydrate (356.7 g) in SWFI (3270 g) with agitation. The buffer pH is adjusted using 1.0N HCl solution as needed and diluted to 3640 g with SWFI to yield the buffer solution. Compound of Formula A (0.340 g) is dissolved in the trehalose-histidine buffer (2800 g) solution with high energy rotor stator mixing at 40° C. for sufficient time to provide a visibly clear, colorless solution, approximately 15-30 min. The pH of the solution is adjusted as needed with 1.0N HCl solution. HPLC is used to determine concentration of the compound of Formula A in the solution and the solution is diluted as needed with the trehalose-histidine buffer solution. The resulting 100 μg/mL solution formulation of the compound of Formula A is sterile filtered through two PVDF sterile filtration modules in series into a sterile, depyrogenated pyrex glass container.

[0700] 10, 30 and 300 μg/mL solution formulations of the compound of Formula A were prepared analogously with a common buffer and with the amount of the compound of Formula A being varied. For example, 0.104 g of the compound of Formula A was used to prepare the 30 μg/mL solution and 0.0363 g of the compound of Formula A was used to prepare the 10 μg/mL solution formulations.

[0701] Table 1 below provides analytical and characterization data for the 10, 30 and 100 μg/mL solution formulations of the compound of Formula A.

TABLE-US-00002 TABLE 1 Analytical and characterization data for the 10, 30, 100 and 300 μg/mL solution formulations of the compound of Formula A 10 μg/mL 30 μg/mL 100 μg/mL 300 μg/mL Appearance* C, C, L, C, C, L, C, C, L, C, C, L, FVP FVP FVP FVP Assay 108 106 103 107 (% LC)** Purity 99.9 99.9 100 100 (area %) Impurities*** RRT 0.64- RRT 0.57- ND ND 0.17% 0.11% PH 5.8 5.5 5.5 5.6 Osmolality 304 302 303 307 (mOsmol/Kg) ≥10 μm 0.1 0.1 0.1 0.4 ≥25 μm 0.0 0.1 0.0 0.15 ≥50 μm 0.0 0.0 0.0 0.0 Bacterial <0.0500 <0.0500 <0.0500 <0.0500 endotoxin (EU/mL) Sterility Sterile Sterile Sterile Sterile *C, C, L, FVP = Clear, Colorless, Liquid, Free from Visible Particles **% LC = % Label Claim ***ND = not detected

[0702] The 10, 30, 100 and 300 μg/mL solution formulations of the compound of Formula A are stable when filled into 2 mL clear type 1 glass vials sealed with chlorobutyl rubber stoppers, as shown by the data in Table 2

TABLE-US-00003 TABLE 2 Stability data for the 10, 30, 100 and 300 μg/mL solution formulations of the compound of Formula A 10 μg/mL 30 μg/mL 100 μg/mL 300 μg/mL 36 36 36 36 months months months months at 25° C. at 25° C. at 25° C. at 25° C. and 60% and 60% and 60% and 60% Initial RH.sup.+ Initial RH.sup.+ Initial RH.sup.+ Initial RH.sup.+ Appearance* C, C, C, C, C, C, C, C, C, C, C, C, C, C, C, C, L, FVP L, FVP L, FVP L, FVP L, FVP L, FVP L, FVP L, FVP Assay (% LC)** 108 109 106 103 103 101 107 106 Purity (area %) 99.9 99.7 99.9 99.9 100 99.8 100 99.9 Impurities RRT 0.32 — — — 0.03% — — — — RRT 0.56-0.58 — 0.10% 0.11% 0.04% — 0.04% — — RRT 0.59-0.60 — 0.06% — — — — — — RRT 0.63-0.65 0.17% 0.05% — — — — — — RRT 0.69 — 0.05% — 0.07% — 0.06% — 0.06% RRT 0.83 — — — 0.03% — — — — RRT 1.34 — 0.04% — — — 0.06% — 0.04% RRT 1.39 — — — — — 0.04% — 0.03% pH 5.8 5.9 5.5 5.6 5.5 5.6 5.6 5.7 Osmolality 304 307 302 307 303 305 307 308 (mOsmol/Kg) Particulate ≥10 μm 0.1 0.25 0.1 0.25 0.1 0.2 0.4 0.6 matter/mL ≥25 μm 0.0 0.2 0.1 0.2 0.0 0.2 0.15 0.55 ≥50 μm 0.0 0.1 0.0 0.15 0.0 0.15 0.0 0.35 Bacterial <0.0500 <0.0500 <0.0500 <0.0500 <0.0500 <0.0500 <0.0500 <0.0500 endotoxin (EU/mL) Sterility Sterile Sterile Sterile Sterile Sterile Sterile Sterile Sterile *C, C, L, FVP = Clear, Colorless, Liquid, Free from Visible Particles **% LC = % Label Claim .sup.+RH = relative humidity

Background Example 2

[0703] Preparative Compositions of 30, 60 and 200 μg/mL Solution Formulations of the Compound of Formula A

[0704] A 9.8% w/w trehalose and 2 mM histidine buffer solution is prepared by dissolving L-histidine monohydrochloride monohydrate (1.33 g), trehalose dihydrate (407.7 g) and L-histidine (0.26 g) in SWFI (3536 g) with agitation. Additional SWFI is added to bring the weight to 4160 g and the mixture agitated. N—[(R)-1-[(S)-1-(4-aminomethyl-benzylcarbamoyl)-2-phenyl-ethylcarbamoyl]-2-(4-ethoxy-phenyl)-ethyl]-benzamide hydrochloride (the hydrochloride salt of the compound of Formula A) (0.066 g) is dissolved in the trehalose-histidine buffer (2080 g) solution with high energy rotor stator mixing at 50° C. for sufficient time to provide a visibly clear, colorless solution, approximately 15-30 min. The pH of the solution is adjusted as needed with 1.0N HCl solution. HPLC is used to determine concentration of the compound of Formula A in the solution and the solution is diluted as needed with the trehalose-histidine buffer solution. The resulting 30 μg/mL solution formulation of the compound of Formula A is sterile filtered through two PVDF sterile filtration modules in series into a sterile, depyrogenated pyrex glass container.

[0705] 60 μg/mL solution formulation of the compound of Formula A was prepared analogously with a common buffer and with 0.131 g of the compound of Formula A being used instead. 200 μg/mL solution formulation of the compound of Formula A was prepared analogously with a common buffer and with 0.436 g of the compound of Formula A being used instead.

[0706] Table 3 below provides analytical and characterization data for the 30, 60 and 200 μg/mL μg/mL solution formulations of the compound of Formula A.

TABLE-US-00004 TABLE 3 Analytical and characterization data for the 30, 60 and 200 μg/mL solution formulations of the compound of Formula A 30 μg/mL 60 μg/mL 200 μg/mL Appearance * C, C, L, FVP C, C, L, FVP C, C, L, FVP Assay (% LC) ** 95 95 195   Purity (area %) 99.9 99.8 100.0 Impurities *** RRT 0.57: 0.13% RRT 0.57: 0.22% ND pH 5.4 5.5  5.7 Osmolality (mOsmol/kg) 307 304 Not tested Particulate ≥10 μm 0.1 0.15 Not tested matter/mL ≥25 μm 0.1 0.3 Not tested ≥50 μm 0.05 0.15 Not tested Bacterial endotoxin (EU/mL) <0.0500 <0.0500 Not tested Sterility Sterile Sterile Not tested * C, C, L, FVP = Clear, Colorless, Liquid, Free from Visible Particles ** % LC = % Label Claim *** ND = not detected

TABLE-US-00005 TABLE 4 Stability data for the 30, 60 and 200 μg/mL solution formulations of the compound of Formula A 30 μg/mL 60 μg/mL 200 μg/mL 24 months 24 months 24 months at 25° at 25° at 25° C. and C. and C. and Initial 60% RH.sup.+ Initial 60% RH.sup.+ Initial 60% RH.sup.+ Appearance* C, C, C, C, C, C, C, C, C, C, C, C, L, FVP L, FVP L, FVP L, FVP L, FVP L, FVP Assay (% LC)** 96 94 99 96 98 96 Purity (area %) 100.0 99.9 100.0 99.9 100.0 99.8 Impurities RRT 0.56-0.58 — — 0.06 — — 0.02 RRT 0.69-0.70 0.04 0.07 — 0.08 — 0.05 RRT 0.94 — — — — — 0.02 RRT 1.12 — — — — — 0.03 RRT 1.14 — — — — — 0.03 RRT 1.33 — — — — — 0.11 pH 5.5 5.5 5.4 5.5 5.7 5.7 Osmolality 308 310 306 311 Not tested Not tested (mOsmol/Kg) Particulate ≥10 μm 0.25 0.25 0.1 0.3 Not tested Not tested matter/mL ≥25 μm 0.15 0.15 0.1 0.25 Not tested Not tested ≥50 μm 0.1 0.1 0.05 0.15 Not tested Not tested Bacterial <0.0500 <0.0500 <0.0500 <0.0500 Not tested Not tested endotoxin (EU/mL) Sterility Sterile Sterile Sterile Sterile Not tested Not tested *C, C, L, FVP = Clear, Colorless, Liquid, Free from Visible Particles **% LC = % Label Claim .sup.+RH = relative humidity

Study 1:

[0707] Study—an Open Label, Single Ascending Dose Study to Investigate the Safety and Tolerability of the Compound of Formula A Administered by Intravitreal Injection in Subjects with Center Involved Diabetic Macular Edema and Reduced Vision

[0708] The primary objective of the trial was to evaluate the local and systemic safety and tolerability of single ascending doses administered via intravitreal injection of the compound of Formula A in adult male and female subjects with central involved diabetic macular edema.

[0709] The secondary objectives were: [0710] To evaluate the plasma profile of the compound of Formula A following intravitreal injection in adult male and female subjects with central involved diabetic macular edema. [0711] To evaluate the pharmacodynamic effect of intravitreal injection of the compound of Formula A in adult male and female subjects with central involved diabetic macular edema.

Methodology:

[0712] Part 1 of the study had a single ascending dose design with up to 4 groups, with 3 subjects per group.

[0713] Following the signing of informed consent, subjects attended the clinic where screening assessments were recorded (Clinic Visit 1). When deemed eligible, subjects attended the clinic where baseline measurements were recorded (recorded as Day 0, Clinic Visit 2). Following confirmation of eligibility and the taking of baseline ophthalmic measurements, a single intravitreal injection of the compound of Formula A, was administered to the study eye as per Diabetic Retinopathy Clinical Research Network (DRCR.net) protocol.

[0714] Each subject returned on Day 1, 7, 14, 28 and 56 for safety and ophthalmic assessment. Pharmacokinetic assessment was also taken. In addition, the subject was contacted by the Study Site on Day 3 (+1-1 day) by telephone to inquire about the subject's visual wellbeing and to ask about any adverse events.

[0715] An independent Data and Safety Monitoring Committee (DSMC) oversaw the conduct of the study.

[0716] Once the highest safe and tolerated (or practical) dose had been established, the study proceeded to Part 2 in which 5 additional subjects were treated with the established highest safe and tolerated (or practical) dose according to the same protocol with the same procedures performed as described for subjects enrolled into Part 1.

Main Criteria for Eligibility:

Inclusion Criteria

[0717] 1. Male or female adult subjects 18 years of age and older [0718] 2. Confirmed diagnosis of Type I or Type II diabetes mellitus [0719] 3. Best corrected visual acuity, using Early Treatment Diabetic Retinopathy Study (ETDRS) electronic visual acuity (EVA) testing, of between 20/40 and 20/400 (Snellen equivalent) in the study eye [0720] 4. Fellow eye acuity 20/80 or better measured as above with no expectation of requirement for anti-vascular endothelial growth factor (anti-VEGF) treatment in fellow eye within 2 months of study drug administration [0721] 5. Presence of central involved DME in the study eye defined as Heidelberg Spectralis Optical Coherence Tomography (OCT) Central Subfield Thickness (CST) 305 μm in women and 320 μm in men in the study eye [0722] 6. Subjects who fulfil one of the following criteria: [0723] a. Subjects who have not previously received an anti-VEGF treatment and who, in the view of the Investigator, can have initiation of anti-VEGF treatment in the study eye deferred for at least 2 months following the date of anticipated study drug administration [0724] b. Subjects who are receiving regular anti-VEGF intravitreal injections who: [0725] i. Have received at least 3 intravitreal injections of an anti-VEGF treatment within the last 5 months (study drug administration will be at least 6 weeks after the most recent intravitreal administration of anti-VEGF) and [0726] ii. In the view of the Investigator, can have continuation of anti-VEGF treatment in the study eye deferred for at least 2 months following the date of anticipated study drug administration [0727] c. Subjects who have received anti-VEGF in the past (>3 months prior to study inclusion) but are not actively receiving treatment and who in the view of the Investigator, can have resumption of anti-VEGF or alternative treatment in the study eye deferred for at least 2 months following anticipated study drug administration [0728] 7. Subjects, who in the view of the Investigator, are not expected to require panretinal laser photocoagulation or intravitreal steroids or intraocular surgery in the study eye for at least 2 months following anticipated study drug administration [0729] 8. No prior treatment with panretinal photocoagulation in the study eye within the previous 3 months (prior focal/grid macular photocoagulation is allowed) [0730] 9. No prior treatment with intravitreal steroid in the study eye within the previous 3 months [0731] 10. No prior treatment with systemic corticosteroids or systemic anti-VEGF therapy within the previous 3 months [0732] 11. No prior vitrectomy in the study eye [0733] 12. No prior intraocular surgery in the study eye within the previous 3 months [0734] 13. For women, post-menopausal, surgically sterile, or agreeable to using highly effective contraception (highly effective means of contraception include use of 2 of the following: hormonal contraceptives (oral, implant, transdermal patch, or injection) at a stable dose for at least 3 months prior to Screening, barrier (condom with spermicide, diaphragm with spermicide, IUD) until 2 months after last dose of study medication) [0735] 14. No ocular disease in the study eye that in the opinion of the Investigator would impact the progression of DME or response to treatments for DME, e.g., extensive macular scarring, active inflammation, ocular or periocular infection, retinal detachment, aphakia, vitreomacular traction or substantial center-involving epiretinal membrane etc. [0736] 15. Ability and willingness, in the opinion of the Investigator, to comply with study procedures, follow up visits and obtain usable OCT scans including not expecting to relocate outside the study covered area during the course of the study [0737] 16. Electrocardiogram (ECG) recording without signs of clinically relevant pathology as determined by an appropriately qualified physician, in particular QTcF (Fridericia's correction) less than 450 ms for men and 470 ms for women (there will be central ECG reading) [0738] 17. Values for hematology and biochemistry tests of blood and urine showing no clinically relevant deviation as judged by an appropriately qualified physician. [0739] 18. Study participant voluntarily agrees to participate in this study and signs the Institutional Review Board (IRB) approved informed consent prior to performing any procedure

Exclusion Criteria

[0740] 1. Females who are pregnant or lactating, or expecting to become pregnant during the course of the study [0741] 2. Poorly controlled diabetes mellitus as defined by having initiated intensive insulin treatment (a pump or multiple daily injections) within prior 4 months or planning to do so in the next 2 months, or 2 or more episodes of diabetic ketoacidosis requiring hospitalization within the preceding 6 months [0742] 3. Uncontrolled hypertension defined as a blood pressure >180/110 mm Hg [0743] 4. Significant co-existing disease (e.g., marked hepatic impairment, end stage renal disease (defined as a current or imminent requirement for dialysis) or symptomatic cardiac failure) that may impact on the ability of the study participant to participate in the study and/or may impact on the interpretation of the study [0744] 5. Participation in an investigational intervention clinical study within 2 months prior to study inclusion other than a non-invasive methodology or observational follow up trial in which no drugs were given [0745] 6. History of alcohol and/or drug abuse in the last 2 years [0746] 7. Men not willing to use appropriate birth control methods such as surgical sterilization or barrier contraception or men with partners of child-bearing potential not willing to use appropriate birth control methods, such as surgical sterilization, hormonal birth control (partner), an intrauterine device (partner) or double barrier method for the entire study period and for 2 months after the last dose of study drug product [0747] 8. Media clarity or pupillary dilation inadequate to obtain reasonable quality OCT and/or fundus image [0748] 9. Subjects employed by the Sponsor or in any relationship of dependence with the Sponsor and/or Investigator

Test Product, Dose and Mode of Administration

[0749] The compound of Formula A for intravitreal injection.

[0750] Single 100 μL intravitreal injection of: [0751] 1 μg-10 μg/mL of the compound of Formula A [0752] 3 μg-30 μg/mL of the compound of Formula A [0753] 100 μg-100 μg/mL of the compound of Formula A

[0754] Criteria for evaluation

Safety

[0755] Best Corrected Visual Acuity as measured by ETDRS EVA [0756] Intraocular pressure [0757] Color vision [0758] Multifocal Electroretinogram (mfERG) [0759] Humphrey Visual Field 24-2 (HVF 24-2) [0760] Treatment-Emergent Adverse Events (TEAEs) [0761] Changes on ophthalmic examination [0762] Clinical laboratory test results [0763] Vital signs [0764] ECG findings

Summary of Safety Results

[0765] Although it was not an eligibility requirement for this study, all the subjects had previously received anti-VEGF treatment in the study eye and the majority had received additional treatments including photocoagulation and intravitreal steroids.

[0766] Overall, 10 of the 14 subjects (71%) reported at least one adverse event. Severe events (1 patient) and study drug-related events (2 patients) were, however, uncommon. There were no deaths or other serious adverse events, nor did any event lead to withdrawal from the study. The majority of adverse events were consistent with those that would be expected from intravitreal injection. The most notable adverse event in the study was an episode of acute ocular pain immediately following injection secondary to a clinical diagnosis of acute increase in intraocular pressure. This diagnosis was supported by the rapid improvement in symptoms following anterior paracentesis.

[0767] There was no apparent deterioration in either mean visual acuity or mean retinal thickness. In contrast, trends of improvement in both mean visual acuity and mean retinal thickness occurred post-injection. Review of adverse events, laboratory results, ECG and physical examinations, revealed no evidence of any adverse systemic effect.

[0768] There was no evidence of any adverse effect associated with systemic exposure.

Pharmacokinetic Results

[0769] Plasma concentrations of the compound of Formula A were quantifiable (greater than the lower limit of quantification (LLOQ), 0.25 μg/mL) in at least one sample in all subjects. Plasma concentrations of the compound of Formula A ranged from <0.25 μg/mL to 1.63 μg/mL and were quantifiable for up to 4 hours post intravitreal injection of 1 μg/eye of compound of Formula A. For the 3 μg/eye dose of the compound of Formula A, plasma concentrations of the compound of Formula A ranged from <0.25 μg/mL to 2.35 μg/mL and were quantifiable up to 24 hours post dosing. Plasma concentrations of the compound of Formula A ranged from <0.25 μg/mL to 11.3 μg/mL and were quantifiable up to 24 hours post dosing of the 10 μg/eye of compound of Formula A.

[0770] Overall, higher plasma levels of the compound of Formula A were recorded in subjects receiving the higher doses. However, it was noted that the recorded plasma levels were exceptionally low, and the ability to quantify at these levels was testament to the sensitivity of the assay. Given the known required levels for in vitro pharmacological activity of plasma kallikrein inhibition, it was considered improbable that intravitreal injection would ever result in pharmacologically meaningful systemic exposures.

Pharmacodynamic Results

[0771] Following a single injection of the compound of Formula A as an average across all dose groups, there was a small but steady mean improvement in visual acuity at each follow up visit follow up to Day 84 (12 out of 14 subjects completed up to day 84) when all subjects were included regardless of dose. Visual acuity improved by 0.7, 1.0, 1.9, 2.8 and 4.1 letters compared with baseline at Days 7, 14, 28, 56 and 84 respectively. The mean improvement at Day 84 was greater for the 10 μg dose (5.5 letters improvement) compared with 1 μg (3.3 letters improvement) and 3 μg (2.0 letters improvement) which, although there was a small sample size, is possibly suggestive of a dose-dependent effect.

CONCLUSION

[0772] Intravitreal injection of the compound of Formula A was well tolerated. The small number of adverse events were consistent with the route of administration rather than any observed specific drug effects. From an efficacy perspective, there was a small improvement in mean visual acuity and reduction in mean retinal thickness across the whole study population, but the small numbers and the absence of a control group preclude formal interpretation.

[0773] The results were sufficiently encouraging to warrant further investigation of the compound of Formula A in the treatment of DME in an appropriately powered, repeat-dose controlled clinical study.

Study 2—Study in Human Subjects with Center-Involving Diabetic Macular Edema (ciDME) Who have had Prior Anti-Vascular Endothelial Growth Factor (VEGF) Treatment

Aims:

[0774] To investigate monthly dosing of intravitreal (IVT) injection of the compound of Formula A in subjects with ciDME who have had prior anti-VEGF treatment. In particular, to evaluate any effect on the efficacy in the treatment, prevention, or prevention of worsening of ciDME in subjects who have had prior anti-VEGF treatment.

[0775] To evaluate the local and systemic safety and tolerability of monthly dosing of the injections of the compound of Formula A in subjects with ciDME who had had prior anti-VEGF treatment.

Methods:

[0776] This study was a randomized, sham-controlled, double-masked, 3-arm study into efficacy, safety and tolerability of monthly intravitreal injections of the compound of Formula A as a monotherapy in adult subjects with ciDME. The subjects had all had prior anti-VEGF treatment.

[0777] 129 adult subjects were chosen using the following inclusion criteria: [0778] 1. Male or female adult subjects 18 years of age and older. [0779] 2. Confirmed diagnosis of Type I or Type II diabetes mellitus (DM). Any of the following were sufficient: [0780] a. Current regular use of insulin for the treatment of diabetes [0781] b. Current regular use of oral anti-hyperglycemia agents for the treatment of diabetes [0782] c. Documented diabetes by American Diabetes Association and/or World Health Organization (VVHO) criteria. [0783] 3. Best Corrected Visual Acuity (BCVA), using Standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart, of ≥19 letters (˜20/400) and ≤73 letters (˜20/40) in the study eye and ≥34 letters (˜20/200 or better) in the fellow eye at Screening and Day 1. [0784] 4. Presence of ciDME in the study eye defined as Heidelberg Spectralis Optical Coherence Tomography (SD-OCT) CST ≥305 μm in women and ≥320 μm in men in the study eye (as assessed at Screening by the Investigator and Central Image Reading Center (CIRC) and on Day 1 by the Investigator). [0785] 5. Subjects' first anti-VEGF injection in the study eye occurred 36 months prior to Day 1. [0786] 6. Subjects received at least 3 anti-VEGF injections in the study eye within a 6-month period within the 36 months prior to Day 1. [0787] 7. Subject's' last anti-VEGF injection in the study eye was 8 weeks prior to Day 1. [0788] 8. Subjects, who in the view of the Investigator, were able to defer treatment in the study eye for at least 6 months following Day 1. [0789] 9. Values for blood and urine safety labs at the Screening visit showed no clinically significant deviation as determined by the Investigator. [0790] 10. Women who were post-menopausal for at least 1 year, surgically sterile for at least 3 months prior to Day 1, or who were agreeable to using highly effective contraception (adequate contraceptive measures include stable use of oral contraceptives or other prescription pharmaceutical contraceptives for two or more menstrual cycles prior to screening; intrauterine device (IUD); bilateral tubal ligation; vasectomy; condom plus contraceptive sponge, foam, or jelly or diaphragm plus contraceptive sponge, foam, or jelly), or abstinence. [0791] 11. Sexually active men who were not vasectomized and had sexual partners of childbearing potential were agreeable to using highly effective contraception. [0792] 12. Provide signed informed consent and were willing and capable of complying with clinic visits and study procedures.

[0793] Subjects were excluded from the trial if they met any of the following criteria: [0794] 1. Females who were pregnant or lactating, or expecting to become pregnant during the course of the study. [0795] 2. Evidence of ocular pathology (e.g. visually significant cataract) that impacted subject's vision in the study eye from any cause other than DME, in the opinion of the Investigator. [0796] 3. Evidence/presence of amblyopia, vitreomacular traction, epiretinal membrane, foveal atrophy, or foveal ischemia, or any other condition in the macula that was thought to impair the subject's vision (other than DME) in the opinion of Investigator. [0797] 4. Prior treatment with panretinal photocoagulation or focal grid macular photocoagulation in the study eye within the previous 3 months prior to Day 1. [0798] 5. Prior treatment with IVT steroid in the study eye (in the 3 months prior to Day 1 for triamcinolone, 6 months prior to Day 1 for Ozurdex and at any time for Iluvien). [0799] 6. Prior treatment with topical NSAIDs or topical steroids in the study eye within 1 month prior to Day 1. [0800] 7. Prior treatment with Jetrea® (ocriplasmin) injection in the study eye within the previous 3 months prior to Day 1. [0801] 8. Prior treatment with systemic corticosteroids or systemic anti-VEGF therapy within 3 months prior to Day 1. [0802] 9. Prior vitrectomy in the study eye. [0803] 10. Prior intraocular surgery in the study eye except for cataract surgery. Cataract surgery within the previous 6 months of Day 1 in the study eye was excluded. [0804] 11. Intraocular pressure (IOP) at Screening or Day 1 of >22 mmHg in the study eye or use of >2 antiglaucoma agents (combination agents count as 2 agents) in the study eye. [0805] 12. Evidence of infectious dacrocystitis, significant blepharitis, active conjunctivitis, infectious keratitis, or scleritis in either eye, or any other condition that might affect the safety of the IVT injection in the opinion of Investigator. [0806] 13. Evidence of active intraocular inflammation in the study eye. [0807] 14. Current active proliferative diabetic retinopathy (PDR), active anterior segment neovascularization (ASNV), active retinal neovascularization, or the presence of vitreous haemorrhage in the study eye. (Note, quiescent PDR is not exclusionary). [0808] 15. Any concurrent ocular condition in the study eye which, in the opinion of the Investigator, could interfere with the evaluation of efficacy or safety. [0809] 16. Poorly controlled DM defined as glycosylated hemoglobin [HgA1c]≥12.0% or having initiated intensive insulin treatment (a pump or multiple daily injections) within prior 4 months or planning to do so in the next 2 months, or two (2) or more episodes of diabetic ketoacidosis requiring hospitalization within the preceding 6 months. [0810] 17. Uncontrolled hypertension at Screening or Day 1 defined as systolic ≥180 mmHg or diastolic ≥110 mmHg. [0811] 18. Significant co-existing disease such as marked hepatic impairment, end stage renal disease (defined as a current or imminent requirement for dialysis), symptomatic cardiac failure, or significant pulmonary dysfunction that may place the subject at higher risk for treatment complications, failure of follow-up, and/or may impact the outcome of the data interpretation of the study, in the opinion of the Investigator. [0812] 19. History of other disease (e.g., unstable psychiatric illness), metabolic dysfunction, physical examination finding, or clinical laboratory finding giving reasonable suspicion of a disease or condition that contraindicated the use of an investigational product, might affect interpretation of the results of the study, or rendered the subject at high risk for treatment complications or lack of follow-up, in the opinion of Investigator. [0813] 20. History of alcohol and/or drug abuse in the last 2 years. [0814] 21. Participation in an interventional investigational clinical study within 3 months or within 5 half-lives of the last dosing of investigational drug (whichever is longer) prior to Screening. [0815] 22. Inadequate media clarity or pupillary dilation that did not allow acquisition of an adequate quality OCT and/or fundus image.

[0816] The study eye was defined as the eye that meets all of the inclusion and none of the exclusion criteria. If both eyes qualified, the eye with the worse BCVA ETDRS at Day 1 was used as the study eye. If both eyes had the same BCVA ETDRS at Day 1, the eye with the highest CST on spectral-domain optical coherence tomography (SD-OCT) on Day 1, as assessed by the Investigator, was used as the study eye. If both eyes qualified and neither was preferred based on the inclusion/exclusion criteria and had the same BCVA ETDRS and CST on Day 1, either eye was chosen as the study eye. In this instance, the Investigator selected the eye that, in their opinion, was most likely to respond to treatment as the study eye. The maximum duration of the study for each randomized subject was up to 28 weeks (including up to 4 weeks for screening, 12 weeks treatment period, and 12 weeks follow-up).

[0817] The study was conducted on an out-patient basis.

[0818] The subjects had the following baseline demographics:

TABLE-US-00006 TABLE 5 Baseline demographics of trial subjects 3 μg of compound 6 μg of compound Sham of Formula A of Formula A Total Variable n = 44 n = 44 n = 41 n = 129 Age mean (SD) 64.6 (8.6) 61.1 (10.7) 63.2 (9.6) 63.0 (9.7) Range 42-85 33-83 37-81 33-85 Gender female/male 23/21 (52.3/47.7) 20/24 (45.5/54.5) 15/26 (36.6/63.4) 58/71 (45.0/55.0) n (%) Race white n (%) 37 (84.1) 37 (84.1) 37 (90.2) 111 (86.0) black n (%) 3 (6.8) 5 (11.4) 4 (9.8) 12 (9.3) other n (%) 4 (9.1) 2 (4.6) 0 (0) 6 (4.7) BMI mean (SD) 31.6 (7.0) 33.0 (7.7) 31.7 (5.4) 32.1 (6.8) Range 18.2-46.6 22.7-58.7 19.9-43.9 18.2-58.7 HbA1c mean (SD) 7.5 (1.2) 7.6 (1.3) 8.0 (1.5) Range  5.5-10.8  5.2-11.8  5.9-11.3

[0819] The study schedule of events was as follows: [0820] 1. Screening Phase:

[0821] The screening period was up to 4 weeks prior to study Day 1. All subjects signed an Informed Consent Form (ICF) prior to any study related procedures being performed. Subjects were 18 years of age or older, at the time of screening, and had a diagnosis of ciDME with prior anti-VEGF treatment.

[0822] A medical and ocular history was taken for each subject.

[0823] Each subject's DME disease history was recorded at the screening visit. The following was documented: [0824] Date of first diagnosis of DME in the study eye [0825] Date and details of the first anti-VEGF injection [0826] Dates and details of the last three anti-VEGF injections [0827] BCVA score or Snellen equivalent of each VA assessment in the study eye beginning with the VA assessment immediately prior to the last three anti-VEGF injections [0828] CST from each OCT assessment in the study eye beginning with the OCT assessment immediately prior to the last three anti-VEGF injections [0829] Estimate or actual total number of anti-VEGF injections [0830] Date of last IVT steroid injection (if any) [0831] Estimate or actual total number of IVT steroid injections (if any)

[0832] The Investigator's assessment of the subject's response to anti-VEGF treatment after the last 3 IVT injections compared to baseline was recorded using the following scales (baseline is defined as the status of edema and vision immediately prior to the first of the 3 injections): [0833] Edema: [0834] Satisfactory response—Absence of intraretinal/subretinal fluid; [0835] Partial response 1—Significant reduction of intraretinal/subretinal fluid; [0836] Partial response 2—Little or some reduction (˜20%) of intraretinal/subretinal fluid; [0837] No response—No reduction or worsening of intraretinal/subretinal fluid. [0838] Vision: [0839] No change in or worsening of BCVA [0840] Gain of 1-4 letters [0841] Gain of 5 to 9 letters [0842] Gain 10 to 14 letters [0843] Gain of ≥15 letters

[0844] Of the study population, the patient subjects had the following distribution of times since their first anti-VEGF treatment: [0845] <6 months-16% [0846] Between 6 months and 1 year-29% [0847] Between 1 and 2 years-35% [0848] Between 2 and 3 years-20%

[0849] Previous and concomitant medication was also documented.

[0850] The following vital signs were assessed at rest (5 minutes in a supine position). The same equipment for each vital sign evaluation was used on given patient for all study visits. Vital signs were conducted prior to study drug administration and approximately 30 minutes post-study drug administration on applicable visits. [0851] Blood pressure (SBP and DBP; mmHg); [0852] Pulse rate (beats per minute); [0853] Body temperature (° C.); [0854] Respiration rate (breaths per minute).

[0855] Physical examinations were performed. The physical examination were symptom directed and include the following body systems: general appearance, skin, lymphatic, head and neck, ears, nose and throat, chest and lungs, cardiovascular, abdomen, extremities, musculoskeletal and neuromuscular.

[0856] Laboratory assessments were also conducted.

[0857] Ophthalmic findings were performed. All ophthalmic assessments were conducted on both eyes except fundus photography which was taken in both eyes at the Screening visit and only in the study eye at subsequent visits. [0858] 2. Treatment Phase:

[0859] On the day of first study drug administration (Day 1), the subject's eligibility was reconfirmed and baseline assessments were performed.

[0860] The subjects had the following baseline DME disease characteristics:

TABLE-US-00007 TABLE 6 Baseline DME disease characteristics of trial subjects 3 μg of 6 μg of compound of compound of Sham Formula A Formula A Total Variable n = 44 n = 44 n = 41 n = 129 BCVA (letters) mean (SD) 60.7 (7.4) 58.8 (12.5) 58.0 (12.8) 59.2 (11.1) range 42-71 23-72 28-73 23-73 BCVA ≤55 n (%) 11 (25.0) 13 (29.5) 11 (26.8) 35 (27.1) CST (μm) mean (SD) 500 (131) 540 (166) 512 (134) 517 (145) range 326-815   322-1,097 307-804   307-1,097 CST ≥450 μm n (%) 27 (61.4) 27 (61.4) 26 (63.4) 80 (62.0) Number of prior anti-VEGF injections (study eye) mean (SD) 8.0 (4.0) 7.4 (4.1) 5.9 (3.0) 7.1 (3.8) range  3-20  3-16  3-14  3-20 n = 42 n = 41 n = 38 n = 121 Duration of DME (yrs) mean (SD) 1.4 (1.3) 1.0 (0.9) 1.0 (1.2) 1.1 (1.1) range 0-8 0-3 0-5 0-8

[0861] As demonstrated in Table 6 above, all subjects that took part in the study had anti-VEGF treatment prior to commencing the study. The minimum number of previous anti-VEGF injections for any patient was 3, and most patients had significantly more than 3 prior anti-VEGF injections.

[0862] The 129 eligible subjects were randomized approximately 1:1:1 into three arms: [0863] 1. Arm 1, N=44: [0864] Received injections of 3 μg/eye (100 μL injection volume at a concentration of 30 μg/mL) of the compound of formula A; [0865] 2. Arm 2, N=41: [0866] Received injections of 6 μg/eye (100 μL injection volume at a concentration of 60 μg/mL) of the compound of formula A; and [0867] 3. Arm 3, N=44: [0868] Received a sham procedure;
during a 12-week, double-masked treatment period (a total of 4 doses given at approximately monthly intervals).

[0869] Subjects visited the study clinic on Day 1 and Weeks 4, 8, and 12 during the Treatment Phase for study drug administration or sham procedure, safety, and ophthalmic assessments.

[0870] The ophthalmic assessments were carried out in approximately the following order at the subjects' visits to the study clinic on Day 1, and Weeks 4, 8 and 12: [0871] BCVA (must be performed prior to all other ophthalmic procedures) [0872] Slit lamp biomicroscopy [0873] Pre-Injection IOP/IOP at visits with no study drug administration (must be done prior to dilation) [0874] Dilated indirect ophthalmoscopy [0875] Fundus photography [0876] SD-OCT [0877] Intravitreal injection [0878] Post-Injection IOP

[0879] The subject remained in the clinic after study drug administration or sham procedure until all post-dose procedures and observations were completed and the Investigator confirmed that the subject may be discharged. Investigators scheduled visits at Week 4, 8, and 12 to provide 28 days between visits. The visit window for these visits is −3 days to +7 days.

[0880] Approximately twenty-four (24) hours after each study drug administration or sham procedure on Day 1 and Weeks 4, 8, and 12, subjects were contacted by telephone to evaluate any reported AEs and changes in concomitant medications. In the event of any reported ocular or systemic AEs that were considered by the Investigator to be a possible cause for concern, the subjects returned to the clinic for assessment as soon as possible. [0881] 3. Follow up Phase:

[0882] All subjects visited the clinic at Weeks 16, 20, and 24 after the last study drug administration or sham procedure for safety and ophthalmic assessments. The visit window for Weeks 16, 20, and 24 is ±7 days.

Early Discontinuation:

[0883] If any subject discontinued the trial early, every effort was made to complete the Week 24/early discontinuation (ED) evaluations as soon as possible and, whenever possible, prior to starting any new medication or treatment. All attempts were made to not discontinue the subject unless necessary.

Rescue Treatment:

[0884] Rescue intervention (e.g., anti-VEGF, focal/grid macular laser photocoagulation, IVT steroids) was administered due to worsening DME (i.e., attributable to worsening DME and not another cause) if either of the following occurred and, where possible, after consultation with the Medical Monitor: [0885] During Treatment Phase [0886] Best corrected visual acuity (BCVA) deteriorated 3 lines (15 letters) or more from baseline [0887] Central Subfield Thickness (CST) worsened >100 μm from baseline [0888] During Follow up Phase (i.e., after week 16) [0889] BCVA deteriorated 3 lines (15 letters) or more from highest BCVA during treatment phase or baseline [0890] CST worsened >100 μm from lowest CST during treatment phase or baseline.

[0891] If a study subject met the criteria for rescue intervention and received a rescue treatment in the study eye, the study subject will be discontinued from further participation in the study.

Assessment of Results

[0892] The assessment measured change from baseline in BCVA letter count in the study eye at Week 16. Change from baseline in BCVA letter count is calculated as Week 16 BCVA letter count minus Day 1 BCVA letter count such that a negative difference indicates a worsening in vision. In addition, treatment comparisons between each dose (Arms 1 and 2) of the injection of the compound of Formula A and the sham are calculated as the injection of the compound of Formula A minus sham.

Study Drug

Identity

[0893] For clinical trial use, the compound of Formula A was formulated as an injection, in accordance with the above outlined preparative methods. Any of the preparative methods outlined above in Background Examples 1 and 2 is suitable for preparing the injectable formulation of the compound of Formula A.

[0894] The injection of the compound of Formula A was supplied in two dose strengths, 60 μg/mL and 30 μg/mL free base equivalent of the compound of Formula A.

Administration

[0895] Injection of the compound of Formula A or sham procedure was administered to the study eye on Day 1 and Weeks 4, 8, and 12 during the Treatment Phase. At each scheduled visit, the date and time of study medication administration was recorded.

[0896] The injecting physician was not the Investigator as they remained masked throughout the study. In order to avoid breaking the mask, real and sham injections were performed by study personnel who were not masked and not otherwise involved in the study (note that post-injection IOP evaluations were performed by study personnel who were unmasked). For sham injections, the subjects were prepared exactly as for a real injection (i.e., including but not limited to: insertion of lid speculum, application of povidone-iodine and subconjunctival injection of an anesthetic) following which an empty syringe with no needle was pressed against the eye to mimic the pressure of an injection.

[0897] The formulation of the compound of Formula A was supplied in three dose strengths, sham, 30 μg/mL and 60 μg/mL free base equivalent solutions. The formulation of the compound of Formula A was presented in a 2 mL Type 1 clear glass serum vial sealed with a rubber stopper and white flip off seal. Each vial was packaged in a five (5) unit container carton. The packaged kits were refrigerated (2 to 8° C.). The formulation of the compound of Formula A was administered as an intravitreal injection in a final volume of 100 μL for the 3 μg (30 μg/mL) dose, and 100 μL for the 6 μg (60 μg/mL) dose.

[0898] On the day of the first injection visit, the kit carton was pulled from the refrigerator and inspected to ensure the tamper evident seal is intact. The kit carton was not used if the tamper evident seal had been compromised. The tamper evident seal was broken, the kit carton was opened, and the vial containing the compound of Formula A, 1 of 5, was removed. The vial was warmed to room temperature for a minimum of 15 minutes. The removable panel of the vial label was peeled and affixed to the subject documentation. The investigational product vial was used for patient dosing within the same working day after removal from refrigerated storage. For subsequent dosing vials were sequentially removed from the kit and use was recorded by affixing vial specific removable panel label to subject documentation.

[0899] The flip-off seal on the vial was removed and the top was wiped with an alcohol pad. Using the provided sterile, single-use 25-gauge needle attached to a sterile, single-use 1 CC tuberculin syringe, sufficient volume (to ensure a final injectable volume of 100 μL remains in the syringe following needle exchange and removal of trapped air as described) of the formulation of the compound of Formula A was withdrawn into the syringe by inserting the needle through the rubber stopper into the vial. Once the formulation of the compound of Formula A was drawn into the syringe, the 25-gauge needle that was used to draw the drug up was replaced with a sterile, single use 30-gauge needle to perform the injection. Trapped air/bubbles and excess volume were removed to medical waste so that 100 μL of the formulation of the compound of Formula A remained in the syringe. Sterility of the needle tips was maintained as well as vial surface during preparation to ensure that there was no contamination of the drug as it was withdrawn from the vial. Unnecessary and repeated removal was avoided, as well as replacement of the needle over cap, as it decreased needle sharpness.

[0900] The dose was administered immediately upon preparation: [0901] 1. The injecting physician and a second person confirmed which eye is the study eye that received the intravitreal injection and confirmed that the patient was being dosed according to their randomization assignment. The study eye was marked with a sticker or marking pen. [0902] 2. The study eye was draped at the injecting physician's discretion, but this was not required as part of the study procedure. [0903] 3. 1-2 drops of a topical anesthetic was instilled into the study eye. [0904] 4. Povidone iodine was applied to the study eye and lashes and skin around the eye. [0905] 5. A sterile eyelid speculum was placed to stabilize the eyelids. [0906] 6. A subconjunctival anesthetic injection was administered to the study eye. This was mandatory and required for both the injection of the compound of Formula A and the sham treatment arms in order to maintain the mask in the study. [0907] 7. For the injection of the compound of Formula A arms only: the needle of syringe was inserted into the study eye 3.5-4 mm posterior to the limbus. The drug was slowly injected to gently distribute into the vitreous cavity with the needle pointing toward the optic nerve. The needle was carefully removed from the eye. [0908] 8. For sham arm only: The hub of a needleless syringe was applied to the conjunctiva and pressed gently to mimic the force of an actual injection.

[0909] Post-injection procedures—for all arms: [0910] 1. The lid speculum was removed, avoiding any excess pressure on the eye. [0911] 2. Immediately after injection, the injecting physician confirmed that the central retinal artery was perfused (even if pulsating) or checked vision to confirm that there was some perception of vision (even hand motion or light perception) in the study eye. [0912] 3. Participant's intraocular pressure (IOP) was measured within 60 minutes post IP injection by unmasked staff. [0913] 4. Subjects were contacted by telephone approximately 24 hours after each injection to evaluate AEs and changes in concomitant medications.

Packaging, Labelling and Storage

[0914] All packaging and labelling operations were performed according to Good Manufacturing Practice for Medicinal Products and the relevant regulatory requirements.

[0915] The drug product was provided in a 2 mL Type 1 glass serum vial sealed with a rubber stopper and flip off seal. Each vial was for a single use and filled with 2 mL of the injection product of the compound of Formula A.

[0916] Supplies for control subjects took the form of boxes identical to those holding the vials of the compound of Formula A but these boxes contained empty vials. All boxes remained closed except while being accessed by the nominated unmasked personnel administering the real and sham injections.

[0917] The Investigator ensured that the drug product was stored in appropriate conditions in a secure, substantially constructed refrigerator with controlled access. Drug product was stored at 2 to 8° C. temperature except on dosing date where it could be at room temperature for up to 1 day. Upon completion of dosing, the used drug product could be destroyed with routine medical waste at the clinical site.

Concomitant Medications/Therapy

[0918] The concomitant use of the following medications was not be allowed in the study: [0919] Anti-VEGF administered systemically; [0920] Any treatment in the study eye or given intravitreally in the study eye for DME other than the study medication. Note, the fellow (non-study) eye may be treated for DME at the Investigator's discretion; [0921] Steroid administered systemically, intravitreally in the study eye, or topically in the study eye; [0922] NSAIDs administered topically in the study eye; [0923] Any Jetrea® (ocriplasmin) intravitreal injection in the study eye. [0924] Any ophthalmic medication that in the opinion of the Investigator might have influenced the interpretation of the safety and/or efficacy parameters in this study.

[0925] Details of all medications (other than those intended to treat the study subjects' DME), therapies and supplements administered within 3 months prior to Screening Visit until the end of the study was recorded

[0926] With the exception of ocular medications intended to treat DME, prior medications are defined as those medications taken within 3 months prior to Screening Visit; concomitant medications are defined as those medications ongoing at or started after Day 1.

Measurement Methods or Assessment:

[0927] The efficacy variable of interest in the study was: BCVA in letters as measured by ETDRS.

[0928] ETDRS is the Early Treatment Diabetic Retinopathy Study, measured using the Early Treatment Diabetic Retinopathy Study (ETDRS) chart

[0929] These further ophthalmic assessments (with which the skilled person would be familiar) were also used: [0930] CST in μm as measured by Spectral Domain OCT [0931] Retinopathy severity as measured by the DRSS and graded from fundus photography [0932] Slit Lamp Biomicroscopy:

[0933] The eyelids, cornea, conjunctiva, anterior chamber, iris/pupil and lens were evaluated. Findings were graded as normal, abnormal non-clinically significant, or abnormal clinically significant. Slit lamp biomicroscopy was performed on both eyes and was conducted prior to study drug administration on applicable visits. [0934] Intraocular Pressure (IOP):

[0935] IOP was assessed in both eyes at all study visits. IOP was assessed with either applanation tonometry or tonopen; the method used was consistent throughout the study. IOP was assessed at both pre- and post-injection at visits with study drug administrations. Pre-injection IOP was performed prior to dilation. Post-injection IOP was assessed within 60 minutes after study drug or sham administration and was assessed by someone who was unmasked. [0936] Dilated Indirect Ophthalmoscopy:

[0937] The vitreous, macula, choroid, optic nerve, and retina of both eyes were assessed. Findings were graded as normal, abnormal non-clinically significant, or abnormal clinically significant. The dilated indirect ophthalmoscopy was performed on both eyes and was conducted prior to study drug administration on applicable visits.

[0938] Safety variables of interest in this study are: [0939] AEs; [0940] Ophthalmic and physical findings; [0941] Laboratory test results (clinical chemistry, hematology, and urinalysis); [0942] Vital signs (SBP, DBP, PR, and respiratory rate).

Results:

[0943]

TABLE-US-00008 TABLE 7 Efficacy assessment - measurement of BCVA at week 16 3 μg of 6 μg of compound of compound of Sham Formula A Formula A BCVA (letters) n = 44 n = 44 n = 41 Any loss from baseline n (%) 24 (54.5) 22 (50.0) 13 (32.5) p-value (trend) 0.0496 Diff. v. sham −4.5 (0.6695) −22.0 (0.0421) (p-value) ≥5 letter loss from baseline n (%) 12 (27.3) 11 (25.0) 8 (20.0) p-value (trend) 0.4503 Diff. v. sham (p-value) −2.3 (0.8083) −7.3 (0.4344) ≥10 letter loss from baseline n (%) 9 (20.5) 4 (9.1) 2 (5.0) p-value (trend) 0.0280 Diff. v. sham (p-value) −11.4 (0.228) −15.5 (0.0516) ≥15 letter loss from baseline n (%) 5 (11.4) 2 (4.5) 0 (0) p-value (trend) 0.0279 Diff. v. sham (p-value) −6.8 (0.4336) −11.4 (0.0565)

TABLE-US-00009 TABLE 8 Change in BCVA letters versus sham over time for 3 μg of compound of Formula A and 6 μg of compound of Formula A (positive value is improvement) BCVA improvement 3 μg of compound 6 μg of compound (letters) of Formula A of Formula A  4 weeks - mean 0.6 0.9  8 weeks - mean 1.2 1.1 12 weeks - mean 3.8 2.9 16 weeks - mean 1.5 2.6 20 weeks - mean −1.2 2.0 24 weeks - mean −0.7 2.1

[0944] These results are also shown graphically in FIG. 1.

TABLE-US-00010 TABLE 9 Change in BCVA letters versus sham over time for early stage compared with all subjects on the dose of 6 μg of compound of Formula A 6 μg of compound of Formula A - early stage BCVA improvement subjects (baseline 6 μg of compound of (letters) BCVA >55 letters) Formula A - all subjects  4 weeks - mean 2.3 0.9  8 weeks - mean 1.8 1.1 12 weeks - mean 4.7 2.9 16 weeks - mean 4.9 2.6 20 weeks - mean 3.5 2.0 24 weeks - mean 2.9 2.1

[0945] These results are also shown graphically in FIG. 2.

[0946] The majority of any reported adverse events (AEs) were mild. Two AEs led to discontinuation, one retinal neovascularization (6 μg arm) and one visual impairment (sham arm). All AEs except for the retinal neovascularization (6 μg arm) were considered unrelated to the treatment. Therefore, in >99% of the subjects, the treatment was safe and well-tolerated.

[0947] As demonstrated in Table 7, administration of the compound of Formula A to subjects that had previously had anti-VEGF treatment resulted in a slowing of the progression of their DME or impaired visual acuity. 22 patients in the group that were administered doses of 3 μg of the compound of Formula A showed any loss in BCVA (letters) from baseline compared to 24 patients that had the sham procedure. Even more markedly, only 13 patients in the group that were administered doses of 6 μg of the compound of Formula A showed any loss in BCVA (letters) from baseline compared to 24 patients that had the sham procedure. Further, 5 patients that had the sham procedure lost ≥15 letters from baseline, whereas only 2 patients in the 3 μg of the compound of Formula A group, and 0 patients in the 6 μg of the compound of Formula A group lost ≥15 letters from baseline.

[0948] The results in Table 8 demonstrate that, for the patients that were administered doses of 6 μg of the compound of Formula A that the improvement in BCVA (letters) score, compared to the sham treatment, was maintained following the 16 week treatment period, through to the 24 week time period. It appears that this effect would be seen for doses greater than those for the group of patients that were administered the 3 μg doses of the compound of Formula A. These data point towards the efficacy of a higher dose treatment, i.e. the 6 μg of the compound of Formula A, as well as higher doses.

[0949] The results in Table 9 demonstrate that the population of patients that had a baseline BCVA score of greater than 55 letters (i.e. ≥56 letters), who may be referred to as the patients in the early stages of their DME or poor visual acuity, on average, and at every measurement taken (both during the treatment procedure and in the follow up phase) had a consistently better average improvement in BCVA score than the overall average population score. Therefore, the treatment represents an efficacious treatment particularly for those patients that were in the early stages of DME or poor visual acuity.

[0950] It will be understood that the invention has been described by way of example only and modifications may be made whilst remaining within the scope and spirit of the invention.