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

2. Disclosure  Funding/Support: Cooperative Agreement with NEI and NIDDK of NIH, U.S. Department of Health and Human Services.  Additional Contributions: Regeneron Pharmaceuticals, Inc. provided the aflibercept; Genentech Inc. provided the ranibizumab. Genentech Inc. also provided funding for blood pressure cuffs and collection of plasma and urine that are not part of the main study reported herein.  A complete list of all DRCR.net investigator financial disclosures can be found at www.drcr.net.www.drcr.net 2

3. Background 3  Diabetic macular edema (DME) affects ~750,000 people in the U.S.  Intravitreous anti-vascular endothelial growth factor (anti-VEGF) injections of either aflibercept (Eylea), bevacizumab (Avastin), or ranibizumab (Lucentis) are effective in treating DME.  The relative efficacy and safety of these agents within a head-to-head study were unknown prior to the results of this trial

4. Background 4  Aflibercept and ranibizumab are FDA approved for DME treatment.  Bevacizumab is not FDA approved for intraocular use,  used “off-label” for DME treatment and  repackaged into aliquots ~1/500 of systemic dose in cancer treatments.  Medicare allowable charges:  Aflibercept (2.0 mg): $1961  Bevacizumab (repackaged 1.25mg): $67  Ranibizumab (0.3 mg): $1189

5. Primary Objective  For eyes with center involved DME with decreased visual acuity, compare one year efficacy and safety of, 1.intravitreous aflibercept (Eylea®), 2.intravitreous bevacizumab (Avastin®) and 3.intravitreous ranibizumab (Lucentis®)

6. Study Design 6 Participants meeting all of the following criteria: At least 18 years old Type 1 or type 2 diabetes Study eye meeting all of the following criteria: ~Snellen equivalent visual acuity 20/32 or worse and 20/320 or better Central-involved DME on clinical exam Central subfield (CSF) thickness ≥ protocol-defined gender and optical coherence tomography (OCT) machine-specific thresholds No history of an anti-VEGF treatment for DME in the past 12 months or any other DME treatment in the past 4 months Randomized, multi-center clinical trial (N = 89 Sites) Primary Outcome: Change in visual acuity at one year adjusted for baseline visual acuity using the intent-to-treat principle

7. Baseline to 1 year Baseline to 1 year Follow-up Schedule Visits every 4 weeks Primary outcome at 1 year Visits every 4 weeks Primary outcome at 1 year  Visit Procedures  Refraction with Electronic-ETDRS visual acuity measurement  OCT spectral domain (97%) or time domain  Dilated ocular exam  Color fundus photos (baseline/1 year only) ETDRS = Early Treatment Diabetic Retinopathy Study

8. Treatment Schedule Through 1 Year (q4 weeks)  Repeat injections at every 4-week visit if eye “improved”* or “worsened”*  Otherwise, defer injections if either:  Visual acuity 20/20 or better and OCT CST “normal” or,  At or after 24 weeks, visual acuity and OCT stable after 2 consecutive injections  Resume injections if VA or OCT worsened* *Improved/worsened defined as: ≥ 5 letter change (~1 Snellen line) from last injection, or, ≥ 10% CST change on OCT from last injection

9. Treatment Schedule Through 1 Year  Focal/grid laser: initiated at or after 24 weeks only if persistent DME not improving after at least 2 injections

10. Randomization 10 Bevacizumab (1.25 mg) N = 218 Bevacizumab (1.25 mg) N = 218 Aflibercept (2.0 mg) N = 224 Aflibercept (2.0 mg) N = 224 Ranibizumab (0.3 mg) N = 218 Ranibizumab (0.3 mg) N = 218 Randomly Assigned Eyes (one per participant): N = 660 Randomly Assigned Eyes (one per participant): N = 660 N = 206 (94%) N = 208 (93%) N = 206 (94%) One Year 97% 94% 96% One Year Excluding Deaths Baseline

11. Baseline Characteristics 11 Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab (N = 218) Age (years) – Median616359 Gender: Women49%47%43% Race White65%64%67% Black/African American 14%17% Hispanic17% 14% Other4%3% Type 2 diabetes88%94%90% Median HbA1c 7.67.77.8

12. 12 Ocular Baseline Characteristics Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab (N = 218) Mean visual acuity letter score (~Snellen Equivalent) 69 (20/40) 69 (20/40) 68 (20/50) Mean OCT CST (µm)387376390 Any Prior Focal/Grid Laser 36%39%37% Any Prior Treatment with anti-VEGF 11%14%13% Phakic74%73%79%

13. Treatment for Diabetic Macular Edema 13

14. 14 DME Treatment Through 1 Year: anti-VEGF and Laser Aflibercept N = 208 Bevacizumab N = 206 Ranibizumab N = 206 P- Value # of Injections (Max = 13) Mean9.29.79.4 Median (25 th, 75 th percentile) 9 (8, 11)10 (8, 12)10 (8, 11) 0.045 † At least one focal/grid laser 37%56%46% <0.001 ‡ † Global (overall 3 group comparison) P-value. Pairwise comparisons (adjusted for multiple comparisons): aflibercept-bevacizumab: P = 0.045, aflibercept-ranibizumab: P = 0.19, bevacizumab-ranibizumab: P = 0.22. ‡ Global (overall 3 group comparison) P-value. Pairwise comparisons (adjusted for multiple comparisons): aflibercept-bevacizumab: P<0.001, aflibercept-ranibizumab: P = 0.058, bevacizumab-ranibizumab: P = 0.061.

15. 15 Efficacy

16. 16 52 Week Treatment Group Comparison*: Aflibercept vs. Bevacizumab P<0.001 Aflibercept vs. Ranibizumab P = 0.034 Ranibizumab vs. Bevacizumab P = 0.12 * P-values adjusted for baseline visual acuity and multiple comparisons +13 +11 +10 Mean Change in Visual Acuity Letter Score, Full Cohort

17. Mean Change in Visual Acuity Letter Score Baseline Visual Acuity 20/32 to 20/40 17 ~+8 ~50% of Cohort

18. Mean Change in Visual Acuity Letter Score Baseline Visual Acuity 20/50 or Worse 18 1-Year Treatment Group Comparison*: Aflibercept vs. Bevacizumab P<0.001 Aflibercept vs. Ranibizumab P = 0.0031 Ranibizumab vs. Bevacizumab P = 0.21 * P-values adjusted for baseline visual acuity and multiple comparisons +19 +14 +12 ~ 50% of Cohort

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

20. 78-74 (20/32) 73-69 (20/40) 68-64 (20/50) 63-54 (20/63-20/80) 53-24 (20/100-20/320) Baseline Visual Acuity Letter Score N = Aflibercept5452362937 Bevacizumab4163353829 Ranibizumab4659323732 Visual Acuity Mean Change: Baseline to 1 Year

21. Visual Acuity Outcomes Baseline = 20/32 to 20/40 21 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +0.7 -1.3 to +2.70.69 Aflibercept vs Ranibizumab -0.4 -2.3 to +1.5 0.69 Ranibizumab vs Bevacizumab +1.1 -0.9 to +3.1 0.69

22. Visual Acuity Outcomes Baseline = 20/32 to 20/40 22 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +6% -9% to +21%0.82 Aflibercept vs Ranibizumab 0% -13% to +14% 0.95 Ranibizumab vs Bevacizumab +6% -10% to +21% 0.82 >10 Letter Improvement

23. Visual Acuity Outcomes Baseline = 20/32 to 20/40 23 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +2% -7% to +11%0.73 Aflibercept vs Ranibizumab +4% -5% to +12% 0.73 Ranibizumab vs Bevacizumab -2% -10% to +7% 0.73 >15 Letter Improvement

24. Visual Acuity Outcomes Baseline = 20/32 to 20/40 24 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +2% -3% to +6%0.54 Aflibercept vs Ranibizumab +3% -1% to +7% 0.54 Ranibizumab vs Bevacizumab -1% -4% to +2% 0.54 >10 Letter Worsening

25. Visual Acuity Outcomes Baseline = 20/50 or Worse 25 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +6.5 +2.9 to +10.1<0.001 Aflibercept vs Ranibizumab +4.7 +1.4 to +8.0 0.0031 Ranibizumab vs Bevacizumab +1.8 -1.1 to +4.8 0.21

26. Visual Acuity Outcomes Baseline = 20/50 or Worse 26 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +17% +2% to +31%0.018 Aflibercept vs Ranibizumab +10% -4% to +23% 0.20 Ranibizumab vs Bevacizumab +7% -6% to +20% 0.28 >10 Letter Improvement

27. Visual Acuity Outcomes Baseline = 20/50 or Worse 27 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +24% +9% to +39%<0.001 Aflibercept vs Ranibizumab +18% +4% to +32% 0.0078 Ranibizumab vs Bevacizumab +6% -7% to +19% 0.34 >15 Letter Improvement

28. Visual Acuity Outcomes Baseline = 20/50 or Worse 28 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab -3% -7% to +2%0.56 Aflibercept vs Ranibizumab -1% -5% to +3% 0.56 Ranibizumab vs Bevacizumab -1% -6% to +3% 0.56 >10 Letter Worsening

29. Overall Mean (µm) Change in OCT CST Over Time 29 Thinner is decreased DME -169 -147 -101 1-Year Treatment Group Comparison*: Aflibercept vs. Bevacizumab P < 0.001 Aflibercept vs. Ranibizumab P = 0.036 Ranibizumab vs. Bevacizumab P = <0.001 * P-values adjusted for baseline visual acuity, OCT central subfield thickness, and multiple comparisons

30. Mean (µm) Change in OCT CST Baseline visual acuity 20/32 to 20/40 30 Thinner is decreased DME 1-Year Treatment Group Comparison*: Aflibercept vs. Bevacizumab P <0.001 Aflibercept vs. Ranibizumab P = 0.057 Ranibizumab vs. Bevacizumab P = <0.001 -67 -129 -119 * P-values adjusted for baseline visual acuity, OCT central subfield thickness, and multiple comparisons

31. Mean (µm) Change in OCT CST Baseline visual acuity 20/50 or Worse 31 Thinner is decreased DME 1-Year Treatment Group Comparison*: Aflibercept vs. Bevacizumab P < 0.001 Aflibercept vs. Ranibizumab P = 0.22 Ranibizumab vs. Bevacizumab P = <0.001 -135 -176 -210 * P-values adjusted for baseline visual acuity, OCT central subfield thickness, and multiple comparisons

32. 32 Treatment Group Comparisons DifferenceCIP- Value Aflibercept vs Bevacizumab -55.8 -78.3 to -32.9<0.001 Aflibercept vs Ranibizumab -18.2 -36.9 to +0.6 0.057 Ranibizumab vs Bevacizumab -37.7 -59.3 to -16.1 <0.001 OCT CSF Outcomes Baseline = 20/32-20/40

33. Visual Acuity Outcomes Baseline = 20/32-20/40 33 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +31% +16% to +45%<0.001 Aflibercept vs Ranibizumab -2% -16% to +12% 0.79 Ranibizumab vs Bevacizumab +33% +17% to +48% 0.001 CSF <250 µm

34. 34 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab -85.8 -121.9 to - 49.7<0.001 Aflibercept vs Ranibizumab -18.5 -48.2 to +11.2 0.22 Ranibizumab vs Bevacizumab -67.3 -101.4 to -33.1 <0.001 OCT CSF Outcomes Baseline = 20/50 or Worse

35. Visual Acuity Outcomes Baseline = 20/50 or Worse 35 Treatment Group Comparisons DifferenceCI P- Value Aflibercept vs Bevacizumab +32% +16% to +48% <0.001 Aflibercept vs Ranibizumab +16% +3% to +30% 0.025 Ranibizumab vs Bevacizumab +16% +2% to +29% 0.025 CSF <250 µm

36. Safety 36

37. Ocular Adverse Events through 1 Year (Study Eye) 37 Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab (N = 218) P- Value No. of injections prior to 1 year 199120552011 Endophthalmitis 000 Inflammation† <1% 1.0 Retinal detachment/tear 0<1% 0.55 Vitreous hemorrhage 2%4%3%0.35 Injection related cataract <1% 00.55 IOP elevation‡ 14%9%11%0.18 †Includes anterior chamber cell/flare, choroiditis, episcleritis, iritis, vitreous cells. ‡Includes intraocular pressure increase ≥10mmHg from baseline at any visit, intraocular pressure ≥30 mmHg at any visit, or initiation of intraocular pressure-lowering medications not in use at baseline. There were no glaucoma surgeries. IOP= Intraocular Pressure

38. Ocular Adverse Events through 1 Year (Non-Study Eye: Study Drug) 38 Aflibercept (N = 129) Bevacizumab (N = 122) Ranibizumab (N = 121) No. of injections prior to 1 year 753841766 Endophthalmitis <1%0 Inflammation ǁ 2%<1%0 Retinal detachment/tear 000 Vitreous hemorrhage 4%7%2% Injection related cataract <1%00 Intraocular pressure elevation ‡ 12%9% ǁ Includes anterior chamber cell/flare, choroiditis, episcleritis, iritis, vitreal cells. ‡Includes intraocular pressure increase ≥10mmHg from baseline at any visit, intraocular pressure ≥30 mmHg at any visit, or initiation of intraocular pressure-lowering medications not in use at baseline. There were no glaucoma surgeries.

39. Systemic Adverse Events APTC* through 1-Year 39 Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab (N = 218) Non-fatal MI 2%<1%1% Non-fatal stroke 02% Vascular death <1%2%1% Any APTC Event 3%4%5% Global P = 0.56 * Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ 1994;308:81-106.

40. Systemic Adverse Events Through 1 Year Pre-specified (Per Participant) 40 Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab (N = 218) P- Value* Death (any cause) 1%2% 0.72 Hospitalization 21%18%22% 0.51 SAEs 26%21%25% 0.40 Gastrointestinal † 20%18%17% 0.84 Kidney Events‡ 13%11% 0.81 Hypertension Events 12%7%12% 0.20 *Global (overall 3 group comparison) P-value from Fisher’s Exact Test. †Includes events with a Medical Dictionary for Regulatory Activities system organ class of gastrointestinal disorders ‡Includes a subset of Medical Dictionary for Regulatory Activities system organ class of renal and urinary disorders events indicative of intrinsic kidney disease, plus increased/abnormal blood creatinine or renal transplant from other system organ classes SAEs = Serious adverse events

41. Post Hoc Analysis: Cardiovascular Events Through 1 Year 41 Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab (N = 218) Global P-Value unadjusted/ adjusted* Any Cardiovascular Event,† excluding Hypertension 9% 17% 0.012 1 0.024 2 Any Cardiovascular Event† 19%16%26% 0.038 3 0.081 4 * Adjusted for potential confounders: gender, age at baseline, Hemoglobin A 1c at baseline, diabetes type, diabetes duration at baseline, insulin use, prior coronary artery disease, prior myocardial infarction, prior stroke, prior transient ischemic attack, prior hypertension, smoking status † Events with a MedDRA system organ class of cardiac disorder or vascular disorder OR considered by the medical monitor as related to a cardiac or vascular event (cardiac murmur, cardiac pacemaker insertion/replacement, coronary arterial stent insertion, heart rate irregular, and stent placement) Pairwise comparisons (adjusted for multiple comparisons): 1.A-B: P=1.0, A-R: P=0.015, B-R: P = 0.014 2.A-B: P=0.68, A-R: P=0.040, B-R: P = 0.024 3.A-B: P=0.53, A-R: P=0.087, B-R: P = 0.038 4.A-B: P=0.37, A-R: P=0.19, B-R: P = 0.081

42. Post Hoc Analysis: Cardiovascular Events 42 Aflibercept (N = 224) Bevacizumab (N = 218) Ranibizumab (N = 218) Any Cardiovascular Event Cardiac Events 6% 11% Cerebrovascular Events 02%5% Peripheral Vascular Disease Events <1% Venous Disease Events <1% Hypertension Events 12%7%12% Other Cardiovascular Events 3%<1%2%

43. Discussion  All three anti-VEGF agents, on average, produced substantial visual acuity improvement by 1 month, sustained through 1 year.  On average, greater improvement occurred with aflibercept, but relative effect varied by initial visual acuity.  Mild initial vision loss (20/32-20/40, 50% of study eyes): little difference in mean visual acuity at 1 year  Worse initial vision loss: aflibercept had an advantage over the other agents Statistically significant: Mean improvement of 18.9 for aflibercept vs. 11.8 for bevacizumab (P<0.001) and vs. 14.2 with ranibizumab (P = 0.003) Clinically meaningful: For example, relative improvement ≥15 letters (>3 Snellen lines) in 63% more aflibercept-treated eyes than bevacizumab- treated eyes, and 34% more than ranibizumab-treated eyes 43

44. Discussion  Bevacizumab had a lesser effect on reducing macular edema than the other two agents, regardless of starting acuity.  Few eyes in any group had substantial visual acuity loss.  Median number of injections: 9 to 10 in all three groups.  Fewer eyes in the aflibercept group received focal/grid laser for DME after 24 weeks, presumably because a greater % of eyes in the aflibercept group had resolution of central DME (which drives decision to apply laser). 44

45. Discussion  Serious adverse event, death, and hospitalization rates appeared similar among treatment groups.  Significant differences in frequencies of major cardiovascular events were not identified However, post-hoc analysis combining MedDRA system organ classes of cardiac and vascular resulted in more participants in the ranibizumab group reporting these adverse events. This is inconsistent with prior studies and may be due to chance.  Endophthalmitis was rare: 0.02% of injections.  No differences in intraocular inflammation. 45

46.  Bevacizumab:  Note: a central pharmacy repackaged into single use vials Testing was completed for sterility, purity, and potency, a standard that may not be available in a clinical practice setting  Results may not apply to eyes with persistent or recurrent DME already receiving anti-VEGF 46 Discussion

47. Conclusion  All three anti-VEGF agents are effective treatments for DME causing vision impairment.  When initial visual acuity loss is mild, on average there is little difference in visual acuity at 1-year.  At worse levels of initial visual acuity aflibercept is more effective at improving vision. 47

48. Thank You on Behalf of Diabetic Retinopathy Clinical Research Network (DRCR.net) 48 A complete list of all DRCR.net investigator financial disclosures and these slides can be found at www.drcr.net.www.drcr.net Full protocol available on clinicalTrials.gov (NCT01627249) Reference: DOI: 10.1056/NEJMoa1414264 Diabetic Retinopathy Clinical Research Network. Aflibercept, ranibizumab, or bevacizumab for diabetic macular edema. NEJM 2015;372:xxx-xxx.