JCHR

Title

A Randomized Clinical Trial Evaluating Fenofibrate for Prevention of Diabetic Retinopathy Worsening

Précis

This randomized trial will evaluate the effect of fenofibrate compared with placebo for prevention of diabetic retinopathy (DR) worsening through 4 years of follow-up in eyes with mild to moderately severe non-proliferative DR (NPDR) and no CI-DME at baseline.

In addition to evaluating efficacy, this study aims to evaluate the feasibility of a model for ophthalmologists to prescribe or collaborate with a primary care provider such as an internist/endocrinologist to prescribe and monitor the drug safely.  If this study demonstrates that fenofibrate is effective for reducing the onset of proliferative diabetic retinopathy (PDR) and the results are adopted by the community of retina specialists, a new strategy to prevent vision threatening complications of diabetes could be widely adopted.  Widespread use of an oral agent effective at reducing worsening of DR would decrease the numbers of patients who undergo more invasive and much more expensive treatment for DR and who are consequently at risk for side effects that adversely affect visual function. 

This study will also assess the relationship of glycemic variability, as measured by continuous glucose monitoring, with DR outcomes. Ancillary studies will characterize functional and structural outcomes in this cohort.

Investigational Drug

Fenofibrate (new indication)

Objectives

The primary objective is to determine if fenofibrate is effective at preventing DR worsening in eyes with mild to moderately severe non-proliferative DR and no CI-DME at baseline.

Additional goals of the study are to 1) provide a model for ophthalmologists to prescribe or collaborate with a primary care provider to prescribe and monitor the drug safely, 2) disseminate standardized prescribing guidelines with the aim to encourage broader use, and 3) collect information on potential predictive biomarkers of DR progression via blood sampling, functional, and structural testing as well as glucose levels from CGM.

Study Design

Randomized, double-masked, placebo-controlled clinical trial

Number of Sites

Approximately 80

Endpoint

Primary Efficacy Outcome:

Worsening of DR through 4 years (time-to-event composite outcome) defined as any of the following in a study eye (see details in Section 10.4.1):

·       2 or more step worsening on ETDRS DR severity on fundus photographs.

·        Development of NV within the 7-modified ETDRS fields on fluorescein angiography.

·       Intraocular procedure undertaken to treat DR including PRP, intraocular anti-VEGF, corticosteroid, or vitrectomy.

Key Safety Outcomes:

Myopathy, rhabdomyolysis, renal disease (eGFR decreased below 30, dialysis, or renal transplant), cholelithiasis, increased liver function tests (ALT or AST), low HDL, muscle pain or weakness, easy bruising or bleeding, death, APTC events

Population

Key Inclusion Criteria

·        Age =18 years and < 80 years.

·        Type 1 or type 2 diabetes.

·        At least one eye with the following:

o   Mild to moderately severe NPDR (defined by ETDRS DR severity level 35 to 47), confirmed by central Reading Center grading of fundus photographs.

o   Best-corrected E-ETDRS visual acuity letter score of =74 (approximate Snellen equivalent 20/32 or better).

·        If only one eye is eligible, the non-study eye must have at least microaneurysms only (DR severity level 20)

Key Exclusion Criteria

Eye-level exclusion criteria (the eye is ineligible if any of the following is met):

·        Current CI-DME based on clinical exam or OCT central subfield thickness (CST)

o   Zeiss Cirrus: CST =290 µm in women or = 305 µm in men

o   Heidelberg Spectralis: CST =305 µm in women or =320 µm in men

·        Any prior treatment for DME or DR, other than focal/grid laser. If the eye has a history of focal/grid laser, it must be at least 12 months prior.

·        History of intraocular anti-VEGF or corticosteroid treatment within the prior year for any indication

Participant-level exclusion criterion (the participant is ineligible if the following criterion is met):

·       Decreased renal function, defined as requiring dialysis or central laboratory eGFR value < 45 mL/min/1.73 m²

Sample Size

910 participants

Treatment Groups

Random assignment (1:1) to fenofibrate or placebo

Participant Duration

4 years of follow-up for each randomized participant. 

Protocol Overview/Synopsis

1. Informed consent will be obtained.
2. Study eligibility will be assessed by the site.
3. Potentially eligible participants will complete a Screening visit after which:
1. Eligibility will be confirmed via lab results and RC grading of DR severity level.
2. Approval to participate in the study will be obtained from the participant’s health care provider responsible for primary systemic management (e.g., endocrinologist or primary care provider).
4. Eligible participants will be randomly assigned 1:1 to fenofibrate or placebo.
5. Participants will return for a follow-up visit at 3 months, 6 months, and every 6 months thereafter through 4 years.
6. Phone calls to the participant will be made at 3-month intervals in-between 6-month interval visits, starting after the 6-month visit.
7. Participation in the study will be considered completed upon completion of the 4-year (48-month) visit. 

Visit

Screening Visit

Randomization

Visit

3-Month Safety Visit

6-Month Visit

Annual Visits (12, 24, 36, 48 Months) *

18, 30, 42-Month Visits

Visit Window

<60 days from Screening

±2 weeks

±4 weeks

±8 weeks

±4 weeks

Randomization

X

Visual acuity^a

X

X

X

X

X

OCT

X

X

X

X

Eye Exam ^b

X

X

X

X

X

Fundus Photography^c

X

X

Fluorescein Angiography^c

X

X

Blood Pressure

X

X

X

X

X

Urine sample for creatinine, albumin, and pregnancy test (if female of child-bearing potential)

X

Pregnancy test only (if > 30 days from screening) ^k

X

X

X

Pregnancy test only (Central Lab)

Whole blood sample for CBC and HbA1c^d

X

CBC only

X

X

Serum sample for LFTs, serum creatinine, eGFR, CK, and lipid panels^e

X

X

X

X

Safety assessment^f

X

X

X

X

Assess Compliance with Study Drug Regimen

X

X

X

X

CGM Insertion^g

X

X

X

X

Ancillary Components – the following tests will only be performed at select sites and/or on select participants

OCT Angiographyⁱ

X

X

X

Humphrey Visual Field^h

X

X

X

X

Contrast sensitivity^j

X

X

Biomarker serum sample

X

X

X

X

RNA sample

X

X

X

X