Effectiviteits- en veiligheidsstudie van Ixoberogene Soroparvovec (Ixo-vec) bij deelnemers met neovasculaire leeftijdsgebonden maculadegeneratie (AQUARIUS) (AQUARIUS)
Een multicenter, gerandomiseerde, dubbelgemaskeerde, actieve-comparator-gecontroleerde, fase 3-studie om de werkzaamheid en veiligheid van Ixoberogene Soroparvovec (Ixo-vec) te evalueren bij deelnemers met neovasculaire leeftijdsgebonden maculadegeneratie (AQUARIUS)
This is a multi-center, randomized, double-masked, active-comparator-controlled, Phase 3 study in a broad participant population (treatment-naïve and treatment-experienced) with neovascular (wet) age-related macular degeneration (nAMD). The study will evaluate a single intravitreal (IVT) injection of Ixo-vec compared to intravitreal aflibercept (active comparator). The primary endpoint of this study is the mean change in best corrected visual acuity (BCVA) of Ixo-vec compared to an active comparator measured as an average at Weeks 52 and 56.
Safety, tolerability, and efficacy will be evaluated throughout the study.
Studie Overzicht
Toestand
Toestand
Conditie
Conditie
Interventie / Behandeling
Interventie / Behandeling
Gedetailleerde beschrijving
The primary objective of this study is to evaluate the non-inferiority in efficacy of a single IVT injection of Ixo-vec 6 x 10^10 vector genome (vg)/eye compared to an active comparator. Non-inferiority will be evaluated using a pre-specified margin defined in the protocol.
Neovascular AMD is a degenerative ocular disease associated with the infiltration of abnormal blood vessels in the retina from the underlying choroid layer and is a leading cause of blindness in patients over 65 years of age. The abnormal angiogenic process in nAMD is stimulated and modulated by vascular endothelial growth factor (VEGF). Treatment of nAMD requires frequent IVT injections of VEGF inhibitors (anti-VEGF) administered every 4-16 weeks. Ixo-vec (also known as ADVM-022 or AAV.7m8-aflibercept) is an adeno-associated virus (AAV)-based gene therapy product being developed for the treatment of nAMD. Ixo-vec is designed to reduce the current treatment burden which often results in undertreatment and vision loss in patients with nAMD receiving anti-VEGF therapy in clinical practice.
Safety, tolerability, and efficacy will be evaluated throughout this study. The primary endpoint of this study is the mean change in BCVA of Ixo-vec compared to an active comparator measured as an average at Weeks 52 and 56 post-treatment.
Due to the long duration of the Screening period, this study will be considered fully enrolled when randomization has been completed.
Studietype
Studietype
Inschrijving (Geschat)
Inschrijving
Fase
Fase
- Fase 3
Contacten en locaties
Studiecontact
Studiecontact
- Naam: Adverum Study Contact
- Telefoonnummer: 650-656-9323
- E-mail: ADVM02213ClinOp@adverum.com
Studie Locaties
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Arizona
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Mesa, Arizona, Verenigde Staten, 85206
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- Adverum Clinical Site 245
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Phoenix, Arizona, Verenigde Staten, 85020
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- Adverum Clinical Site 178
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Phoenix, Arizona, Verenigde Staten, 85014
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- Adverum Clinical Site 126
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Phoenix, Arizona, Verenigde Staten, 85020
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- Adverum Clinical Site 223
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Scottsdale, Arizona, Verenigde Staten, 85255
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- Adverum Clinical Site 229
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Sun City, Arizona, Verenigde Staten, 85351
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- Adverum Clinical Site 242
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Arkansas
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Springdale, Arkansas, Verenigde Staten, 72764
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- Adverum Clinical Site 198
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California
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Bakersfield, California, Verenigde Staten, 93309
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- Adverum Clinical Site 109
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Beverly Hills, California, Verenigde Staten, 90211
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- Adverum Clinical Site 100
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Campbell, California, Verenigde Staten, 95008
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- Adverum Clinical Site 201
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Encino, California, Verenigde Staten, 91436
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- Adverum Clinical Site 172
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Fullerton, California, Verenigde Staten, 92835
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- Adverum Clinical Site 169
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Huntington Beach, California, Verenigde Staten, 92647
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- Adverum Clinical Site 224
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Poway, California, Verenigde Staten, 92064
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- Adverum Clinical Site 130
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Redlands, California, Verenigde Staten, 92374
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- Adverum Clinical Site 215
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Sacramento, California, Verenigde Staten, 95825
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- Adverum Clinical Site 140
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Sacramento, California, Verenigde Staten, 95841
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- Adverum Clinical Site 212
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Santa Barbara, California, Verenigde Staten, 93103
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- Adverum Clinical Site 175
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Torrance, California, Verenigde Staten, 90503
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- Adverum Clinical Site 202
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Walnut Creek, California, Verenigde Staten, 94598
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- Adverum Clinical Site 189
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Colorado
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Denver, Colorado, Verenigde Staten, 80207
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- Adverum Clinical Site 116
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Denver, Colorado, Verenigde Staten, 800222
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- Adverum Clinical Site 200
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Connecticut
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Waterford, Connecticut, Verenigde Staten, 06385
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- Adverum Clinical Site 165
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Florida
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Deerfield Beach, Florida, Verenigde Staten, 33064
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- Adverum Clinical Site 124
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Deerfield Beach, Florida, Verenigde Staten, 33064
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- Adverum Clinical Site 184
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Fort Lauderdale, Florida, Verenigde Staten, 33308
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- Adverum Clinical Site 176
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Fort Myers, Florida, Verenigde Staten, 33912
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- Adverum Clinical Site 221
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Gainesville, Florida, Verenigde Staten, 32607
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- Adverum Clinical Site 236
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Lakeland, Florida, Verenigde Staten, 33805
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- Adverum Clinical Site 214
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Miami Springs, Florida, Verenigde Staten, 33166
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- Adverum Clinical Site 168
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Orlando, Florida, Verenigde Staten, 32806
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- Adverum Clinical Site 213
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Plantation, Florida, Verenigde Staten, 33324
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- Adverum Clinical Site 206
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South Miami, Florida, Verenigde Staten, 33143
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- Adverum Clinical Site 183
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St. Petersburg, Florida, Verenigde Staten, 33711
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- Adverum Clinical Site 120
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Tampa, Florida, Verenigde Staten, 33609
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- Adverum Clinical Site 148
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Winter Haven, Florida, Verenigde Staten, 33880
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- Adverum Clinical Site 238
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Georgia
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Augusta, Georgia, Verenigde Staten, 30909
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- Adverum Clinical Site 182
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Illinois
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Chicago, Illinois, Verenigde Staten, 60616
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- Adverum Clinical Site 246
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Oak Forest, Illinois, Verenigde Staten, 60452
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- Adverum Clinical Site 179
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Oak Park, Illinois, Verenigde Staten, 60304
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- Adverum Clinical Site 207
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Indiana
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Carmel, Indiana, Verenigde Staten, 46032
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- Adverum Clinical Site 205
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Carmel, Indiana, Verenigde Staten, 46032
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- Adverum Clinical Site 195
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Carmel, Indiana, Verenigde Staten, 46032
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- Adverum Clinical Site 253
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Maryland
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Hagerstown, Maryland, Verenigde Staten, 21740
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- Adverum Clinical Site 204
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Hagerstown, Maryland, Verenigde Staten, 21740
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- Adverum Clinical Site 197
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Mississippi
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Jackson, Mississippi, Verenigde Staten, 39202
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- Adverum Clinical Site 216
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New Jersey
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Bloomfield, New Jersey, Verenigde Staten, 07003
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- Adverum Clinical Site 240
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Teaneck, New Jersey, Verenigde Staten, 07666
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- Adverum Clinical Site 171
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New York
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Liverpool, New York, Verenigde Staten, 13088
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- Adverum Clinical Site 225
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Rochester, New York, Verenigde Staten, 14620
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- Adverum Clinical Site 244
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North Carolina
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Asheville, North Carolina, Verenigde Staten, 28803
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- Adverum Clinical Site 196
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Cary, North Carolina, Verenigde Staten, 27511
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- Adverum Clinical Site 234
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Greensboro, North Carolina, Verenigde Staten, 27401
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- Adverum Clinical Site 211
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Greensboro, North Carolina, Verenigde Staten, 27401
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- Adverum Clinical Site 219
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Hickory, North Carolina, Verenigde Staten, 28602
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- Adverum Clinical Site 220
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Wake Forest, North Carolina, Verenigde Staten, 27587
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- Adverum Clinical Site 209
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Ohio
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Beachwood, Ohio, Verenigde Staten, 44122-5846
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- Adverum Clinical Site 248
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Cleveland, Ohio, Verenigde Staten, 44130
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- Adverum Clinical Site 247
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Oklahoma
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Edmond, Oklahoma, Verenigde Staten, 73013
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- Adverum Clinical Site 254
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Oregon
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Portland, Oregon, Verenigde Staten, 97225
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- Adverum Clinical Site 252
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Pennsylvania
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Erie, Pennsylvania, Verenigde Staten, 16505
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- Adverum Clinical Site 181
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Philadelphia, Pennsylvania, Verenigde Staten, 19107
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- Adverum Clinical Site 110
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Philadelphia, Pennsylvania, Verenigde Staten, 19102
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- Adverum Clinical Site 239
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South Carolina
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Bluffton, South Carolina, Verenigde Staten, 29910
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- Adverum Clinical Site 241
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Ladson, South Carolina, Verenigde Staten, 29456
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- Adverum Clinical Site 222
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Tennessee
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Nashville, Tennessee, Verenigde Staten, 37203
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- Adverum Clinical Site 101
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Texas
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Arlington, Texas, Verenigde Staten, 76012
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- Adverum Clinical Site 145
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Austin, Texas, Verenigde Staten, 78705
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- Adverum Clinical Site 127
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Austin, Texas, Verenigde Staten, 78750
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- Adverum Clinical Site 243
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Conroe, Texas, Verenigde Staten, 77384
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- Adverum Clinical Site 107
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Dallas, Texas, Verenigde Staten, 75231
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- Adverum Clinical Site 194
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McAllen, Texas, Verenigde Staten, 78503
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- Adverum Clinical Site 162
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San Antonio, Texas, Verenigde Staten, 78240
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- Adverum Clinical Site 185
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San Marcos, Texas, Verenigde Staten, 78666
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- Adverum Clinical Site 232
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Schertz, Texas, Verenigde Staten, 78154
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- Adverum Clinical Site 228
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The Woodlands, Texas, Verenigde Staten, 77384
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- Adverum Clinical Site 231
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Tyler, Texas, Verenigde Staten, 75703
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- Adverum Clinical Site 237
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Virginia
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Lynchburg, Virginia, Verenigde Staten, 24502
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- Adverum Clinical Site 199
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Washington
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Silverdale, Washington, Verenigde Staten, 98383
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- Adverum Clinical Site 249
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Deelname Criteria
Geschiktheidscriteria
Geschiktheidscriteria
Leeftijden die in aanmerking komen voor studie
Accepteert gezonde vrijwilligers
Geslachten die in aanmerking komen voor studie
Beschrijving
Inclusion Criteria:
- Able and willing to provide informed consent (or have a legally authorized representative who is able and willing to provide informed consent) prior to any study assessments and procedures and comply with the study requirements and visits.
- Male or female with a diagnosis of CNV secondary to nAMD in the study eye, with nAMD disease activity at Screening Visit 1.
- At least 50 years old at Screening Visit 1.
- An ETDRS BCVA letter score of 35 - 78 (approximate Snellen equivalent of 20/200 to 20/32) in the study eye at Screening Visit 1.
- Demonstrated a meaningful anatomic response to anti-VEGF therapy during screening.
- Able to reliably use eye drops per protocol.
Exclusion Criteria:
General Exclusion Criteria
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History of a medical condition giving reasonable suspicion of a condition that contraindicates the use of Ixo-vec, compromises the participant's ability to comply with the planned study activities, or that might affect the interpretation of the results of the study or render the participant at high risk for treatment complications in the opinion of the Investigator. History of severe coronavirus disease (COVID-19) infection may meet this exclusion criterion if, in the opinion of the Investigator, it is likely to lead to any important complications.
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Received any prior gene therapy.
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Prior treatment with any non-gene therapy investigational medicinal product (IMP) or medical device in the study eye within 3 months of Screening Visit 1 or 5 half-lives of the IMP prior to dosing with Ixo-vec, whichever is longer.
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Female participants who are pregnant or breastfeeding or who intend to become pregnant or breastfeed in the future.
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History or evidence of any of the following cardiovascular diseases:
- Myocardial infarction in the 6-month period prior to Week 1.
- Uncontrolled hypertension defined as systolic blood pressure > 160 mmHg or diastolic blood pressure > 100 mmHg during screening.
- Stroke in the 6-month period prior to Week 1.
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History of ongoing bleeding disorders. The use of aspirin or other anticoagulants (e.g., Factor Xa inhibitors) is permitted.
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Use of systemic immunosuppressive drugs within 90 days prior to Screening Visit 1. Short courses of oral corticosteroids are permitted, as well as any inhaled, intra-articular, nasal or dermal steroid use.
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Evidence of poorly controlled diabetes or glycated hemoglobin (HbA1c) ≥ 8.0% during screening.
Ocular Exclusion Criteria
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Any active ocular or periocular infection in the study eye from Screening Visit 1.
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History or evidence of the following in the study eye:
- Intraocular or refractive surgery within 5 months prior to Week 1.
- Any previous penetrating keratoplasty or vitrectomy.
- Any previous panretinal photocoagulation.
- Any previous submacular surgery, other surgical intervention (including port delivery system) or laser treatment for age-related macular degeneration.
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Any history or evidence of retinal detachment (with or without repair) or retinal pigment epithelium rip/tear in the study eye, as determined by the Investigator during screening or at Week 1.
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Uncontrolled ocular hypertension or glaucoma in the study eye from Screening Visit 1 to Week 1 or current use of ≥ 2 intraocular pressure (IOP) lowering medications or normal tension glaucoma/suspect in the study eye or history of any of the following procedures in the study eye prior to Week 1:
- Incisional glaucoma surgery (i.e., glaucoma drainage implant/shunt or trabeculectomy)
- Ocular angle-based surgery (i.e., goniotomy or canaloplasty)
- Minimally Invasive Glaucoma Surgery (MIGS) in the study eye.
- Angle-based glaucoma surgery (e.g., Argon or Selective Laser Trabeculoplasty)
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Any history of IOP elevation related to topical steroid administration in either eye.
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Any history of uveitis or inflammation (grade trace or above) except mild anticipated post operative inflammation that resolved in either eye.
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Any history of treatment with complement inhibitors for geographic atrophy in the study eye.
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Known history of ocular herpes simplex virus, varicella-zoster virus, or cytomegalovirus, including viral uveitis, retinitis, or keratitis in either eye.
Studie plan
Hoe is de studie opgezet?
Ontwerpdetails
- Primair doel: Behandeling
- Toewijzing: Gerandomiseerd
- Interventioneel model: Parallelle opdracht
- Masker: Dubbele
Aantal wapens
Wapens en interventies
Deelnemersgroep / ArmDeelnemersgroep / Arm |
Interventie / BehandelingInterventie / Behandeling |
|---|---|
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Experimenteel: Ixo-vec
Participants will receive 3 monthly loading doses of aflibercept 2 mg IVT, a single IVT injection of Ixo-vec 6 x 10^10 vg/eye at Week 1, and sham injections every 8 weeks. |
Ixo-vec will be administered intravitreally. Aflibercept will be administered intravitreally. |
|
Actieve vergelijker: Aflibercept
Participants will receive 3 monthly loading doses of aflibercept 2 mg IVT, a sham injection at Week 1, and aflibercept 2 mg IVT every 8 weeks. |
Aflibercept will be administered intravitreally. |
Wat meet het onderzoek?
Primaire uitkomstmaten
Primaire uitkomstmaten
Uitkomstmaat |
Maatregel Beschrijving |
Tijdsspanne |
|---|---|---|
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Mean Change from Baseline in BCVA Based on an Average at Weeks 52 and 56
Tijdsspanne: Baseline, Week 52 and Week 56
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BCVA will be measured using an Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart. |
Baseline, Week 52 and Week 56
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Secundaire uitkomstmaten
Secundaire uitkomstmaten
Uitkomstmaat |
Maatregel Beschrijving |
Tijdsspanne |
|---|---|---|
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Gemiddeld aantal ontvangen Aflibercept IVT-injecties
Tijdsspanne: Week 4 tot en met Week 56
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Week 4 tot en met Week 56
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Percentage deelnemers met BCVA van 73 letters of meer vanaf week 4 tot en met week 56
Tijdsspanne: Week 4 tot en met Week 56
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Week 4 tot en met Week 56
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Percentage van deelnemers die geen Aflibercept-injectie kregen
Tijdsspanne: Week 4 tot en met Week 56
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Week 4 tot en met Week 56
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Percentage deelnemers die 0 of 1 Aflibercept-injectie ontvingen
Tijdsspanne: Week 4 tot en met Week 56
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Week 4 tot en met Week 56
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Percentage of Participants with Worsened BCVA
Tijdsspanne: Through Week 56
|
BCVA measured by ETDRS. |
Through Week 56
|
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Percentage of Participants with Improved BCVA
Tijdsspanne: Through Week 56
|
BCVA measured by ETDRS. |
Through Week 56
|
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Mean Change from Baseline in BCVA Over Time Based on an Average at Weeks 52 and 56
Tijdsspanne: Baseline Through Week 56
|
BCVA measured by ETDRS. |
Baseline Through Week 56
|
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Mean Change from Week 1 in BCVA Based on an Average at Weeks 52 and 56
Tijdsspanne: Week 1 through Week 56
|
BCVA measured by ETDRS. |
Week 1 through Week 56
|
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Mean Change in Central Subfield Thickness (CST) from Baseline Over Time Through Week 56
Tijdsspanne: Baseline Through Week 56
|
CST as measured by spectral domain optical coherence tomography (SD-OCT). |
Baseline Through Week 56
|
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Percentage of Participants with CST ≤ 300 μm Over Time Through Week 56
Tijdsspanne: Through Week 56
|
CST will be assessed by a central reading center (CRC) using SD-OCT. |
Through Week 56
|
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Mean Number of CST Fluctuations > 50 μm From Week 1 Over Time Through Week 56
Tijdsspanne: Week 1 through Week 56
|
CST will be assessed by a CRC using SD-OCT images and the mean number of fluctuations with thickness of more than 50 μm will be summarized. |
Week 1 through Week 56
|
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Percentage of Participants with CST Fluctuations > 50 μm from Week 1 Over Time Through Week 56
Tijdsspanne: Week 1 through Week 56
|
CST will be assessed using SD-OCT. |
Week 1 through Week 56
|
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Percent Reduction in Mean Rate of Annualized Anti-VEGF Injections
Tijdsspanne: Through Week 56
|
Percent reduction in mean rate of annualized anti-VEGF injections will be assessed relative to the reduction in mean rate of annualized anti-VEGF injections received in the year prior to screening in treatment-experienced participants. |
Through Week 56
|
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Mean Change in Area of Choroidal Neovascularization (CNV) Lesion from Baseline Over Time Through Week 56
Tijdsspanne: Baseline through Week 56
|
CNV is the infiltration of abnormal blood vessels in the retina from the underlying choroid layer. It will be assessed by a CRC using SD-OCT. |
Baseline through Week 56
|
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Mean Change in Macular Volume from Baseline Over Time Through Week 56
Tijdsspanne: Baseline through Week 56
|
Macular volume will be measured as part of the full ophthalmic examination. |
Baseline through Week 56
|
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Percentage of Participants Without Intraretinal Fluid (IRF) Over Time Through Week 56
Tijdsspanne: Through Week 56
|
IRF will be assessed using SD-OCT. |
Through Week 56
|
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Percentage of Participants Without Subretinal Fluid (SRF) Over Time Through Week 56
Tijdsspanne: Through Week 56
|
SRF will be assessed using SD-OCT. |
Through Week 56
|
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Percentage of Participants Without IRF and/or SRF Over Time Through Week 56
Tijdsspanne: Through Week 56
|
IRF and SRF will be assessed using SD-OCT. |
Through Week 56
|
|
Time to Dry Retina
Tijdsspanne: Through Week 56
|
Dry retina is defined as no IRF or SRF (i.e., absence of both). IRF and SRF will be assessed using SD-OCT. |
Through Week 56
|
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Time to Sustained Dry Retina
Tijdsspanne: Through Week 56
|
Sustained dry retina is defined as no IRF or SRF (i.e., absence of both) maintained for 2 consecutive visits. |
Through Week 56
|
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Number of Participants Who Experienced Ocular Adverse Events
Tijdsspanne: Through Week 56
|
The number of participants who experience an ocular adverse event will be summarized. |
Through Week 56
|
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Number of Participants Who Experienced Mild, Moderate or Severe Ocular Adverse Events
Tijdsspanne: Through Week 56
|
The number of participants who experience a mild, moderate or severe ocular adverse event will be summarized. |
Through Week 56
|
|
Number of Participants Who Experienced Non-ocular Adverse Events
Tijdsspanne: Through Week 56
|
The number of participants who experience a non-ocular adverse event will be summarized. |
Through Week 56
|
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Number of Participants Who Experienced Mild, Moderate or Severe Non-ocular Adverse Events
Tijdsspanne: Through Week 56
|
The number of participants who experience a mild, moderate or severe non-ocular adverse event will be summarized. |
Through Week 56
|
|
Mean Change in 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) Total and Subscale Scores
Tijdsspanne: Day 1 to Week 28 and Week 56
|
The NEI VFQ-25 measures vision-targeted patient-reported outcomes of individuals with chronic eye diseases. It comprises 25 questions. The assessment generates an overall composite score and includes the following subscales: global vision rating, difficulty with near vision activities, difficulty with distance vision activities, limitations in social functioning due to vision, role limitations due to vision, dependency on others due to vision, mental health symptoms due to vision, driving difficulties, limitations with peripheral and color vision, and ocular pain. A decrease in the NEI VFQ-25 score represents an improvement in disease severity. |
Day 1 to Week 28 and Week 56
|
|
Mean Change in the 5-item Health-related Quality of Life Questionnaire (EQ-5D-5L)
Tijdsspanne: Day 1 to Week 28 and Week 56
|
The EQ-5D-5L is a concise, generic self-reported health questionnaire which is weighted to reflect the relevant importance to patients of various different health problems. In retinal disease, the questionnaire is used to assess quality of life in the context of vision loss. It measures five parameters; mobility, self-care, usual activities, pain/discomfort and anxiety/depression. An increase in the EQ-5D-5L score represents an improvement in disease severity. |
Day 1 to Week 28 and Week 56
|
Medewerkers en onderzoekers
Sponsor
Sponsor
Onderzoekers
Onderzoekers
- Studie directeur: Adam Turpcu, PhD, Adverum Biotechnologies, Inc.
Studie record data
Bestudeer belangrijke data
Studie start (Werkelijk)
Studie start
Primaire voltooiing (Geschat)
Primaire voltooiing
Studie voltooiing (Geschat)
Studie voltooiing
Studieregistratiedata
Eerst ingediend
Eerst ingediend
Eerst ingediend dat voldeed aan de QC-criteria
Eerst ingediend dat voldeed aan de QC-criteria
Eerst geplaatst (Werkelijk)
Eerst geplaatst
Updates van studierecords
Laatste update geplaatst (Werkelijk)
Laatste update geplaatst
Laatste update ingediend die voldeed aan QC-criteria
Laatste update ingediend die voldeed aan QC-criteria
Laatst geverifieerd
Laatst geverifieerd
Meer informatie
Termen gerelateerd aan deze studie
Trefwoorden
- Natte AMD
- Neovasculaire AMD
- Aflibercept
- AAV
- Gentherapie
- Neovasculaire leeftijdsgebonden maculaire degeneratie
- CNV
- Blindheid
- ADVM-022
- AAV.7m8
- AAV.7m8-aflibercept
- Oogziekte
- wAMD
- nAMD
- AAV-vector
- ADVM
- Natte leeftijdsgebonden maculadegeneratie
- Ixoberogeen soroparvovec
- Ixo-vec
- Adeno-geassocieerde virussen
- ADVM-022-13
Aanvullende relevante MeSH-voorwaarden
Andere studie-ID-nummers
Andere studie-ID-nummers
- ADVM-022-13
Plan Individuele Deelnemersgegevens (IPD)
Bent u van plan om gegevens van individuele deelnemers (IPD) te delen?
Beschrijving IPD-plan
Adverum is committed to transparency. Appropriately de-identified participant-level data and supporting documents may be shared under appropriate conditions (e.g. when contractually permitted and when participants provide appropriate consent). Individual patient-level data would only be shared following completion of this study (and any associated studies), completion of applicable regulatory submissions, and in accordance with applicable regulations and laws, as well as criteria established by Adverum, our collaborators and/or industry best practices. Shared datasets and/or documents may be de-identified and/or redacted to protect participant identity and to protect sensitive and confidential information. For inquiries, please contact us at datasharing@adverum.com.
Informatie over medicijnen en apparaten, studiedocumenten
Bestudeert een door de Amerikaanse FDA gereguleerd geneesmiddel
Bestudeert een door de Amerikaanse FDA gereguleerd apparaatproduct
product vervaardigd in en geëxporteerd uit de V.S.
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