Evaluation of Oral Minocycline in the Treatment of Geographic Atrophy Associated With Age-Related Macular Degeneration

Objective: Age-related macular degeneration (AMD), the leading cause of blindness in people
over age 65 in the United States, is a heterogeneous clinical entity in which retinal
degeneration occurs predominantly in the macula in the context of aging and leads to
impairment of central visual acuity (VA). AMD occurs in two general forms, one of which
involves choroidal neovascularization (CNV) with subsequent formation of a disciform scar.
This is often referred to as the neovascular or wet form. A second form, the subject of this
study, is termed dry /atrophic macular degeneration or otherwise geographic atrophy (GA) and
involves a slow progressive atrophy of retinal pigment epithelial (RPE) cells and
photoreceptors in the macula, also resulting in central vision loss. GA is estimated to
affect up to 1 million persons in the U.S. and there is no current treatment that can prevent
its onset or retard its progression. While the etiology of GA is not completely understood,
inflammatory processes involving the activation of resident immune cells of the retina called
microglia is likely to contribute. Minocycline inhibits the activation of microglia which
produce inflammatory factors implicated in GA development. The objective of this study is to
investigate the safety and possible efficacy of oral minocycline in patients with GA.

Study Population: Forty-five participants with unilateral or bilateral GA associated with AMD
will be enrolled. However, up to an additional 15 participants may be enrolled to replace
participants who may withdraw from the study prior to reaching the Month 33 visit.

Design: This is a multi-center, prospective, single-arm, Phase II study to evaluate
minocycline as a potential treatment to decrease the rate of worsening of GA associated with
AMD. Participants will assignedundergo a nine month run-in phase prior to receiving
investigational product (IP). During this run-in phase, participants will have a total of
four pre-treatment visits. Following the run-in phase, beginning at Month 9, participants
will receive an oral dose of 100 mg of minocycline twice daily for 36 months. There will be a
common termination date, which will take place when the last recruited participant has
received 36 months of treatment. Participants who were recruited in the earlier part of the
study will continue treatment and be followed every six months until the common termination
date.

Outcome Measures: The primary outcome is the rate of change in area of GA based on grading by
an external Reading Center of fundus autofluorescence (FAF) images in the assigned study eye.
The primary outcome will compare the rates of GA area expansion as determined on FAF images
before and following the initiation of IP until 24 months of treatment. Secondary outcomes
will compare differences in rates of change in best-corrected visual acuity (BCVA),
low-luminance VA, area of GA based on fundus photography, and macular sensitivity as measured
using microperimetry between the run-in and treatment phases. Safety outcomes will include
the number and severity of adverse events (AEs). Ocular safety outcomes will be indicated by
changes in VA, ocular surface changes, intraocular inflammation and any other ocular changes
not consistent with the natural progression of GA.

- INCLUSION CRITERIA:

To be eligible, the following inclusion criteria must be met, where applicable:

- Participant must be 55 years of age or older.

- Participant must understand and sign the protocol s informed consent document.

- Participant must have evidence of early or intermediate AMD as defined by
characteristic presence of drusen and/or pigmentary changes.

- Participant must be able to swallow capsules.

- Participant must have normal renal function and liver function or have mild
abnormalities not above grade 1 as defined by the Common Terminology Criteria for
Adverse Events v4.0 (CTCAE).

- Participant must agree to minimize exposure to sunlight or artificial ultraviolet (UV)
rays and to wear protective clothing, sunglasses and sunscreen (minimum sun protection
factor (SPF) 15) if s/he must be out in the sun.

- Any female participant of childbearing potential (see Appendix 1 for definition) must
have a negative pregnancy test at screening and be willing to undergo pregnancy tests
throughout the study.

- Any female participant of childbearing potential (see Appendix 1 for definition) and
any male participant able to father children must have (or have a partner who has) had
a hysterectomy or vasectomy, be completely abstinent* from intercourse or must agree
to practice two acceptable methods of contraception throughout the course of the study
and for at least one week after investigational product (IP) discontinuation.
Acceptable methods of contraception include:

1. hormonal contraception (i.e., birth control pills, injected hormones, dermal
patch or vaginal ring),

2. intrauterine device,

3. barrier methods (diaphragm, condom) with spermicide, or,

4. surgical sterilization (hysterectomy or tubal ligation).

- Abstinence is only acceptable when it is the participant s preferred and
usual lifestyle choice. Periodic abstinence (e.g., calendar, ovulation,
symptothermal, post-ovulation methods) and withdrawal are not acceptable
methods of contraception.

EXCLUSION CRITERIA:

A participant is not eligible if any of the following exclusion criteria are present.

- Participant is actively receiving study therapy in another investigational study.

- Any female participant of childbearing potential (see Appendix 1 for definition) that
is pregnant, breast-feeding or planning to become pregnant during the study.

- Participant is expected to be unable to comply with study procedures or follow-up
visits.

- Participant is on ocular or systemic medications known to be toxic to the lens, retina
or optic nerve (e.g., ethambutol, chloroquine, or hydroxychloroquine).

- Participant has a condition that would preclude participation in the study (e.g.,
unstable medical status including blood pressure and glycemic control) by interfering
with the participant s ability to engage in the required protocol evaluation and
testing and/or comply with study visits.

- Participant has a history of chronic renal failure requiring dialysis or kidney
transplant.

- Participant has a history of chronic hepatitis or liver failure.

- Participant has a history of thyroid cancer.

- Participant has an allergy or hypersensitivity to minocycline or any drug in the
tetracycline family.

- Participant is currently taking minocycline or another tetracycline medication.

- Participant is taking any medication that could adversely interact with minocycline
such as methoxyflurane.

- Participant has a prior history of idiopathic intracranial hypertension.

STUDY EYE ELIGIBILITY CRITERIA:

The participant must have at least one eye meeting all inclusion criteria and none of the
exclusion criteria listed below.

STUDY EYE INCLUSION CRITERIA:

- The study eye must have at least (Omega) disc area (approximately 1 mm(2)) of GA
compatible with dry AMD. GA is defined as one or more well-defined and often circular
patches of partial or complete depigmentation of the RPE, typically with exposure of
underlying choroidal blood vessels. Even if much of the RPE appears to be preserved
and large choroidal vessels are not visible, a round patch of RPE partial
depigmentation may be classified as early GA. The GA in the study eye must be able to
be photographed in their entirety, and it must not be contiguous with any areas of
peripapillary atrophy, which can complicate area measurements.

- The total area of GA lesions combined should be less than 7.0 MPS disc areas (DA)
(17.78 mm(2)) as evident on FAF imaging.

- The VA of the study eye should be greater than or equal to19 E-ETDRS letters (i.e.,
20/400 or better).

- The study eye must have clarity of ocular media and degree of pupil dilation
sufficient to permit adequate fundus photographs.

STUDY EYE EXCLUSION CRITERIA:

- Current evidence of choroidal neovascularization (CNV) as determined by the treating
physician or a history of treatments for CNV

- Evidence of retinal atrophy due to causes other than atrophic AMD.

- Current evidence or history of ocular disorders in the study eye that in the opinion
of the investigator confounds study outcome measures, including (but not limited to):

1. non-proliferative diabetic retinopathy involving 10 or more hemorrhages or
microaneurysms, or active proliferative diabetic retinopathy

2. Branch or central retinal vein or artery occlusion

3. Macular hole

4. Pathologic myopia

5. Uveitis

6. Pseudovitelliform maculopathy

- History of vitreoretinal surgery.

- Need for ocular surgery during the course of the study.

- Recent history of lens removal (less than 3 months) or Yttrium Aluminum Garnet (YAG)
laser capsulotomy (less than 1 month).