Maraviroc Intensification of cART in Patients with Suboptimal Immunological Recovery: A 48-Week, Placebo-Controlled Randomized Trial

Objective The immunomodulatory effects of the CCR5-antagonist maraviroc might be beneficial in patients with a suboptimal immunological response, but results of different cART (combination antiretroviral therapy) intensification studies are conflicting. Therefore, we performed a 48-week placebo-controlled trial to determine the effect of maraviroc intensification on CD4+ T-cell counts and immune activation in these patients. Design Double-blind, placebo-controlled, randomized trial. Methods Major inclusion criteria were 1. CD4+ T-cell count <350 cells/μL while at least two years on cART or CD4+ T-cell count <200 cells/μL while at least one year on cART, and 2. viral suppression for at least the previous 6 months. HIV-infected patients were randomized to add maraviroc (41 patients) or placebo (44 patients) to their cART regimen for 48 weeks. Changes in CD4+ T-cell counts (primary endpoint) and other immunological parameters were modeled using linear mixed effects models. Results No significant differences for the modelled increase in CD4+ T-cell count (placebo 15.3 CD4+ T cells/μL (95% confidence interval (CI) [1.0, 29.5] versus maraviroc arm 22.9 CD4+ T cells/μL (95% CI [7.4, 38.5] p = 0.51) or alterations in the expression of markers for T-cell activation, proliferation and microbial translocation were found between the arms. However, maraviroc intensification did increase the percentage of CCR5 expressing CD4+ and CD8+ T-cells, and the plasma levels of the CCR5 ligand MIP-1β. In contrast, the percentage of ex-vivo apoptotic CD8+ and CD4+ T-cells decreased in the maraviroc arm. Conclusions Maraviroc intensification of cART did not increase CD4+ T-cell restoration or decrease immune activation as compared to placebo. However, ex-vivo T-cell apoptosis was decreased in the maraviroc arm. Trial Registration ClinicalTrials.gov NCT00875368


PROTOCOL SIGNATURE SHEET
Nature and extent of the burden and risks associated with participation, benefit and group relatedness: 1. In the treatment group subjects will start with a registered antiretroviral agent (maraviroc).
2. During the treatment year patients will perform several study visits, probably three more compared with regular visits on the outpatient clinic.
3. Each visit, blood will be drawn by venapuncture for immunologic and virologic investigations (see flow chart).

INTRODUCTION AND RATIONALE
The management of patients with HIV infection now allows for the suppression of plasma HIV RNA to ≤50 copies/ml in the majority of antiretroviral therapy (ART)-naive patients within the first 6 months of treatment [1]. Sustained suppression of HIV-1 RNA load associated with the use of "Highly Active Antiretroviral Therapy" (HAART) results in immunologic improvement. In a large prospective cohort of treatment-naive patients, 84% achieved HIV RNA levels of <400 copies/ml within 6 months of starting ART, which corresponded to mean increases in CD4 + T-cell count of 114 cells/µl at 6 months and 181 cells/µl at 12 months [2].
Similarly, a systematic review found mean increases in CD4 + T-cell count of 123 cells/µl at 24 weeks and 160 cells/µl at 48 weeks in treatment-naive patients initiating ART [1]. In patients whose HIV RNA levels are consistently suppressed, CD4 + T-cell counts typically continue to increase for 4 years or more after treatment initiation [3].
Unfortunately, a poor immune reconstitution despite a good virological control (the so called "immunologic non responders") is relatively frequent after initiation of HAART among patients with a baseline CD4 count of <350 cells/microl, older age and the baseline immunological and virological status of the patients.
In the multicenter EuroSIDA study, 29% of patients starting ART at CD4 + T-cell counts <350 cells/µl and in whom HIV RNA load was <500 copies/ml at 6 months had a 'low' CD4 + T-cell increase (defined by an increase in CD4 + T-cell count of <50 cells/µl after 6 months or a similarly low increase up to 12 months) [6]. Likewise, in a multicenter study of subjects starting protease inhibitor (PI)-based therapy for the first time, 17.3% did not achieve an increase of ≥50 CD4 + T-cells/µl at 6 months despite suppression of HIV RNA by at least 1 log 10 copies/ml or to <1,000 copies/ml. Such subjects had a higher risk of clinical progression than subjects who had a similar virological response but who did achieve an increase of ≥50 CD4 + T-cells/µl at 6 months [4].
In the Dutch Athena Cohort 17 % out of 6106 patients entered and still on HAART with a suppressed HIV RNA load had a CD4+ count < 200 T-cells/µl at 12 months (F de wolf, personal communication) A lack of CD4 + T-cell count recovery appears to be the strongest independent predictor of HIV-associated clinical events and death in patients on ART, even when compared with HIV RNA levels [4,5].
It is now well established that in patients on HAART immune restoration (CD4+ cell increase) is determined by having undetectable HIV viral load. Deeks et al, have shown that this relates to still increased levels of T cell turnover in these patients. It is thought that (as in untreated patients infected with HIV), HIV-induced T cell activation is the driver for first naive and later memory T cell depletion (7)(8)(9). Mounting evidence has accumulated from several laboratory that immune activation, either directly by effects of HIV or by bacterial translocation due to HIV, induces massive depletion of CD4+ T memory cells from the gut have indicated that particular amino acid changes in the viral envelope protein are associated with increases in CD4+ T cell count [11].
It is our hypothesis that maraviroc has, by interference with CCR5 activation through its natural ligands or residual HIV, an inhibitory effect on the residual systemic immune activation in patients on HAART which relates to lower CD4+ T cell turnover and increased naive CD4+ T cell gain. This will result in a broader TCR repertoire and better immune competence in the long run.

Hypothesis
Therefore maraviroc, by a yet unknown mechanism, stimulates immune recovery by increasing CD4+ cell count.

OBJECTIVES
Primary Objective: to confirm the hypothesis that maraviroc stimulates immune recovery by increasing the CD4+ cell count.
Secondary Objective: to explore, by virologic and immunologic investigations, the underlying mechanisms of this hypothesis.

General
The MIRS study is a double blind, randomized, placebo-controlled, multicenter exploratory mechanistic study in patients on HAART (in The Netherlands), that after a minimum of 6 months viral suppression (< 50 copies/ml) still have inadequate immune recovery. There will be two study groups (both with undetectable plasma HIV RNA): group one with CD4+ cells < 200 cells per µL and group 2 with CD4 cells between 200-350 CD4+ cells per µL. In both study groups, patients will be randomized to receive either maraviroc or placebo added to the current antiretroviral regimen. After randomization 50% of the patients will receive maraviroc, the remaining 50% placebo. The dose of maraviroc will be adjusted to the co-medication the study subjects are taking (because of farmacokinetic interactions), from 150 mg BID to 600 mg BID according to instructions in the "summary of product characteristics (SPC)" of maraviroc. The duration of study will be one year (48 weeks). Each visit (see below for schedule) blood will be drawn for CD4+ cell count (procedure to be performed in local laboratory at study site). Also, each visit 30 ml of heparin blood en 10 ml of EDTA blood will be drawn for immunologic en virologic studies. All other blood investigations are to be decided on and performed by the treating physician according to standard of care.
Furthermore, each visit study subjects will be asked for any adverse events, vital signs will be recorded and physical examination will be performed. At the screening visit and at the end of study visit a complete physical examination will be performed. Depending on local laboratory logistics, in certain sites the 10 ml EDTA blood that will be drawn for virological studies will be partly used for this purpose; in other sites extra EDTA blood (4.5 ml) will have to be drawn at these visits.

Population (base)
The populations of interest for this study are those patients infected with HIV-1 in which treatment with HAART did not result in an adequate immunological response despite viral suppression (the so called "immunological non responders"). The study subjects will be recruited from a potential study population of approximately 550 known patients in the Netherlands (A. van Sighem, SHM, personal communication).

Sample size calculation
Sample size calculation was based on an expected difference in rise in CD4 cells of 30% in the treatment group compared with placebo. For this calculation an estimated CD4 cell increase of 10% in the placebo group was used. Estimated standard deviations of CD4 cells are 40% and 30% in the treatment group and placebo group, respectively.
We used an alpha=0.05 and beta=0.10 (power is 0,90). According to this calculation 124 study subjects are needed (62 in the treatment group, 62 in the placebo group). Anticipating a small loss of follow-up, we aim to include 130 patients.

Investigational product/treatment
The study population will be randomised to receive either the registered, antiretroviral agent maraviroc (a CCR5 inhibitor) or placebo. This will be added to the antiretroviral regimen that the study subject is already taking. Normal dosage is 300 mg BID, but dosage should be adjusted in the case of concomitant use of CYP3A4 inhibitors (150 mg BID) or inducers (600 mg BID). For more details please see Summary of Product Charasterics of maraviroc.

Use of co-intervention
1. Maraviroc will be added tot the antiretroviral regimen the study subject is already taking.
2. If necessary for clinical reasons, the antiretroviral regimen can be changed at the discretion of the treating physician.
3. Maraviroc is a substrate for CYP3A4 inhibition. The dose of maraviroc has to be adjusted if other medication is co-administered that induces or inhibits CYP3A4 metabolism (see SPC).

The concomitant use of maraviroc and St. John`s wort or products that contain St.
John`s wort is not recommended (St. John`s wort is expected to decrease maraviroc concentration to suboptimal levels). 5. Patients are advised to use adequate contraception, since there are no data in humans with respect to the potential teratogenicity of maraviroc.

Escape medication (if applicable)
Not applicable

Name and description of investigational medicinal product
Maraviroc (generic name maraviroc). See Summary of Product Characteristics (SPC) of maraviroc.

Summary of findings from non-clinical studies
For product information regarding maraviroc, please SPC.

Summary of findings from clinical studies
Please see SPC.

Summary of known and potential risks and benefits
Please see SPC.

Description and justification of route of administration and dosage
The study medication (maraviroc or placebo) will be supplied as tablets in 150 mg dosage units. Drug supplies will be provided to the central investigator site (pharmacy, department of clinical trial support) as pre-packaged bottles containing 70 tablets per bottle. Subjects will be provided the study medication in sufficient quantities until the next visit.

Dosages, dosage modifications and method of administration
Maraviroc should be dosed BID, with total dose adjusted according to the other drugs the patient is taking (see SPC). Maraviroc may be taken with or without food. No dose adjustment of other antiretroviral medication the patient is taking is required due to the presence of maraviroc.

Preparation and labelling of Investigational Medicinal Product
The study medication (maraviroc and placebo) will be prepared, labeled and supplied by Pfizer Inc. This will be done according to relevant GMP guidelines.

Drug accountability
The study medication will be shipped by Pfizer Inc to the pharmacy (department of clinical trial support) of the central site (UMC Utrecht) and will be stored under recommended storage conditions and in accordance with applicable regulatory requirements. Each visit, study medication will be dispensed by the pharmacy after a receipt has been prepared by the investigator. Other sites will receive all the necessary medication of each study subject for the entire study from the pharmacy of the central site. The study medication will be stored at the pharmacy of the site and will be dispensed after a receipt has been prepared by the investigator. The investigator will dispose the medication to the study subject. The study subjects will be asked to bring back empty bottles and unused study medication. The number of tablets will be counted and, if more or less than expected, subjects will be asked to account for the difference. Study medication that is left will be destructed by the pharmacy at the site.

Main study parameter/endpoint
A 30% increase of the amount CD4+ cells in the treatment group compared with the placebo group (for both study groups).

Secondary study parameters/endpoints
-Changes in plasma HIV RNA

Other study parameters (if applicable)
Not applicable.

Randomisation, blinding and treatment allocation
Randomization to receive either maraviroc or placebo will be done by the pharmacy at the central site. The randomization code will be kept at the pharmacy of the central site.
In case of medical safety problems for the patient, the investigator or treating physician can contact the pharmacy of the central site for breaking the randomization code.

Study visits and procedures
An overview of the schedule of study visits and procedures is presented as a flowchart (see paragraph 3 "study design"). Study subjects will be asked to visit the outpatient clinic for study visits. There will be nine visits during the study: screenings visit, baseline visit, 6 interim visits and end of study visit. Assuming the patient would perform a visit on the outpatient clinic every three months if he was not participating in this study, this means 5 extra visits to the outpatient clinic. Each study visit CD4+ cell count will be performed in the local laboratory at the study site (2 ml EDTA blood). Also, each visit (except screeningsvisit) 40 ml blood (10 ml EDTA blood and 30 ml heparin blood) will be drawn by venapunction for immunologic and virologic studies. Taken into account that the blood investigations performed as part of this study will partly replace the investigations the treating physician would otherwise anyway perform, this would mean that maximum approximately 322.5 ml blood per study subject will be drawn extra for studypurposes during the study period (48 weeks). If a patient has to be withdrawn from the study and a follow up visit is needed, then an additional 42 ml of blood will have to be drawn (30 nl for immunological investigations, 10 ml for virological investigations and 2 ml for CD4+ cell count). The blood samples will be transported to the central site (UMC Utrecht) for further analysis. Each visit (except baseline) patients will be questioned for adverse events. Vital signs and weight will be recorded, and, if necessary, targeted physical examination will be performed (to detect changes compared with baseline). Complete physical examination will be performed at baseline and end of study visits. At baseline and interim visits the study medication will be dispensed. Dosing adherence will be assessed (by counting) and drug accountability will be performed at interim and end of study visits

General
The heparin blood drawn at the study visits will immediately be transported to the department of Immunology of the central site (WKZ, UMC Utrecht) for further analysis. This will be done by a courier under the required storage conditions and regulations. PBMC`s will be isolated and each visit 5 x 10E6 PBMC`s will be sent to the department of virology (Medical Microbiology, UMC Utrecht) for further analysis. The EDTA blood drawn at the study visits will be processed and frozen at the site laboratory. It will be transported to the department of virology of the UMC Utrecht for further analysis.
Plasma HIV RNA will be measured by the site laboratory at the following visits: screening, week 12, week 24, week 36 and week 48 (or early termination visit).

Immunologic and virologic investigations
A. To study the mechanism of MVC on the CD4 T cell, we will first address the hypothesis that the CCR5 antagonist has a yet unanticipated effect on CD4+ and not CD8+ T cell homing which may impose a slightly changed distribution between cells in circulation (blood) and tissues. As the bulk of cells (>98) is in the tissues, a minor change in redistribution will have a major effect on CD4 cell numbers in the blood. To analyze this effect in detail, we will phenotype the T cells with well tested naive and memory/effector markers. A rather quick rise in memory cells after start of treatment may point to a redistribution effect, as we have shown after the start of HAART [12]. E. To investigate whether addition of maraviroc is associated with further reduction in viral production or replication (even below 50 copies/ml), ultrasensitive plasma HIV-1 RNA quantification (5 copies/ml) will be performed on all longitudinally obtained samples. Furthermore, an ultra-sensitive analysis of the plasma HIV-1 variable part (V3) of the envelope will be performed to investigate (lack of) viral evolution and tropism.
F. Currently, we are setting up a novel diagnostic tool, the Amplicot assay [13] to analyze the diversity of the T cell receptor repertoire. It has been suggested that the inability of the immune system to respond to a pathogen is caused by the absence of antigen specific T cells, i.e. a to narrow TCR repertoire. With this assay we can test whether the increased CD4 T cell numbers lead to a broader TCR repertoire and improvement of cell immunity.

Background
We hypothesize that either a low production or a short life span of CD4 cells is causing the so called 'immunologic non-response' in certain HIV infected patients treated with HAART. In the 'Maraviroc Immune Recovery Study' (MIRS) these patients will be treated either with maraviroc (an new antiretroviral agent) or placebo, to investigate the hypothesis that maraviroc does increase the CD4 cell count in this particular group of patients (due to an immunological mechanism). To further investigate this hypothesis, we plan to do labeling studies with 'deuterated water' in these patients. Using this method, it is possible to study the kinetics of CD4 cells, i.e. to measure the production and life span of these cells. This technology is available in the UMC Utrecht in collaboration with the AMC, and has been recently used by us to study (naive) T cell dynamics in controls and treatment naive HIV infected patients (Vrisekoop et al submitted).

Objectives
1. Measurement of production of CD4 cells 2. Measurement of life span of newly produced cells 3. To compare variables 1 and 2 in patients receiving maraviroc (verum) with patients receiving placebo.

Studypopulation
We aim to include10 study subjects participating in the MIRS study in the UMC Utrecht (no study subjects for labeling studies will be recruited in other centres). No unblinding of the study will be performed. The analysis of the study results of these patients will be descriptive, because due to the size of the study population not enough statistical power is available to perform comparative statistics.

Methods
Deuterated water ( 2 H 2 O) is a stable isotope and can be safely used in humans 13,14 and various studies have been performed using this technique 15 . Study subjects will be asked to drink deuterated water during a period of nine weeks (see flowchart for amount and frequency). During that period and 16 weeks thereafter (total 25 weeks), urine and blood samples will be taken (total 500 ml heparin blood). These blood samples will be taken in addition to those that will be taken for the 'general' MIRS study. During cell proliferation, deuterium is built in the DNA of new cells. Using the Gas Chromatography and Mass-Spectometry (GCMS) technique, the amount of labeled adenosine can be measured. Subsequently, by mathematical models the kinetics of CD4 cells proliferation and life span can be calculated. The Deuterated water is manufactured bij Cambridge Isotope Laboratories, Inc (Cambridge, MA, USA). A certificate of analysis can be provided. It will be stored in the pharmacy in accordance with GCP guidelines. Study subjects meeting the in-and exclusion criteria of the MIRS, will be asked separately if they want to participate in the investigations with deuterated water.

Withdrawal of individual subjects
Subjects can leave the study at any time for any reason if they wish to do so without any consequences. The investigator can decide to withdraw a subject from the study for urgent medical reasons.

Specific criteria for withdrawal (if applicable)
If antiretroviral therapy is failing in a study subject (according to the criteria of the national guidelines [14]), the subject will be withdrawn from the study. This study subject will visit the outpatient clinic within two weeks for an 'end of study visit' and 20 ml of EDTA blood will be drawn for further analysis.

Replacement of individual subjects after withdrawal
Subjects will only be replaced after withdrawal from the study, if necessary for the power of the study.

Follow-up of subjects withdrawn from treatment
When a study subject has to be withdrawn from the study, an early termination visit will be planned as soon as possible. There will be one follow up visit during which blood will be drawn. This follow up visit will be planned 4 weeks after the early termination visit, or earlier if the patients` antiretroviral regimen will be changed. Further treatment of the study subject will be decided on by the treating physician.

Premature termination of the study
When unexpectedly, authorities decide for safety reasons to withdraw the registration of maraviroc and hence will be no longer available, the study can be terminated.

Section 10 WMO event
In accordance to section 10, subsection 1, of the WMO, the investigator will inform the subjects and the reviewing accredited METC if anything occurs, on the basis of which it appears that the disadvantages of participation may be significantly greater than was foreseen in the research proposal. The study will be suspended pending further review by the accredited METC, except insofar as suspension would jeopardise the subjects' health. The investigator will take care that all subjects are kept informed.

Adverse and serious adverse events
Adverse events are defined as any undesirable experience occurring to a subject during a clinical trial, whether or not considered related to the investigational drug. All adverse events reported spontaneously by the subject or observed by the investigator or his staff will be recorded.
A serious adverse event is any untoward medical occurrence or effect that at any dose results in death; is life threatening (at the time of the event); requires hospitalisation or prolongation of existing inpatients' hospitalisation; results in persistent or significant disability or incapacity; is a congenital anomaly or birth defect; is a new event of the trial likely to affect the safety of the subjects, such as an unexpected outcome of an adverse reaction, lack of efficacy of an IMP used for the treatment of a life threatening disease, major safety finding from a newly completed animal study, etc.
All SAEs will be reported to the accredited METC that approved the protocol, according to the requirements of that METC.
Since this is a multicentre study, all serious adverse events will be reported to the central site. The central site will report the serious adverse events to the manufacturer of maraviroc (Pfizer Inc.), using their serious adverse event reporting form for investigator driven research (see addendum).

Suspected unexpected serious adverse reactions (SUSAR)
Adverse reactions are all untoward and unintended responses to an investigational product related to any dose administered.
Unexpected adverse reactions are adverse reactions, of which the nature, or severity, is not consistent with the applicable product information (e.g. Investigator's Brochure for an unapproved IMP or Summary of Product Characteristics (SPC) for an authorised medicinal product).
The sponsor will report expedited the following SUSARs to the METC: The sponsor will report expedited all SUSARs to the competent authority, the Medicine Evaluation Board and the competent authorities in other Member States.
The expedited reporting will occur not later than 15 days after the sponsor has first knowledge of the adverse reactions. For fatal or life threatening cases the term will be maximal 7 days for a preliminary report with another 8 days for completion of the report.

Annual safety report
In addition to the expedited reporting of SUSARs, the sponsor will submit, once a This safety report consists of: − a list of all suspected (unexpected or expected) serious adverse reactions, along with an aggregated summary table of all reported serious adverse reactions, ordered by organ system, per study; − a report concerning the safety of the subjects, consisting of a complete safety analysis and an evaluation of the balance between the efficacy and the harmfulness of the medicine under investigation.

Follow-up of adverse events
All adverse events will be followed until they have abated, or until a stable situation has been reached. Depending on the event, follow up may require additional tests or medical procedures as indicated, and/or referral to the general physician or a medical specialist.

Data Safety Monitoring Board (DSMB)
Not applicable.

Descriptive statistics
Not applicable.

Univariate analysis
Not applicable.

Multivariate analysis
Data will be analyzed according to intention to treat principle. Repeated measures analysis and regression analysis will be performed to detect whether the development over time in CD4 count between the treatment and control group differ significantly.

Interim analysis (if applicable)
Not applicable.

Analysis of withdrawn subjects and subjects with missing data
Analysis of subjects who are withdrawn from the study and of subjects with missing data is decribed in the 'statistical analysis plan', which is available on request.

Regulation statement
The study will be conducted according to ICH GCP guidelines, the principles of the Declaration of Helsinki (adopted by WMA general assembly, Tokyo 2004) and in accordance with the Medical Research Involving Human Subjects Act (WMO) and other guidelines, regulations and Acts.

Recruitment and consent
Subjects will be informed about the study and asked for their consent by the investigator.
They will be given as much time as they need to consider their decision. See also patient information letter and informed consent form.

Objection by minors or incapacitated subjects (if applicable)
Not applicable.

Benefits and risks assessment, group relatedness
This study investigates the possible effect of the antiretroviral agent maraviroc (generic name maraviroc) on immune recovery. If the proposed hypothesis is true (a positive effect of maraviroc on immune recovery in immunologic non-responders on HAART) than this would be beneficial for this particular group of patients and could lead to new treatment modalities. Therefore, this study cannot be performed without the participation of subjects who are HIV infected.

Compensation for injury
The sponsor has a liability insurance which is in accordance with article 7, subsection 6 of the WMO. The insurance of the UMC Utrecht, which has been taken out for this purposes, will cover this.
The sponsor (also) has an insurance which is in accordance with the legal requirements in the Netherlands (Article 7 WMO and the Measure regarding Compulsory Insurance for Clinical Research in Humans of 23th June 2003). This insurance provides cover for damage to research subjects through injury or death caused by the study.
1. € 450.000,--(i.e. four hundred and fifty thousand Euro) for death or injury for each subject who participates in the Research; 2. € 3.500.000,--(i.e. three million five hundred thousand Euro) for death or injury for all subjects who participate in the Research; 3. € 5.000.000,--(i.e. five million Euro) for the total damage incurred by the organisation for all damage disclosed by scientific research for the Sponsor as 'verrichter' in the meaning of said Act in each year of insurance coverage.
The insurance applies to the damage that becomes apparent during the study or within 4 years after the end of the study.

Incentives (if applicable)
Not applicable.

General
Data will be handled anonymously and confidential. Each study subject will receive a randomisation code which will be used to process the data. Only the investigators will have access to the data. Collected data and samples will be stored for 15 years, so that other analysis in the future will be possible.

Monitoring of the study
Monitoring of the study will be performed by qualified monitors of the Julius Center for Health Sciences and Primary Care, UMC Utrecht. A monitoring plan is available on request.

Data management
Data of study subjects will be recorded in a Case Record form (CRF) at the study site. Data from virologic and immunologic analysis performed at the central site will be kept at the central site in a study subject specific file. A database will be constructed for analysis of the data. Statistical analysis will be performed with assistance of a statistician.

Amendments
A 'substantial amendment' is defined as an amendment to the terms of the METC application, or to the protocol or any other supporting documentation, that is likely to affect to a significant degree: the safety or physical or mental integrity of the subjects of the trial; the scientific value of the trial; the conduct or management of the trial; or the quality or safety of any intervention used in the trial.
All substantial amendments will be notified to the METC and to the competent authority.
Non-substantial amendments will not be notified to the accredited METC and the competent authority, but will be recorded and filed by the sponsor.

Annual progress report
The sponsor/investigator will submit a summary of the progress of the trial to the accredited METC once a year. Information will be provided on the date of inclusion of the first subject, numbers of subjects included and numbers of subjects that have completed the trial, serious adverse events/ serious adverse reactions, other problems, and amendments.

End of study report
The sponsor will notify the accredited METC and the competent authority of the end of the study within a period of 90 days. The end of the study is defined as the last patient's last visit.
In case the study is ended prematurely, the sponsor will notify the accredited METC and the competent authority within 15 days, including the reasons for the premature termination.
Within one year after the end of the study, the investigator/sponsor will submit a final study report with the results of the study, including any publications/abstracts of the study, to the accredited METC and the Competent Authority.

Public disclosure and publication policy
The investigator will publish the collected data in medical journals and/or present them on scientific meetings.