Trial Outcomes & Findings for Open-label Extension Study of Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) in Neovascular ("Wet") Age-related Macular Degeneration (AMD) (NCT NCT00964795)

NCT ID: NCT00964795

Last Updated: 2015-03-23

Results Overview

The primary endpoint in the study is the safety and tolerability of Intravitreal Aflibercept Injection in patients with neovascular AMD (Age-related Macular Degeneration) from day 1 through the end of treatment visit (week 180) based on the number of participants who experienced any treatment-emergent adverse event (TEAE). Treatment-emergent adverse events were categorized according to Ocular TEAEs in the study eye, Ocular TEAEs in the fellow eye, and Non-Ocular TEAEs

Recruitment status

COMPLETED

Study phase

PHASE3

Target enrollment

323 participants

Primary outcome timeframe

Baseline (day 1) through end of treatment (Week 180)

Results posted on

2015-03-23

Participant Flow

After informed consent was obtained, the 323 participants who completed the parent study, VGFT-OD-0605 (NCT00509795), and met the protocol eligibility criteria, were enrolled at 71 clinical sites in the US \& Canada. The first visit occurred concurrently with the last visit in the parent study. The last participant entered this study on 18-May-2011.

Intravitreal Aflibercept Injection \[commercially known EYLEA® (aflibercept) Injection\] was approved in the US for treatment of neovascular ("wet") age-related macular degeneration (AMD) as the study was ongoing. For collection of long-term safety and best corrected visual acuity data on EYLEA®, the study was extended in the US from 30 to 45 months.

Participant milestones

Participant milestones
Measure
Open-label Intravitreal Aflibercept Injection
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting with amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Overall Study
STARTED
323
Overall Study
Number of Participants Treated
320
Overall Study
COMPLETED
16
Overall Study
NOT COMPLETED
307

Reasons for withdrawal

Reasons for withdrawal
Measure
Open-label Intravitreal Aflibercept Injection
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting with amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Overall Study
Withdrawal by Subject
79
Overall Study
Adverse Event
12
Overall Study
Death
14
Overall Study
Lost to Follow-up
7
Overall Study
Termination of Study by Sponsor
169
Overall Study
Unwilling to sign ICF for amendment 4
3
Overall Study
Other
23

Baseline Characteristics

Open-label Extension Study of Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) in Neovascular ("Wet") Age-related Macular Degeneration (AMD)

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure
Open-label Intravitreal Aflibercept Injection
n=323 Participants
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting with amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Age, Continuous
79 years
STANDARD_DEVIATION 7.83 • n=93 Participants
Sex: Female, Male
Female
196 Participants
n=93 Participants
Sex: Female, Male
Male
127 Participants
n=93 Participants

PRIMARY outcome

Timeframe: Baseline (day 1) through end of treatment (Week 180)

The primary endpoint in the study is the safety and tolerability of Intravitreal Aflibercept Injection in patients with neovascular AMD (Age-related Macular Degeneration) from day 1 through the end of treatment visit (week 180) based on the number of participants who experienced any treatment-emergent adverse event (TEAE). Treatment-emergent adverse events were categorized according to Ocular TEAEs in the study eye, Ocular TEAEs in the fellow eye, and Non-Ocular TEAEs

Outcome measures

Outcome measures
Measure
Open-label Intravitreal Aflibercept Injection
n=323 Participants
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2 mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting with amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Number of participants with any TEAE
290 participants
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Any ocular TEAE
239 participants
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Any ocular TEAE: Study eye
204 participants
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Any ocular TEAE: Fellow eye
169 participants
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Any non-ocular TEAE
232 participants
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Any serious TEAE
105 participants
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Discontinuation of study due to AE
12 participants
Safety and Tolerability of Intravitreal Aflibercept Injection in Participants With Neovascular AMD
Any Death due to TEAE
17 participants

SECONDARY outcome

Timeframe: Baseline through Week 116

The secondary endpoint in the study is the change in BCVA letter score from baseline through Week 116. (mLOCF: The last non-missing observation prior to the missing visit was carried forward to impute the missing data; no imputation after last visit; no baseline value carried forward).

Outcome measures

Outcome measures
Measure
Open-label Intravitreal Aflibercept Injection
n=323 Participants
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2 mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting with amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Change in BCVA Letter Score (mLOCF)
-2.7 letters correctly read
Standard Deviation 12.50

OTHER_PRE_SPECIFIED outcome

Timeframe: Baseline through end of treatment (Week 180)

Treatment Duration = (last dose date - first dose date + 28)/7

Outcome measures

Outcome measures
Measure
Open-label Intravitreal Aflibercept Injection
n=323 Participants
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2 mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting with amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Summary of Treatment Duration (Weeks)
110.4 weeks
Standard Deviation 42.16

OTHER_PRE_SPECIFIED outcome

Timeframe: Baseline through end of treatment (Week 180)

Study Duration = (last visit/ discontinuation date - first dose date + 28)/7

Outcome measures

Outcome measures
Measure
Open-label Intravitreal Aflibercept Injection
n=323 Participants
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2 mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting with amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Summary of Study Duration (Weeks)
116.9 weeks
Standard Deviation 44.3

Adverse Events

Open-label Intravitreal Aflibercept Injection

Serious events: 105 serious events
Other events: 102 other events
Deaths: 0 deaths

Serious adverse events

Serious adverse events
Measure
Open-label Intravitreal Aflibercept Injection
n=323 participants at risk
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2 mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting from amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Injury, poisoning and procedural complications
Upper Limb Fracture
0.31%
1/323
Injury, poisoning and procedural complications
Wrist Fracture
0.31%
1/323
Blood and lymphatic system disorders
Anaemia
0.62%
2/323
Blood and lymphatic system disorders
Coagulopathy
0.31%
1/323
Blood and lymphatic system disorders
Haemorrhagic Anaemia
0.31%
1/323
Blood and lymphatic system disorders
Iron Deficiency Anaemia
0.31%
1/323
Cardiac disorders
Acute Myocardial Infarction
1.5%
5/323
Cardiac disorders
Angina Pectoris
0.93%
3/323
Cardiac disorders
Arrhythmia
0.62%
2/323
Cardiac disorders
Atrial Fibrillation
3.7%
12/323
Cardiac disorders
Bundle Branch Block Right
0.31%
1/323
Cardiac disorders
Cardiac Arrest
1.2%
4/323
Cardiac disorders
Cardiac Failure Acute
0.93%
3/323
Cardiac disorders
Cardiac Failure Congestive
0.93%
3/323
Cardiac disorders
Cardiogenic Shock
0.31%
1/323
Cardiac disorders
Cardiomyopathy
0.31%
1/323
Cardiac disorders
Coronary Artery Disease
1.2%
4/323
Cardiac disorders
Myocardial Infarction
1.2%
4/323
Cardiac disorders
Myocardial Rupture
0.31%
1/323
Cardiac disorders
Pericarditis
0.31%
1/323
Cardiac disorders
Tachycardia
0.31%
1/323
Cardiac disorders
Ventricular Tachycardia
0.31%
1/323
Gastrointestinal disorders
Appendix Disorder
0.31%
1/323
Gastrointestinal disorders
Colitis
0.31%
1/323
Gastrointestinal disorders
Colitis Ischaemic
0.31%
1/323
Gastrointestinal disorders
Diarrhoea
0.93%
3/323
Gastrointestinal disorders
Dysphagia
0.31%
1/323
Gastrointestinal disorders
Gastrointestinal Angiodysplasia Haemorrhagic
0.31%
1/323
Gastrointestinal disorders
Hiatus Hernia
0.31%
1/323
Gastrointestinal disorders
Ileus
0.31%
1/323
Gastrointestinal disorders
Impaired Gastric Emptying
0.31%
1/323
Gastrointestinal disorders
Intestinal Obstruction
0.31%
1/323
Gastrointestinal disorders
Large Intestine Perforation
0.31%
1/323
Gastrointestinal disorders
Lower Gastrointestinal Haemorrhage
0.31%
1/323
Gastrointestinal disorders
Nausea
0.31%
1/323
Gastrointestinal disorders
Pancreatitis
0.62%
2/323
Gastrointestinal disorders
Vomiting
0.93%
3/323
General disorders
Asthenia
0.31%
1/323
General disorders
Chest Pain
0.31%
1/323
General disorders
Device Dislocation
0.31%
1/323
General disorders
Multi-Organ Failure
0.31%
1/323
General disorders
Non-Cardiac Chest Pain
0.31%
1/323
Hepatobiliary disorders
Biliary Dyskinesia
0.31%
1/323
Hepatobiliary disorders
Cholecystitis Acute
0.31%
1/323
Hepatobiliary disorders
Hepatic Haemorrhage
0.31%
1/323
Immune system disorders
Anaphylactic Reaction
0.31%
1/323
Infections and infestations
Abdominal Abscess
0.31%
1/323
Infections and infestations
Abscess
0.31%
1/323
Infections and infestations
Appendicitis
0.31%
1/323
Infections and infestations
Bronchitis
0.31%
1/323
Infections and infestations
Bronchitis Viral
0.31%
1/323
Infections and infestations
Cellulitis
0.93%
3/323
Infections and infestations
Clostridium Difficile Colitis
0.31%
1/323
Infections and infestations
Escherichia Urinary Tract Infection
0.31%
1/323
Infections and infestations
Gastroenteritis
0.31%
1/323
Infections and infestations
Gastroenteritis Norovirus
0.31%
1/323
Infections and infestations
Gastroenteritis Viral
0.31%
1/323
Infections and infestations
Pericolic Abscess
0.31%
1/323
Infections and infestations
Peritonitis
0.31%
1/323
Infections and infestations
Pneumonia
1.5%
5/323
Infections and infestations
Pneumonia Bacterial
0.31%
1/323
Infections and infestations
Pneumonia Respiratory Syncytial Viral
0.31%
1/323
Infections and infestations
Pneumonia Viral
0.31%
1/323
Infections and infestations
Pyelonephritis Acute
0.31%
1/323
Infections and infestations
Sepsis
0.93%
3/323
Infections and infestations
Septic Shock
0.31%
1/323
Infections and infestations
Urinary Tract Infection
1.5%
5/323
Infections and infestations
Urosepsis
0.31%
1/323
Injury, poisoning and procedural complications
Accident
0.62%
2/323
Injury, poisoning and procedural complications
Coronary Artery Restenosis
0.31%
1/323
Injury, poisoning and procedural complications
Facial Bones Fracture
0.93%
3/323
Injury, poisoning and procedural complications
Fall
5.0%
16/323
Injury, poisoning and procedural complications
Femoral Neck Fracture
0.62%
2/323
Injury, poisoning and procedural complications
Gastrointestinal Anastomotic Leak
0.31%
1/323
Injury, poisoning and procedural complications
Hip Fracture
0.62%
2/323
Injury, poisoning and procedural complications
Humerus Fracture
0.93%
3/323
Injury, poisoning and procedural complications
Pancreatic Leak
0.31%
1/323
Injury, poisoning and procedural complications
Radius Fracture
0.31%
1/323
Injury, poisoning and procedural complications
Road Traffic Accident
0.31%
1/323
Injury, poisoning and procedural complications
Splenic Rupture
0.62%
2/323
Investigations
Blood Pressure Increased
0.31%
1/323
Metabolism and nutrition disorders
Dehydration
1.2%
4/323
Metabolism and nutrition disorders
Diabetes Mellitus Inadequate Control
0.31%
1/323
Metabolism and nutrition disorders
Hyperglycaemia
0.31%
1/323
Metabolism and nutrition disorders
Hypokalaemia
0.31%
1/323
Metabolism and nutrition disorders
Hyponatraemia
0.31%
1/323
Metabolism and nutrition disorders
Malnutrition
0.31%
1/323
Musculoskeletal and connective tissue disorders
Arthritis
0.31%
1/323
Musculoskeletal and connective tissue disorders
Back Pain
0.31%
1/323
Musculoskeletal and connective tissue disorders
Haemarthrosis
0.31%
1/323
Musculoskeletal and connective tissue disorders
Osteoarthritis
1.2%
4/323
Musculoskeletal and connective tissue disorders
Osteoporotic Fracture
0.31%
1/323
Musculoskeletal and connective tissue disorders
Spinal Osteoarthritis
0.62%
2/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Bone Cancer
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Breast Cancer
0.62%
2/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Breast Cancer Recurrent
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Chronic Leukaemia
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Chronic Myelomonocytic Leukaemia
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Intraductal Proliferative Breast Lesion
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Invasive Ductal Breast Carcinoma
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Laryngeal Squamous Cell Carcinoma
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Lung Adenocarcinoma
0.62%
2/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Oesophageal Carcinoma
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Rectal Adenocarcinoma
0.62%
2/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Renal Cancer
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Squamous Cell Carcinoma
0.31%
1/323
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Squamous Cell Carcinoma Of Lung
0.31%
1/323
Nervous system disorders
Carotid Artery Stenosis
0.31%
1/323
Nervous system disorders
Cerebral Haemorrhage
0.31%
1/323
Nervous system disorders
Cerebral Infarction
0.31%
1/323
Nervous system disorders
Cerebrovascular Accident
1.5%
5/323
Nervous system disorders
Convulsion
0.31%
1/323
Nervous system disorders
Embolic Stroke
0.31%
1/323
Nervous system disorders
Facial Neuralgia
0.31%
1/323
Nervous system disorders
Hemiplegia
0.31%
1/323
Nervous system disorders
Hypertensive Encephalopathy
0.31%
1/323
Nervous system disorders
Intracranial Haematoma
0.31%
1/323
Nervous system disorders
Ischaemic Stroke
0.31%
1/323
Nervous system disorders
Subarachnoid Haemorrhage
0.31%
1/323
Nervous system disorders
Syncope
2.5%
8/323
Nervous system disorders
Transient Ischaemic Attack
1.2%
4/323
Psychiatric disorders
Major Depression
0.31%
1/323
Psychiatric disorders
Mental Status Changes
0.93%
3/323
Psychiatric disorders
Psychotic Disorder
0.31%
1/323
Renal and urinary disorders
Calculus Ureteric
0.31%
1/323
Renal and urinary disorders
Nephrolithiasis
0.31%
1/323
Renal and urinary disorders
Obstructive Uropathy
0.31%
1/323
Renal and urinary disorders
Renal Failure Acute
1.2%
4/323
Renal and urinary disorders
Renal Failure Chronic
0.31%
1/323
Renal and urinary disorders
Ureteric Obstruction
0.31%
1/323
Reproductive system and breast disorders
Uterine Polyp
0.31%
1/323
Respiratory, thoracic and mediastinal disorders
Acute Respiratory Failure
0.31%
1/323
Respiratory, thoracic and mediastinal disorders
Aspiration
0.31%
1/323
Respiratory, thoracic and mediastinal disorders
Chronic Obstructive Pulmonary Disease
1.2%
4/323
Respiratory, thoracic and mediastinal disorders
Dyspnoea
0.31%
1/323
Respiratory, thoracic and mediastinal disorders
Laryngospasm
0.31%
1/323
Respiratory, thoracic and mediastinal disorders
Pleural Effusion
0.31%
1/323
Respiratory, thoracic and mediastinal disorders
Pulmonary Embolism
0.62%
2/323
Respiratory, thoracic and mediastinal disorders
Respiratory Arrest
0.31%
1/323
Skin and subcutaneous tissue disorders
Perivascular Dermatitis
0.31%
1/323
Surgical and medical procedures
Colectomy
0.31%
1/323
Surgical and medical procedures
Medical Device Removal
0.31%
1/323
Vascular disorders
Hypertension
0.31%
1/323
Eye disorders
Retinal Haemorrhage
0.62%
2/323
Eye disorders
Angle Closure Glaucoma
0.31%
1/323
Eye disorders
Cataract
0.31%
1/323
Eye disorders
Glaucoma
0.31%
1/323
Eye disorders
Retinal Oedema
0.31%
1/323
Eye disorders
Visual Acuity Reduced
0.31%
1/323
Infections and infestations
Endophthalmitis
0.93%
3/323
Injury, poisoning and procedural complications
Corneal Abrasion
0.31%
1/323
Investigations
Intraocular Pressure Increased
0.31%
1/323
Injury, poisoning and procedural complications
Femur Fracture
0.62%
2/323

Other adverse events

Other adverse events
Measure
Open-label Intravitreal Aflibercept Injection
n=323 participants at risk
Open-label Intravitreal Aflibercept Injection (IAI; EYLEA®; BAY86-5321) 2 mg (40 mg/mL) was administered no more frequently than every 4 weeks, but no less frequently than every 12 weeks until amendment 4. Starting from amendment 4, Intravitreal Aflibercept Injection was administered no less frequently than every 8 weeks. Within these limits, the investigator would determine the interval of Intravitreal Aflibercept Injection administration on an as-needed basis according to the protocol-suggested re-treatment criteria, however the injections must have occurred at least every 12 weeks prior to amendment 4, and at least every 8 weeks starting from amendment 4 as noted above.
Gastrointestinal disorders
Nausea
6.8%
22/323
Infections and infestations
Bronchitis
5.9%
19/323
Infections and infestations
Nasopharyngitis
6.8%
22/323
Infections and infestations
Upper Respiratory Tract Infection
6.2%
20/323
Injury, poisoning and procedural complications
Fall
7.1%
23/323
Musculoskeletal and connective tissue disorders
Arthralgia
5.3%
17/323
Vascular disorders
Hypertension
9.0%
29/323
Eye disorders
Age-Related Macular Degeneration
9.3%
30/323
Eye disorders
Retinal Haemorrhage
10.5%
34/323
Eye disorders
Cataract
5.3%
17/323
Eye disorders
Conjunctival Haemorrhage
9.3%
30/323
Eye disorders
Posterior Capsule Opacification
5.6%
18/323
Eye disorders
Retinal Detachment
5.3%
17/323

Additional Information

Clinical Trials Administrator

Regeneron

Phone: 9148475385

Results disclosure agreements

  • Principal investigator is a sponsor employee The investigator (PI) may publish results provided a copy of oral/ written publication is received by sponsor at least 45 days in advance for review \& comment. If the parties disagree, PI agrees to meet with sponsor prior to submission to resolve any disagreement. Sponsor reserves the right to remove confidential information from such submission. It is also agreed that publication of results shall be made only as part of a publication of the results obtained by all sites performing the study.
  • Publication restrictions are in place

Restriction type: OTHER