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MS-SMART: Multiple Sclerosis-Secondary Progressive Multi-Arm Randomisation Trial (MS-SMART)

Primary Purpose

Secondary Progressive Multiple Sclerosis

Status
Completed
Phase
Phase 2
Locations
United Kingdom
Study Type
Interventional
Intervention
Amiloride
Riluzole
Fluoxetine
Placebo
Sponsored by
University College, London
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Secondary Progressive Multiple Sclerosis focused on measuring Secondary Progressive Multiple Sclerosis, Neuroprotective, Repurposed drugs, Brain atrophy, Percentage Brain Volume Change, Magnetic Resonance Imaging, Optical Coherence Tomography, Cerebrospinal fluid, Amiloride, Riluzole, Double blind, Placebo, Fluoxetine

Eligibility Criteria

25 Years - 65 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Confirmed diagnosis of SPMS. Steady progression rather than relapse must be the major cause of increasing disability in the preceding 2 years. Evidence of progression, either an increase of at least one point in EDSS or clinical documentation of increasing disability in patient notes
  • Expanded Disability Status Scale (EDSS) 4.0-6.5
  • Aged 25 to 65 inclusive
  • Women and men with partners of childbearing potential must be using an appropriate method of contraception to avoid any unlikely teratogenic effects of the 3 drugs from time of consent, to 6 weeks after treatment inclusive
  • Women must have a negative pregnancy test within 7 days prior to the baseline visit unless not of child bearing potential (e.g. have undergone a hysterectomy, bilateral tubal ligation or bilateral oophorectomy or they are postmenopausal)
  • Willing and able to comply with the trial protocol (e.g. can tolerate MRI and fulfils the requirements for MRI, e.g. not fitted with pacemakers or permanent hearing aids), ability to understand and complete questionnaires
  • Written informed consent provided

Exclusion Criteria:

  • Pregnancy or breast feeding patients
  • Baseline MRI scan not of adequate quality for analysis (e.g. too much movement artefact)
  • Significant organ co-morbidity (e.g. malignancy or renal or hepatic failure)
  • Relapse within 3 months of baseline visit
  • Patients who have been treated with iv or oral steroids for an MS relapse/progression within 3 months of baseline visit (these patients can undergo future screening visits once the 3 month window has expired), patients on steroids for another medical condition may enter as long as the steroid prescription is not for multiple sclerosis (relapse/ progression).
  • Use of Simvastatin at 80mg dose within 3 months of baseline visit (lower doses of Simvastatin and other statins are permissible)
  • Commencement of fampridine within 6 months of baseline visit
  • Use of immunosuppressants (e.g. azathioprine, methotrexate, cyclosporine) or disease modifying treatments (β-interferons, glatiramer) within 6 months of baseline visit
  • Use of fingolimod/fumarate/teriflunomide/laquinomod/or other experimental disease modifying treatment (including research of an investigational medicinal product) within 12 months of baseline visit
  • Use of mitoxantrone/ natalizumab/ alemtuzumab/ daclizumab if treated within 12 months of baseline visit
  • Primary progressive MS
  • Relapsing-remitting MS
  • Known hypersensitivity to the active substances and their excipients to any of the active drugs for this trial
  • Use of: lithium, chlorpropamide, triamterene and spironolactone within 6 months of the baseline visit
  • Current use of potassium supplements
  • Current use of tamoxifen
  • Current use of herbal treatments containing St. John's Wort
  • Significant signs of depression
  • Use of an SSRI within 6 months of the baseline visit
  • Use of monoamine oxidase inhibitors, phenytoin, L-tryptophan) and/or neuroleptic drugs within 6 months of the baseline visit
  • A Beck Depression Index score of 19 or higher
  • Bipolar disorder
  • Receiving or previously received Electro-Convulsive Therapy
  • Epilepsy/seizures
  • Glaucoma
  • Patients with a history of bleeding disorders or currently on anticoagulants Routine screening blood values (LFT) >/ 3 x upper limit of normal (ULN) of site reference ranges (ALT/AST, bilirubin,ˠGT) Potassium <2.8mmol/l or >5.5mmol/l
  • Sodium <125mmol/l
  • Creatinine >130μmol/l
  • WBCs <3 x 109/l
  • Lymphocytes <0.8 x 109/l
  • Neutrophil count <1.0 x 109 /l
  • Platelet count <90 x 109 /l
  • Haemoglobin <80g/l

Sites / Locations

  • Anne Rowling Regenerative Neurology Clinic, Royal Infirmary of Edinburgh
  • Gartnavel Royal Hospital, 1055 Great Western Road
  • Brighton and Sussex University Hospitals
  • St James's University Hospital
  • The Walton Centre
  • The National hospital for Neurology and Neurosurgery, University College London
  • The Royal Victoria Infirmary
  • Queens Medical Centre
  • John Radcliffe Hospital, Oxford University Hospitals NHS Trust
  • Derriford Hospital
  • Royal Hallamshire Hospital
  • University Hospital of North Staffordshire
  • Royal Cornwall Hospital

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm 4

Arm Type

Experimental

Experimental

Experimental

Placebo Comparator

Arm Label

Amiloride

Riluzole

Fluoxetine

Placebo

Arm Description

Amiloride 5 mg twice per day (5 mg once per day for first 4 weeks) for 96 weeks

Riluzole 50 mg twice per day (50 mg once per day for first 4 weeks) for 96 weeks

Fluoxetine 20 mg twice per day (20 mg once per day for first 4 weeks) for 96 weeks

Matched placebo 1 capsule twice per day (1 capsule a day for first 4 weeks) for 96 weeks

Outcomes

Primary Outcome Measures

MRI-derived Percentage Brain Volume Change (PBVC).
To establish whether a drug, from a panel of 3 leading candidate neuroprotective drugs, slows the rate of brain volume loss in SPMS over 96 weeks using MRI-derived percentage brain volume change (PBVC).

Secondary Outcome Measures

Multi-arm trial strategy assessment
To establish that a multi-arm trial strategy is an efficient way of screening drugs in SPMS and can become the template for future work.
Count of new and enlarging T2 lesions
To explore any anti-inflammatory drug activity using the count of new and enlarging T2 lesions.
Pseudo-atrophy
Examining for evidence of pseudo-atrophy (to ensure reliability of the primary outcome measure).
Clinical measure of neuroprotection
To examine the clinical effect of neuroprotection as measured by clinician - EDSS, MSFC, SDMT, SLCVA, relapse rate and patient reported outcome measures - MSIS29 v2, MSWS v2, Pain - NPRS and BPI and Fatigue - NFI.
Health economics
To collect basic health economic data (EQ-5D) to inform future phase III trials.

Full Information

First Posted
July 19, 2013
Last Updated
March 25, 2020
Sponsor
University College, London
Collaborators
Medical Research Council, National Institute for Health Research, United Kingdom, National Multiple Sclerosis Society, University of Edinburgh, Queen Mary University of London, Keele University, University of Sheffield, University of Leeds, University of Warwick
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1. Study Identification

Unique Protocol Identification Number
NCT01910259
Brief Title
MS-SMART: Multiple Sclerosis-Secondary Progressive Multi-Arm Randomisation Trial
Acronym
MS-SMART
Official Title
A Multi-arm Phase IIB Randomised, Double Blind Placebo-controlled Clinical Trial Comparing the Efficacy of Three Neuroprotective Drugs in Secondary Progressive Multiple Sclerosis.
Study Type
Interventional

2. Study Status

Record Verification Date
March 2020
Overall Recruitment Status
Completed
Study Start Date
December 18, 2014 (Actual)
Primary Completion Date
June 14, 2018 (Actual)
Study Completion Date
July 4, 2018 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University College, London
Collaborators
Medical Research Council, National Institute for Health Research, United Kingdom, National Multiple Sclerosis Society, University of Edinburgh, Queen Mary University of London, Keele University, University of Sheffield, University of Leeds, University of Warwick

4. Oversight

Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Multiple sclerosis (MS) is a disabling and progressive neurological disease that affects approximately 100,000 people in the UK. Many patients with MS experience two phases of disease; early MS (also called relapsing remitting MS, RRMS) and late MS (also called secondary progressive MS (SPMS). Early MS is due to inflammation of the nerves and the insulation (called myelin) that surrounds the nerves. Early MS is often characterised by periods of "attacks" interspersed with periods of "remission" with no or low disease symptoms. Late or progressive MS, which affects the majority of patients and typically emerges after 10-15 years of disease, results from actual nerve death (also called neurodegeneration). The progressive stage of disease results not in individual attacks but slow, cumulative and irreversible disability affecting walking, balance, vision, cognition, pain control, bladder and bowel function. Critically, and unlike early disease, there is no proven treatment for the late stage of MS. This is therefore an urgent and major unmet health need. MS-SMART directly addresses this need and will evaluate in this clinical trial three drugs (fluoxetine, riluzole or amiloride), all of which have shown some promise in MS, and in particular in SPMS. The trial is randomised and blinded. Randomisation means patients can get any one of the three active drugs or the inactive placebo/dummy; blinded means that neither patients nor the doctors will know which drug or placebo patients are receiving. Randomisation and blinding are standard approaches in clinical trials to ensure unbiased testing of drugs. All patients in MS-SMART will have periodic MRI (magnetic resonance imaging) brain scans and after 96 weeks these will be analysed. We will then compare the scans of each drug to the placebo or dummy to see if any of the drugs slow the rate of brain shrinkage that normally occurs in SPMS. This measured change in brain size is the primary (major) outcome of MS-SMART.
Detailed Description
MS-SMART will test the efficacy and mechanism of action of three repurposed drugs (fluoxetine, riluzole and amiloride). All three drugs are in human use and have a good safety record. Critically for the purpose of MS-SMART they all have shown promise in early phase human MS clinical trials and target one or more of the pivotal neurodegenerative causing pathways implicated in SPMS. This is a Type B trial, as the IMPs are all in human use, have a good safety profile but are not currently used for this patient population. The major need for patients with established and progressive MS is neuroprotective or disease modifying treatments that will slow or even stop disease progression. This study will evaluate three highly promising putative neuroprotective drugs as well as comprehensively address several of the current knowledge gaps related to the understanding of neuroprotection and neurodegeneration in SPMS through MRI and CSF examination. MS-SMART is a multicentre, multi-arm, double blind, placebo-controlled phase IIb randomised controlled trial. A total of 440 patients with SPMS, with an entry criteria of an EDSS score of 4.0-6.5 will be equally randomised to receive placebo or one of the three active agents (fluoxetine 20mg bd, amiloride 5mg bd or riluzole 50mg bd). Patients will be followed up for 96 weeks with outcome-data collected after 0, 24, 48 and 96 weeks. That is, the duration of the trial for a trial participant is 96 weeks (a telephone assessment at week 100, 4 weeks post completion will be conducted). This is standard practice for phase II trials in SPMS.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Secondary Progressive Multiple Sclerosis
Keywords
Secondary Progressive Multiple Sclerosis, Neuroprotective, Repurposed drugs, Brain atrophy, Percentage Brain Volume Change, Magnetic Resonance Imaging, Optical Coherence Tomography, Cerebrospinal fluid, Amiloride, Riluzole, Double blind, Placebo, Fluoxetine

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
445 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Amiloride
Arm Type
Experimental
Arm Description
Amiloride 5 mg twice per day (5 mg once per day for first 4 weeks) for 96 weeks
Arm Title
Riluzole
Arm Type
Experimental
Arm Description
Riluzole 50 mg twice per day (50 mg once per day for first 4 weeks) for 96 weeks
Arm Title
Fluoxetine
Arm Type
Experimental
Arm Description
Fluoxetine 20 mg twice per day (20 mg once per day for first 4 weeks) for 96 weeks
Arm Title
Placebo
Arm Type
Placebo Comparator
Arm Description
Matched placebo 1 capsule twice per day (1 capsule a day for first 4 weeks) for 96 weeks
Intervention Type
Drug
Intervention Name(s)
Amiloride
Intervention Description
Comparison with placebo
Intervention Type
Drug
Intervention Name(s)
Riluzole
Intervention Description
Comparison with placebo
Intervention Type
Drug
Intervention Name(s)
Fluoxetine
Intervention Description
Comparison with placebo
Intervention Type
Drug
Intervention Name(s)
Placebo
Intervention Description
Placebo comparator
Primary Outcome Measure Information:
Title
MRI-derived Percentage Brain Volume Change (PBVC).
Description
To establish whether a drug, from a panel of 3 leading candidate neuroprotective drugs, slows the rate of brain volume loss in SPMS over 96 weeks using MRI-derived percentage brain volume change (PBVC).
Time Frame
2 years
Secondary Outcome Measure Information:
Title
Multi-arm trial strategy assessment
Description
To establish that a multi-arm trial strategy is an efficient way of screening drugs in SPMS and can become the template for future work.
Time Frame
2 years
Title
Count of new and enlarging T2 lesions
Description
To explore any anti-inflammatory drug activity using the count of new and enlarging T2 lesions.
Time Frame
2 years
Title
Pseudo-atrophy
Description
Examining for evidence of pseudo-atrophy (to ensure reliability of the primary outcome measure).
Time Frame
6 months
Title
Clinical measure of neuroprotection
Description
To examine the clinical effect of neuroprotection as measured by clinician - EDSS, MSFC, SDMT, SLCVA, relapse rate and patient reported outcome measures - MSIS29 v2, MSWS v2, Pain - NPRS and BPI and Fatigue - NFI.
Time Frame
2 years
Title
Health economics
Description
To collect basic health economic data (EQ-5D) to inform future phase III trials.
Time Frame
2 years
Other Pre-specified Outcome Measures:
Title
New T1 hypotense lesion count
Description
Persistent new T1 hypointense lesion count to assess neuroprotection in new lesions.
Time Frame
2 years
Title
Grey matter volume change
Description
Grey matter volume change to assess cortical neuroprotection.
Time Frame
2 years
Title
MR spectroscopy measured N-acetyl aspartate, myoinositol and glutamate
Description
MR spectroscopy (MRS) to measure N-acetyl aspartate (reversal of neuronal mitochondrial dysfunction), myoinositol (prevention of glial cell inflammation) and glutamate (prevention of excitotoxicity).
Time Frame
2 years
Title
Myelination
Description
Magnetic Transfer Ratio (MTR) to evaluate myelination.
Time Frame
2 years
Title
Cervical cord imaging
Description
Cervical cord imaging to assess cord neuroprotection.
Time Frame
2 years
Title
Composite MRI/disability scores
Description
Composite MRI/disability scores to increase sensitivity and study interaction of treatment mechanisms.
Time Frame
2 years
Title
Cerebrospinal fluid (CSF) neurofilament levels
Description
Quantification of Cerebrospinal fluid (CSF) neurofilament levels to measure neuroprotection.
Time Frame
2 years
Title
Optical Coherence Tomography (OCT) measured Retinal Nerve Fibre Layer (RNFL) thickness
Description
Optical Coherence Tomography (OCT) measured Retinal Nerve Fibre Layer (RNFL) thickness as a measure of neuroprotection.
Time Frame
2 years

10. Eligibility

Sex
All
Minimum Age & Unit of Time
25 Years
Maximum Age & Unit of Time
65 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Confirmed diagnosis of SPMS. Steady progression rather than relapse must be the major cause of increasing disability in the preceding 2 years. Evidence of progression, either an increase of at least one point in EDSS or clinical documentation of increasing disability in patient notes Expanded Disability Status Scale (EDSS) 4.0-6.5 Aged 25 to 65 inclusive Women and men with partners of childbearing potential must be using an appropriate method of contraception to avoid any unlikely teratogenic effects of the 3 drugs from time of consent, to 6 weeks after treatment inclusive Women must have a negative pregnancy test within 7 days prior to the baseline visit unless not of child bearing potential (e.g. have undergone a hysterectomy, bilateral tubal ligation or bilateral oophorectomy or they are postmenopausal) Willing and able to comply with the trial protocol (e.g. can tolerate MRI and fulfils the requirements for MRI, e.g. not fitted with pacemakers or permanent hearing aids), ability to understand and complete questionnaires Written informed consent provided Exclusion Criteria: Pregnancy or breast feeding patients Baseline MRI scan not of adequate quality for analysis (e.g. too much movement artefact) Significant organ co-morbidity (e.g. malignancy or renal or hepatic failure) Relapse within 3 months of baseline visit Patients who have been treated with iv or oral steroids for an MS relapse/progression within 3 months of baseline visit (these patients can undergo future screening visits once the 3 month window has expired), patients on steroids for another medical condition may enter as long as the steroid prescription is not for multiple sclerosis (relapse/ progression). Use of Simvastatin at 80mg dose within 3 months of baseline visit (lower doses of Simvastatin and other statins are permissible) Commencement of fampridine within 6 months of baseline visit Use of immunosuppressants (e.g. azathioprine, methotrexate, cyclosporine) or disease modifying treatments (β-interferons, glatiramer) within 6 months of baseline visit Use of fingolimod/fumarate/teriflunomide/laquinomod/or other experimental disease modifying treatment (including research of an investigational medicinal product) within 12 months of baseline visit Use of mitoxantrone/ natalizumab/ alemtuzumab/ daclizumab if treated within 12 months of baseline visit Primary progressive MS Relapsing-remitting MS Known hypersensitivity to the active substances and their excipients to any of the active drugs for this trial Use of: lithium, chlorpropamide, triamterene and spironolactone within 6 months of the baseline visit Current use of potassium supplements Current use of tamoxifen Current use of herbal treatments containing St. John's Wort Significant signs of depression Use of an SSRI within 6 months of the baseline visit Use of monoamine oxidase inhibitors, phenytoin, L-tryptophan) and/or neuroleptic drugs within 6 months of the baseline visit A Beck Depression Index score of 19 or higher Bipolar disorder Receiving or previously received Electro-Convulsive Therapy Epilepsy/seizures Glaucoma Patients with a history of bleeding disorders or currently on anticoagulants Routine screening blood values (LFT) >/ 3 x upper limit of normal (ULN) of site reference ranges (ALT/AST, bilirubin,ˠGT) Potassium <2.8mmol/l or >5.5mmol/l Sodium <125mmol/l Creatinine >130μmol/l WBCs <3 x 109/l Lymphocytes <0.8 x 109/l Neutrophil count <1.0 x 109 /l Platelet count <90 x 109 /l Haemoglobin <80g/l
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Jeremy Chataway
Organizational Affiliation
University College, London
Official's Role
Principal Investigator
First Name & Middle Initial & Last Name & Degree
Siddharthan Chandran
Organizational Affiliation
University of Edinburgh
Official's Role
Principal Investigator
Facility Information:
Facility Name
Anne Rowling Regenerative Neurology Clinic, Royal Infirmary of Edinburgh
City
Edinburgh
ZIP/Postal Code
EH16 4SA
Country
United Kingdom
Facility Name
Gartnavel Royal Hospital, 1055 Great Western Road
City
Glasgow
ZIP/Postal Code
G12 OXH
Country
United Kingdom
Facility Name
Brighton and Sussex University Hospitals
City
Haywards Heath
ZIP/Postal Code
RH16 4EX
Country
United Kingdom
Facility Name
St James's University Hospital
City
Leeds
ZIP/Postal Code
LS9 7TF
Country
United Kingdom
Facility Name
The Walton Centre
City
Liverpool
ZIP/Postal Code
L9 7LJ
Country
United Kingdom
Facility Name
The National hospital for Neurology and Neurosurgery, University College London
City
London
ZIP/Postal Code
WC1N 3BG
Country
United Kingdom
Facility Name
The Royal Victoria Infirmary
City
Newcastle
ZIP/Postal Code
NE1 4LP
Country
United Kingdom
Facility Name
Queens Medical Centre
City
Nottingham
ZIP/Postal Code
NG7 2UH
Country
United Kingdom
Facility Name
John Radcliffe Hospital, Oxford University Hospitals NHS Trust
City
Oxford
ZIP/Postal Code
OX3 9DU
Country
United Kingdom
Facility Name
Derriford Hospital
City
Plymouth
ZIP/Postal Code
PL6 8DH
Country
United Kingdom
Facility Name
Royal Hallamshire Hospital
City
Sheffield
ZIP/Postal Code
S10 2JF
Country
United Kingdom
Facility Name
University Hospital of North Staffordshire
City
Stoke-on-Trent
ZIP/Postal Code
ST4 7LN
Country
United Kingdom
Facility Name
Royal Cornwall Hospital
City
Truro
ZIP/Postal Code
TR1 3LJ
Country
United Kingdom

12. IPD Sharing Statement

Citations:
PubMed Identifier
35945550
Citation
Williams T, Alexander S, Blackstone J, De Angelis F, John N, Doshi A, Beveridge J, Braisher M, Gray E, Chataway J; MS-SMART and MS-STAT2 Investigators. Optimising recruitment in clinical trials for progressive multiple sclerosis: observational analysis from the MS-SMART and MS-STAT2 randomised controlled trials. Trials. 2022 Aug 9;23(1):644. doi: 10.1186/s13063-022-06588-z.
Results Reference
derived
PubMed Identifier
31981516
Citation
Chataway J, De Angelis F, Connick P, Parker RA, Plantone D, Doshi A, John N, Stutters J, MacManus D, Prados Carrasco F, Barkhof F, Ourselin S, Braisher M, Ross M, Cranswick G, Pavitt SH, Giovannoni G, Gandini Wheeler-Kingshott CA, Hawkins C, Sharrack B, Bastow R, Weir CJ, Stallard N, Chandran S; MS-SMART Investigators. Efficacy of three neuroprotective drugs in secondary progressive multiple sclerosis (MS-SMART): a phase 2b, multiarm, double-blind, randomised placebo-controlled trial. Lancet Neurol. 2020 Mar;19(3):214-225. doi: 10.1016/S1474-4422(19)30485-5. Epub 2020 Jan 22.
Results Reference
derived
PubMed Identifier
30166303
Citation
Connick P, De Angelis F, Parker RA, Plantone D, Doshi A, John N, Stutters J, MacManus D, Prados Carrasco F, Barkhof F, Ourselin S, Braisher M, Ross M, Cranswick G, Pavitt SH, Giovannoni G, Gandini Wheeler-Kingshott CA, Hawkins C, Sharrack B, Bastow R, Weir CJ, Stallard N, Chandran S, Chataway J; UK Multiple Sclerosis Society Clinical Trials Network. Multiple Sclerosis-Secondary Progressive Multi-Arm Randomisation Trial (MS-SMART): a multiarm phase IIb randomised, double-blind, placebo-controlled clinical trial comparing the efficacy of three neuroprotective drugs in secondary progressive multiple sclerosis. BMJ Open. 2018 Aug 30;8(8):e021944. doi: 10.1136/bmjopen-2018-021944.
Results Reference
derived
Links:
URL
http://ms-smart.org
Description
Trial website

Learn more about this trial

MS-SMART: Multiple Sclerosis-Secondary Progressive Multi-Arm Randomisation Trial

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