Cladribine Tablets After Treatment With Natalizumab (CLADRINA)

Multiple Sclerosis Clinical Trial

Official title:

Cladribine Tablets After Treatment With Natalizumab (CLADRINA)

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT04178005
• Other study ID #: STU 2019-1618
• Status: Active, not recruiting
• Phase: Phase 4
• Start date: February 19, 2020
• Est. completion date: December 2026

Study information

• Verified date: January 2024
• Source: University of Texas Southwestern Medical Center
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The purpose of this study is to generate hypotheses regarding the safety, efficacy, and immunological impact of cladribine tablets after treatment with natalizumab in patients with relapsing-remitting multiple sclerosis (RRMS) and active secondary progressive multiple sclerosis (active SPMS).

Description:

This will be an open label, single arm, multicenter, collaborative phase 4 research study, designed to generate hypotheses regarding the transition to cladribine tablets after treatment with natalizumab in patients with relapsing forms of multiple sclerosis MS, to include relapsing-remitting multiple sclerosis (RRMS) and active secondary progressive multiple sclerosis (SPMS).

The total duration of this interventional study will be 2 years, but patients who require additional time (up to 6 months) for recovery of Absolute lymphocyte count (ALC) to 800 cells/ul prior to the second treatment course will be followed for up to 6 additional months in order to have a full second year of follow up after initiation of the second year's treatment course (for a total study duration of up to 30 months in some patients). A total of 40 study participants with relapsing forms of MS, to include RRMS and active SPMS, who meet the criteria for treatment with cladribine tablets as per the approved United States Prescribing Information (USPI) are planned to be enrolled at up to three centers in the United States. All study participants will receive treatment with cladribine 10 mg tablets during year 1 and year 2 according to the approved USPI (EMD Serono, 2019). Cladribine 10 mg tablets will be provided as commercial material. Treatment with cladribine tablets is intended to be initiated approximately 14 days after the last infusion of natalizumab (e.g., a 14-day "washout"), with a maximum permissible washout period of no more than four weeks.

After successful completion of the study, all participants in CLADRINA will be offered to participate in the CLADRINA 2-Year Extension study. During this extension trial, there will be no intervention. Patient will be followed for an additional 24 months, and their clinical and paraclinical disease activity will be assessed through neurological examinations, EDSS scores, brain MRI, and biological markers.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 40
• Est. completion date: December 2026
• Est. primary completion date: August 30, 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 60 Years

Eligibility

Inclusion Criteria:

Patients who meet the following inclusion criteria will be eligible for enrollment in the study:

1. Age between 18 and 60 years, inclusive.

2. Diagnosis of relapsing forms of MS, to include RRMS and active SPMS, diagnosed with McDonald Criteria 2005, 2010, and/or 2017 (1-3)

3. EDSS 0 - 5.5 (Functional system changes in cerebral (or mental) functions and in bowel and bladder functions not used in determining EDSS for protocol eligibility).

4. Has had a minimum of 12 months of continuous natalizumab therapy (300 mg/d), including patients receiving extended interval dosing of natalizumab (e.g., less frequently than every-4-week infusion).

5. Negative history for any relapses at least 28 days prior to enrollment.

6. Weighing between 40 kilograms or more.

7. Female subjects of childbearing potential must use effective methods of contraception to prevent pregnancy for 4 weeks before initiation of cladribine tablets and must agree to continue to practice adequate contraception for at least 6 months after the last dose. Women using systemically acting hormonal contraceptives should add a barrier method during cladribine treatment and for at least 4 weeks after the last dose in each treatment year.

8. Female subjects must not be pregnant; female subjects must not be lactating or breast-feeding at least 10 days after the last dose.

9. Male subjects must be willing to use a condom during dosing and for six months after the last dose. Alternatively, their female partner must use another form of contraception (such as an intra-uterine device [IUD], barrier method with spermicide, or hormonal contraceptive [e.g., implant, injectable, patch or oral]) during dosing and for six months after last dose.

10. Understands and is capable of following through with study protocol requirements and assessments.

11. Willing to provide voluntary and informed consent based on the Health Insurance Portability and Accountability Act (HIPPA).

Exclusion Criteria:

Patients who meet any of the following exclusion criteria will not be eligible for enrollment in the study:

1. Natalizumab failure based on clinician's discretion.

2. Not active progressive MS (4).

3. A diagnosis of PML or any suspicion of PML.

4. A diagnosis of Clinically Isolated Syndrome

5. Known hypersensitivity to cladribine.

6. Any prior exposure to cladribine.

7. Lymphocyte count not within normal limits of the local, hospital laboratory.

8. Previous or current exposure to mitoxantrone, azathioprine, methotrexate, cyclophosphamide, myelosuppressive treatments, total lymphoid irradiation.

9. Receiving oral or systemic corticosteroid treatments within the 28 days prior to enrollment.

10. Receiving cytokine base treatment, Intra Venous Immuno Globulin (IVIG) or Plasma pheresis, 3 months prior to enrollment in the study.

11. Having platelet count or neutrophil count below the lower limit of the normal range within the 28 days prior to enrollment in the study.

12. Positive for HIV, or positive hepatitis C antibody test or hepatitis B surface antigen test and/or core antibody test for IgG and/or IgM.

13. History of tuberculosis (TB), presence of active tuberculosis, or latent tuberculosis as detected by local standard of practice like imaging (e.g., chest X-ray, chest CT scan, MRI) and/or positive QuantiFERON-TB Gold test and/or skin test and/or clinical examination or has had latent TB disease at any time in the past.

14. Immunocompromised subjects, including subjects currently receiving immunosuppressive or myelosuppressive therapy with, e.g., monoclonal antibodies, methotrexate, cyclophosphamide, cyclosporine or azathioprine, or chronic use of corticosteroids.

15. Active malignancy or history of malignancy.

16. Received a live vaccine within 6 weeks prior to cladribine tablet administration or intends to receive a live vaccination during the trial. After the last dose of cladribine tablets, the subject should avoid live vaccine as long as the subject's white blood cell counts are not within normal limits.

17. Allergy or hypersensitivity to gadolinium and/or any other contraindication to perform an MRI.

18. Has any renal condition that would preclude the administration of gadolinium (e.g. acute or chronic severe renal insufficiency (GFR < 30 mL/min/1.73m2)

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Related Conditions & MeSH terms

• Multiple Sclerosis

Intervention

Drug:
• Cladribine
All study participants will receive treatment with cladribine 10 mg tablets at the recommended cumulative dose of 3.5 mg/kg, divided into 2 yearly treatment courses (1.75 mg/kg per treatment course). This regimen corresponds to the recommended dosage as per the USPI

Locations

Country	Name	City	State
United States	UT Southwestern Medical center	Dallas	Texas
United States	College Park Family Care Center Physicians Group	Overland Park	Kansas

Sponsors (2)

Lead Sponsor	Collaborator
University of Texas Southwestern Medical Center	EMD Serono

Country where clinical trial is conducted

United States, 

References & Publications (39)

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* Note: There are 39 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	The Expanded Disability Status Scale : Neurological disability outcome	The Expanded Disability Status Scale (EDSS) will be utilized to measure the accumulation of neurological disability.; The change in EDSS from baseline will be reported at month 12 and month 24. The EDSS scale ranges from 0 to 10 in 0.5 unit increments that represent higher levels of disability.; EDSS steps 1.0 to 4.5 refer to people with MS who are able to walk without any aid and is based on measures of impairment in eight functional systems (FS): muscle weakness or difficulty moving limbs, ataxia, loss of balance, coordination or tremor, problems with speech, swallowing and nystagmus, numbness or loss of sensations, bowel and bladder function, problems with sight, problems with thinking and memory, other A functional system (FS) represents a network of neurons in the brain with responsibility for particular tasks. Each FS is scored on a scale of 0 (no disability) to 5 or 6 (more severe disability).; EDSS steps 5.0 to 9.5 are defined by the impairment to walking.	24 months
Other	Magnetic Resonance imaging (MRI) outcomes	The mean number of new or new/ enlarging T2 lesions, and the number of gadolinium (Gd)-enhancing lesions.	24 months
Primary	Absolute and percent change of T cells, B cells, DC subset and NfL levels in blood.	The absolute and percent change from baseline will be presented for each time point for CD3+ T lymphocytes, CD19+ B lymphocytes, CD11c+ DC subsets, NfL levels in blood, with a two-sided 95% CI and p value. As these data are not expected to be normally distributed, the nonparametric Wilcoxon signed rank test will be used to compare each biomarker at baseline and during treatment. Spearman rank correlations will be used to examine the relationship between biomarkers and clinical/safety endpoints.	24 months
Secondary	Annualized Relapse Rate (ARR)	The ARR over the 12- and 24-month periods will be presented, accompanied by the respective 95% CIs. The proportion (and 95% CI) of participants experiencing a relapse over the 12 month and 24-month periods will also be presented.	12 months