Study to Assess Immune Function and MRI Disease Activity in RRMS Patients When Switching From Natalizumab to Gilenya (ToFingo2)

A 32-week, Monocentric, Exploratory, Single Arm Study to Assess Immune Function and MRI Disease Activity in Patients With RRMS Transferred From Previous Treatment With Natalizumab to Gilenya® (Fingolimod)

A trial in patients with relapsing remitting multiple sclerosis (RRMS)

Main objectives:

• To evaluate changes in the reconstitution of immune surveillance over time upon switching from natalizumab to fingolimod assessed by a change in the expression of CD49d.
• To evaluate changes in the migratory capacity of immune cells/peripheral blood mononuclear cells (PBMCs) upon switching from natalizumab to fingolimod in an in-vitro model of the blood-brain-barrier (BBB).
• To evaluate changes in paraclinical disease activity over time upon switching from natalizumab to fingolimod assessed by MRI (changes in Gd+, T2w lesions and DTI).
• To evaluate changes in T1w / FLAIR lesions upon switching from natalizumab to fingolimod.

Study Overview

• Status: Unknown
• Conditions: Relapsing Remitting Multiple Sclerosis
• Intervention / Treatment: Drug: Fingolimod; Drug: Natalizumab

Detailed Description

Patients are screened and must sign informed consent at visit 1. At the 2nd visit, all patients receive a baseline infusion of Natalizumab, which is followed by an 8 week washout Phase. After the washout Phase all patients receive fingolimod for 32 weeks.

• Study Type: Interventional
• Enrollment (Anticipated): 15
• Phase: Phase 4

Contacts and Locations

• Study Contact: Name: Luisa Klotz, PD Dr. med.; Phone Number: 00 +49 251 98029; Email: luisa.klotz@ukmuenster.de

Study Locations

• Germany
  • Muenster, Germany, 48149
    • Recruiting
    • Universitaetsklinikum Muenster, Department of Neurology
    • Contact: Luisa Klotz, PD Dr. med.; Phone Number: 52 +49 251 83444; Email: luisa.klotz@ukmuenster.de
    • Principal Investigator: Luisa Klotz, PD Dr. med.

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Written informed consent must be obtained before any assessment is performed.
2. Male and female subjects aged 18-65 yrs.
3. Subjects with RRMS, defined by 2010 rev. McDonald criteria.
4. Patients with an (EDSS) score of 0-6.0 inclusive.

5. Patients on treatment with natalizumab for ≥ 12 months prior to screening where treatment discontinuation is considered for any of the following reasons:

   • treatment duration for more than 2 years
   • positive JC virus (JCV) antibody status
   • adverse effects including hypersensitivity reactions
   • presence of anti-natalizumab neutralizing antibodies
   • any other valid medical reason

Exclusion Criteria:

1. Patients with a history of chronic disease of the immune system other than MS, which requires systemic immunosuppressive treatment, or a known immunodeficiency syndrome.
2. Patients with Crohn´s disease or ulcerative colitis.

3. Patients who have been treated with:

   • systemic corticosteroids or immunoglobulins within 1 month prior to baseline.
   • immunosuppressive medications such as azathioprine, cyclophosphamide or methotrexate within 3 months prior to baseline.
   • monoclonal antibodies (excluding natalizumab) within 3 months prior to baseline.
   • cladribine or mitoxantrone at any time.
4. History of malignancy of any organ system (other than cutaneous basal cell carcinoma).
5. Uncontrolled diabetes mellitus (HbA1c >7%).
6. Diagnosis of macular edema during Screening Phase.
7. Severe active infections, active chronic infection.
8. Negative for varicella-zoster virus immunoglobulin G antibodies prior to baseline.
9. Patients that received any live or live-attenuated vaccine (including varicella-zoster virus or measles) within 1 month prior to baseline.
10. Patients who have received total lymphoid irradiation or bone marrow transplantation.
11. Patients with any medically unstable condition, as assessed by the investigator.
12. Patients with certain cardiovascular conditions and/or findings in the screening ECG.
13. Patients with certain lung diseases.
14. Patients with certain hepatic conditions.
15. Patients with a screening white blood cell (WBC) count <3,500/mm3 or lymphocyte count <800/mm3.
16. Patients with certain neurologic/psychiatric disorders:
17. Patients unable to undergo MRI scans, including claustrophobia or history of hypersensitivity to gadolinium-diethylenetriaminepentacetate (Gd-DTPA).
18. Patients who have received an investigational drug or therapy within 180 days or 5 half-lives before baseline, whichever is longer.
19. Pregnant or nursing (lactating) women, confirmed by a positive human chorionic gonadotropin laboratory.
20. Women of child-bearing potential unless they are using effective contraception during the study and for 5 half-lives after stopping treatment. In case of use of oral contraception women should have been stable on the same medication for a minimum of 3 months before baseline.
21. History of hypersensitivity to the study drugs or to drugs of similar chemical classes.
22. Prior participation in a trial with fingolimod.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Natalizumab - Washout - Fingolimod; One experimental arm: Patients receive one final dose of natalizumab 300mg followed by an 8-week washout Phase and subsequent 32-week treatment Phase with fingolimod 0.5mg o.i.d.	Drug: Fingolimod; Fingolimod: 0.5 mg p.o. (o.i.d); Other Names: Gilenya; FTY720; Drug: Natalizumab; Natalizumab: 300 mg i.v. (once at baseline); Other Names: Tysabri

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Temporal changes in the expression of CD49d	First Co-Primary Objective; Flow-cytometric analysis of temporal changes in the expression of CD49d of PBMCs; unit of measure: mean fluorescence intensity (MFI)	weeks: 12, 16, 20, 24, 28, 32
Migratory capacity of immune cells	Second Co-Primary Objective; in-vitro model of the blood-brain-barrier (BBB) with subsequent flow-cytometric analysis and bead based quantification assessing temporal changes in the migratory capacity of immune cells; unit of measure: fluorescence intensity	weeks: 12, 32

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
MRI disease activity over time by GD+, T2w and DTI	Number of active (new or newly enlarging) lesions are assessed over time by MRI (changes in Gadolinium (GD+), T2w lesions and DTI (Diffusion Tensor Imaging))	weeks: 0, 8, 12, 16, 24, 32
MRI disease activity over time by T1w / FLAIR	Number of active (new or newly enlarging) lesions are assessed over time by MRI (T1w / FLAIR (Fluid Attenuated Inversion Recovery)	weeks: 0, 8, 12, 16, 24, 32

Collaborators and Investigators

• Sponsor: University Hospital Muenster
• Collaborators: Novartis
• Investigators: Principal Investigator: Luisa Klotz, PD. Dr. med., Universitätsklinikum Muenster, Germany

Publications and helpful links

General Publications

• Lohmann L, Janoschka C, Schulte-Mecklenbeck A, Klinsing S, Kirstein L, Hanning U, Wirth T, Schneider-Hohendorf T, Schwab N, Gross CC, Eveslage M, Meuth SG, Wiendl H, Klotz L. Immune Cell Profiling During Switching from Natalizumab to Fingolimod Reveals Differential Effects on Systemic Immune-Regulatory Networks and on Trafficking of Non-T Cell Populations into the Cerebrospinal Fluid-Results from the ToFingo Successor Study. Front Immunol. 2018 Jul 9;9:1560. doi: 10.3389/fimmu.2018.01560. eCollection 2018.

Study record dates

Study Major Dates

• Study Start: March 1, 2014
• Primary Completion (Anticipated): April 1, 2016
• Study Completion (Anticipated): April 1, 2016

Study Registration Dates

• First Submitted: September 4, 2014
• First Submitted That Met QC Criteria: December 19, 2014
• First Posted (Estimate): December 25, 2014

Study Record Updates

• Last Update Posted (Estimate): December 25, 2014
• Last Update Submitted That Met QC Criteria: December 19, 2014
• Last Verified: December 1, 2014

More Information

Terms related to this study

• Keywords: immune function; disease activity; RRMS (relapsing remitting multiple sclerosis); Cluster of differentiation 49d (CD49d)
• Additional Relevant MeSH Terms: Pathologic Processes; Nervous System Diseases; Immune System Diseases; Demyelinating Autoimmune Diseases, CNS; Autoimmune Diseases of the Nervous System; Demyelinating Diseases; Autoimmune Diseases; Multiple Sclerosis; Sclerosis; Multiple Sclerosis, Relapsing-Remitting; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Immunosuppressive Agents; Immunologic Factors; Sphingosine 1 Phosphate Receptor Modulators; Natalizumab; Fingolimod Hydrochloride
• Other Study ID Numbers: UKM12_0037; 2013-004616-21 (EudraCT Number); CFTY720D2415T (Other Identifier: Novartis)