Multiple Sclerosis-Simvastatin Trial 2 (MS-STAT2)

A Phase 3 Randomised, Double Blind, Clinical Trial Investigating the Effectiveness of Repurposed Simvastatin Compared to Placebo, in Secondary Progressive Multiple Sclerosis, in Slowing the Progression of Disability

Multiple Sclerosis (MS) is a progressive neurological disorder of the brain and spinal cord. It affects approximately 120,000 people in the United Kingdom and 2.5 million people globally. Most people with MS experience two stages of the disease:

Early MS - Relapsing-Remitting MS (RRMS), which is partially reversible, and Late MS - Secondary Progressive MS (SPMS), which affects the majority of patients, usually after 10 to 15 years after diagnosis.

SPMS results from progressive neuronal degeneration that causes accumulating and irreversible disability affecting walking, balance, manual function, vision, cognition, pain control, bladder and bowel function. The pathological process driving the accrual of disability in SPMS is not known at present.

Immunomodulatory anti-inflammatory disease modifying therapies (DMTs) are increasingly effective in reducing relapse frequency in RRMS, however, they have been unsuccessful in slowing disease progression in SPMS. This is the overwhelming conclusion from an analysis of 18 phase 3 trials (n=8500), of which 70% of the population had SPMS, all performed in the last 25 years. There is no current disease modifying treatment (DMT) for SPMS.

In an earlier study (Multiple Sclerosis-Simvastatin 1; MS-STAT1), 140 people with SPMS were randomly assigned to receive either placebo or simvastatin for a period of two years. The investigators found that the rate of brain atrophy (loss of neurons - 'brain shrinkage'), as measured by magnetic resonance imaging (MRI), was reduced in patients receiving simvastatin compared to those taking placebo.

Several other long term studies have also reported that there might be a relationship between the rate of brain atrophy and the degree of impairment. The study is designed to test the effectiveness of repurposed simvastatin (80mg) in a phase 3 double blind, randomised, placebo controlled trial (1:1) in patients with secondary progressive MS (SPMS), to determine if the rate of disability progression can be slowed over a 3 year period.

The results generated from this trial may help to improve the treatment options of people with MS. In addition, taking part in this trial will mean regular review by an experienced neurologist regardless of the drug that patients are randomly allocated to receive.

Study Overview

• Status: Active, not recruiting
• Conditions: Secondary Progressive Multiple Sclerosis (SPMS)
• Intervention / Treatment: Drug: Simvastatin; Drug: Placebo

• Study Type: Interventional
• Enrollment (Actual): 964
• Phase: Phase 3

Contacts and Locations

Study Locations

• United Kingdom
  • Belfast, United Kingdom, BT9 7AB
    • Belfast City Hospital
  • Brighton, United Kingdom, BN2 5BE
    • Royal Sussex County Hospital
  • Cambridge, United Kingdom, CB2 0QQ
    • Addenbrooke's Hospital
  • Cardiff, United Kingdom, CF14 4XW
    • University Hospital of Wales
  • Edinburgh, United Kingdom, EH16 4SB
    • The Anne Rowling Regenerative Neurology Clinic
  • Exeter, United Kingdom, EX2 5DW
    • Royal Devon and Exeter Hospital
  • Glasgow, United Kingdom, G51 4TF
    • The Queen Elizabeth University Hospital
  • Leeds, United Kingdom, LS1 3EX
    • Leeds General Infirmary
  • Leeds, United Kingdom, LS1 3EX
    • The Leeds Teaching Hospital
  • Liverpool, United Kingdom, L9 7LJ
    • The Walton Centre NHS Foundation Trust
  • London, United Kingdom, W6 8RF
    • Charing Cross Hospital
  • London, United Kingdom, RM7 0AG
    • Queen's Hospital, Barking, Havering and Redbridge University Hospitals
  • London, United Kingdom, SE5 8EF
    • King's College Hopsital
  • London, United Kingdom, WC1N 3BG
    • University College London Hospital
  • Manchester, United Kingdom, M6 8HD
    • Salford Royal Hospital
  • Newcastle Upon Tyne, United Kingdom, NE1 4LP
    • Royal Victoria Infirmary
  • Nottingham, United Kingdom, NG7 2UH
    • Queen's Medical Centre
  • Nottingham, United Kingdom, NG5 1PB
    • Nottingham Teaching Hospitals
  • Oxford, United Kingdom, OX3 9DU
    • John Radcliffe Hospital
  • Plymouth, United Kingdom, PL6 8BH
    • Derriford Hospital
  • Poole, United Kingdom, BH15 2JB
    • Poole Hospital
  • Sheffield, United Kingdom, S10 2JF
    • Royal Hallamshire Hospital
  • Stoke-on-Trent, United Kingdom, ST4 6QG
    • University Hospital of North Staffordshire
  • Swansea, United Kingdom
    • Morriston & Neath Port Talbot Hospitals (Abertawe Bro Morgannwg University Local Health Board)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 25 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Patients with a confirmed diagnosis of multiple sclerosis (MS) that have entered the secondary progressive stage. Steady progression rather than relapse must be the major cause of increasing disability in the preceding 2 years. Progression can be evident from either an increase of at least 1 point if EDSS score <6, or an increase of 0.5 point if EDSS score ≥6, or clinical documentation of increasing disability
2. EDSS 4.0 - 6.5 (inclusive)
3. Aged 25 to 65 years old
4. Patients must be able and willing to comply with the terms of this protocol.
5. Written informed consent provided

Exclusion Criteria:

1. Relapse within 3 months of baseline visit;
2. Patients that have been treated with steroids (intravenous and/or oral) due to MS relapse/progression within 3 months of baseline visit. These patients may undergo a further screening visit once the 3 month window has expired and may be included if no steroid treatment has been administered in the intervening period; (Note: Patients on steroids for another medical condition may be included in the trial provided the steroid prescription is not for MS relapse/progression)
3. Significant organ co-morbidity e.g. cardiac failure, renal failure, malignancy;
4. Screening levels of alanine aminotransferase (ALT) / aspartate aminotransferase (AST) or creatinine kinase (CK) ≥3 x upper limit of normal (ULN);
5. Current use of a statin; or any use within the last 6 months;
6. Medications that interact unfavourably with simvastatin as outlined in the current summary of product characteristics (SmPC); including but not limited to CYP3A4 inhibitors (e.g. itraconazole, ketoconazole, posaconazole, voriconazole, fluconazole, HIV protease inhibitors (e.g. nelfinavir), boceprevir, erythromycin, clarithromycin, telithromycin, telaprevir, nefazodone, fibrates (including fenofibrates), nicotinic acid (or products containing niacin), azole anti-fungal preparations, macrolide antibiotics, protease inhibitors, verapamil, amiodarone, amlodipine, gemfibrozil, ciclosporin, danazol, diltiazem, rifampicin, fusidic acid, grapefruit juice or alcohol abuse;
7. Primary progressive MS;
8. Diabetes mellitus type 1;
9. Uncontrolled hypothyroidism;
10. Female participants that are pregnant or breast feeding. Women of child bearing potential (WOCBP) who are unwilling or unable to use an acceptable method to avoid pregnancy for the entire study period, and up to 4 weeks after the last dose of study drug;
11. Use of immunosuppressants (e.g. azathioprine, methotrexate, ciclosporine) or disease modifying treatments (avonex, rebif, betaferon, glatiramer) within the previous 6 months;
12. Use of mitoxantrone, natalizumab, alemtuzumab, daclizumab or other monoclonal antibody treatment, if treated within the last 12 months;
13. Use of fingolimod, fumarate, teriflunomide within the last 12 months;
14. Use of other experimental disease modifying treatment within the last 6 months;
15. Commencement of fampridine ≤6 months from day of randomisation;
16. Concurrent participation in another clinical trial of an investigational medicinal product or medical device;
17. Patients with rare hereditary problems of galactose intolerance, the lapp lactase deficiency or glucose-galactose malabsorption.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: Placebo	Drug: Placebo; One (1) placebo tablet once daily at night for 1 month; Two (2) placebo tablets once daily at night, for the next 35 months
Active Comparator: Simvastatin	Drug: Simvastatin; One (1 = 40mg) simvastatin tablet once daily at night for 1 month; Two (2 = 80mg) simvastatin tablets once daily at night, for the next 35 months

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to confirmed disability progression between simvastatin and placebo arm based on change in EDSS scores compared to baseline.	The initial disability progression event is finalised as positive if disability is sustained and confirmed ≥6* months later. Progression of disability defined as an increase of at least 1 point if EDSS baseline score <6, or an increase of 0.5 point if baseline EDSS score is ≥6.	6 monthly - baseline, month 6, 12, 18, 24, 30, 36

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Response rate on the patient reported outcome form Multiple Sclerosis Walking Scale-12 version 2 (MSWS-12v2)	MSWS-12v2 is a12 item patient report measure on the impact of MS on the individual's walking ability over the previous 2 weeks. Each item will be summed to generate a total score and transformed to a scale with a range of 0 to 100 with high scores indicating greater impact on walking.	Annually - baseline, month 12, 24 and 36
Response rate on the patient reported outcome form Multiple Sclerosis Impact Scale-29 version 2 (MSIS-29v2)	MS Impact Scale-29 version 2 (MSIS-29v2) - A psychometrically validated patient-reported outcome measure increasingly used for measuring the impact of MS on people's lives. The 29-item scale assesses the impact of MS on people's health related quality of life in terms of their physical and psychological well-being over the previous 2 weeks.	Annually - baseline, month 12, 24 and 36
Cost effectiveness of intervention	To estimate the incremental cost and cost-effectiveness of simvastatin versus standard care for the trial period and for the lifetime horizon using the Client Client Services Receipt Inventory Form.	6 monthly - baseline, month 6, 12, 18, 24, 30, 36
Change in time taken to complete 25-Foot Timed Walk (T25FW)	T25-FW is a quantitative mobility and leg function performance test based on a timed 25-foot walk	6 monthly - baseline, month 6, 12, 18, 24, 30, 36
Change in time taken to complete 9 hole peg test (9HPT)	The 9HPT is a brief, standardized, quantitative test of upper extremity function. Participants are instructed to pick up 9 pegs, one at a time, as quickly as possible and are required to insert them into 9 empty peg holes. Once all nine pegs have been inserted, the participant should immediately remove the pegs, one at a time. The total time taken to complete the task is recorded. Two consecutive trials with the dominant hand are immediately followed by two consecutive trials with the non-dominant hand. The two trials for each hand are averaged.	6 monthly - baseline, month 6, 12, 18, 24, 30, 36
Evaluating change in degree of disability based on the modified Rankin scale (mRS)	mRS is used to evaluate the degree of disability in daily activities of those with neurological disability.	Annually - baseline, month 12, 24 and 36
Difference in the number and severity of multiple sclerosis related relapse events between treatment groups	A relapse will be defined as new or worsening neurological symptom(s) in the absence of fever, lasting for more than 24 hours, and have been preceded by a period of clinical stability of at least 30 days, with no other explanation than MS.	6 monthly - baseline, month 6, 12, 18, 24, 30, 36
Change in visual function based on the Sloan Low Contrast Visual Acuity (SLCVA)	Sloan chart testing is a reliable, quantitative, and clinically practical measure of visual function that will be administered by trained assessors. The chart consists of rows of grey letters on a white background. Letters are displayed in decreasing order from the top of the chart to the bottom. Testing will be conducted at three different contrast levels (100%, 2.5% and 1.25%). The chart will be scored based on the number of letters correctly identified out of 60.	Annually - baseline, month 12, 24 and 36
Difference in patient reported quality of life based on the EuroQoL Health Related Quality of Life - 5 Dimensions - 5 Levels (EQ-5D 5L) scores	EQ-5D 5L is a 5 item questionnaire (assessing - mobility, self-care, usual activities, pain/discomfort, anxiety/depression) and visual analogue scale (VAS) enables calculation of quality adjusted life years (QALY) to enable health economic analyses to be performed. Each dimension assessed has 5 response scales to select from: no problems, slight problems, moderate problems, severe problems, and extreme problems	6 monthly - baseline, month 6, 12, 18, 24, 30, 36
Change in a modified Multiple Sclerosis Functional Composite scores	A Modified Multiple Sclerosis Functional Composite (MSFC) score comprised of 3 components (T25FW, 9HPT, SDMT). The Symbol digit modalities test (SDMT) will replace the Paced Auditory Serial Addition Test (PASAT), one of the three components in the Standard MSFC.	Annually - baseline, month 12, 24 and 36
Change in cognitive performance as measured by Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS)	BICAMS is a composite cognitive assessment tool comprising of the three components : Symbol Digit Modalities Test (SDMT) , California Verbal Learning Test-II (CVLT-II) and Brief visuospatial memory test- Revised (BVMT-R)	Baseline and month 36
Change in cognitive impairment based on Symbol Digit Modalities Test (SDMT) scores	SDMT is a brief measure of cognitive processing speed. It measures information processing speed for visually presented stimuli, but is self-paced, with at least equal reliability and sensitivity to the presence of worsening cognitive impairment.	Annually - baseline, month 12, 24 and 36
Evaluating the time to disability progression based on a secondary composite progression outcome measure	A secondary composite progression outcome measure defined as one or more of: ≥20% increase in time taken to complete the 25 Foot Walk (T25FW); or ≥20% increase in time to complete 9 Hole Peg Test (9HPT); or increase in EDSS (0.5 point increase if baseline ≥6 /1.0 point increase if baseline <6). The initial disability progression event will be finalised as positive if it is sustained and confirmed ≥6 months later*. The time to event analysis will be from randomisation until date of the initial disability progression (if subsequently confirmed)	6 monthly - baseline, month 6, 12, 18, 24, 30, 36
Change in fatigue as measured by the Chalder Fatigue Scale	A questionnaire measuring the severity of physical and mental fatigue. The total score range is minimum of 0 and maximum of 33. For the subscales, physical fatigue score has a minimum of 0 and maximum of 21. The Mental fatigue score has a minimum of 0 and maximum of 12.	Annually - baseline, month 12, 24 and 36
Change in rates of service utilisation as measured by the Client Service Receipt Inventory (CSRI) questionnaire	The CSRI is a questionnaire that collects information on service utilisation, income, accommodation and other cost-related variables. Its primary purpose is to allow resource use patterns in each of the two arms to be described, and support costs to be estimated for health economics purposes.	6 monthly - baseline, month 6, 12, 18, 24, 30, 36

Collaborators and Investigators

• Sponsor: University College, London
• Collaborators: London School of Hygiene and Tropical Medicine; The Leeds Teaching Hospitals NHS Trust; University of Leeds; Queen Mary University of London; University of Edinburgh; Imperial College Healthcare NHS Trust
• Investigators: Principal Investigator: Jeremy Chataway, University College, London

Publications and helpful links

General Publications

• 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.
• Williams TE, Holdsworth KP, Nicholas JM, Eshaghi A, Katsanouli T, Wellington H, Heslegrave A, Zetterberg H, Frost C, Chataway J. Assessing Neurofilaments as Biomarkers of Neuroprotection in Progressive Multiple Sclerosis: From the MS-STAT Randomized Controlled Trial. Neurol Neuroimmunol Neuroinflamm. 2022 Jan 14;9(2):e1130. doi: 10.1212/NXI.0000000000001130. Print 2022 Mar.
• Williams T, Tur C, Eshaghi A, Doshi A, Chan D, Binks S, Wellington H, Heslegrave A, Zetterberg H, Chataway J. Serum neurofilament light and MRI predictors of cognitive decline in patients with secondary progressive multiple sclerosis: Analysis from the MS-STAT randomised controlled trial. Mult Scler. 2022 Oct;28(12):1913-1926. doi: 10.1177/13524585221114441. Epub 2022 Aug 9.

Study record dates

Study Major Dates

• Study Start (Actual): March 28, 2018
• Primary Completion (Anticipated): August 31, 2024
• Study Completion (Anticipated): August 31, 2024

Study Registration Dates

• First Submitted: November 28, 2017
• First Submitted That Met QC Criteria: December 21, 2017
• First Posted (Actual): January 2, 2018

Study Record Updates

• Last Update Posted (Actual): July 7, 2022
• Last Update Submitted That Met QC Criteria: July 4, 2022
• Last Verified: July 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Nervous System Diseases; Immune System Diseases; Neoplasms; Demyelinating Autoimmune Diseases, CNS; Autoimmune Diseases of the Nervous System; Demyelinating Diseases; Autoimmune Diseases; Neoplastic Processes; Multiple Sclerosis; Multiple Sclerosis, Chronic Progressive; Sclerosis; Neoplasm Metastasis; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antimetabolites; Anticholesteremic Agents; Hypolipidemic Agents; Lipid Regulating Agents; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Simvastatin
• Other Study ID Numbers: 17/0158; 2017-003328-56 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No