ChariotMS - Cladribine to Halt Deterioration in People With Advanced Multiple Sclerosis (ChariotMS)

ChariotMS - A National (UK) Phase IIb, Multi-centre, Randomised, Double-blind, Placebo Controlled (1:1) Efficacy Trial With Cost-utility Analysis of Cladribine Tablets (3.5mg/kg Over Two Years) in People With Advanced Multiple Sclerosis. Is Cladribine Superior to Placebo in Protecting Upper Limb Function?

MS is a chronic inflammatory and degenerative disease of the central nervous system (CNS) affecting more than 120,000 people in the UK.and 2.5 million people worldwide.

Without disease modifying treatment (DMT),the majority of people with MS (pwMS) will develop significant disability within 10 years of onset, and 50% will require wheelchair assistance within 20 years. convenient, highly effective and CNS penetrant DMT for patients with relapsing multiple sclerosis (pwRMS) administered in short (8-10 days/year over 2 years) treatment courses.

It effectively depletes B cells, particularly Memory B cells, a likely key mechanism of disease control in MS. Cladribine is the investigational product in this study as it not currently used to treat patients with an EDSS of 6.5 - 8.5. This is a multi-centre, randomised double-blind placebo-controlled phase IIb to test cladribine tablets (MAVENCLAD®) (3.5mg/kg over 24 months) for safety, efficacy, and cost effectiveness, and to advance mechanistic understanding of its action in people with advanced MS (pwAMS).

Study Overview

• Status: Recruiting
• Conditions: Progressive Multiple Sclerosis; Advanced Multiple Sclerosis
• Intervention / Treatment: Drug: Cladribine (MAVENCLAD®); Drug: Placebo

• Study Type: Interventional
• Enrollment (Estimated): 200
• Phase: Phase 2; Phase 3

Contacts and Locations

• Study Contact: Name: Klaus Schmierer, PhD, FRCP; Phone Number: +44 (0)20 7882 6246; Email: k.schmierer@qmul.ac.uk
• Study Contact Backup: Name: Svetlana Milca, MSc; Phone Number: +44 (0)7907252008; Email: chariot@qmul.ac.uk

Study Locations

• United Kingdom
  • Belfast, United Kingdom, BT12 6BA
    • Recruiting
    • Queens University Belfast (Belfast Health and Social Care Trust)
    • Principal Investigator: Stella Hughs
  • Birmingham, United Kingdom, B15 2TH
    • Recruiting
    • University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham
    • Principal Investigator: Niraj Mistry
    • Sub-Investigator: Tom Hayton
    • Sub-Investigator: Gordon Mazibrada
  • Cardiff, United Kingdom, CF14 4XW
    • Recruiting
    • Cardiff University Hospital
    • Principal Investigator: Emma Tallantyre
    • Sub-Investigator: Karim Kreft
    • Sub-Investigator: Magdalene Randa
  • Coventry, United Kingdom, CV2 2DX
    • Not yet recruiting
    • University Hospitals of Coventry and Warwickshire NHS Trust
    • Principal Investigator: Tarunya Arun
  • Edinburgh, United Kingdom, EH16 4SB
    • Recruiting
    • Anne Rowling Clinic, University of Edinburgh
    • Principal Investigator: Don Mahad
  • Glasgow, United Kingdom, G51 4TF
    • Recruiting
    • Queen Elizabeth University Hospital Glasgow
    • Principal Investigator: Colin O'Leary
  • Glasgow, United Kingdom, G75 8RG
    • Recruiting
    • University Hospital Hairmyres, NHS Lanarkshire
    • Principal Investigator: Niall MacDougall
  • Leeds, United Kingdom, LS1 3EX
    • Recruiting
    • Leeds Teaching Hospitals NHS Trust
    • Principal Investigator: Helen Ford
  • Liverpool, United Kingdom, L9 7LJ
    • Recruiting
    • Walton Centre NHS Trust
    • Principal Investigator: Carolyn Young
  • London, United Kingdom, NW3 2QG
    • Recruiting
    • Royal Free London NHS Foundation Trust
    • Principal Investigator: Gerard Davies
  • London, United Kingdom, E1 1FR
    • Recruiting
    • Royal London Hospital
    • Principal Investigator: Klaus Schmierer, PhD, FRCP
    • Sub-Investigator: Bader Mohamed
  • London, United Kingdom, SE13 6LH
    • Recruiting
    • Lewisham and Greenwich NHS Trust
    • Principal Investigator: Eli Silber
  • London, United Kingdom, RM7 0AG
    • Recruiting
    • Queen's Hospital (Havering and Redbridge University Hospitals NHS Trust)
    • Principal Investigator: Miriam Mattoscio
    • Sub-Investigator: Laura Azzopardi
    • Sub-Investigator: Chulika Makawita
  • London, United Kingdom, SW17 0RE
    • Recruiting
    • St George's University Hospitals NHS Foundation Trust
    • Principal Investigator: Liquin Zhang
    • Sub-Investigator: Dr Bhavini Patel
  • Luton, United Kingdom, LU4 0DZ
    • Recruiting
    • Luton and Dunstable Hospital
    • Principal Investigator: Floriana DeAngelis
  • Manchester, United Kingdom, M6 8HD
    • Recruiting
    • Salford Royal Hospital NHS Trust
    • Principal Investigator: David Rog
  • Newport, United Kingdom, NP20 2UB
    • Recruiting
    • Aneurin Bevan University Health Board
    • Principal Investigator: Katharine Harding
    • Sub-Investigator: Alistair Church
  • Nottingham, United Kingdom, NG7 2UH
    • Recruiting
    • Nottingham University Hospital (Nottingham University Hospitals NHS Trust)
    • Principal Investigator: Nikos Evangelou
    • Sub-Investigator: Pritesh Pranay
  • Plymouth, United Kingdom, PL6 8DH
    • Recruiting
    • University Hospitals Plymouth NHS Trust
    • Principal Investigator: Jeremy Hobart
  • Sheffield, United Kingdom, S10 2JF
    • Recruiting
    • Sheffield Teaching Hospitals NHS Foundation Trust
    • Principal Investigator: Basil Sharrack
  • Stoke-on-Trent, United Kingdom, ST4 6QG
    • Not yet recruiting
    • University Hospitals of North Midlands NHS Trust
    • Principal Investigator: Seema Kalra
  • Swansea, United Kingdom, SA6 6NL
    • Recruiting
    • Morriston Hospital, Swansea
    • Principal Investigator: Owen Pearson

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion criteria:

1. pwAMS aged 18+ years with an EDSS of 6.5-8.5 (inclusive)
2. History of bowel cancer screening for men, and women and cervical and breast cancer screening for women as per NHS recommended guidelines https://www.nhs.uk/conditions/nhs-screening/.
3. Ability to complete the 9HPT with at least one upper limb within 180 seconds. The average score of both attempts for each hand should be used to assess eligibility.
4. Confirmation of MS diagnosis according to the McDonald Criteria (2017) Thompson et al. 2018).
5. In the judgement of the investigator, evidence of deterioration of upper limb function during the 2 years running up to the screening date.

Exclusion Criteria

1. Participants with known hypersensitivity to Cladribine of any grade (as per CTCAE grading system) should be excluded
2. Any uncontrolled diabetes, arterial hypertension and hypercholesterolaemia as determined by PI or delegated sub-investigator
3. A history of stroke, deep vein or sinus venous thrombosis (including pulmonary embolus) and/or myocardial infarction
4. Moderate to severe renal impairment (creatinine clearance <60 ml/min)
5. Moderate to severe hepatic impairment (Child-Pugh score >6)
6. Significant comorbidity, e.g. cardiac failure, renal failure, malignancy, or other health condition that in the view of the PI or delegated sub-investigator precludes participation. Patients who, following discussion with their cancer treatment team, are deemed to be cured from malignancy, may be eligible to participate as per the clinical judgement of the local PI.
7. Pregnancy including planning to father a child or breastfeeding
8. Body weight less <40kg
9. Unwillingness to use effective contraception throughout the trial period until at least six months after the last administration of IMP. This is not applicable for post-menopausal women
10. Acute infection (uncontrolled)
11. Infection with Human Immunodeficiency Virus 1 and/or 2
12. Active chronic infection (Syphilis, Tuberculosis, Hepatitis). Patients with active TB will be excluded. However, patients who have a positive IGRA, Elispot or Quantiferon test, but exhibit no symptoms for TB and evidence of a normal Chest X Ray, can be included in the study as per judgement of the local PI and after clarification with the CI.
13. Precancerous condition
14. Total lymphocyte count <1.0*109/L

15. Seronegativity for varicella zoster virus. Potential participants who are IgG negative may undergo vaccination, and can be screened again once full course has been completed.

    Seronegativity for all of the following: measles, mumps, rubella. Potential participants who are IgG negative for all 3 viruses, may undergo vaccination and can be screened again once full course has been completed.

16. Relapse within six months before screening
17. Inability to complete an MRI (contraindications for MRI, including but not limited to, MRI-non-compatible pacemaker, cochlear implants, intracranial vascular clips, surgery within 6 weeks of entry in the study, coronary stent implanted within 8 weeks prior to the time of the intended MRI, severe anxiety or claustrophobia etc.) or contraindication to Gd administration.
18. Treatment with steroids due to MS relapse/progression within three months of screening. pwAMS who fall in this category may undergo a further screening visit once the three months' window has expired and may be included if no steroid treatment has been administered in the intervening period.
19. Treatment with any interferon-beta, glatiramer acetate, teriflunomide or dimethyl-fumarate within three months before screening.
20. Treatment with natalizumab, fingolimod, siponimod, ponesimod, ozanimod (or other Sphingosine-1-phosphate receptor modulators) within three months of screening.
21. Treatment with azathioprine, methotrexate, or cyclosporine within six months before screening.
22. pwAMS treated with teriflunomide will need to undergo accelerated elimination of the compound before being considered (Research and Case Medical Research 2019).
23. Treatment with haematopoietic stem cell transplantation (HSCT), mitoxantrone, cyclophosphamide, cladribine, alemtuzumab or another B cell depleting compound, such as rituximab, ocrelizumab, ublitiuximab, ofatumumab, or biosimilars, unless the participant concerned has a memory B cell level of ≥20% of the CD19+ population in the peripheral blood. Such a level would normally not be expected earlier than a minimum of six months after the last drug administration. Participants who underwent such treatment will therefore have to be tested for their CD19+/CD27+ memory B cell level at screening.
24. Treatment with fampridine: If they are already on treatment for at least six months, participants should continue throughout the trial. However, starting continuous fampridine treatment after signing the consent sheet will lead to exclusion from treatment with IMP/placebo.
25. Concurrent participation or previous participation within the last 6 months in another clinical trial of an IMP or medical device.
26. Unable to swallow tablets

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; Placebo administered as weight adjusted tablets in two treatment courses (12 months apart) lasting 8-10 days each. Placebo 10mg available in blister packs of 1 tablet, 4 tablets and 6 tablets.
Active Comparator: Cladribine (MAVENCLAD®)	Drug: Cladribine (MAVENCLAD®); Cladribine (MAVENCLAD®) 3.5mg/kg, administered as weight-adjusted 10mg tablets in two treatment courses (12 months apart) lasting 8- 10 days each. Cladribine (MAVENCLAD®) 10mg available in blister packs of 1 tablet, 4 tablets and 6 tablets.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The 9-HPT peg speed (tasks/second) at 24 months	To establish whether there is efficacy superiority of cladribine tablets over placebo in reducing deterioration of upper limb function in pwAMS. To investigate whether cladribine tablets 3.5mg/kg over 24 months is an effective DMT in pwAMS as measured using the 9-hole peg test (9HPT) peg speed at 24 months.	24 months
9-HPT proportion of patients who do not deteriorate at 24 months		24 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change over 24 months of the study in clinical outcome measure: EDSS	The proportion of the cladribine versus placebo arms with an increase of >=0.5 in EDSS score over 24 months.	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: ARAT	ARAT (Upper Limb Function Test) upper limb function test score	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: ABILHAND	ABILHAND score for manual ability	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: T25ftWT	Lower Limb Function: The T25ftWT (Timed 25 foot walk test) will be collected in all pwAMS able to walk the required distance twice.	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: SLCVA	SLCVA (Sloan low contrast letter visual acuity) score.	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: MSIS-29v2	MSIS-29v2 (Multiple Sclerosis Impact Scale) quality of life score	Screening, , Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: SDMT	SDMT (The Symbol Digit Modalities Test) score.	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: NFI-MS	NFI-MS (Neurological Fatigue Index-Multiple Sclerosis) score.	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: EuroQoL EQ-5D-5L	Cost-utility: Patient's generic health-related quality of life, measured using the EuroQoL EQ-5D-5L and, separately, carer's generic health-related quality of life, measured using the EuroQoL EQ-5D-5L, health and social care and other costs.	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: EuroQoL EQ-5D-5L	Cost-utility: Carer's generic health-related quality of life, measured using the EuroQoL EQ-5D-5L	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: EuroQoL EQ-5D-5L	Cost-utility: health and social care and other costs.	Screening, Month 6, 12, 18 and 24
Change over 24 months of the study in clinical outcome measure: WPAI-GH	WPAI-GH (Work Productivity and Activity Impairment Questionnaire: General Health V2.0 (WPAI:GH) score	Baseline, Month 6, 12, 18 and 24
Safety/occurrence of adverse events	Safety: Any AEs/SAEs,; Lymphopenia (peripheral blood lymphocyte counts),; Severe infections,; Malignancies.; Pregnancies; Special situations (e.g. overdose)	Through study completion, an average of 24 months
Preventing loss of brain volume	(MRI) Change over 24 months of the study in ventricular volume assessed using the VIENA technique.	Screening, Month 6 and 24
Preventing loss of brain volume	(MRI) Change over 24 months in brain volume assessed using the "Structural Image Evaluation, using Normalisation, of Atrophy" (SIENA) technique	Screening, Month 6 and 24
Preventing loss of spinal cord cross sectional area	(MRI) Change in the total cross-sectional area of spinal cord (at level C2) over 24 months	Screening, Month 6 and 24
Preventing new focal demyelinating lesions and T2 burden of disease increase.	(MRI) Total number of new focal demyelinating brain lesions over 24 months	Screening, Month 6 and 24
Preventing new hypo-intense lesions ("black holes") on T1 weighted MRI	(MRI) Total number of new hypo-intense T1 lesions over 24 months	Screening, Month 6 and 24
Degree of unblinding	To determine the perception of treatment allocation for both participants and trial teams at 24 months.	Month 24

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
To determine if cladribine correlates with memory Bcell count.	Memory B-Cell (total number and percentage of CD19+ cell count) and its association with upper limb function as measured using 9HPT speed.	Screening, Month 12 and 24
To determine association between Memory B cell count and 9HPT speed.	9HPT speed	Screening, Month 6, 12, 18 and 24
To determine association between Memory B cell count and 9HPT speed.	ARAT score	Screening, Month 6, 12, 18 and 24
To determine association between Memory B cell count, upper limb function and s-NfL level.	Serum-NfL at 6 and 24 months compared to baseline.	Screening, Month 12 and 24
To determine effects of IMP on cortical and deep grey matter volumes, thalamic, hippocampal and ventricular volumes (VIENA) and slowly expanding (i.e. chronically active) lesions.	(MRI) Change over 24 months of the study in cortical brain volume	Screening, Month 6 and 24
To determine effects of IMP on cortical and deep grey matter volumes, thalamic, hippocampal and ventricular volumes (VIENA) and slowly expanding (i.e. chronically active) lesions.	(MRI) Change over 24 months of the study in thalamic brain volume	Screening, Month 6 and 24
To determine effects of IMP on cortical and deep grey matter volumes, thalamic, hippocampal and ventricular volumes (VIENA) and slowly expanding (i.e. chronically active) lesions.	(MRI) Change over 24 months of the study in hippocampal brain volume	Screening, Month 6 and 24
To determine effects of IMP on cortical and deep grey matter volumes, thalamic, hippocampal and ventricular volumes (VIENA) and slowly expanding (i.e. chronically active) lesions.	(MRI) Change over 24 months of the study in new slowly expanding/evolving lesions (SELs)	Screening, Month 6 and 24

Collaborators and Investigators

• Sponsor: Queen Mary University of London
• Collaborators: Barts & The London NHS Trust; National Institute for Health Research, United Kingdom; National Multiple Sclerosis Society; Merck Serono Limited, UK; Multiple Sclerosis Society of Great Britain & Northern Ireland

Study record dates

Study Major Dates

• Study Start (Actual): June 25, 2021
• Primary Completion (Estimated): October 31, 2024
• Study Completion (Estimated): December 31, 2027

Study Registration Dates

• First Submitted: November 6, 2020
• First Submitted That Met QC Criteria: January 4, 2021
• First Posted (Actual): January 5, 2021

Study Record Updates

• Last Update Posted (Actual): July 11, 2023
• Last Update Submitted That Met QC Criteria: July 10, 2023
• Last Verified: April 1, 2023

More Information

Terms related to this study

• Keywords: Multiple Sclerosis; Quality of life; Upper limb function; Cognition; Biomarkers; Neurofilament light chain; Lymphocytes; Magnetic Resonance Imaging (MRI); Cladribine; B cells; Progressive multiple sclerosis; Health Economics; Advanced multiple sclerosis
• 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; Disease Attributes; Chronic Disease; Multiple Sclerosis; Multiple Sclerosis, Chronic Progressive; Sclerosis; Physiological Effects of Drugs; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Cladribine
• Other Study ID Numbers: 258909; 2018-005038-39 (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
• product manufactured in and exported from the U.S.: No