- ICH GCP
- US Clinical Trials Registry
- Klinisk utprøving NCT03500328
Tradisjonell versus tidlig aggressiv terapi for multippel sklerose (TREAT-MS)
En pragmatisk utprøving for å evaluere mellomtidseffektene av tidlig, aggressiv versus eskaleringsterapi hos personer med multippel sklerose
FDA-approved multiple sclerosis (MS) disease-modifying therapies (DMTs) target the relapsing phase of MS but have minimal impact once the progressive phase has begun. It is unclear if, in the relapsing phase, there is an advantage of early aggressive therapy with respect to preventing long-term disability. The infectious risks and other complications associated with higher-efficacy treatments highlight the need to quantify their effectiveness in preventing disability.
The TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial is a pragmatic, randomized controlled trial that has two primary aims: 1) to evaluate, jointly and independently among patients deemed at higher risk vs. lower risk for disability accumulation, whether an "early aggressive" therapy approach, versus starting with a traditional, first-line therapy, influences the intermediate-term risk of disability, and 2) to evaluate if, among patients deemed at lower risk for disability who start on first-line MS therapies but experience breakthrough disease, those who switch to a higher-efficacy versus a new first-line therapy have different intermediate-term risk of disability.
Studieoversikt
Status
Intervensjon / Behandling
- Annen: Natalizumab/natalizumab-sztn, Alemtuzumab, Ocrelizumab, Rituximab/rituximab-arrx/rituximab-abbs/rituximab-pvvr, Cladribine, Ofatumumab, Ublituximab-xiiy, Ocrelizumab and hyaluronidase-ocsq
- Annen: Glatiramer acetate, Interferons (intramuscular, subcutaneous, pegylated) Teriflunomide, Fumarates (dimethyl, diroximel, monomethyl) Fingolimod, Siponimod, Ozanimod, Ponesimod
Detaljert beskrivelse
FDA-approved multiple sclerosis (MS) disease-modifying therapies (DMTs) target the relapsing phase of MS but have minimal impact once the progressive phase has begun. It is unclear if, in the relapsing phase, there is an advantage of early aggressive therapy with respect to preventing long-term disability. The infectious risks and other complications associated with higher-efficacy treatments highlight the need to quantify their effectiveness in preventing disability.
The TRaditional versus Early Aggressive Therapy for MS (TREAT-MS) trial is a pragmatic, randomized controlled trial that has two primary aims: 1) to evaluate, jointly and independently among patients deemed at higher risk vs. lower risk for disability accumulation, whether an "early aggressive" therapy approach, versus starting with a traditional, first-line therapy, influences the intermediate-term risk of disability, and 2) to evaluate if, among patients deemed at lower risk for disability who start on first-line MS therapies but experience breakthrough disease, those who switch to a higher-efficacy versus a new first-line therapy have different intermediate-term risk of disability.
Hypotheses/Objectives: The main hypothesis is that intermediate-term disability will be reduced by earlier use of higher-efficacy medications. Additional objectives include a) evaluating the magnitude of the treatment effect in patients deemed to be at higher risk versus lower risk of longer-term disability (we hypothesize that the effect size will be greater in the former group) and b) evaluating if, among those without indications of a high risk of longer-term disability, breakthrough disease can be successfully managed by switching to a different first-line therapy or if escalation is required at that time (we hypothesize that switching to a higher-efficacy therapy will be more effective in preventing disability in this group).
There is a great unmet need to identify the most appropriate treatment strategy for people with MS, especially early in the disease course when it may be possible to maximize an individual's chance for preventing long-term disability. There is a paucity of evidence-based guidelines to help clinicians, patients, and payers determine which treatment strategy is best for an individual with MS. Making treatment decisions is a daunting task, and the individualized benefit-risk assessment becomes increasingly difficult as new therapies emerge. Without the availability of direct comparative trials, clinicians and patients are forced to scrutinize observational studies that only provide basic insights into what may be the best treatment path moving forward. It is equally challenging to define what constitutes a suboptimal response to a DMT for an individual patient. Clinicians lack guidance on when to switch therapies and whether to consider a different first-line or if clinicians should escalate immediately to higher-efficacy therapies, so further consensus is needed to determine the optimal time to switch therapies and escalate therapy if an individual is on a first-line therapy from the start. The TREAT-MS trial will help inform patients and the broader health care community on whether patients would most benefit from early, possibly more risky aggressive therapy or if starting with a less aggressive (and, often, less risky) therapy, followed by a switch if breakthrough disease occurs, is warranted. In addition, this study may help identify specific patient populations and/or short-term clinical and paraclinical biomarkers that are strongly predictive of long-term disability that can ensue from MS.
Accrual of sustained disability is the most feared complication for people with MS, and the patient's own perception of their well-being or ill-being has a profound impact on their quality of life. The heterogeneity and unpredictability of MS, along with lack of agreed upon treatment guidelines, augments this fear, leading to a significant negative impact on quality of life. Even patients who are deemed to have "mild" MS experience a significant negative impact on their health-related quality of life that is similar in magnitude to what patients with other severe chronic conditions (i.e., congestive heart failure and chronic obstructive pulmonary disease) report. An extremely important goal for any intervention is to help improve or maintain a high quality of life; therefore, in addition to classic clinical endpoints (e.g. slowing disability progression), the TREAT-MS trial will capture several important and meaningful PROs that will shed light on what treatment strategies may be the best from a patient-centered perspective.
COVID-19 Related Substudy:
Since early 2020, the coronavirus disease 2019 (COVID-19) pandemic has caused clinical care and research disruptions nationwide, including for patients enrolled in the TREAT-MS trial. Many patients with MS, as well as their clinicians, are fearful that MS or the MS therapy they are using may increase the risk or severity of COVID-19 infection. Whether a person with early MS is more likely to experience more severe COVID-19 if treated with a higher-efficacy therapy is not known. Further, whether COVID-19-induced disruptions in therapy or other clinical care increase MS disease activity or MS symptoms is not clear but is relevant, particularly since greater MS activity in the early therapeutic course is associated in observational studies with worse long-term outcomes. Moreover, it is unclear if pre-pandemic anxiety and depression, common comorbidities in people with MS, contribute to decisions to delay care, overall or differently depending on therapeutic strategy (higher-efficacy vs. traditional). TREAT-MS provides an optimal cohort in which to investigate the effect of the COVID-19 pandemic on MS outcomes.
COVID-19 Substudy Aim 1. To evaluate if patients enrolled in TREAT-MS delayed or altered their disease-modifying therapy schedule or other MS care, and whether such alterations are associated with a greater degree of breakthrough inflammatory disease activity or the development of new (or worsening baseline) MS symptoms.
COVID-19 Substudy Aim 2: To evaluate if patients with MS treated with higher-efficacy, versus traditional, therapies differ in the risk of severe COVID-19 infection, defined as requiring hospitalization (with or without intubation) or mortality due to COVID-19.
Studietype
Registrering (Faktiske)
Fase
- Ikke aktuelt
Kontakter og plasseringer
Studiesteder
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Alabama
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Birmingham, Alabama, Forente stater, 35233
- University of Alabama at Birmingham
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Mobile, Alabama, Forente stater, 36604
- The University of South Alabama
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Arizona
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Phoenix, Arizona, Forente stater, 85013
- St. Joseph's Hospital & Medical Center - Barrow Neurological Institute
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California
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Carmichael, California, Forente stater, 95608
- CommonSpirit Health Research Institute
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Los Angeles, California, Forente stater, 90095
- University of California, Los Angeles
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Los Angeles, California, Forente stater, 90048
- Cedars-Sinai Medical Center
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San Diego, California, Forente stater, 92037
- University of California, San Diego
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San Francisco, California, Forente stater, 94158
- University of California, San Francisco
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Delaware
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Newark, Delaware, Forente stater, 19713
- Christiana Care Health Services, Inc.
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District of Columbia
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Washington D.C., District of Columbia, Forente stater, 20007
- Georgetown University
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Florida
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Gainesville, Florida, Forente stater, 32611
- University of Florida
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Miami, Florida, Forente stater, 33136
- University of Miami
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Tampa, Florida, Forente stater, 33612
- University of South Florida Health
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Illinois
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Chicago, Illinois, Forente stater, 60612
- Rush University Medical Center
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Kansas
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Kansas City, Kansas, Forente stater, 66160
- The University of Kansas Medical Center (KUMC)
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Kentucky
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Louisville, Kentucky, Forente stater, 40207
- Norton Neurology MS Services
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Maryland
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Baltimore, Maryland, Forente stater, 21287
- The Johns Hopkins Hospital
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Baltimore, Maryland, Forente stater, 21201
- University of Maryland, Baltimore
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Massachusetts
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Boston, Massachusetts, Forente stater, 02114
- Massachusetts General Hospital
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Worcester, Massachusetts, Forente stater, 01655
- University of Massachusetts Medical School
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Michigan
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Ann Arbor, Michigan, Forente stater, 48109
- University of Michigan
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Detroit, Michigan, Forente stater, 48201
- Wayne State University
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Minnesota
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Rochester, Minnesota, Forente stater, 55905
- Mayo Clinic
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Montana
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Billings, Montana, Forente stater, 59101
- Billings Clinic
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Great Falls, Montana, Forente stater, 59405
- Advanced Neurology Specialists
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Nebraska
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Omaha, Nebraska, Forente stater, 68198
- University of Nebraska Medical Center
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New Jersey
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Hackensack, New Jersey, Forente stater, 07601
- Hackensack University Medical Center
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New York
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New York, New York, Forente stater, 10032
- Columbia University Medical Center
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New York, New York, Forente stater, 10016
- New York University School of Medicine
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New York, New York, Forente stater, 10029
- Icahn School of Medicine at Mount Sinai
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Ohio
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Cincinnati, Ohio, Forente stater, 45219
- University of Cincinnati
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Columbus, Ohio, Forente stater, 43214
- OhioHealth Research Institute
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Oklahoma
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Oklahoma City, Oklahoma, Forente stater, 73104
- Oklahoma Medical Research Foundation
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Oregon
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Portland, Oregon, Forente stater, 97225
- Providence Health and Services - Oregon
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Pennsylvania
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Danville, Pennsylvania, Forente stater, 17822
- Geisinger Clinic
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Pittsburgh, Pennsylvania, Forente stater, 15212
- Allegheny Health Network Research Institute
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Tennessee
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Nashville, Tennessee, Forente stater, 37215
- Vanderbilt Comprehensive MS Center
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Texas
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Dallas, Texas, Forente stater, 75246
- Baylor Scott and White Health
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Dallas, Texas, Forente stater, 75390-8806
- University of Texas Southwestern Medical Center
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Round Rock, Texas, Forente stater, 78681
- Central Texas Neurology Consultants
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Utah
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Salt Lake City, Utah, Forente stater, 84108
- University of Utah
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Vermont
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Burlington, Vermont, Forente stater, 05405
- The University of Vermont and State Agricultural College
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Virginia
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Christiansburg, Virginia, Forente stater, 24073
- Blacksburg Neurology
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Norfolk, Virginia, Forente stater, 23502
- Neurology Consultants of Tidewater
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Washington
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Seattle, Washington, Forente stater, 98122
- Swedish Health Services
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Seattle, Washington, Forente stater, 98133
- University of Washington
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Wisconsin
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Milwaukee, Wisconsin, Forente stater, 53226
- Medical College of Wisconsin
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Deltakelseskriterier
Kvalifikasjonskriterier
Alder som er kvalifisert for studier
Tar imot friske frivillige
Kjønn som er kvalifisert for studier
Beskrivelse
Inclusion Criteria:
- Aged 18-60 years
- Meets 2017 McDonald criteria for relapsing-remitting MS [patients with clinically isolated syndrome (CIS) are not eligible]
- Must be EITHER John Cunningham (JC) virus antibody negative or low positive (index antibody titer <0.9), OR negative for: Hepatitis B and C, tuberculosis
- HIV negative
- No chemotherapy in past year; if patient has prior history of chemotherapy or malignancy, documentation in chart explaining why potential risks of higher-efficacy therapy are justified
Exclusion Criteria:
- Prior treatment with rituximab, ocrelizumab, ofatumumab, alemtuzumab, mitoxantrone or cladribine
- Prior treatment with any other MS DMT for more than 6 months
- Prior treatment with experimental aggressive therapies (e.g., T-cell vaccine, total lymphoid radiation, stem cells)
- Treatment with teriflunomide within past 2 years (even for ≤ 6 months), unless rapid wash out done (i.e., with cholestyramine or activated charcoal)
- Treatment in the past 6 months with any MS DMT
- Prior treatment with any other investigational immune-modulating /suppressing drug for MS not listed above
- Pregnant or breast-feeding
- Women of child-bearing age who are planning or strongly considering conception during the study time frame
Studieplan
Hvordan er studiet utformet?
Designdetaljer
- Primært formål: Behandling
- Tildeling: Randomisert
- Intervensjonsmodell: Parallell tildeling
- Masking: Enkelt
Våpen og intervensjoner
Deltakergruppe / Arm |
Intervensjon / Behandling |
|---|---|
|
Aktiv komparator: Early Aggressive Therapy
Early Aggressive Therapy choices and maximum allowable doses:
|
Early Aggressive Therapy
Andre navn:
|
|
Aktiv komparator: Traditional Therapy
Traditional Therapy choices and maximum allowable doses:
|
Traditional Therapy
Andre navn:
|
Hva måler studien?
Primære resultatmål
Resultatmål |
Tiltaksbeskrivelse |
Tidsramme |
|---|---|---|
|
Time to sustained disability progression
Tidsramme: From date of randomization until the date of first documented sustained disability progression, up to 99 months
|
Time to sustained disability progression is measured by the Expanded Disability Status Scale plus (EDSS+): a composite endpoint that includes EDSS change (change at any 6 month time point of > or = 1.0 point if baseline EDSS is < or = 5.5 or of > or = 0.5 if baseline EDSS is > or = 6.0, that is sustained 6 months later) OR 20% worsening on either of two specific components of the Multiple Sclerosis Functional Composite (MSFC), the timed 25-foot walk test (T25FWT) and the nine hole peg test (9HPT) that is sustained 6 months later. |
From date of randomization until the date of first documented sustained disability progression, up to 99 months
|
|
Change in Overall Burden of MS
Tidsramme: up to 48 weeks from enrollment into COVID-19 related substudy
|
The change in overall burden of MS will be defined for the COVID-19 related substudy as the occurrence of breakthrough disease (relapses or new MRI activity) or the development of new (or worsening baseline) MS symptoms, which are (for TREAT-MS) and will continue to be (during the substudy) documented at clinical visits, whether in-person or on tele-visits. |
up to 48 weeks from enrollment into COVID-19 related substudy
|
Sekundære resultatmål
Resultatmål |
Tiltaksbeskrivelse |
Tidsramme |
|---|---|---|
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Patient-Determined Disease Steps (PDDS)
Tidsramme: up to 99 months
|
PDDS is a self-assessment scale of disability due to MS on a scale from 0 to 8 and will be administered as an electronic patient-reported outcome (PRO). |
up to 99 months
|
|
Multiple Sclerosis Functional Composite (MSFC) Composite Score
Tidsramme: up to 99 months
|
The MSFC consists of the timed 25 foot walk test, the 9-hole peg test, and the Paced Auditory Serial Addition Test (PASAT) and a composite MSFC z-score will be evaluated. |
up to 99 months
|
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Timed 25 Foot Walk Test
Tidsramme: up to 99 months
|
Time taken to complete the timed 25 foot walk test, measured twice in units of seconds, will be averaged and evaluated. |
up to 99 months
|
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Nine-hole Peg Test
Tidsramme: up to 99 months
|
Time taken to complete the nine-hole peg test, measured twice for each hand (dominant and non-dominant) in units of seconds, will be averaged for each hand and evaluated. |
up to 99 months
|
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Paced Auditory Serial Addition Test (PASAT)
Tidsramme: up to 99 months
|
The paced auditory serial addition test that measures processing speed will be administered once; number and percent correct will be evaluated. |
up to 99 months
|
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Low contrast visual acuity
Tidsramme: up to 99 months
|
Low-contrast letter acuity (binocular, 2.5% contrast Sloan charts) |
up to 99 months
|
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Patient-reported incomplete relapse recovery
Tidsramme: up to 99 months
|
Among participants identified to have a relapse, relapse recovery will be defined as complete or incomplete based on patient self-report. |
up to 99 months
|
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Neurologic exam-based incomplete relapse recovery
Tidsramme: up to 99 months
|
Among participants identified to have a relapse, relapse recovery will be defined as complete or incomplete based on neurologic examination (those who have increased Functional System scores, corresponding to the relapse symptoms, of 1.0 point or greater for at least 6 months after the relapse onset, without subsequent accrual of worsening in that same Functional System (e.g. more indicative of progression), will be considered to have incomplete relapse recovery). |
up to 99 months
|
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Cognition using Symbol Digit Modality Test (SDMT)
Tidsramme: up to 99 months
|
The SDMT is commonly used in MS to assess processing speed and will be administered orally and used to evaluate changes in cognition throughout the study. |
up to 99 months
|
|
Multiple Sclerosis Impact Scale (MSIS-29)
Tidsramme: up to 99 months
|
The MSIS-29 will be used to evaluate the impact of MS on the participants and will be administered as an electronic PRO.Multiple Sclerosis Impact Scale (MSIS-29) is an instrument used for measuring the physical (20 items) and psychological (nine items) impact of multiple sclerosis. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Anxiety Subscale
Tidsramme: up to 99 months
|
The Anxiety Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Depression Subscale
Tidsramme: up to 99 months
|
The Depression Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Fatigue Subscale
Tidsramme: up to 99 months
|
The Fatigue Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Upper Extremity Function
Tidsramme: up to 99 months
|
The Upper Extremity Function Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Lower Extremity Function
Tidsramme: up to 99 months
|
The Lower Extremity Function Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Cognitive Function
Tidsramme: up to 99 months
|
The Cognitive Function Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Positive Affect/Well-being
Tidsramme: up to 99 months
|
The Positive Affect/Well-being Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Sleep Disturbance
Tidsramme: up to 99 months
|
The Sleep Disturbance Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Ability to Participate in Social Roles and Activities
Tidsramme: up to 99 months
|
The Ability to Participate in Social Roles and Activities Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Satisfaction with Social Roles and Activities
Tidsramme: up to 99 months
|
The Satisfaction with Social Roles and Activities Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Quality of Life in Neurological Disorders (Neuro-QoL): Stigma
Tidsramme: up to 99 months
|
The Stigma Subscale of Neuro-QoL will be administered as an electronic PRO. |
up to 99 months
|
|
Employment status
Tidsramme: up to 99 months
|
The incidence of change in employment to "disabled" or "looking for work, unemployed," will be evaluated for all participants through an electronic PRO. |
up to 99 months
|
|
Marital status
Tidsramme: up to 99 months
|
Incident divorce or separation, among those who previously were married or in a domestic partnership, will be evaluated for all participants through an electronic PRO. |
up to 99 months
|
|
Serious Adverse Events (SAEs)
Tidsramme: up to 99 months
|
SAEs (clinically significant infections, malignancies, or the development of other serious comorbidities, as well as unplanned hospitalizations [for non-elective issues, excluding MS relapse] and death) |
up to 99 months
|
|
Adverse event resulting in a decision to change disease-modifying therapy
Tidsramme: up to 99 months
|
Adverse events meaningful enough to lead to medication discontinuation |
up to 99 months
|
|
Severe COVID-19 Infection
Tidsramme: up to 48 weeks from enrollment into COVID-19 related substudy
|
Severe COVID-19 infection will be defined as an outcome of "hospitalization or death" due to confirmed or suspected COVID-19 infection |
up to 48 weeks from enrollment into COVID-19 related substudy
|
Samarbeidspartnere og etterforskere
Sponsor
Etterforskere
- Hovedetterforsker: Ellen M. Mowry, MD, MCR, Johns Hopkins University
- Hovedetterforsker: Scott D. Newsome, DO, Johns Hopkins University
Publikasjoner og nyttige lenker
Studierekorddatoer
Studer hoveddatoer
Studiestart (Faktiske)
Primær fullføring (Faktiske)
Studiet fullført (Faktiske)
Datoer for studieregistrering
Først innsendt
Først innsendt som oppfylte QC-kriteriene
Først lagt ut (Faktiske)
Oppdateringer av studieposter
Sist oppdatering lagt ut (Faktiske)
Siste oppdatering sendt inn som oppfylte QC-kriteriene
Sist bekreftet
Mer informasjon
Begreper knyttet til denne studien
Ytterligere relevante MeSH-vilkår
- Sykdommer i nervesystemet
- Autoimmune sykdommer
- Sykdommer i immunsystemet
- Demyeliniserende autoimmune sykdommer, CNS
- Autoimmune sykdommer i nervesystemet
- Demyeliniserende sykdommer
- Multippel sklerose
- Multippel sklerose, tilbakefallende-remitterende
- Peptider
- Aminosyrer, peptider og proteiner
- Proteiner
- Organiske kjemikalier
- Heterocykliske forbindelser
- Heterocykliske forbindelser, 2-ring
- Heterocykliske forbindelser, smeltet ringen
- Terapeutikk
- Drug Administration -ruter
- Medikamentell terapi
- Nukleinsyrer, nukleotider og nukleosider
- Biologiske faktorer
- Syrer, acyklisk
- Karboksylsyrer
- Aminer
- Antistoffer, monoklonalt, humanisert
- Antistoffer, monoklonalt
- Antistoffer
- Immunoglobuliner
- Immunoproteiner
- Blodproteiner
- Serumglobuliner
- Globuliner
- Puriner
- Alkoholer
- Glykoler
- Membranproteiner
- Nukleosider
- Ribonukleosider
- Intercellulære signalpeptider og proteiner
- Aminoalkoholer
- Sfingosin
- Propylenglykoler
- Antistoffer, monoklonale, murine-avledede
- Deoxyribonucleosides
- Cytokiner
- Interferon type I.
- 2-kloradenosin
- Adenosin
- Purin nukleosider
- Deoxyadenosines
- Injeksjoner
- Dikarboksylsyrer
- Vesikulære transportproteiner
- Interferon-beta
- Interferon beta-1a
- Rituximab
- Natalizumab
- Fingolimod hydroklorid
- Interferon beta-1b
- Alemtuzumab
- Glatirameracetat
- Dimetylfumarat
- Interferoner
- Kladribin
- Ozanimod
- Teriflunomid
- Ocrelizumab
- Ofatumumab
- Injeksjoner, subkutan
- Peginterferon beta-1a
- Siponimod
- Diroximel Fumarat
- Monometylfumarat
- ponesimod
- Injeksjoner, intramuskulær
- Fumarates
- Belegg proteinkompleks i
Andre studie-ID-numre
- IRB00143534
Legemiddel- og utstyrsinformasjon, studiedokumenter
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