Multiple sclerosis is the most common inflammatory disease of the central nervous system and a common cause of disability in young adults. Depleting B cells from the circulation with an anti-cluster of differentiation (CD) 20 antibodies has proven to be an effective strategy in reducing relapses and disability in patients with the relapsing-remitting disease. However, continuous and long-term depletion of B-cells can result in reduced immunoglobulin levels, immunosuppression, and an increased tendency for severe infections and perhaps, even malignancy. Blocking B-cell Activating Factor (BAFF) is effective for the treatment of several autoimmune disorders. Belimumab, a BAFF blocking antibody, has been approved by the Food and Drug Administration for the treatment of systemic lupus erythematosus. Belimumab has been shown to have immunomodulatory properties, without resulting in overt immunosuppression. The investigators hypothesize that belimumab, given to patients who received a short course of treatment with B-cell depleting antibody (ocrelizumab), will be safe and equally effective in reducing MS disease activity (as compared to patients receiving continuous treatment with ocrelizumab); while resulting in less immunosuppression, as measured by antibody response to pneumococcal vaccination. Currently, available treatment strategies in relapsing MS sacrifice higher efficacy for long-term safety or vice versa. The proposed strategy in this application combines the long-term safety and high efficacy to treat patients with relapsing-remitting multiple sclerosis (RRMS) and, if eventually proven effective, can be adopted in a large proportion of patients with this chronic disease. This is a randomized, open-labeled trial. Forty eligible participants will be randomized 1:1 to either receiving a form of standard of care, ocrelizumab (300 mg two infusions two weeks apart at baseline and then 600 mg as a single infusion every six months) or belimumab (200 mg subcutaneous (SC) weekly for 36 months) plus two courses of ocrelizumab (300 mg two infusions two weeks apart at baseline and 600 mg as a single infusion six months later). Co-primary outcomes of the study include pneumococcal vaccine antibody response, the return of MS disease activity, and proportions of patients with adverse events and serious adverse events.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
4
200 mg SC weekly for 36 months
300 mg, two infusions two weeks apart and then 600 mg as a single infusion after six months (only one time) (total of two courses of treatment)
300 mg, two infusions two weeks apart and then 600 mg as a single infusion every six months for a total of 36 months
Johns Hopkins University
Baltimore, Maryland, United States
Pneumococcal Vaccine Antibody Response
The proportion of patients with positive antibody responses to \>/=1 of the 23 pneumococcal vaccine serotypes measured four weeks post-vaccination (vaccination given at month 24). A positive antibody response is defined as a two-fold increase from pre-vaccination levels against \>/=1 of the 23 pneumococcal serotypes measured.
Time frame: Month 25
Safety as Assessed by Adverse Events
Adverse events (AEs) and serious adverse events (SAEs), including AEs of special interest (opportunistic infections, herpes zoster, malignancies, hypersensitivity and infusion reactions, suicidal ideation, intent or behavior and all-cause mortality).
Time frame: 24 months
Difference Between the Two Treatment Groups in GM-CSF/IL-10 Ratio
Granulocyte-macrophage colony-stimulating factor (GM-CSF)/Interleukin (IL)-10 ratio (produced by stimulated repopulated B-cells).
Time frame: Month 36
Difference Between the Two Treatment Groups in IL-6/IL-10 Ratio
IL-6/IL-10 ratio (produced by stimulated repopulated B-cells).
Time frame: Month 36
Assessment of Return of Disease Activity by Month 24
Proportions of patients with a return of the disease activity, as objectively demonstrated by the development of new T2 hyperintense lesions or Gd-enhancing lesions on the MRI (noted on a scan performed more than six months after treatment initiation) or a clinical relapse, defined as new or worsening neurologic symptom(s) with an objective change on the EDSS of at least 1.5 points for participants with baseline EDSS scores of 0 or 0.5 and at least 1-point change for participants with EDSS of 1 or more, as determined by the examining neurologist. Symptoms must have been attributable to multiple sclerosis (MS), last ≥48 hours, been present at normal body temperature, and preceded by at least 30 days of clinical stability.
Time frame: Month 24
Assessment of Return of Disease Activity by Month 36
Proportions of patients with a return of the disease activity, as objectively demonstrated by the development of new T2 hyperintense lesions or Gd-enhancing lesions on the MRI (noted on a scan performed more than six months after treatment initiation) or a clinical relapse, defined as new or worsening neurologic symptom(s) with an objective change on the EDSS of at least 1.5 points for participants with baseline EDSS scores of 0 or 0.5 and at least 1-point change for participants with EDSS of 1 or more, as determined by the examining neurologist. Symptoms must have been attributable to MS, last ≥48 hours, been present at normal body temperature, and preceded by at least 30 days of clinical stability.
Time frame: Month 36
Assessment of Clinical Disease Activity by Month 24
Annualized relapse rate (ARR) which is the number of relapses divided by the number of follow up years.
Time frame: Month 24
Assessment of Clinical Disease Activity by Month 36
Annualized relapse rate (ARR) which is the number of relapses divided by the number of follow up years.
Time frame: Month 36
Proportion of Participants With a Three-month Confirmed Increase in EDSS Score
Assessment of disability progression by the proportion of participants with a three-month confirmed increase in Expanded Disability Status Scale (EDSS) score.
Time frame: Month 24
Proportion of Participants With a Three-month Confirmed Increase in EDSS Score
Assessment of disability progression by the proportion of participants with a three-month confirmed increase in Expanded Disability Status Scale (EDSS) score.
Time frame: Month 36
Proportion of Participants With a Three-month Confirmed Decrease in EDSS Score
Assessment of disability progression by the proportion of participants with a three-month confirmed decrease in EDSS score.
Time frame: Month 24
Proportion of Participants With a Three-month Confirmed Decrease in EDSS Score
Assessment of disability progression by the proportion of participants with a three-month confirmed decrease in EDSS score.
Time frame: Month 36
Change in Serum Neurofilament Light Chain (NfL) in pg/mL
Assessment of a serum biomarker of neuroaxonal degeneration.
Time frame: Baseline and Month 24
Change in Serum Neurofilament Light Chain (NfL) in pg/mL
Assessment of a serum biomarker of neuroaxonal degeneration.
Time frame: Baseline and Month 36
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