Tolebrutinib a Brain-penetrant Bruton s Tyrosine Kinase Inhibitor for the Modulation of Chronically Inflamed White Matter Lesions in Multiple Sclerosis

  • STATUS
    Recruiting
  • End date
    Dec 31, 2022
  • participants needed
    20
  • sponsor
    National Institute of Neurological Disorders and Stroke (NINDS)
Updated on 19 September 2021
rituximab
MRI
ocrelizumab

Summary

Background

Some multiple sclerosis (MS) lesions stay inflamed for very long periods of time. This type of inflammation is not affected by any MS medications. These lesions can lead to slow worsening of MS symptoms. Researchers want to see if a new drug can help.

Objective

To see if tolebrutinib can help clear inflammation in MS brain lesions.

Eligibility

Adults ages 18 and older with MS who are on an anti-CD20 therapy.

Design

Participants will be screened under protocol #89-N-0045.

Participants will have a medical history. They will have physical and neurological exams. They will have blood and urine tests. The progression of their MS will be assessed.

Participants will have MRIs of the brain. The MRI scanner is shaped like a cylinder. It uses a magnetic field and radio waves to take pictures of the body. During the MRIs, participants will lie on a table that slides in and out of the scanner. Soft padding or a coil will be placed around their head.

Participants may have electrocardiograms to measure the heart s electrical activity.

Participants may have lumbar punctures ( spinal taps ). A small needle will be inserted into the spinal canal in the lower back. Fluid will be collected.

Some participants will take tolebrutinib pills by mouth once a day for at least 96 weeks. They will stop their anti-CD20 therapy. They will have at least 10 study visits.

Some participants will not take tolebrutinib. They will stay on their anti-CD20 therapy. They will have 5 study visits.

Participation will last at least 96 weeks.

Description

Study Description:

The primary goal of this protocol is to test whether 48 weeks of treatment with tolebrutinib, an investigational, orally available, brain-penetrant, Bruton s tyrosine kinase (BTK) inhibitor, affects an imaging marker (the paramagnetic rim ) associated with chronically inflamed white matter lesions in multiple sclerosis (MS). In this rater-blinded but otherwise open-label study, ten adults with MS who are on stable disease-modifying treatment with intravenous anti-CD20 antibody therapy and are within 3 months of their most recent dose, have at least one paramagnetic rim lesion on 7-tesla magnetic resonance imaging (MRI), and have developed no new white matter lesions or clinical relapses for at least 6 months, will initiate treatment with tolebrutinib 60 mg/day and agree to forego further anti-CD20 or other disease-modifying therapy for the duration of the trial. Radiological, clinical, and biological outcomes are measured at 24, 48 (primary), 72, and 96 weeks, with additional interspersed visits for safety monitoring. Participants may subsequently continue on treatment until tolebrutinib is marketed or commercial development halted. A comparison group of 10 participants who meet inclusion criteria but choose to stay on anti-CD20 therapy will also be enrolled. The primary outcome measure is disappearance of one or more paramagnetic rims from white matter lesions identified at baseline. Secondary outcomes include safety and tolerability and additional radiological outcomes. Exploratory clinical, radiological, and laboratory measures will be obtained to investigate the mechanism of action of tolebrutinib and for biomarker development, and to compare the tolebrutinib and anti-CD20 cohorts.

Objectives

Primary Objective: To evaluate the effects of 48 weeks of tolebrutinib treatment on the paramagnetic rim of chronically inflamed white matter lesions, as seen on 7-tesla MRI.

Secondary Objectives: (1) To assess safety and tolerability of 96 weeks of treatment with tolebrutinib following intravenous anti-CD20 antibody therapy. (2) To assess the possible repair of chronically inflamed white matter lesions in which inflammation at the lesion edge has been modulated by tolebrutinib.

Endpoints

Primary Endpoint: Per-patient proportion of lesions in which the paramagnetic rim has disappeared at the end of 48 weeks.

Secondary Endpoints: (1) Adverse event tables. (2) Changes in T1 relaxation time within paramagnetic rim lesions at the end of 96 weeks, relative to non-rim lesions. (3) Changes in size of paramagnetic rim lesions at the end of 96 weeks, relative to non-rim lesions.

Study Population:

Up to 10 adults with multiple sclerosis, targeting at least 7 participants who complete 96 weeks of tolebrutinib therapy. Up to 10 adults with multiple sclerosis who meet inclusion criteria but choose to stay on anti-CD20 therapy.

Phase

2

Description of Study Intervention:

Oral tolebrutinib 60 mg per day for 96 weeks, with optional long-term extension and follow-up

Study Duration:

5 years

Participant Duration:

96 weeks for the primary study plus optional long-term extension and follow-up

Details
Condition Multiple Sclerosis, Radiologically Isolated Syndrome, Dermatite Atopique modérée ou grave, multiple sclerosis (ms)
Treatment Tolebrutinib
Clinical Study IdentifierNCT04742400
SponsorNational Institute of Neurological Disorders and Stroke (NINDS)
Last Modified on19 September 2021

Eligibility

Yes No Not Sure

Inclusion Criteria

In order to be eligible to participate in this study, an individual must meet
all of the following criteria
Tolebrutinib Cohort Inclusion Criteria
Able to provide informed consent
Willingness to comply with all study procedures and availability for the duration of the study
Male or female, aged greater than or equal to 18
Diagnosed with multiple sclerosis according to the 2017 revision of the McDonald diagnostic criteria, with no new lesion formation by comparison of baseline MRI scan with a historical MRI scan at least 6 months prior
On intravenous anti-CD20 antibody treatment (specifically ocrelizumab or rituximab) for at least 6 months, with the most recent dose at most 6 months prior to enrollment
Willing to forego further anti-CD20 antibody treatment for the duration of the study
Has a prior 7-tesla MRI scan, no more than 1 year prior to enrollment, demonstrating at least one white matter lesion with a paramagnetic rim
For females of reproductive potential: agrees to use highly effective contraception for at least 1 month prior to dosing and to use such a method during study participation and for an additional 12 weeks after the end of tolebrutinib administration
For males of reproductive potential: agrees to use condoms or other methods to ensure effective contraception with partner; agrees not to donate sperm from the inclusion up to 12 weeks after the last dose
QuantiFERON-TB Gold negative; skin testing (e.g., tuberculin skin test) will be allowed if blood testing is not available or the blood test result is indeterminate
Agrees to adhere to Lifestyle Considerations throughout study duration
Control Cohort Inclusion Criteria
Able to provide informed consent
Willingness to comply with all study procedures and availability for the duration of the study
Male or female, aged greater than or equal to 18
Diagnosed with multiple sclerosis according to the 2017 revision of the McDonald diagnostic criteria, with no new lesion formation by comparison of baseline MRI scan with a historical MRI scan at least 6 months prior
On intravenous anti-CD20 antibody treatment (specifically intravenous ocrelizumab or rituximab) for at least 6 months, with the most recent dose at most 6 months prior to enrollment. (Participants in this cohort should not be on ofatumumab, another anti-CD20 treatment, at baseline, but they may switch from ocrelizumab or rituximab to ofatumumab after week 48.)
Has a prior 7-tesla MRI scan, no more than 1 year prior to enrollment, demonstrating at least one white matter lesion with a paramagnetic rim
Agrees not to participate in any other interventional study while participating in this protocol
For females of reproductive potential: agrees to use highly effective contraception during study participation
Agrees not to participate in any other interventional study while participating in this protocol

Exclusion Criteria

An individual who meets any of the following criteria will be excluded from
participation in this study
Tolebrutinib Cohort Exclusion Criteria
Pregnancy or lactation
MS relapse in the 6 months prior to dosing
Febrile illness within 4 weeks prior to dosing, or persistent chronic or active infection requiring treatment with systemic antibiotics, antivirals, or antifungals
Treatment with another investigational drug or other investigational intervention within 3 months prior to baseline
Contraindications for 7-tesla MRI
Presence of any screening laboratory or ECG values outside normal limits that are considered in the PI or MAI s judgment to be clinically significant, including but not limited to
Presence of liver injury defined as underlying hepatobiliary disease or screening alanine aminotransferase (ALT) more than 1.5 times the upper limit of normal (ULN)
At screening, positive for hepatitis B surface antigen and/or hepatitis B core antibody and/or positive for hepatitis C antibody
Any of the following
Bleeding disorder or known platelet dysfunction at any time prior to the first screening visit
Platelet count less than 150,000/microL at the screening visit
Lymphocyte count less than 1000 cells/dL at the screening visit
Is HIV-positive
Has received any live (attenuated) vaccine (including but not limited to varicella zoster, oral polio, and nasal influenza) within 2 months before dosing
Has received any of the following medications/treatments within the specified time frame before baseline assessment
Medication: Systemic corticosteroids, adrenocorticotropic hormone; Exclusionary if used/used within required wash-out period: 1 month prior to baseline MRI scan
Medication: Dimethyl fumarate; Exclusionary if used/used within required wash-out period: 6 months prior to dosing
Medication: Intravenous immunoglobulin, fingolimod, natalizumab; Exclusionary if used/used within required wash-out period: 6 months prior to dosing
Medication: Teriflunomide; Exclusionary if used/used within required wash-out period: 2 years prior to dosing or 1 month prior to dosing
if participant undergoes an accelerated elimination procedure and has
documented teriflunomide plasma level below 0.02 mg/L
before dosing
Medication: Mildly to moderately immunosuppressive/chemotherapeutic medications such azathioprine and methotrexate; Exclusionary if used/used within required wash-out period: 6 months prior to dosing
Medication: Highly immunosuppressive/chemotherapeutic medications: mitoxantrone up to 120 mg/m2 body surface area, cyclophosphamide, cladribine; Exclusionary if used/used within required wash-out period: 2 years prior to dosing
Medication: Alemtuzumab; Exclusionary if used/used within required wash-out period: 4 years prior to dosing
Medication: Lymphoid irradiation, bone marrow transplantation, mitoxantrone (with evidence of cardiotoxicity following treatment, or cumulative lifetime dose >120 mg/m2), other strongly immunosuppressive treatments with very long-lasting effects; Exclusionary if used/used within required wash-out period: Any time
Medication: Any BTK inhibitor; Exclusionary if used/used within required wash-out period: Any time 10. Is receiving strong inducers or inhibitors of CYP3A or CYP2C8 hepatic enzymes 11. Is receiving anticoagulant/antiplatelet therapies, including
Acetylsalicylic acid (aspirin); half-life elimination: Parent drug: Plasma concentration: 15 to 20 minutes; Salicylates (dose dependent): 3 hours at lower doses (300 to 600 mg), 5 to 6 hours (after 1 g), 10 hours with higher doses
Antiplatelet drugs (eg, clopidogrel); half-life: 6 hours
Warfarin (vitamin K antagonist); half-life: 20-60 hours
Heparin, including low molecular weight heparin (antithrombin agents); half-life: 60-90 minutes
Dabigatran (direct thrombin inhibitor); half-life:12-17 hours
Apixaban (IV half-life: approximately 5 hours, oral half-life: approximately 12 hours), edoxaban (half-life: 10-14 hours), rivaroxaban (half-life: 5-9 or 11-13 hours in younger or elderly individuals, respectively) (direct factor Xa inhibitors)
Note: All above drugs need to be stopped at least 5 half-lives before study
drug administration except for aspirin, which needs to be stopped at least 8
days before
\. Has a history or presence of significant other concomitant illness that
according to the PI or MAI s judgment, would adversely affect participation in
this study; examples include but are not limited to clinically significant
cardiovascular, renal, hepatic, or metabolic
disease
\. Unwilling to allow coded samples to be processed offsite
\. Unwilling to have coded samples and/or data saved or used in other
studies
Control Cohort Exclusion Criteria
Pregnancy or lactation
MS relapse in the 6 months prior to baseline
Treatment with another investigational drug or other investigational intervention within 3 months prior to baseline
Contraindications for 7-tesla MRI
Has received any of the following medications/treatments within the specified time frame before baseline assessment
Medication: Systemic corticosteroids, adrenocorticotropic hormone; Exclusionary if used/used within required wash-out period: 1 month prior to baseline MRI scan
Medication: Dimethyl fumarate; Exclusionary if used/used within required wash-out period: 6 months prior to dosing
Medication: Intravenous immunoglobulin, fingolimod, natalizumab; Exclusionary if used/used within required wash-out period: 2 years prior to dosing or 1 month prior to dosing if participant undergoes an accelerated elimination procedure and has documented
teriflunomide plasma level below 0.02 mg/L before dosing
Medication: Mildly to moderately immunosuppressive/chemotherapeutic medications such azathioprine and methotrexate; Exclusionary if used/used within required wash-out period: 6 months prior to dosing
Medication: Highly immunosuppressive/chemotherapeutic medications: mitoxantrone up to 120 mg/m2 body surface area, cyclophosphamide, cladribine; Exclusionary if used/used within required wash-out period: 2 years prior to dosing
Medication: Lymphoid irradiation, bone marrow transplantation, mitoxantrone (with evidence of cardiotoxicity following treatment, or cumulative lifetime dose >120 mg/m2), other strongly immunosuppressive treatments with very long-lasting effects; Exclusionary if used/used within required wash-out period: Any time
Medication: Any BTK inhibitor; Exclusionary if used/used within required wash-out period: Any time 6. Has a history or presence of significant other concomitant illness that, according to the PI or MAI s judgment, would adversely affect participation in this study; examples include but are not limited to clinically significant cardiovascular, renal, hepatic, or metabolic
disease
\. Unwilling to allow coded samples to be processed offsite
\. Unwilling to have coded samples and/or data saved or used in other studies
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