E.1 Medical condition or disease under investigation |
E.1.1 | Medical condition(s) being investigated |
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E.1.1.1 | Medical condition in easily understood language |
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E.1.1.2 | Therapeutic area | Diseases [C] - Nervous System Diseases [C10] |
MedDRA Classification |
E.1.3 | Condition being studied is a rare disease | No |
E.2 Objective of the trial |
E.2.1 | Main objective of the trial |
Core part:
Demonstrate that remibrutinib is superior to teriflunomide in reducing the frequency of confirmed relapses
Extension part:
To assess long-term safety, tolerability and efficacy parameters in participants treated with remibrutinib |
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E.2.2 | Secondary objectives of the trial |
Core
Assess whether remibrutinib is superior to teriflunomide in
● Delaying disability progression based on the pooled data from both identical pivotal studies
● Reducing new inflammatory activity on MRI, based on MRI cohort data
● Reducing neuronal damage
● Disease-Activity-free status based on pooled data from both identical pivotal studies (MRI Cohort)
Extension (exploratory)
●Explore effect of remibrutinib versus terifunomide on brain MRI, relationship between remibrutinib exposure (PK) and efficacy and safety endpoints and relationship between potential biomarkers and their relationship with disease activity, disease course and treatment response
●Perform exploratory pharmacogenetic analysis based on blood samples for DNA (optional)
● Explore the effect of remibrutinib versus teriflunomide on disease activity free status and effect of remibrutinib versus teriflunomide on disability progression independent of relapse activity
See protocol for complete list of objectives
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E.2.3 | Trial contains a sub-study | Yes |
E.2.3.1 | Full title, date and version of each sub-study and their related objectives |
1) DNA sampling / Pharmacogenetics
The study includes an optional genetic research component. The purpose of genetic research may be to better understand the safety and efficacy of remibrutinib, or to learn more about human diseases, or to help develop ways to detect, monitor and treat diseases. As technology changes over time, the most appropriate technology will be used at the time the exploratory genetic research is performed. This may include the study of the entire genome. The use of DNA to search for biomarkers of disease and drug action is exploratory.
2) MRI Cohort
Only selected sites will participate in the MRI cohort; it is planned that approximately 400 participants will be included in this MRI cohort after signature of an additional (optional) consent. All eligible participants from these selected sites will undergo MRI scanning of the brain (see protocol for details).
MRI scans will be transmitted by the sites to the central MRI reading center, designated by Novartis, for quality checks and central read. Further details on the image acquisition can be found in the MRI manual of the central MRI reading center. Details regarding the central read can be found in the central MRI reading center independent review charter.
Each MRI scan performed for the study needs to be previewed by a local neuroradiologist/radiologist. The Investigator must be contacted in case of unexpected findings (e.g. not consistent with MS) detected on the MRI scan for safety actions and AE reporting.
The MRIs required for the MRI cohort as part of this study are defined in the protocol. Routine MRIs that are mandated by the local treatment guidelines or local Health Authority will be conducted outside the trial (not sent to the central MRI reading center or included in the study database) for any participant.
3) Additional Biomarker assessment
Transcriptomic profiling may be assessed, using RNA from whole blood. mRNA expression patterns and patterns of other RNA species, will be derived from application of various technologies which may include sequencing of cDNA libraries related to the RNA extracted from blood. These analyses will be used to examine the effect of remibrutinib on transient RNA and may support the identification of pathways/markers that characterize the disease or response of treatment with remibrutinib. Due to exploratory nature, the data will not be recorded in the clinical database. For this Transcriptomics (RNA) assessment, PAXgene whole blood samples (one aliquot with 2.5 ml blood) will be collected at designated visits and stored for long-term storage. Transcriptomic assessment will be triggered based on results obtained in this study or other MS studies.
4) PK sub-study
There will be two pharmacokinetic assessments (PK) cohorts, for "rich" and "sparse" sampling. “Rich PK sampling” will be performed in a minimum of 160 randomized participants (to ensure these are available for 80 completers per treatment arm), and requires sampling at Day 28 (M1) at pre-dose (0 h) and post-dose at the following times after dosing: 0.5 hour (± 15 mins), 1.0 hour (±15 mins), 2.0 hours (±15 mins), 3.0 hours (±30 mins) and 4.0 hours (±30 mins), and at M6 at pre-dose (0 h) and at 1.0 hour (±15 mins) post-dose. "Sparse PK sampling" will be performed in all other randomized participants and requires sampling at Day 28 (M1) and M6 at both pre-dose (0 h) and 1.0 hour (±15 mins) post-dose at both visits. PK assessments are only performed during the Core Part of the study.
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E.3 | Principal inclusion criteria |
1. Signed informed consent obtained prior to any assessment performed (confirm at screening visit)
2. Male or female participants 18 to 55 years of age (inclusive) at screening
3. Diagnosis of RMS according to the 2017 McDonald diagnostic criteria
(this would include relapsing-remitting course (RRMS) or secondary progressive (SPMS) course with disease activity) as confirmed at screening visit.
4. At least: 1 documented relapse within the previous year, OR 2 documented relapses within the previous 2 years, prior to screening, OR 1 active Gadolinium (Gd)-enhancing lesion in the 12 months prior to screening
5. EDSS score of 0 to 5.5 (inclusive) at screening and randomization
6. Neurologically stable within 1 month prior to screening and randomization (including no MS relapse in this period)
Please see protocol for complete detailed list of inclusion criteria |
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E.4 | Principal exclusion criteria |
1. Diagnosis of primary progressive multiple sclerosis (PPMS) according to the 2017 revision of the McDonald diagnostic criteria (Thompson et al 2018) at screening
2. Disease duration of more than 10 years in participants with EDSS score of 2 or less at screening
3. History of clinically significant CNS disease (e.g. stroke, traumatic brain or spinal injury, history or presence of myelopathy) or neurological disorders which may mimic MS at screening
4. Ongoing substance abuse (drug or alcohol) or any other factor (e.g. serious psychiatric condition) that may interfere with the participant's ability to cooperate and comply with the study procedures prior to randomization
5. History of malignancy of any organ system (other than complete resection of localized basal cell carcinoma of the skin or in situ cervical cancer), treated or untreated, within the past 5 years, regardless of whether there is evidence of local recurrence or metastases, at screening
6. Participants with history of confirmed Progressive Multifocal Leukoencephalopathy (PML) or Neurological symptoms consistent with PML prior to randomization
7. Women of child bearing potential unless they are using highly effective methods of contraception while taking study treatment and for at least 4 weeks after stopping study medication
8. Sexually active males, unless they agree to use a condom while taking study treatment and for at least 4 weeks after stopping double blind study medication
Please see protocol for complete detailed list of exclusion criteria |
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E.5 End points |
E.5.1 | Primary end point(s) |
Core part:
Annualized relapse rate (ARR) of confirmed relapses
Extension Part:
● Adverse events, laboratory data, vital signs, electrocardiogram (ECG), Columbia Suicide Severity Rating
● ARR, number of new or enlarging T2 lesions on MRI per year (annualized T2 lesion rate), time to 6mCDP (EDSS), change in SDMT, NfL, Patient Reported Outcomes scores
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E.5.1.1 | Timepoint(s) of evaluation of this end point |
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E.5.2 | Secondary end point(s) |
Core part:
● Time to 3-month confirmed disability progression (3mCDP) on Expanded Disability Status Scale (EDSS)
● Time to 6-month confirmed disability progression (6mCDP) on EDSS
● Number of new or enlarging T2 lesions on MRI per year (annualized T2 lesion rate)
● Total number of Gd-enhancing T1 lesions per MRI scan
● Neurofilament light chain (NfL) concentration in serum
● Percentage of participants with No Evidence of Disease Activity-3 (NEDA-3), as assessed by absence of confirmed MS relapses, 6mCDP and new/enlarging T2 lesions on MRI
Extension part (exploratory)
● Annualized rate of brain volume loss (BVL), based on percentage brain volume change from baseline
● Change from baseline in cortical grey matter volume, hemispheric white matter volume and thalamus volume
● Slowly Expanding Lesions (SEL) in MRI
● T2 lesions, ARR, 3mCDP, safety endpoints etc. (as applicable)
● NfL, GFAP, total IgG, total IgM, B-cells, T2 lesions, ARR, 3mCDP etc. (as applicable)
● Evaluate the relationship of genetic polymorphisms data with drug metabolism, the indication, the drug target pathway, and treatment response
● Percentage of participants with NEDA-4, as assessed by the absence of confirmed MS relapses, 6mCDP, new/enlarging T2 lesions on MRI and brain volume loss > -0.4%/year
● Time to 3mCDP, 6mCDP
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E.5.2.1 | Timepoint(s) of evaluation of this end point |
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E.6 and E.7 Scope of the trial |
E.6 | Scope of the trial |
E.6.1 | Diagnosis | No |
E.6.2 | Prophylaxis | No |
E.6.3 | Therapy | Yes |
E.6.4 | Safety | Yes |
E.6.5 | Efficacy | Yes |
E.6.6 | Pharmacokinetic | Yes |
E.6.7 | Pharmacodynamic | No |
E.6.8 | Bioequivalence | No |
E.6.9 | Dose response | No |
E.6.10 | Pharmacogenetic | Yes |
E.6.11 | Pharmacogenomic | No |
E.6.12 | Pharmacoeconomic | No |
E.6.13 | Others | Yes |
E.6.13.1 | Other scope of the trial description |
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E.7 | Trial type and phase |
E.7.1 | Human pharmacology (Phase I) | No |
E.7.1.1 | First administration to humans | No |
E.7.1.2 | Bioequivalence study | No |
E.7.1.3 | Other | No |
E.7.1.3.1 | Other trial type description | |
E.7.2 | Therapeutic exploratory (Phase II) | No |
E.7.3 | Therapeutic confirmatory (Phase III) | Yes |
E.7.4 | Therapeutic use (Phase IV) | No |
E.8 Design of the trial |
E.8.1 | Controlled | Yes |
E.8.1.1 | Randomised | Yes |
E.8.1.2 | Open | No |
E.8.1.3 | Single blind | No |
E.8.1.4 | Double blind | Yes |
E.8.1.5 | Parallel group | Yes |
E.8.1.6 | Cross over | No |
E.8.1.7 | Other | Yes |
E.8.1.7.1 | Other trial design description |
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E.8.2 | Comparator of controlled trial |
E.8.2.1 | Other medicinal product(s) | Yes |
E.8.2.2 | Placebo | Yes |
E.8.2.3 | Other | No |
E.8.2.4 | Number of treatment arms in the trial | 2 |
E.8.3 |
The trial involves single site in the Member State concerned
| No |
E.8.4 | The trial involves multiple sites in the Member State concerned | Yes |
E.8.4.1 | Number of sites anticipated in Member State concerned | 2 |
E.8.5 | The trial involves multiple Member States | Yes |
E.8.5.1 | Number of sites anticipated in the EEA | 69 |
E.8.6 Trial involving sites outside the EEA |
E.8.6.1 | Trial being conducted both within and outside the EEA | Yes |
E.8.6.2 | Trial being conducted completely outside of the EEA | No |
E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned |
Argentina |
Chile |
China |
Colombia |
Guatemala |
Hong Kong |
India |
Malaysia |
United States |
France |
Latvia |
Lithuania |
Poland |
Bulgaria |
Netherlands |
Spain |
Switzerland |
Czechia |
Germany |
Italy |
Belgium |
Croatia |
Hungary |
Russian Federation |
Slovakia |
United Kingdom |
Serbia |
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E.8.7 | Trial has a data monitoring committee | Yes |
E.8.8 |
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
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E.8.9 Initial estimate of the duration of the trial |
E.8.9.1 | In the Member State concerned years | 7 |
E.8.9.1 | In the Member State concerned months | 6 |
E.8.9.1 | In the Member State concerned days | 3 |
E.8.9.2 | In all countries concerned by the trial years | 7 |
E.8.9.2 | In all countries concerned by the trial months | 11 |
E.8.9.2 | In all countries concerned by the trial days | 9 |