Assessment of Bone Marrow-derived Cellular Therapy in Progressive Multiple Sclerosis (ACTiMuS) (ACTiMuS)
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|ClinicalTrials.gov Identifier: NCT01815632|
Recruitment Status : Recruiting
First Posted : March 21, 2013
Last Update Posted : June 27, 2018
Multiple sclerosis - MS - affects 1.3m people worldwide, costing the European Union economy €9 billion/year, through both direct and indirect consequences of progressive disability. Despite the usual relapsing-remitting presentation, over 80% of patients develop progressive disability; 40% require a wheelchair within 10 years of diagnosis. At present, there are no treatments that reverse, halt or even slow progressive disability in MS.
The investigators recently completed one of the first feasibility/safety trials in the world of reparative bone marrow cell therapy in 6 patients with longstanding MS (www.nature.com/clpt/journal/v87/n6/full/clpt201044a.html). Safety was confirmed, and intensive repeated tests on the patients measuring nerve conduction in various pathways in the brain and in the spinal cord showed statistically significant improvements at 12 months in every patient. While highly preliminary and involving only a very small number of patients, these results at least raise the possibility of a significant (though very partial) underlying repair effect within the damaged nervous system.
The investigators believe this urgently requires further testing - both to accelerate benefit for patients, and to begin improving therapeutic efficacy. The investigators therefore propose a programme of translational and clinical stem cell research, aiming (1) to continue translation with a phase two controlled trial of bone marrow cells in patients with longstanding MS; and (2) to explore in parallel the potential mechanisms of action, by studying bone marrow cells from treated patients and control subjects, aiming to establish which of the various relevant bone marrow subpopulations contribute to efficacy, and which particular reparative mechanism(s) are important. The investigators hope these studies will not only confirm the therapeutic benefit of this approach, but also provide the basis for improving the magnitude and impact of this novel and exciting treatment modality.
|Condition or disease||Intervention/treatment||Phase|
|Progressive Multiple Sclerosis||Other: Early infusion of autologous marrow Other: Late infusion of autologous marrow||Phase 2|
The primary objective is to determine whether autologous bone marrow (BM) (ie taken from the patients themselves rather than from a BM donor) cell therapy is truly beneficial in chronic multiple sclerosis - as our small, uncontrolled phase 1 trial suggested (www.nature.com/clpt/journal/v87/n6/full/clpt201044a.html).
The investigators also aim to answer the following questions:
- Do BM mesenchymal stem cells from patients with MS differ in the range or extent of reparative and neuroprotective properties from those from control individuals?
- What reparative and neuroprotective properties do BM stem cell subpopulations other than mesenchymal stem cells possess, and do these differ between MS patients and controls?
- Can BM stem cell subpopulations be isolated from blood samples from MS patients following treatment, and, if so, for how long?
Bone marrow contains stem cells capable of replacing all the cells in the blood. Recently, bone marrow has been found to contain cells capable of replacing cells in tissues and organs other than blood. In addition, infusion of bone marrow-derived cells has been shown to have significant effects on the immune system and to promote the survival of central nervous system cells under toxic conditions. These properties are of considerable interest to those working to develop cell-based therapies for neurodegenerative disease.
The potential of such cells to aid repair in multiple sclerosis (MS) has been examined in experimental models of MS. Myelin is the substance that insulates neurons within the central nervous system and is attacked in MS. Infusion of adult bone marrow cells into a vein aids myelin repair (remyelination) in these models of MS. Recently, the investigators performed a small pilot study to examine the effects of harvesting bone marrow from MS patients and infusing this back into each patient's vein. This was well tolerated and no significant adverse events were encountered. Electrophysiological studies appeared to show some improvement but, given the small numbers of participants in the phase 1 trial, no definitive conclusion can be made regarding this.
The current study seeks to address the question of whether genuine improvements in neurophysiological tests are seen in MS patients with progressive disease following infusion of bone marrow.
A prospective, randomised, double-blind, placebo-controlled, stepped wedge design will be employed at a single centre (Bristol, UK). Eighty patients with progressive MS will be recruited; 60 will have secondary progressive disease (SPMS) but a subset (n=20) will have primary progressive disease (PPMS). Participants will be randomised to either early (immediate) or late (1 year) intravenous infusion of autologous, unfractionated bone marrow. The placebo intervention is infusion of autologous blood. The primary outcome measure is global evoked potential derived from multimodal evoked potentials. Secondary outcome measures include adverse event reporting, clinical (EDSS and MSFC) and self-assessment (MSIS-29) rating scales, optical coherence tomography (OCT) as well as brain and spine MRI. Participants will be followed up for a further year following the final intervention. Outcomes will be analyzed on an intention-to-treat basis.
|Study Type :||Interventional (Clinical Trial)|
|Estimated Enrollment :||80 participants|
|Intervention Model:||Crossover Assignment|
|Masking:||Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)|
|Official Title:||Assessment of Bone Marrow-derived Cellular Therapy in Progressive Multiple Sclerosis (ACTiMuS)|
|Study Start Date :||January 2014|
|Estimated Primary Completion Date :||October 2019|
|Estimated Study Completion Date :||October 2019|
Experimental: Early infusion of autologous marrow
Intravenous infusion of autologous bone marrow (without myeloablation) on the day of bone marrow harvest. Infusion of autologous blood at one year post-harvest
Other: Early infusion of autologous marrow
Intravenous infusion of autologous bone marrow without prior myeloablation on the day of bone marrow harvest and infusion of autologous blood at one year post-bone marrow harvest
Experimental: Late infusion of autologous marrow
Intravenous infusion of autologous blood on the day of bone marrow harvest. Infusion of autologous bone marrow (without myeloablation) at one year post-harvest
Other: Late infusion of autologous marrow
Infusion of blood on day of bone marrow harvest with intravenous infusion of autologous bone marrow without prior myeloablation one year post-bone marrow harvest.
- Global evoked potential (GEP): mean change from time of marrow infusion to end of study [ Time Frame: Entry and every 6 months for 2 years ]
Multimodal evoked potentials will be examined at 0, 6, 12, 18 and 24 months. Evoked potential abnormalities will be quantified according to a 4-point graded ordinal score modified from Leocani et al (JNNP 2006, 77:1030-1035) (0=normal; 1=increased latency; 2=increased latency and abnormal amplitude; 3=absent).
The recording of the evoked potentials shall be in accordance with the Guidelines of the International Federation of Clinical Neurophysiology and analysis will be performed using standard methods. Electrophysiological responses shall be considered abnormal if they exceed 2.5 standard deviations of the normal values or cannot be detected.
- Safety [ Time Frame: Continuous throughout study period (2 years) ]Evaluation of number and nature of adverse events
- Expanded disability status scale [ Time Frame: At entry then 6 weeks, 6 months and 1 year after each infusion ]Time to EDSS progression of at least one point from a baseline EDSS of 4.0, 4.5 or 5.0 or at least 0.5 points from a baseline EDSS ≥5.5
- Multiple sclerosis impact scale (MSIS-29) [ Time Frame: At entry then 6 weeks, 6 months and 1 year after each infusion ]Mean change from baseline to end of study on the patient-based MSIS-29 scale
- Multiple sclerosis functional composite (MSFC) [ Time Frame: At entry then 6 weeks, 6 months and 1 year after each infusion ]Mean change on MSFC score from baseline to final visit
- MRI head and cord [ Time Frame: At entry, 1 year and 2 years post-harvest ]
The secondary MRI outcome measures will relate to 1) lesion load, 2) atrophy measures both of the brain and of cross-sectional area of the spinal cord, and changes in mean diffusivity.
Exploratory analysis of the resting-state fMRI data will investigate correlations between network patterns and 'strength' of networks connectivity from the resting-state fMRI with classifications revealed by the various evoked potential studies
- Optical coherence tomography [ Time Frame: Entry, 1 year and 2 years post-harvest ]Measurement of retinal nerve fibre layer thickness and macular volume
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01815632
|Contact: Claire M Rice, MA MRCP PhD||00 44 117 firstname.lastname@example.org|
|Contact: Neil J Scolding, PhD FRCP||00 44 117 email@example.com|
|Bristol, United Kingdom, BS10 5NB|
|Principal Investigator: Neil J Scolding, FRCP PhD|
|Sub-Investigator: Claire M Rice, MA MRCP PhD|
|Principal Investigator:||Neil J Scolding, FRCP PhD||University of Bristol & North Bristol NHS Trust|