Safety and Tolerability of Quetiapine in Multiple Sclerosis

Background:

Multiple sclerosis causes episodes of inflammation that injure or kill nerve cells and the cells that coat them with myelin. These episodes of inflammation may cause a relapse (attack) or the inflammation may only be detectable with brain MRI. Inflammatory episodes are the main feature of relapsing-remitting MS (RRMS). Most relapses can be prevented by current treatments for RRMS. This remains important because dead nerve cells cannot be replaced.

Fortunately, there are also repair processes that can rescue injured nerve and myelin cells. An important aspect of repair is regeneration of the myelin forming cells. If the myelin can be protected or even replaced the nerves have a better chance of survival. However if injured myelin is not repaired or replaced the nerve cell is not protected and will likely later also die; this may be the underlying process that causes the progression. The investigators obviously need therapies in MS that do more than just reduce the frequency of relapses and the silent episodes of inflammation. The investigators need treatments that help repair.

Quetiapine is a medication which has been shown to stimulate the myelin forming cells (called oligodendrocytes) to improve myelin repair in mice. It therefore may also improve myelin repair in people with MS. However, before testing the effects of quetiapine on myelin repair, the investigators must first determine if the medication is safe and if the dose is tolerated in people with MS in short-term treatment trials.

Quetiapine is currently approved in Canada to treat several psychiatric conditions including depression and psychosis. It has also been shown to be useful to treat anxiety and insomnia. Quetiapine is available as an extended release pill that can be taken once daily. Doses up to 800 mg per day may be used to treat some of these conditions but the investigators estimate that a dose of only 300 mg daily will be needed to stimulate myelin repair. It is not clear if the dose of 300 mg will be well tolerated by people with MS who may not need a medication to treat these conditions.

Visit schedule:

Screen period, baseline, week 1 [telephone], week 2 [telephone], week 3 [telephone], week 4, and week 8. Treatment with quetiapine XR will last for 4 weeks or until day 28. On day 29, the dose of quetiapine will be tapered by 50 mg every two days to avoid development of withdrawal syndrome and insomnia.

Treatment and Dose schedule:

Quetiapine XR dosing schedule for relapsing-remitting MS Group 1 Dose schedule Day 1-3: 50 mg Day 4-6: 100 mg Day 7-28: 150 mg Day 29-30: 100mg Day 31-32: 50mg Group 2 Dose schedule Day 1-2: 50 mg Day 3-4: 150 mg Day 5-6: 200 mg Day 7-28: 300 mg Day 29-30: 250mg Day 31-32: 200mg Day 33-34: 150mg Day 35-36: 100mg Day 37-38: 50mg Group 3 Dose Schedule Day 1: 50 mg Day 2: 100 mg Day 3: 200 mg Day 4-28: 300 mg Day 29-30: 250mg Day 31-32: 200mg Day 33-34: 150mg Day 35-36: 100mg Day 37-38: 50mg Quetiapine XR dosing schedule for progressive MS Group 1 Dose schedule Day 1-14: 50 mg Day 15-28: 100 mg Day 29-30: 50mg Group 2 Dose schedule Day 1-5: 50 mg Day 6-10: 100 mg Day 11-15: 150 mg Day 16-28: 200 mg Day 29-30: 150mg Day 31-32: 100mg Day 33-34: 50mg Group 3 Dose Schedule Day 1-5: 50 mg Day 6-10: 100 mg Day 11-15: 200 mg Day 16-28: 300 mg Day 29-30: 250mg Day 31-32: 200mg Day 33-34: 150mg Day 35-36: 100mg Day 37-38: 50mg

Measures:

1. Determination of dose-limiting toxicity Dose-limiting toxicity for any patient in this study is defined as early discontinuation of quetiapine XR due to an AE that is possibly, probably or definitely due to use of study drug. Patients who discontinue medication due to an AE will still be kept in the trial for safety assessment at weeks 4 and 8. Because of the small number of treated participants anyone who discontinues study drug for a reason or adverse event unrelated to use of the study drug will be excluded from the analysis and replaced. The dose-limiting toxicity will be determined for each group of patients: RRMS and progressive MS. The maximally tolerated dose and dose escalation schedule for future trials is the dose where fewer than 33% of participants reached dose-limiting toxicity. This will differ for each group of patients, RRMS and progressive MS.

2. Scales

   1. Functional Systems (FS) and Expanded Disability Status Scale (EDSS) A score based on a standardized neurological examination, observation of ambulation distance (up to 500 metres), and questions regarding bladder, bowel and sexual function.
   2. Extrapyramidal Symptom Rating Scale (ESRS) Neurological assessment of four extrapyramidal abnormalities: dystonia, dyskinesia, parkinsonism, akathisia, as well as subjective extrapyramidal symptoms
   3. 9-hole Peg Test (9-HPT) Timed test of arm/hand function
   4. Timed 25-Foot Walk (T25-FW) Timed test of ambulation
   5. Symbol Digit Modalities Test (SDMT) Timed test of cognitive processing speed and working memory
   6. Epworth Sleepiness Scale (ESS) 8 self-report items measuring sleepiness
   7. Modified Fatigue Impact Scale (MFIS) 21 self-report items measuring fatigue
   8. Athens Insomnia Scale (AIS) 8 self-report items measuring insomnia
   9. Center for Epidemiologic Studies Depression Scale (CES-D) 20 self-report items measuring depression