Danish Non-inferiority Study of Ocrelizumab and Rituximab in MS (DanNORMS): A Randomized Study Comparing the Efficacy of Ocrelizumab and Rituximab in Active Multiple Sclerosis

Official Summary

The DanNORMS study is a phase 3, non-inferiority clinical trial examining whether treatment of active multiple sclerosis with rituximab is non-inferior to ocrelizumab regarding efficacy and safety.

Eligibility Requirements

• Minimum Age: 18 Years
• Maximum Age: 65 Years

Study Design

• Study Type: INTERVENTIONAL
• Allocation: RANDOMIZED
• Model: PARALLEL
• Masking: SINGLE
• Enrollment: 600 participants

Study Arms

• Rituximab (EXPERIMENTAL)
  Intravenous biosimilar rituximab (Ruxience®, Rixathon® or other biosimilar rituximab) 1000 mg given every 6th month (first 2 infusions 1000mg/1000 mg given 2 weeks apart).
• Ocrelizumab (ACTIVE_COMPARATOR)
  Intravenous ocrelizumab (Ocrevus®) 600 mg every 6th month (first 2 infusions 300 mg/300 mg given 2 weeks apart).

Interventions

• DRUG: Rituximab — Rituximab is a chimeric mouse/human monoclonal immunoglobulin gamma-1 (IgG1) antibody which depletes cluster of differentiation antigen 20 (CD20)-positive cells. Rituximab is approved for non-hodgkin lymphoma, chronic lymphocytic leukemia, rheumatoid arthritis, granulomatosis with polyangitis and microscopic polyangitis, and pemphigus vulgaris.
• DRUG: Ocrelizumab — Ocrelizumab is a recombinant humanised monoclonal IgG1 antibody which depletes CD20-positive cells. Ocrelizumab is approved for multiple sclerosis.
• DRUG: Fexofenadine — Premedication with oral fexofenadine 360 mg is given before every infusion to reduce frequency and intensity of infusion related reactions.
• DRUG: Paracetamol — Premedication with oral. paracetamol 1000 mg is given before every infusion to reduce frequency and intensity of infusion related reactions.
• DRUG: Methylprednisolone — Premedication with oral methylprednisolone 100 mg is given before every infusion to reduce frequency and intensity of infusion related reactions.

Primary Outcomes

• Percentage of patients without new or enlarging T2 white matter lesions on brain MRI scans (Month 6 to month 24)

Secondary Outcomes

• Percentage of patients with 6-month confirmed disability progression (CDP) in Expanded Disability Status Scale (EDSS) (Baseline to month 24)
• Annualised relapse rate based on cumulative number of confirmed relapses from baseline to months 24 (Baseline to month 24)
• Percentage of patients with 6-months CDP in Timed 25 Foot Walk (T25FW) (Baseline to month 24)
• Percentage of patients with 6-months CDP in 9-Hole-Peg Test (9HPT) (Baseline to month 24)
• Percentage of patients with 6-months CDP in Symbol Digit Modalities Test (SDMT) (Baseline to month 24)

Eligibility Criteria

Inclusion Criteria:

* MS diagnosis and definition of disease course according to the 2017 McDonald criteria
* Expanded disability status scale (EDSS) ≤6.5
* Fulfilling criteria for active MS:

  * Treatment naïve relapsing remitting multiple sclerosis (RRMS) patients (never treated, or no DMT the previous 2 years):

    1. ▪≥2 relapse previous 12 months OR
    2. 1 relapse previous 12 months with severe residual symptoms and EDSS ≥ 3.0 OR
    3. 1 relapse previous 12 months AND ≥9 T2 lesions on brain and/or spinal cord MRI AND

       * 1 contrast-enhancing lesion or ≥1 new or enlarging T2 lesion on brain and/or spinal cord MRI previous 12 month
  * Previously treated RRMS patients:

    1. ≥1 relapse previous 12 months OR
    2. ≥1 contrast-enhancing lesion or ≥2 new/enlarging T2 lesions on brain and/or spinal cord MRI previous 12 months
  * Progressive MS patients:

    1. ≥1 relapse previous 12 months OR
    2. ≥1 contrast-enhancing lesion previous 12 months or ≥1 new/enlarging T2 lesions on brain and/or spinal cord MRI previous 12 months or ≥2 new or enlarging T2 lesion on brain and/or spinal cord MRI previous 24 months OR
    3. Increased levels of neurofilament light chain (NFL) in serum or cerebrospinal fluid (CSF) in sample collected previous 12 months. Progressive MS patients not fulfilling the clinical/MRI criteria for active disease, may qualify for inclusion in the study if:

       (A) CSF NFL level (measured with NF-Light® ELISA assay from Uman Diagnostics or Simoa):
       * 18 to 40 years \>560 ng/l
       * 41 to 60 years \>890 ng/l
       * 61 to 65 years \>1850 ng/l

       or

       (B) Serum NFL level (measured with Simoa™ NF-light® Advantage Kit)

       o Increased sNFL based on individual age-determined cut-off: \>4.19 × 1.029\^age ng/L

       OR

       o Increased sNFL based age-partitioned cut-offs:
       * 18 to 20 years \>7.4 ng/L
       * 21 to 30 years \>9.9 ng/L
       * 31 to 40 years \>13.1 ng/L
       * 41 to 50 years \>17.5 ng/L
       * 51 to 60 years \>23.3 ng/L
       * 61 to 65 years \>30.9 ng/L
* Signed written informed consent

Exclusion Criteria:

* Pregnancy or breast feeding
* Lack of effective contraception for women of child-bearing potential (effective contraception include oral contraception, intrauterine devices and other forms of contraception with failure rate \<1%)
* Receipt of a live or live-attenuated vaccine within 6 weeks prior to randomization
* Known active malignant disease
* Severe heart failure (New York Heart Association Class IV) or severe, uncontrolled cardiac disease
* Positive test for HIV, hepatitis B or C, or symptoms or signs of active tuberculosis in a patient with a positive Quantiferon test.
* Negative test for varicella zoster
* Lymphopenia grade 2 (0.5 to 0.8 × 10\^9/L) or higher grades of lymphopenia. In case of switching from fingolimod, siponimod or ozanimod lymphopenia is accepted at screening visit. Patients switching from dimethylfumarate who have persistent lymphopenia 5 to 6 weeks after stopping dimethylfumarate can be included if lymphopenia is grade 2 or lower, and treating phycisian judge CD20-depleting therapy safe.
* Neutropenia grade 2 (1.0 to 1.5 × 10\^9/L) or higher grades
* Thrombocytopenia grade 2 (50 to 75 × 10\^9/L) or higher grades
* Previous treatment with alemtuzumab or hematopoietic stem-cell transplantation
* Previous treatment with cladribine, CD20-depleting antibodies, daclizumab or other immune suppressive treatment which is judged to still exert immune suppressive effect by treating physician
* Methylprednisolone treatment within 1 month of baseline visit
* Findings on the screening MRI judged to preclude participation by the treating physician
* Other diseases judged to be relevant by the treating physician
* Contraindication to MRI
* Known allergy or hypersensitivity to rituximab or ocrelizumab

Trial Locations

• Danish Multiple Sclerosis Center, Rigshospitalet, Glostrup Municipality, Copenhagen, Denmark
• Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
• Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
• Department of Neurology, Hospital of South West Jutland, Esbjerg, Esbjerg, Denmark
• Department of Neurology, Herlev Hospital, Herlev, Denmark
• Department of Neurology, Nordsjællands Hospital i Hillerød, Hillerød, Denmark
• Department of Neurology, Regionshospitalet Holstebro, Holstebro, Denmark
• Department of Neurology, Kolding Hospital, Kolding, Denmark
• Department of Neurology, Odense University Hospital, Odense, Denmark
• Department of Neurology, Hospital of Southern Jutland, Sønderborg, Sønderborg, Denmark
• ...and 1 more locations

Study Officials

• Jeppe Romme Christensen, MD, PhD — PRINCIPAL_INVESTIGATOR
  Danish Multiple Sclerosis Center Rigshospitalet

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