Motor Neurone Disease - Systematic Multi-Arm Adaptive Randomised Trial

Overview

MND-SMART is investigating whether selected drugs can slow down the progression of motor neuron disease (MND) and improve survival. The study is 'multi-arm' meaning more than one treatment will be tested at the same time. The trial started with 3 arms; drug 1 (memantine), drug 2 (trazodone) and placebo (dummy drug). A third drug, amantadine, was added in April 2023. A fourth drug, tacrolimus, was added in March 2025 in Edinburgh and across all sites in April 2025. The first two drugs, memantine and trazodone, were removed from the trial in September 2023 due to lack of benefit. The trial currently has 4 recruiting arms; amantadine, liquid placebo (matched to amantadine), tacrolimus, and tablet placebo (matched to tacrolimus). This allows the evaluation of each drug versus placebo. Participants will be randomly allocated between the treatment arms they are eligible for. Medicines being tested are already approved for use in other conditions. MND-SMART has an 'adaptive' design. This means medicines being studied can change according to emerging results. Treatments shown to be ineffective can be dropped and new drugs can be added over the duration of the study. This will allow many treatments, over time, to be efficiently and definitively evaluated. The medicines being tested have been selected following a rigorous process involving a systematic, unbiased, and comprehensive review of past clinical trials data, as well as information from pre-clinical research (studies in laboratories), for MND and other related neurodegenerative disorders. Drugs have been ranked for inclusion in MND-SMART by a group of independent MND experts according to set criteria. These include consideration of how the drugs work, their safety profiles, and the quality of previous studies. New drugs will be selected for investigation in MND-SMART based on continuous review of constantly updated scientific evidence as well as findings from state-of-the-art human stem cell based drug discovery platforms. These can be added by substantial amendment to the protocol.

Detailed description

For further information, please visit: https://mnd-smart.org/

Interventions

• Drug Memantine Hydrochloride Oral Solution
  Memantine hydrocholoride taken once daily
• Drug Trazodone Hydrochloride oral solution
  Trazodone Hydrochloride taken once daily
• Drug Placebo oral solution
  Placebo taken once daily
• Drug Amantadine Hydrochloride Oral Solution
  Amantadine Hydrochloride taken once daily
• Drug Tacrolimus 1Mg Cap
  Tacrolimus 1Mg overencapsulated tablet taken once daily
• Drug Placebo capsule
  Placebo taken once daily

Primary outcome measures

• Change in decline of ALS-FRS(R) over 18months [Time frame: 18 months]
• Survival [Time frame: 18 months]

Secondary outcome measures (6)

• Cognition and behaviour [Time frame: 18 months]
• Respiratory function - Forced vital capacity [Time frame: 18 months]
• King's ALS Clinical stage [Time frame: 18 months]
• Changes in anxiety and depression [Time frame: 18 months]
• Changes in Quality of Life [Time frame: 18 months]
• Safety and tolerability of IMPs [Time frame: 18 months]

Eligibility criteria

Participants will be considered eligible for randomisation if they fulfil all the core inclusion criteria and none of the exclusion criteria as defined below. In addition, investigators must simultaneously check and ensure participants do not meet any of the drug specific exclusion criteria. If exclusion criteria are met for an arm, participants can still be considered for other arms and randomised accordingly to eligible arms.

Core inclusion criteria:

• Confirmed diagnosis of MND. This includes the following subtypes: ALS by El Escorial Criteria (possible, probable, and definite) or Gold Coast Criteria, Primary Lateral Sclerosis, and Progressive Muscular Atrophy
• Over 18
• Women of childbearing potential according to CTFG guidelines must have a negative pregnancy test within 7 days prior to, or at, the baseline visit
• Women of childbearing potential and fertile men must be using an appropriate method of contraception to avoid any unlikely teratogenic effects of the selected drugs from time of consent, to 4 weeks after treatment inclusive
• Willing and able to comply with the trial protocol and ability to understand and complete questionnaires
• Written informed consent (in the case of limb dysfunction verbal consent can be given in the presence of a witness who can sign)

Core Exclusion Criteria:

• Patients diagnosed with Frontotemporal Dementia (FTD-MND) or any other significant psychiatric disorder that prevents informed consent being given.
• Alcoholism (current self-reported - at the investigator's discretion)
• Active suicide ideation assessed using the Columbia-Suicide Severity Rating Scale
• On concurrent investigational devices and medication (including biological therapy)
• Pregnancy or breast-feeding females
• If ALT, ALP, bilirubin or GGT >3 times the upper limit of normal.
• If creatinine clearance (creatinine clearance or eGFR) <35 ml/min.
• If TSH <0.2mU/l (if possible to test free T4, then Serum free T4 >25pmol/l)
• If corrected QT interval on 12 lead ECG >500 ms
• Patient's diagnosed with ventricular arrhythmias, significant heart block (at the investigator's discretion)) or in the immediate recovery period after myocardial infarction (< 6 weeks).
• Patients who the PI considers will not be able to comply with the study protocol.

Amantadine Exclusion Criteria:

• Patients in the manic phase of bipolar disorder.
• Patients with history of proven peptic ulcer confirmed on endoscopy
• Patients with active epilepsy
• Already taking the IMP in this comparison
• Known hypersensitivity, including hereditary fructose intolerance, or adverse reaction to the active substances and their excipients (as per SPCs for this comparison) or any past medical history contraindicating use of the IMP in this comparison

Tacrolimus Exclusion Criteria:

• Poorly controlled hypertension (Systolic BP>180 mmHg or Diastolic BP>100mmHg)
• Poorly controlled diabetes (HbA1c>6.4% or 48mmol/mol)
• Hypertrophic cardiomyopathy or history of QT prolongation (including family history), congestive heart failure, bradyarrhythmias, and electrolyte abnormalities
• History of bleeding disorders or significant haematological or immune diseases including, congenital or acquired immune deficiency, anaemia (Hb<130g/L for males and Hb<120 g/L in females) and thrombocytopenia (platelet count <150 × 109/L), use of other biological agents and immunosuppressant medications including oral/IV steroids
• Active or chronic infection (at PI discretion)
• History of Hepatitis B or C
• History of lymphoma and active malignancy
• Risk of dehydration due to reduced oral intake and lack of parenteral route
• Patient's contraindicated to tacrolimus according to SPC section 4.3
• Use of concomitant medications that interacts with tacrolimus according to the SPC, including but not limited to strong CYP3A4 inhibitors (i.e. azoles, protease inhibitors) or CYP3A4 inducers (rifampicin, phenytoin, carbamazepine), barbiturates, macrolides, digoxin, statins, PPI inhibitors, ergotamine, tricyclic antidepressants, herbal supplements (St. John's wort, extracts of Schisandra sphenanthera)
• Inability to swallow capsules
• Already taking the IMP in this comparison
• Known hypersensitivity, including lactose and gelatin intolerance, or adverse reaction to the active substances and their excipients (as per SPCs for this comparison) or any past medical history contraindicating use of the IMP in this comparison
• Receipt of a live attenuated vaccine within four weeks prior to receipt of tacrolimus. These include, but are not limited to live influenza vaccine (Fluenz Tetra), Shingles (varicella zoster virus) Zostavax, Varicella (Varilrix, Varilvax), Oral typhoid (Ty21a), and yellow fever vaccines.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Quadruple blind

Primary purpose

Treatment

Study locations

United Kingdom · 22 centers

• Southern Health and Social Care Trust, Craigavon Area Hospital — Portadown
• Aberdeen Royal Infirmary — Aberdeen
• University Hospitals of Birmingham NHS Foundation Trust — Birmingham
• University Hospitals Sussex NHS Foundation Trust — Brighton
• West Suffolk NHS Foundation Trust — Bury St Edmunds
• Cambridge University Hospitals NHS Foundation Trust — Cambridge
• Cardiff and Vale University Local Health Board — Cardiff
• Clinical Research Centre , Ninewells Hospital — Dundee
• … and 14 more centers

Publications

• Pal S, Chataway J, Swingler R, Macleod MR, Carragher NO, Hardingham G, Selvaraj BT, Smith C, Wong C, Newton J, Lyle D, Stenson A, Dakin RS, Ihenacho A, Colville S, Mehta AR, Stallard N, Carpenter JR, Parker RA, Keerie C, Weir CJ, Virgo B, Morris S, Waters N, Gray B, MacDonald D, MacDonald E, Parmar MKB, Chandran S; MND SMART Investigators. Safety and efficacy of memantine and trazodone versus plac PMID 39307154
• Wong C, Gregory JM, Liao J, Egan K, Vesterinen HM, Ahmad Khan A, Anwar M, Beagan C, Brown FS, Cafferkey J, Cardinali A, Chiam JY, Chiang C, Collins V, Dormido J, Elliott E, Foley P, Foo YC, Fulton-Humble L, Gane AB, Glasmacher SA, Heffernan A, Jayaprakash K, Jayasuriya N, Kaddouri A, Kiernan J, Langlands G, Leighton D, Liu J, Lyon J, Mehta AR, Meng A, Nguyen V, Park NH, Quigley S, Rashid Y, Salzin PMID 36725099
• Parker RA, Weir CJ, Pham TM, White IR, Stallard N, Parmar MKB, Swingler RJ, Dakin RS, Pal S, Chandran S. Statistical analysis plan for the motor neuron disease systematic multi-arm adaptive randomised trial (MND-SMART). Trials. 2023 Jan 16;24(1):29. doi: 10.1186/s13063-022-07007-z. PMID 36647114
• Wong C, Dakin RS, Williamson J, Newton J, Steven M, Colville S, Stavrou M, Gregory JM, Elliott E, Mehta AR, Chataway J, Swingler RJ, Parker RA, Weir CJ, Stallard N, Parmar MKB, Macleod MR, Pal S, Chandran S. Motor Neuron Disease Systematic Multi-Arm Adaptive Randomised Trial (MND-SMART): a multi-arm, multi-stage, adaptive, platform, phase III randomised, double-blind, placebo-controlled trial of r PMID 35798516

Identifiers

NCT: NCT04302870 · AC18082

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗