Treatment of Inflammatory Myelitis and Optic Neuritis With Early vs Rescue Plasma Exchange (TIMELY-PLEX)

Official title

A Randomized Controlled, Open-Label, Rater-Blinded Pragmatic Trial, Treatment of Inflammatory Myelitis and Optic Neuritis With Early vs Rescue Plasma Exchange (TIMELY-PLEX)

Overview

The purpose of this research is to evaluate if early vs rescue Therapeutic Plasma Exchange (PLEX) treatment algorithm leads to better visual outcomes in severe Optic Neuritis and leads to better neurological disability outcomes in severe Transverse Myelitis.

Interventions

• Drug High-dose corticosteroids (HDCS)
  Subjects will receive initial treatment with high-dose corticosteroids (HDCS) in the form of methylprednisolone (1,000mg daily) administered intravenously for 5 days or a bioequivalent dose of oral corticosteroids (e.g., 1,250mg prednisone daily or 176mg dexamethasone daily). Subjects will be escalated to PLEX if there is an insufficient response to HDCS (decision point at 14±2 days for the ON sub-trial and 7±2 days for the TM sub-trial) PLEX will be performed as 5 sessions over 5-10 days, with
• Drug High-dose corticosteroids (HDCS) and PLEX
  Subjects will receive treatment with high-dose corticosteroids (HDCS) and PLEX initiated concurrently. HDCS will be administered in the form of methylprednisolone (1,000mg daily) administered intravenously for 5 days or a bioequivalent dose of oral corticosteroids (e.g., 1,250mg prednisone daily or 176mg dexamethasone daily). PLEX will be performed as 5 sessions over 5-10 days, with 1-1.5 plasma volumes exchanged per session.

Primary outcome measures

• High contrast visual acuity [Time frame: 6 months]
• Expanded Disability Status Score (EDSS) [Time frame: 6 months]

Secondary outcome measures (11)

• Low contrast (2.5%) visual acuity [Time frame: 6 months]
• Peri-papillary retinal nerve fiber layer (RNFL thickness) [Time frame: 6 months]
• Macular ganglion cell-inner plexiform layer (GCIPL) thicknesses [Time frame: 6 months]
• Hardy Rand and Rittler (HRR) color plates [Time frame: 6 months]
• National Eye Institute (NEI) 10-Item Neuro-Ophthalmic Supplement [Time frame: 6 months]
• Ambulatory disability [Time frame: 6 months]
• Manual dexterity (Nine-Hole Peg Test) [Time frame: 6 months]
• Patient Determined Disease Steps (PDDS) [Time frame: 6 months]
• Spinal Cord Injury Quality of Life questionnaire (SCI-QoL) [Time frame: 6 months]
• PLEX Complications [Time frame: 2 weeks, 1 month]
• National Eye Institute (NEI) Visual Function Questionnaire (VFQ)-25 [Time frame: 6 months]

Eligibility criteria

Study Population and Setting

The proposal will recruit participants presenting to participating sites with severe ON or severe TM to two separate sub-trials. The detailed inclusion and exclusion criteria for each sub-trial are listed below:

Optic Neuritis Sub-Trial:

Inclusion criteria

• ≥18 years of age
• MRI orbits demonstrating evidence of new T2 hyperintensity and/or post-gadolinium contrast enhancement of the optic nerve(s) and meeting the clinical criteria for Optic Neuritis
• Visual acuity 20/200 or worse
• Within 8 days of onset of visual symptoms
• Able to initiate PLEX within 72h of the first dose of HDCS (if randomized to the "Early PLEX" treatment arm)
• Able to sign and date informed consent form
• Willingness to comply with all study procedures and availability for the duration of the study

Exclusion criteria

• Evidence of prior episode of optic neuritis in the affected eye (by history or ophthalmological evaluation)
• Ophthalmological comorbidity that would significantly affect best corrected visual acuity or visual fields
• Pregnancy
• Presence of any contraindication to receiving HDCS or PLEX, including, but not limited to, hemodynamic instability, significant bleeding/coagulopathy, or sepsis.
• Any medical condition that, in the opinion of the investigator, may interfere with the patient's participation in the trial, pose any added risk for the patient, or confound the assessment of the patient (including but not limited to concurrent neurological disease and/or medical comorbidity)
• Treatment with any investigational agent within 6 months of baseline or five half-lives of the investigational agent (whichever is longer)
• Ongoing/prior treatment with immune-modulating/immunosuppressive therapy including:

• Mycophenolate mofetil, azathioprine, methotrexate, fingolimod, siponimod, ponesimod, ozanimod, tocilizumab, satralizumab, eculizumab or ravulizumab within 3 months of randomization
• Anti-CD20 (rituximab, ocrelizumab, ofatumumab, ublituximab) or anti-CD19 (inebilizumab) therapy within 6 months of randomization
• Intravenous or subcutaneous immune globulin within 3 months of randomization
• Plasma exchange within 3 months of randomization
• Interferon-beta, glatiramer acetate, fumarates (dimethyl fumarate, monomethyl fumarate, diroximel fumarate) within 1 month of randomization
• Teriflunomide use within prior 24 months
• Systemic corticosteroid therapy (intravenous or oral; excluding inhaled or topical corticosteroids) within 1 month of randomization
• Any previous treatment with alemtuzumab, cladribine, mitoxantrone or cyclophosphamide
• Previous treatment with any immune-modulating or immunosuppressive therapy not mentioned above within 6 months of randomization or five-half-lives (whichever is longer)

Transverse Myelitis Sub-Trial:

Inclusion criteria

• ≥18 years of age
• Diagnosis of Transverse Myelitis (defined based on modified criteria adapted from the 2002 Transverse Myelitis Consortium Working Group; ALL are required)

• Development of sensory, motor and/or autonomic symptomatology attributable to spinal cord dysfunction
• Onset of symptoms to nadir >12 hours
• Exclusion of extra-axial compressive etiology by neuroimaging
• Demonstration of inflammation within the spinal cord by presence of intramedullary T2 lesion (post-gadolinium enhancing OR non-enhancing) on MRI
• Expanded Disability Status Scale \[EDSS\] ≥3.0 (excluding visual and cerebral functional systems)
• EDSS Pyramidal Functional System Score ≥ 2
• Within 8 days of onset of motor symptoms
• Able to initiate PLEX within 48h of the first dose of HDCS (if randomized to the "Early PLEX" treatment arm)
• Able to sign and date informed consent form
• Willingness to comply with all study procedures and availability for the duration of the study

Exclusion criteria

• Pre-existing ambulatory, motor, sensory, or bowel/bladder disability of any cause that could confound trial assessments
• Fulfillment of possible, probable or definite spinal cord infarction diagnosis per proposed diagnostic criteria (Zalewski et al. JAMA Neurology 2018)
• History of radiation to the spine
• Pregnancy
• High clinical suspicion for infectious etiology of myelitis (e.g., fever, rash or other findings)
• Presence of any contraindication to receiving HDCS or PLEX, including, but not limited to, hemodynamic instability, significant bleeding/coagulopathy, or sepsis.
• Any medical condition that, in the opinion of the investigator, may interfere with the patient's participation in the trial, pose any added risk for the patient, or confound the assessment of the patient (including but not limited to concurrent neurological disease and/or medical comorbidity)
• Treatment with any investigational agent within 24 weeks of baseline or five half-lives of the investigational agent (whichever is longer)

• Ongoing/prior treatment with immune-modulating/immunosuppressive therapy including: Mycophenolate mofetil, azathioprine, methotrexate, fingolimod, siponimod, ponesimod, ozanimod, tocilizumab, satralizumab, eculizumab or ravulizumab within 3 months of randomization
• Anti-CD20 (rituximab, ocrelizumab, ofatumumab, ublituximab) or anti-CD19 (inebilizumab) therapy within 6 months of randomization
• Intravenous or subcutaneous immune globulin within 3 months of randomization
• Plasma exchange within 3 months of randomization
• Interferon-beta, glatiramer acetate, fumarates (dimethyl fumarate, monomethyl fumarate, diroximel fumarate) within 1 month of randomization
• Teriflunomide use within prior 24 months
• Systemic corticosteroid therapy (intravenous or oral; excluding inhaled or topical corticosteroids) within 1 month of randomization
• Any previous treatment with alemtuzumab, cladribine, mitoxantrone or cyclophosphamide
• Previous treatment with any immune-modulating or immunosuppressive therapy not mentioned above within 6 months of randomization or five-half-lives (whichever is longer)

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

Open label

Primary purpose

Treatment

Study locations

United States · 33 centers

• Mayo Clinic Arizona — Scottsdale
• Loma Linda University — Loma Linda
• University of California, Davis — Sacramento
• University of Colorado - Anschutz Medical — Aurora
• Yale University School of Medicine — North Haven
• Mayo Clinic Florida — Jacksonville
• University of Miami — Miami
• University of Illinois Chicago — Chicago
• … and 25 more centers

Identifiers

NCT: NCT07100990 · 25-000657

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗