Safety of Switching From Rituximab to Ocrelizumab in MS Patients

• ClinicalTrials.gov Identifier: NCT02980042
• Recruitment Status: Completed
• First Posted: December 2, 2016
• Results First Posted: January 14, 2020
• Last Update Posted: July 21, 2021
• Sponsor: University of Colorado, Denver
• Information provided by (Responsible Party): University of Colorado, Denver

Study Description

Brief Summary:

This is a prospective between and within group observational study to determine differences in tolerability, immunogenicity and safety related outcomes for 100 multiple sclerosis (MS) patients who have been administered at least two infusions of rituximab, six months apart and are willing to be switched to ocrelizumab compared to a 100 patients who are continuing on rituximab as a comparison cohort from the clinic population treated as part of clinical care.

Condition or disease	Intervention/treatment	Phase
Multiple Sclerosis	Drug: Ocrelizumab; Drug: Rituximab	Phase 3

Detailed Description:

Studies of rituximab, a chimeric monoclonal antibody against CD20 have shown that B-cell depletion is of clinical benefit as a potential treatment in relapsing forms of multiple sclerosis (MS).1 Ocrelizumab is a humanized monoclonal antibody that targets CD20 and selectively depletes CD20 expressing cells, while preserving the capacity for B cell reconstitution. When compared with rituximab, ocrelizumab is associated with increased antibody-dependent cell-mediated cytotoxic effects, and reduced complement-dependent cytotoxic effects in vitro.2 By increasing antibody-dependent cell mediated cytotoxic effects, ocrelizumab might modulate tissue-dependent mechanisms of pathogenic response more effectively compared to rituximab. As a humanized molecule, ocrelizumab is expected to be less immunogenic with repeated infusions and might thus present a more favorable safety profile when compared to rituximab.2

Despite rituximab's current off label use in the treatment of MS, currently there is only data available from phase 2 trials. The HERMES group conducted a phase 2, double-blind, 48-week trial involving 104 patients with relapsing forms of MS; 69 patients received 1000 mg of intravenous rituximab and 35 patients received placebo on days 1 and 15.3 A significantly higher number of patients in the rituximab group (78.3%) versus the placebo group (40.0%) had an infusion related reaction (IRR) events within 24 hours after the first infusion. Within 24 hours after the second infusion, fewer patients in the rituximab group (20.3%) than in the placebo group (40%) had similar events. A majority of the rituximab group with IRR events (92.6%) were classified as mild to moderate (grade 1 or 2) in severity.

Safety data from the Investigators Brochure on the OPERA I and II phase 3 trials comparing ocrelizumab to interferon β-1a on relapsing MS patients showed that IRRs were the most common adverse events experienced by patients treated with 600 mg of ocrelizumab.4 The percentage of patients experiencing IRRs was higher in the ocrelizumab group (relapsing forms of MS: 34.3%; primary progressive forms of MS 39.9%) compared with the interferon β-1a (active control) group who received placebo infusions (relapsing forms of MS: 9.7%; primary progressive forms of MS: 25.5%). The rate of IRRs was highest during the first infusion or Dose 1 (27.5% on Day 1; 4.71% on Day 15 of Dose 1) and decreased over time (13.7%; 9.6% and 7.8% following Dose 2, 3, and 4 respectively) for the ocrelizumab treated group. Comparatively, interferon β-1a users experienced 6.5% of IRRs on Day 1, 2.58% on Day 15, < 2.00% after doses 2, 3 and 4 respectively. The reported IRRs were primarily mild-to-moderate in severity (Grades 1 and 2). Serious IRRs occurred in 0.1% and 1.0% respectively of relapsing and progressive patients and treated with ocrelizumab.

Clinical data describing the efficacy and tolerability profile of rituximab and ocrelizumab has utilized populations with different prior treatment characteristics. In the phase 2 HERMES trials, a majority (78.5%) of rituximab patients had been previously been treated with a disease modifying therapy in the last 2 years.3 In contrast, the OPERA I and II phase 3 clinical trials, a majority of ocrelizumab patients (72.9% in OPERA I and 73.8% in OPERA II) represented a treatment naïve population.4 Examining IRRs in patients who have switched from rituximab to ocrelizumab versus those continuing on rituximab will examine the magnitude of the IRRs and subsequent tolerability of ocrelizumab in a real world population.

Earlier concepts of MS disease pathology have suggested that pathogenic T cells are sufficient for the full expression of MS. However, it is now evident that full autoimmune B cells and humoral immune mechanisms also play key roles. 5 Ocrelizumab is a humanized monoclonal antibody that targets CD20 and selectively depleted CD-20 expressing B cells. CD20 is a B cell surface molecule that is expressed on pre B cells and mature B cells, but not expressed earlier in the development of B cells or on mature plasma cells. In all three ocrelizumab studies (with relapsing and progressive populations), treatment with 600 mg of ocrelizumab led to rapid and complete depletion of circulating CD19+ B cells within 14 days post treatment. 4 B cell depletion was sustained throughout treatment period. The median time to repletion of B cells was 72 weeks (range 27-175 weeks). We hypothesize that in switching rituximab treated patients to ocrelizumab, the proportion of patients with B cell depletion (< 1%) 6 months after the first and third infusion of ocrelizumab will be the same as the baseline assessment which will be 6 months after the last dose of rituximab and similar to findings in OPERA I and II.

Immunogenicity results from the OPERA I and II trials examined the number of patients who had treatment induced anti-drug antibodies (ADA) to ocrelizumab. 4 Of the 807 patients who received ocrelizumab and had an ADA assay from a post baseline sample during the controlled treatment period, 3 patients (0.4%) showed treatment induced ADA to ocrelizumab. Of these, 1 patient tested positive for neutralizing antibodies (NAB) to ocrelizumab. During the open label extension phase, the prevalence of ADA continued to remain low with post baseline incidence of 1.9% (2/103 with treatment induced ADA). Currently there is little evidence examining the prevalence of treatment induced ADAs to both rituximab and ocrelizumab in patients that switch from the former to the latter in comparison to continuing rituximab patients. Therefore, we will perform assays to detect ADAs to both rituximab and ocrelizumab in all patients switching from rituximab to ocrelizumab at Day 1, 6 months and 12 months on ocrelizumab.

Finally, IRRs have been hypothesized to be a reaction by autoantibodies to the treatment drug or possibly from the release of cytokines from CD20 expressing cells as they are destroyed by ocrelizumab causing a "cytokine storm". Understanding this process may lead to mechanisms that may aid in ameliorating these infusion reactions. If they are associated with ADA, then it might be possible to predictively premedicate these patients only. Alternatively, if they are associated with cytokine release, it may be possible to eliminate premedication in patients who are already CD20+cell depleted in subsequent infusions. Therefore, we will assay the profile of certain cytokines in the serum 4 hours after start of ocrelizumab infusion.

With ocrelizumab expected to enter the MS therapeutic market within the next year, we expect third party payers within and outside the US will require that the FDA or EMA approved versions of anti-CD20 monoclonal antibodies be used in the treatment of MS, namely ocrelizumab. Currently, we estimate several thousand MS patients in the US and Sweden are taking rituximab currently. Thus, it will be important to demonstrate that switching from a chimeric anti-CD20 to a fully humanized anti-CD20 does not lead to unexpected infusion reactions and does not increase the probability of development of anti-drug antibodies.

The Rocky Mountain MS Center (RMMSC) at the University of Colorado Anschutz Medical Campus prescribed rituximab infusions for 533 MS patients in the last 12 months, of which 323 patients received their infusion at the University of Colorado Hospital's Outpatient Infusion Center between September, 2015-March, 2016. The RMMSC is one of the few sites nationwide with large numbers of MS patients treated with rituximab. With the anticipated approval of ocrelizumab, current rituximab users are being counselled by their MS providers at RMMSC to consider switching to ocrelizumab post approval, particularly if US Payers adopt the FDA approved version as the preferred anti-CD20 agent for MS.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 200 participants
• Allocation: Non-Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Evaluating the Tolerability and Safety Profile of Switching From Rituximab to Ocrelizumab: A Real World Evaluation of Patients With Relapsing Forms of Multiple Sclerosis
• Actual Study Start Date: January 1, 2017
• Actual Primary Completion Date: March 6, 2019
• Actual Study Completion Date: March 6, 2019

Arms and Interventions

Arm	Intervention/treatment
Experimental: Switching Group; 600 mg of ocrelizumab will be administered as one 600-mg IV infusions at a scheduled interval of every 24 weeks. The first dose of ocrelizumab will be a split dose of 300 mg on day 1 and day 15 followed by 600 mg, six months later. Each ocrelizumab infusion should be given as a slow IV infusion over approximately 150 minutes (2.5 hours) for the 300-mg dose. Ocrelizumab must not be administered as an IV push or bolus. Well-adjusted infusion pumps should be used to control the infusion rate, and ocrelizumab should be infused through a dedicated line.	Drug: Ocrelizumab; A humanized monoclonal antibody that targets CD20 and selectively depleted CD-20 expressing B cells; Other Name: Ocrevus
Active Comparator: Comparator Group; Standard of care rituximab doses are 1000 mg infusion given as first dose followed by 500mg (or 1000 mg if evidence of early B cell recovery) infusion every 6 months thereafter. Rituximab must not be administered as an IV push or bolus. Well-adjusted infusion pumps should be used to control the infusion rate, and rituximab should be infused through a dedicated line	Drug: Rituximab; A chimeric monoclonal antibody against CD20.; Other Name: Rituxan

Outcome Measures

Primary Outcome Measures :

1. Proportion of Infusions With >= 1 IRR Between the Switching and Comparator Groups [ Time Frame: Day 1, Day 15, Week 24 ]
   The investigators will report the proportion of infusions with >= 1 IRR (infusion-related reaction) between the switching and comparator groups. Data was collected at Day 1, Day 15, and Week 24 and combined to determine the overall proportion of IRRs over the life of the study.
2. Difference in the Total Number of IRRs After Each Infusion of Ocrelizumab Compared to Rituximab Infusions in the Comparator Group. [ Time Frame: Pre-study (Enrollment), Day 1, Day 15, Week 24 ]
   The investigators will report the difference in the total number of IRRs after each infusion of ocrelizumab compared to combined rituximab infusions in the comparator group.
3. Severity of IRRs Following the Day 1 Infusion of Ocrelizumab in the Switching and the Comparator Groups Infusions [ Time Frame: Day 1, pre-study infusions ]
   The severity of IRRs will be assessed following each infusion of ocrelizumab in the switching and comparator group using the National Cancer Institute's Common Terminology for Adverse Events Scale (Grades range from 1-5, with higher Grades indicating more severe reactions). The frequency of each severity grade of IRR will be compared in a similar fashion .
4. Severity of IRRs Following the Day 15 Infusion of Ocrelizumab in the Switching and the Comparator Groups Infusions [ Time Frame: Day 15, pre-study infusions ]
   The severity of IRRs will be assessed following each infusion of ocrelizumab in the switching and comparator group using the National Cancer Institute's Common Terminology for Adverse Events Scale (Grades range from 1-5, with higher Grades indicating more severe reactions). The frequency of each severity grade of IRR will be compared in a similar fashion.
5. Severity of IRRs Following the Week 24 Infusion of Ocrelizumab in the Switching and the Comparator Groups Infusions [ Time Frame: Week 24, pre-study infusions ]
   The severity of IRRs will be assessed following each infusion of ocrelizumab in the switching and comparator group using the National Cancer Institute's Common Terminology for Adverse Events Scale (Grades range from 1-5, with higher Grades indicating more severe reactions). The frequency of each severity grade of IRR will be compared in a similar fashion .
6. Proportion of Patients With an IRR at Day 1 Versus Day 15 and Week 24 Infusions [ Time Frame: Day 1, Day 15, Week 24 ]
   We will also compare the proportion of patients with an IRR following day 1 infusion versus the proportion of patients with an IRR at day 15 and month 6 infusions of ocrelizumab in the switching group.

Secondary Outcome Measures :

1. Presence of Ocrelizumab Anti-drug Anti-bodies [ Time Frame: Day 1 and Week 24 ]
   Proportion of ocrelizumab patients who test positive for ocrelizumab anti-drug anti-bodies
2. Presence of Rituximab Anti-drug Anti-bodies [ Time Frame: Day 1 and Week 24 ]
   Proportion of patients who test positive for rituximab anti-drug anti-bodies.
3. B Cell Depletion (CD19) [ Time Frame: Day 1, Week 24, 1 Year ]
   Proportion of patients with CD19% <= 1%.
4. B Cell Depletion (CD20) [ Time Frame: Day 1, Week 24, 1 Year ]
   Proportion of patients with CD20% <= 1%
5. Cytokine: Eotaxin - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
   Comparing Eotaxin concentration between pre and post ocrelizumab infusion - Day 1
6. Cytokine: IFN-gamma - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
   Comparing IFN-gamma concentration between pre and post ocrelizumab infusion - Day 1
7. Cytokine: IL-10 - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
   Comparing IL-10 concentration between pre and post ocrelizumab infusion - Day 1
8. Cytokine: IL-12/IL-23p40 - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
   Comparing IL-12/IL-23p40 concentration between pre and post ocrelizumab infusion - Day 1
9. Cytokine: IL-16 - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
   Comparing IL-16 concentration between pre and post ocrelizumab infusion - Day 1
10. Cytokine: IL-1RA - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing IL-1RA concentration between pre and post ocrelizumab infusion - Day 1
11. Cytokine: IL-27 - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing IL-27 concentration between pre and post ocrelizumab infusion - Day 1
12. Cytokine: IL-6 - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing IL-6 concentration between pre and post ocrelizumab infusion - Day 1
13. Cytokine: IL-7 - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing IL-7 concentration between pre and post ocrelizumab infusion - Day 1
14. Cytokine: IL-8(HA) - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing IL-8(HA) concentration between pre and post ocrelizumab infusion - Day 1
15. Cytokine: MCP-1 - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing MCP-1 concentration between pre and post ocrelizumab infusion - Day 1
16. Cytokine: MDC - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing MDC concentration between pre and post ocrelizumab infusion - Day 1
17. Cytokine: MIP-1alpha - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing MIP-1alpha concentration between pre and post ocrelizumab infusion - Day 1
18. Cytokine: MIP-1beta - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing MIP-1beta concentration between pre and post ocrelizumab infusion - Day 1
19. Cytokine: MIP-3alpha - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing MIP-3alpha concentration between pre and post ocrelizumab infusion - Day 1
20. Cytokine: TARC - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing TARC concentration between pre and post ocrelizumab infusion - Day 1
21. Cytokine: TNF-alpha - Pre-Post Infusion - Day 1 [ Time Frame: Day 1 ]
    Comparing TNF-alpha concentration between pre and post ocrelizumab infusion - Day 1
22. Cytokine: Exotaxin - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing Exotaxin concentration between pre and post ocrelizumab infusion - Day 15
23. Cytokine: IFN-gamma - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing IFN-gamma concentration between pre and post ocrelizumab infusion - Day 15
24. Cytokine: IL-10 - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing IL-10 concentration between pre and post ocrelizumab infusion - Day 15
25. Cytokine: IL-12/IL-23p40 - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing IL-12/IL-23p40 concentration between pre and post ocrelizumab infusion - Day 15
26. Cytokine: IL-16 - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing IL-16 concentration between pre and post ocrelizumab infusion - Day 15
27. Cytokine: IL-1beta - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing IL-1beta concentration between pre and post ocrelizumab infusion - Day 15
28. Cytokine: IL-7 - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing IL-7 concentration between pre and post ocrelizumab infusion - Day 15
29. Cytokine: IL-8 - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing IL-8 concentration between pre and post ocrelizumab infusion - Day 15
30. Cytokine: MCP-1 - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing MCP-1 concentration between pre and post ocrelizumab infusion - Day 15
31. Cytokine: MCP-4 - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing MCP-4 concentration between pre and post ocrelizumab infusion - Day 15
32. Cytokine: MDC - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing MDC concentration between pre and post ocrelizumab infusion - Day 15
33. Cytokine: MIP-1beta - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing MIP-1beta concentration between pre and post ocrelizumab infusion - Day 15
34. Cytokine: MIP-3alpha - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing MIP-3alpha concentration between pre and post ocrelizumab infusion - Day 15
35. Cytokine: TNF-alpha - Pre-Post Infusion - Day 15 [ Time Frame: Day 15 ]
    Comparing TNF-alpha concentration between pre and post ocrelizumab infusion - Day 15

Eligibility Criteria

• Ages Eligible for Study: 18 Years to 65 Years (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: Yes

Criteria

Inclusion Criteria:

Switching group:

• Current active patient of RMMSC
• 18-65 years
• Diagnosis of relapsing forms of MS

• Completed ≥ two doses of rituximab with the last dose having been administered:

  1. Within 12 months of screening and
  2. At least 6 months prior to the first planned infusion of study drug
• Are receiving their current infusions of rituximab at the University of Colorado Outpatient Infusion Center
• Have discussed the possibility of switching to ocrelizumab with their MS provider
• Screened for Hepatitis B and C and TB within 2 years of first dose of ocrelizumab
• A negative serum pregnancy test must be available for premenopausal women and for women <12 months after the onset of menopause, unless they have undergone surgical sterilization.
• Women of childbearing potential must agree to use a "highly effective", hormonal form of contraception or two "effective" forms of non-hormonal contraception. Contraception must continue for the duration of study treatment and for at least three months after the last dose of study treatment
• Are able to complete patient reported outcomes developed as English written scales.
• Must be able and willing to give meaningful, written informed consent prior to participation in the trial, in accordance with local regulatory requirements

Comparator group:

• Current active patient of RMMSC
• 18-65 years
• Diagnosis of relapsing forms of MS
• Completed ≥ two doses of rituximab with the last dose having been administered within 12 months of screening as standard of care
• Are receiving their current infusions of rituximab as standard of care at the University of Colorado Outpatient Infusion Center and will continue to do so
• Are willing to be followed for up to two additional rituximab infusions during the study period as standard of care
• Must be able and willing to give meaningful, written informed consent prior to participation in the trial, in accordance with local regulatory requirements

Exclusion Criteria:

Both groups:

• Pregnant or lactating women
• Hypersensitivity to trial medications
• Hepatic Dysfunction (liver enzymes are 5 times greater than normal)
• History of Congestive Heart Failure
• Any history of a positive blood assay for Hepatitis B or C
• Any history of TB or a positive Quantiferon Gold Assay
• Concurrent use of immunosuppressant medications
• Any history of immunodeficiency or other medical condition increasing risk of anti-CD 20 therapy.
• No serious infection at the time of a scheduled study infusion.
• Any medical, psychiatric or other condition that could result in the patient not being able to give fully informed consent, or to comply with the protocol requirements as determined by the investigator

Contacts and Locations

Locations

United States, Colorado

University of Colorado Hospital

Aurora, Colorado, United States, 80045

Sponsors and Collaborators

University of Colorado, Denver

Investigators

• Principal Investigator: Timothy Vollmer, MD; University of Colorado, Denver
• Principal Investigator: Kavita Nair, PhD; University of Colorado, Denver
• Principal Investigator: Enrique Alvarez, MD, PhD; University of Colorado, Denver

  Study Documents (Full-Text)

Documents provided by University of Colorado, Denver:

Study Protocol and Statistical Analysis Plan  [PDF] November 7, 2018

More Information

• Responsible Party: University of Colorado, Denver
• ClinicalTrials.gov Identifier: NCT02980042
• Other Study ID Numbers: 16-1354
• First Posted: December 2, 2016
• Results First Posted: January 14, 2020
• Last Update Posted: July 21, 2021
• Last Verified: July 2021

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Additional relevant MeSH terms:

Multiple Sclerosis; Sclerosis; Pathologic Processes; Demyelinating Autoimmune Diseases, CNS; Autoimmune Diseases of the Nervous System; Nervous System Diseases; Demyelinating Diseases; Autoimmune Diseases; Immune System Diseases; Rituximab; Ocrelizumab; Antineoplastic Agents, Immunological; Antineoplastic Agents; Immunologic Factors; Physiological Effects of Drugs; Antirheumatic Agents