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Using Patient Reported Outcomes (PROs) to Evaluate Teriflunomide Treatment in Relapsing Multiple Sclerosis (RMS) Patients (TERI-PRO)

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ClinicalTrials.gov Identifier: NCT01895335
Recruitment Status : Completed
First Posted : July 10, 2013
Results First Posted : December 6, 2016
Last Update Posted : December 6, 2016
Sponsor:
Information provided by (Responsible Party):
Sanofi

Brief Summary:

Primary Objective:

To describe efficacy, tolerability and convenience of teriflunomide treatment through the evaluation of Participant Reported Outcomes (PROs).

Secondary Objectives:

To describe disease progression using PROs. To describe clinical outcomes (ie, treated relapses) in teriflunomide treated participant.

To describe the change in cognition in teriflunomide treated participants. To describe safety of teriflunomide in participant treated (based on adverse events reporting).

To describe adherence and persistence to teriflunomide treatment. To describe quality of life, activity and leisure over the period of teriflunomide treatment.

To compare Participant Determined Disease Steps (PDDS) and Expanded Disability Status Scale (EDSS) in assessing Multiple Sclerosis (MS) disease progression.


Condition or disease Intervention/treatment Phase
Multiple Sclerosis Drug: Teriflunomide Phase 4

Detailed Description:

The total duration of the study per participant was up to 50 or 54 weeks (if accelerated elimination procedure performed):

Screening: up to 2 weeks Teriflunomide treatment: 48 weeks Accelerated elimination procedure: 4 weeks when performed

An accelerated elimination procedure at any time after discontinuation of teriflunomide treatment was possible and it was particularly recommended for women of child-bearing potential.


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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 1001 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: A Prospective, Single-Arm, Clinical-Setting Study to Describe Efficacy, Tolerability and Convenience of Teriflunomide Treatment Using Patient Reported Outcomes (PROs) in Relapsing Multiple Sclerosis (RMS) Patients
Study Start Date : June 2013
Actual Primary Completion Date : November 2015
Actual Study Completion Date : November 2015

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: Teriflunomide
Teriflunomide 14 mg or 7 mg according to local labelling once daily (QD) orally for 48 weeks.
Drug: Teriflunomide
Pharmaceutical form: film-coated tablet; Route of administration: oral
Other Names:
  • HMR1726
  • Aubagio®




Primary Outcome Measures :
  1. Treatment Satisfaction Questionnaire for Medication (TSQM) Version 1.4 - Assessment of Global Satisfaction Subscale Score With Teriflunomide Treatment at Week 48 [ Time Frame: Week 48 ]

    TSQM version 1.4 is a global satisfaction scale used to assess the overall level of participant's satisfaction or dissatisfaction with their medications. It comprises of 14 items assessing the following 4 domains: effectiveness (questions: 1-3), side effects (questions: 4-8), convenience (questions: 9-11), global satisfaction (questions:12-14).

    Primary outcome was the global satisfaction score. The score of the corresponding item was added based on the algorithm to create a score of 0 to 100. Higher score indicated greater satisfaction in that domain.



Secondary Outcome Measures :
  1. Change From Baseline in TSQM Scores in Participants Switching From Another Disease Modifying Therapy (DMT) at Week 4 and Week 48 [ Time Frame: Baseline, Week 4, Week 48 ]
    TSQM version 1.4 is a global satisfaction scale used to assess the overall level of participant's satisfaction or dissatisfaction with their medications. It comprises of 14 items assessing the following 4 domains: effectiveness (questions: 1-3), side effects (questions: 4-8), convenience (questions: 9-11), global satisfaction (questions: 12-14). For each of the 4 domains the scores of the corresponding items were added based on an algorithm to create a score of 0 to 100. Higher scores indicated greater satisfaction .

  2. Change From Week 4 in TSQM Scores in Naïve Participants to Week 48 [ Time Frame: Week 4, Week 48 ]
    TSQM version 1.4 is a global satisfaction scale used to assess the overall level of participant's satisfaction or dissatisfaction with their medications. It comprises of 14 items assessing the following 4 domains: effectiveness (questions: 1-3), side effects (questions: 4-8), convenience (questions: 9-11), global satisfaction (questions: 12-14). For each of the 4 domains the scores of the corresponding items were added based on an algorithm to create a score of 0 to 100. Higher scores indicated greater satisfaction.

  3. Change From Baseline in Disease Progression Using Patient Determined Disease Steps (PDDS) Score at Week 48 [ Time Frame: Baseline, Week 48 ]
    PDDS scale developed to assess the disability in Multiple Sclerosis (MS) participants and in assessing disease progression that focuses mainly on how participants walk. PDDS scale consists of 0 = normal; 1 = mild disability; 2 = moderate disability; 3 = gait disability; 4 = early cane; 5 = late cane; 6 = bilateral support; 7 = wheelchair/scooter and 8 = bedridden. A higher score represented higher level of disability.

  4. Change From Baseline in Multiple Sclerosis Performance Scale (MSPS) Score at Week 24 and Week 48 [ Time Frame: Baseline, Week 24, Week 48 ]
    MSPS was a self-reported measure for MS associated disability in which participants were asked to indicate the category that best described their condition during the past month on the following 8 subscales: mobility, hand function, vision, fatigue, cognitive symptoms, bladder/bowel, sensory symptoms and spasticity symptoms. MSPS used a single question to assess each of 8 subscales. All of the subscales ranged from 0= normal to 5= total disability, except mobility subscale which ranged from 0= normal to 6=total disability. Total MSPS score ranged from 0 =normal to 41=greater disability, where higher score reflected greater disability.

  5. Annualized Treated Relapse Rate [ Time Frame: Baseline up to end of treatment (up to Week 48) ]
    Annualized treated relapse rate was defined as the total number of treated relapses during the study treatment period divided by the total number participants-years of treatment. Only events occurred during the treatment period (first drug administration to last drug administration) were considered for analysis.

  6. Time to Relapse: Kaplan-Meier Estimates of the Probability of Treated Relapse at Week 4, Week 24 and Week 48 [ Time Frame: Baseline up to end of treatment (up to Week 48) ]
    A treated relapse was defined as a relapse treated by a systemic corticosteroid treatment or by another DMT. If a participant had no treated relapse before treatment discontinuation/completion, then the participant was considered as free of treated relapse until the date of treatment discontinuation/completion. Only treated relapse occurred during the treatment period (first drug administration to last drug administration) were considered for analysis. Kaplan-Meier method was used to estimate the probability of treated MS relapse at 4, 24 and 48 weeks.

  7. Change From Baseline in Cognition Measured by Symbol Digit Modalities Test (SDMT) Score at Week 48 [ Time Frame: Baseline, Week 48 ]
    SDMT measures the time to pair abstract symbols with specific numbers. It is a simple substitution task that gives the examinee 90 seconds to pair specific numbers with given geometric figures as a measure for screening cognitive impairment. The score is computed as a ratio of number of correct responses divided by the total number of responses. The test score range from 0 (worst outcome) to 1 (best outcome). Higher scores are indicative of better cognition function.

  8. Overview of Adverse Events (AEs) [ Time Frame: From first study drug intake up to 112 days after last intake for participant with no AEP or to last AEP follow up visit for participants with AEP ]
    Any untoward medical occurrence in a participant who received investigational medicinal product (IMP) was considered an AE without regard to possibility of causal relationship with this treatment. Treatment-emergent adverse events (TEAEs) were defined as AEs that developed or worsened or became serious during from first study drug intake up to 112 days after last intake for participant with no accelerated elimination procedure (AEP) or to last AEP follow up visit for participants with AEP. A serious adverse event (SAE) was defined as any untoward medical occurrence that resulted in any of the following outcomes: death, life-threatening, required initial or prolonged in-patient hospitalization, persistent or significant disability/incapacity, congenital anomaly/birth defect, or considered as medically important event. Any TEAE included participants with both serious and non-serious AEs.

  9. Percentage of Participants With Treatment Compliance of ≥80% During the Study Treatment Period [ Time Frame: Baseline up to end of treatment (up to Week 48) ]
    Percentage of compliance for a participant was defined as the number of days that the participant was compliant (1 tablet/day) divided by the exposure duration in days (from the first dose administration to the last dose administration) times 100.

  10. Duration of Teriflunomide Treatment Exposure [ Time Frame: Baseline up to end of treatment (up to Week 48) ]
    Duration of exposure was defined as last dose date - first dose date + 1 day, regardless of unplanned intermittent discontinuations and regardless of dosage administered (14 mg or 7 mg).

  11. Change From Baseline in Multiple Sclerosis International Quality of Life (MusiQoL) Score at Week 48 [ Time Frame: Baseline, Week 48 ]
    The MusiQoL is a quality of life questionnaire that consists of 31 questions, divided into 9 dimensions: activities of daily living, physiological well-being, symptoms, relationship with friends, relationship with family, sentimental and sexual life, coping, rejection and relationship with healthcare system. All the 9 dimension scores and the global scores are linearly transformed and standardized on 0 (worst outcome) -100 (best outcome) scale. Higher scores represents higher quality of life.

  12. Change From Baseline in Stern Leisure Activity Scale at Week 48 [ Time Frame: Baseline, Week 48 ]
    The Stern Leisure Activity Scale is a self-reported scale that consists of 13 questions assessing the participant's participation in leisure activities during the preceding month. One point is given for participation in each of the 13 activities and an aggregate score (range from 0 to 13) is obtained. ≤ 6 score is considered as low leisure activity and > 6 score as high leisure activity.

  13. Expanded Disability Status Scale (EDSS) Score at Baseline and Week 48 [ Time Frame: Baseline, Week 48 ]
    EDSS is a method of quantifying disability in MS participants and monitoring changes in the level of disability over time. EDSS quantifies disability in 8 functional systems: pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual, cerebral, and other. EDSS scale ranges from 0 to 10 in 0.5 unit increments that represents higher levels of disability. EDSS score 1.0 to 4.5 refers to people with MS who are fully ambulatory; EDSS score 5.0 to 9.5 refers to impairment to ambulation; EDSS score 10 refers to death due to MS.



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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion criteria:

Participants with a relapsing form of multiple sclerosis (RMS) having signed written informed consent.

Exclusion criteria:

  • According to local labelling,
  • Less than 18 years of age,
  • Current or history of receiving teriflunomide,
  • Previous treatment with leflunomide within 6 months prior to baseline,
  • Participants with preexisting acute or chronic liver disease, or those with serum alanine aminotransferase (ALT) greater than 2 times the upper limit of normal (ULN),
  • Known history of active tuberculosis (TB) or latent TB infection, either diagnosed by standard medical practice or guidelines (including skin or blood test, chest X-ray, or as appropriate per local practice),
  • Known history of severe immunodeficiency, acquired immunodeficiency syndrome (AIDS), bone marrow disease, acute or severe active infections,
  • Women who were pregnant or breast-feeding,
  • Female participants with a positive pregnancy test at screening or women of child-bearing potential who did not agree to use reliable contraception throughout the course of the study,
  • Male participants (only when required according to local labeling): unwilling to use reliable contraception during the course of the study,
  • Additional exclusion criteria applicable for Europe (EU) countries (in accordance with contraindications of EU summary of product characteristics [SmPC]):

    • Participants with significantly impaired bone marrow function or significant anaemia, leukopenia, neutropenia or thrombocytopenia,
    • Participants with severe active infection until resolution,
    • Participants with severe renal impairment undergoing dialysis, because insufficient clinical experience was available in this participant group,
    • Participants with severe hypoproteinaemia, e.g. in nephrotic syndrome.
  • Hypersensitivity to the active substance or to any of the excipients,
  • Other additional contraindications per local labeling.

The above information is not intended to contain all considerations relevant to a participant's potential participation in a clinical trial.


Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01895335


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Locations
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United States, Alabama
Investigational Site Number 840077
Birmingham, Alabama, United States, 35209
Investigational Site Number 840007
Cullman, Alabama, United States
United States, Arizona
Investigational Site Number 840087
Phoenix, Arizona, United States, 85004
Investigational Site Number 840114
Phoenix, Arizona, United States, 85008
Investigational Site Number 840080
Scottsdale, Arizona, United States, 85258
Investigational Site Number 840032
Tucson, Arizona, United States, 85704
United States, Arkansas
Investigational Site Number 840021
Phoenix, Arkansas, United States
United States, California
Investigational Site Number 840018
Fullerton, California, United States, 92835
Investigational Site Number 840037
Fullerton, California, United States, 92835
Investigational Site Number 840108
Long Beach, California, United States, 90806
Investigational Site Number 840014
Newport Beach, California, United States, 92663
Investigational Site Number 840019
Oceanside, California, United States, 92056
United States, Colorado
Investigational Site Number 840097
Boulder, Colorado, United States, 80304
Investigational Site Number 840040
Colorado Springs, Colorado, United States, 80907
Investigational Site Number 840046
Denver, Colorado, United States, CO
Investigational Site Number 840016
Englewood, Colorado, United States, 80113
Investigational Site Number 840094
Fort Collins, Colorado, United States, 80528
United States, Florida
Investigational Site Number 840024
Bradenton, Florida, United States, FL
Investigational Site Number 840089
Clearwater, Florida, United States, 33756
Investigational Site Number 840055
Coconut Creek, Florida, United States, 33073
Investigational Site Number 840104
Hialeah, Florida, United States, 33013
Investigational Site Number 840101
Miami Lakes, Florida, United States, 33014
Investigational Site Number 840011
Ormond Beach, Florida, United States
Investigational Site Number 840059
Sarasota, Florida, United States, 34239
Investigational Site Number 840008
St. Petersburg, Florida, United States
Investigational Site Number 840081
Sunrise, Florida, United States, 33351
United States, Georgia
Investigational Site Number 840002
Atlanta, Georgia, United States, 30318
Investigational Site Number 840075
Macon, Georgia, United States, 31210
United States, Indiana
Investigational Site Number 840012
Fort Wayne, Indiana, United States
Investigational Site Number 840010
Indianapolis, Indiana, United States
United States, Kentucky
Investigational Site Number 840034
Louisville, Kentucky, United States, 40207
United States, Maine
Investigational Site Number 840047
Rockport, Maine, United States, 04843
United States, Massachusetts
Investigational Site Number 840107
Foxboro, Massachusetts, United States, 02035
Investigational Site Number 840030
Springfield, Massachusetts, United States, 01104
United States, Michigan
Investigational Site Number 840073
Clinton Township, Michigan, United States, 48035
United States, Minnesota
Investigational Site Number 840068
Golden Valley, Minnesota, United States, 55422
Investigational Site Number 840098
Golden Valley, Minnesota, United States, 55422
United States, Missouri
Investigational Site Number 840086
Chesterfield, Missouri, United States, 63017
Investigational Site Number 840058
St. Louis, Missouri, United States, 63110
United States, Nebraska
Investigational Site Number 840026
Lincoln, Nebraska, United States, 68521
United States, Nevada
Investigational Site Number 840020
Henderson, Nevada, United States, 89012
United States, New Jersey
Investigational Site Number 840049
Freehold, New Jersey, United States, 07728
Investigational Site Number 840044
Toms River, New Jersey, United States, 08755
United States, New York
Investigational Site Number 840100
East Setauket, New York, United States, 11733-345
Investigational Site Number 840005
New York, New York, United States
Investigational Site Number 840064
NY, New York, United States, 14203
Investigational Site Number 840071
Schenectady, New York, United States, 12308
Investigational Site Number 840091
Staten Island, New York, United States, 10306
Investigational Site Number 840045
Syracuse, New York, United States, 13202
United States, North Carolina
Investigational Site Number 840084
Asheville, North Carolina, United States, 28806
Investigational Site Number 840078
Charlotte, North Carolina, United States, 28204
Investigational Site Number 840042
Raliegh, North Carolina, United States
Investigational Site Number 840105
Sanford, North Carolina, United States
Investigational Site Number 840074
Wilmington, North Carolina, United States, 28401
Investigational Site Number 840090
Winston Salem, North Carolina, United States, 27103
United States, North Dakota
Investigational Site Number 840041
Bismarck, North Dakota, United States
United States, Ohio
Investigational Site Number 840003
Canton, Ohio, United States, 44718
Investigational Site Number 840009
Dayton, Ohio, United States
United States, Pennsylvania
Investigational Site Number 840053
Monaca, Pennsylvania, United States, 15061
Investigational Site Number 840056
Philadelphia, Pennsylvania, United States, 19107
United States, Rhode Island
Investigational Site Number 840072
Cranston, Rhode Island, United States, 02920
United States, Tennessee
Investigational Site Number 840048
Nashville, Tennessee, United States, 37215
Investigational Site Number 840035
Tullahoma, Tennessee, United States, 37388
United States, Texas
Investigational Site Number 840060
Dallas, Texas, United States, 75246
Investigational Site Number 840052
Mansfield, Texas, United States, 76063
Investigational Site Number 840028
San Antonio, Texas, United States, 78229
United States, Virginia
Investigational Site Number 840070
Henrico, Virginia, United States, 23226
Investigational Site Number 840109
Richmond, Virginia, United States, 23298
Investigational Site Number 840017
Roanoke, Virginia, United States, 24018
Investigational Site Number 840054
Vienna, Virginia, United States, 22182
United States, Washington
Investigational Site Number 840069
Spokane, Washington, United States, 99220-3649
United States, West Virginia
Investigational Site Number 840079
Morgantown, West Virginia, United States, 26506-9180
United States, Wisconsin
Investigational Site Number 840038
Milwaukee, Wisconsin, United States, 53215
Investigational Site Number 840112
Milwaukee, Wisconsin, United States
Investigational Site Number 840076
Neenah, Wisconsin, United States, 54956
Austria
Investigational Site Number 040-001
Linz, Austria
Investigational Site Number 040-002
Wien, Austria
Belgium
Investigational Site Number 056006
Brasschaat, Belgium, 2930
Investigational Site Number 056001
Bruxelles, Belgium, 1200
Investigational Site Number 056003
Edegem, Belgium, 2650
Investigational Site Number 056002
Kortrijk, Belgium, 8500
Investigational Site Number 056007
Leuven, Belgium, 3000
Investigational Site Number 056008
Liège, Belgium, 4000
Investigational Site Number 056009
Liège, Belgium, 4000
Investigational Site Number 056005
Melsbroek, Belgium, 1820
Canada
Investigational Site Number 124006
Cambridge, Canada, N1R7L6
Investigational Site Number 124007
St. John, Canada, E2L 4L2
Chile
Investigational Site Number 152003
Concepcion, Chile
Investigational Site Number 152001
Santiago, Chile
Investigational Site Number 152005
Santiago, Chile
Finland
Investigational Site Number 246004
Hämeenlinna, Finland, 13530
Investigational Site Number 246005
Kuopio, Finland
Investigational Site Number 246006
Oulu, Finland, 90220
Investigational Site Number 246001
Turku, Finland, 20520
Investigational Site Number 246003
Turku, Finland, 20520
France
Investigational Site Number 250002
Agen Cedex, France, 47923
Investigational Site Number 250003
Aix En Provence, France, 13616
Investigational Site Number 250004
Albi, France, 81000
Investigational Site Number 250005
Amiens Cedex 1, France, 80054
Investigational Site Number 250006
Bayonne, France, 64109
Investigational Site Number 250007
Bordeaux, France, 33000
Investigational Site Number 250008
Caen, France, 14000
Investigational Site Number 250009
CAHORS Cedex 9, France, 46005
Investigational Site Number 250011
Chambery, France, 73000
Investigational Site Number 250012
Colmar, France, 68024
Investigational Site Number 250001
Dijon, France, 21000
Investigational Site Number 250015
GRENOBLE cedex, France, 38043
Investigational Site Number 250017
Le Mans Cedex 9, France, 72037
Investigational Site Number 250018
Lille Cedex, France, 59037
Investigational Site Number 250019
Limoges Cedex, France, 87000
Investigational Site Number 250020
Lyon Cedex 03, France, 69275
Investigational Site Number 250021
Marseille, France, 13008
Investigational Site Number 250022
Metz-Tessy, France, 74370
Investigational Site Number 250023
Montbeliard, France, 25200
Investigational Site Number 250024
MONTPELLIER Cedex 5, France, 34295
Investigational Site Number 250025
Mulhouse, France, 68100
Investigational Site Number 250026
Nancy, France
Investigational Site Number 250027
Nantes, France, 44093
Investigational Site Number 250028
Nimes, France, 30029
Investigational Site Number 250016
PARIS Cedex 13, France, 75013
Investigational Site Number 250029
PARIS Cedex 20, France, 75970
Investigational Site Number 250043
Pau, France, 64000
Investigational Site Number 250031
Quimper, France, 29000
Investigational Site Number 250032
Reims, France, 51100
Investigational Site Number 250033
Rouen, France, 76000
Investigational Site Number 250030
St Germain En Laye, France, 78100
Investigational Site Number 250035
Strasbourg, France, 67091
Investigational Site Number 250037
Toulouse, France, 31200
Investigational Site Number 250038
Tours, France, 37044
Investigational Site Number 250039
Valence Cedex 9, France, 26953
Investigational Site Number 250040
Valenciennes, France, 59322
Investigational Site Number 250013
VICHY Cedex, France, 03201
Germany
Investigational Site Number 276001
Bergisch-Gladbach, Germany, 51429
Investigational Site Number 276003
Berlin, Germany, 12099
Investigational Site Number 276004
Freiburg, Germany, 79098
Greece
Investigational Site Number 300002
Athens, Greece, 11521
Investigational Site Number 300001
Athens, Greece, 11525
Investigational Site Number 300005
Larissa, Greece, 41110
Investigational Site Number 300004
Thessaloniki, Greece, 546 36
Italy
Investigational Site Number 380008
Ancona, Italy, 60126
Investigational Site Number 380009
Bari, Italy, 70124
Investigational Site Number 380002
Gallarate (VA), Italy, 21013
Investigational Site Number 380001
Milano, Italy, 20132
Investigational Site Number 380004
Milano, Italy, 20133
Investigational Site Number 380006
Napoli, Italy, 80138
Investigational Site Number 380005
Orbassano (TO), Italy, 10043
Norway
Investigational Site Number 578002
Bergen, Norway, 5021
Investigational Site Number 578003
Namsos, Norway, 7800
Investigational Site Number 578001
Oslo, Norway, 0407
Spain
Investigational Site Number 724002
Barcelona, Spain, 08035
Investigational Site Number 724010
Córdoba, Spain, 14004
Investigational Site Number 724008
Donostia, Spain, 20014
Investigational Site Number 724001
El Palmar (MURCIA), Spain, 30120
Investigational Site Number 724004
La Coruña, Spain, 15006
Investigational Site Number 724006
Santiago de Compostela, Spain, 15706
Investigational Site Number 724007
Valencia, Spain, 46009
Investigational Site Number 724005
Valladolid, Spain, 47011
Sweden
Investigational Site Number 752001
Karlstad, Sweden, 65185
Investigational Site Number 752003
Kungsbacka, Sweden, 43480
Investigational Site Number 752002
Motala, Sweden, 59185
United Kingdom
Investigational Site Number 826-005
Birmingham, United Kingdom, B152TH
Investigational Site Number 826-003
Brighton, United Kingdom, BN25BE
Investigational Site Number 826-007
Glasgow, United Kingdom, G116NT
Investigational Site Number 826-008
Leeds, United Kingdom, LS13EX
Investigational Site Number 826-010
Leicester, United Kingdom, LE54PW
Investigational Site Number 826-009
London, United Kingdom, SW170QT
Investigational Site Number 826-001
Norwich, United Kingdom, nr34dg
Investigational Site Number 826-006
Romford, United Kingdom, RM70AG
Investigational Site Number 826-004
Salford, United Kingdom, M68HD
Sponsors and Collaborators
Sanofi
Investigators
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Study Director: Clinical Sciences & Operations Sanofi

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: Sanofi
ClinicalTrials.gov Identifier: NCT01895335     History of Changes
Other Study ID Numbers: LPS13567
U1111-1139-8730 ( Other Identifier: UTN )
First Posted: July 10, 2013    Key Record Dates
Results First Posted: December 6, 2016
Last Update Posted: December 6, 2016
Last Verified: October 2016

Additional relevant MeSH terms:
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Sclerosis
Multiple Sclerosis
Pathologic Processes
Demyelinating Autoimmune Diseases, CNS
Autoimmune Diseases of the Nervous System
Nervous System Diseases
Demyelinating Diseases
Autoimmune Diseases
Immune System Diseases