Teriflunomide and Fatigability in MS

The goal of this observational study is to learn about the effects of teriflunomide on walking and cognitive fatigability in individuals with relapsing multiple sclerosis (MS) who are starting this treatment as part of their routine medical care. The main question it aims to answer is:

Does teriflunomide reduce walking fatigability and cognitive fatigability in individuals with relapsing MS over a 12-month period? Participants who have recently started teriflunomide as part of their standard MS treatment will undergo clinical evaluations at baseline, 3 months, 6 months, and 12 months. These assessments will include functional tests (6-Minute Walk Test, Symbol Digit Modalities Test, 9-Hole Peg Test, EDSS, and 25-Foot Walk Test), patient-reported outcomes (HADS, TSQM, fatigue and hair-related assessments), and routine clinical data collection (MRI and laboratory tests).

Study Overview

This prospective, multicenter, observational study aims to assess the real-world effectiveness and safety of teriflunomide in individuals with relapsing multiple sclerosis (MS). The study will evaluate the impact of teriflunomide on walking fatigability and cognitive fatigability over a 12-month follow-up period. As this is an observational study, no interventions will be assigned, and participants will continue their prescribed teriflunomide treatment as part of their routine MS care.

Study Objectives

The primary objective is to determine whether teriflunomide reduces walking fatigability, measured by the 6-Minute Walk Test (6MWT), and cognitive fatigability, assessed through the Symbol Digit Modalities Test (SDMT).

The secondary objectives include evaluating:

Functional performance, including the Expanded Disability Status Scale (EDSS), 25-Foot Walk Test, and 9-Hole Peg Test (9-HPT).

Patient-reported outcomes (PROMs) such as anxiety, depression, treatment satisfaction, fatigue, and hair-related concerns.

Radiological findings, including MRI-based lesion evolution over the study period.

Safety assessments, including laboratory results and adverse events classified using Common Terminology Criteria for Adverse Events (CTCAE).

Study Design \& Data Collection

Participants will be evaluated at four time points: baseline (before or at treatment initiation), 3 months, 6 months, and 12 months. The data collection includes:

Functional and cognitive tests (6MWT, SDMT, 9-HPT, EDSS, 25-Foot Walk Test). Patient-reported outcomes (HADS, TSQM, Fatigue Severity Scale, and VAS scales for hair thinning and hair loss).

Routine MRI and laboratory test results, collected as part of regular clinical care.

Adverse event reporting following the CTCAE classification system.

Data Quality and Validation

A quality assurance plan will be implemented to ensure the validity and reliability of the collected data.

Data validation procedures will include automatic range checks and logical consistency verification between data fields.

Source data verification will be performed through electronic medical records (EMRs) to ensure completeness and accuracy.

A data dictionary will be established, detailing all variables, coding systems (such as MedDRA for adverse events), and predefined normal ranges.

Registry Procedures and Standard Operating Procedures (SOPs)

The study will follow SOPs for:

Patient recruitment, ensuring adherence to inclusion/exclusion criteria. Data collection and management, with electronic case report forms (eCRFs) designed to capture all relevant clinical and patient-reported outcomes.

Adverse event monitoring and reporting, using standardized grading systems. Change management, including protocols for addressing protocol amendments and modifications.

Statistical Analysis Plan

A sample size assessment will be conducted to ensure sufficient statistical power to detect meaningful differences in walking and cognitive fatigability over the study period.

Primary analysis will involve repeated-measures mixed-effects modeling to evaluate within-subject changes in walking and cognitive fatigability from baseline to 12 months.

Secondary analyses will include linear regression models and subgroup analyses based on disease characteristics, MRI findings, and patient-reported outcomes.

Handling of missing data will follow an intent-to-treat approach, using multiple imputation techniques for sensitivity analyses.

This real-world observational study will provide critical insights into the long-term effects of teriflunomide on functional performance, patient experience, and safety in individuals with relapsing MS.

Eligibility Criteria:
Inclusion Criteria:

* Relapsing Multiple Sclerosis (RRMS or active SPMS) diagnosis, confirmed according to the 2017 revised McDonald criteria.
* 18 years or older at the time of enrollment.
* Newly initiated teriflunomide treatment as part of routine clinical care.
* Ambulatory status (EDSS ≤ 7.0), capable of completing study assessments.
* Ability and willingness to provide informed consent and comply with study procedures.

Exclusion Criteria:

* Diagnosis of Primary Progressive Multiple Sclerosis (PPMS).
* Severe comorbidities affecting mobility or cognitive function (e.g., advanced cardiovascular, pulmonary, or neuromuscular disease).
* Neurological or psychiatric conditions that prevent cognitive testing (e.g., advanced cognitive impairment, untreated severe depression).
* Severe upper extremity motor dysfunction, limiting 9-Hole Peg Test (9-HPT) or Symbol Digit Modalities Test (SDMT) completion.
* Pregnancy or breastfeeding at the time of enrollment.
* Inability to comply with study visits at baseline, 3 months, 6 months, and 12 months.