Immunoglobulin Deficiency a Treatable Cause of Fatigue in Patients With Multiple Sclerosis (MS)?

Study Overview
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Brief Summary
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The investigators hypothesize that hypogammaglobulinemia (defined as IgG serum concentration <7.0g/L) is a treatable cause of fatigue in people with MS: The primary objective is to prove the link between hypogammaglobulinemia and fatigue in patients with multiple sclerosis. The secondary objective is to show that fatigue is mediated via frequent infections in people with MS and hypogammaglobulinemia.

Detailed Description
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Multiple sclerosis (MS) is the most common cause of mental and physical disability in young adults affecting approximately 10'000-15'000 persons in Switzerland (incidence 16/100000; prevalence 190/100000). MS-fatigue affects at least 75% of the MS-patients (affected persons in Switzerland 7500-11250). MS-related fatigue has socioeconomic consequences leading to increased sick leaves and a higher probability of unemployment. Effective treatment strategies for MS-fatigue are missing, despite the appearance of more effective immunotherapies to treat autoimmune neuroinflammation and to control MS disease activity. The reason for the lack of therapeutic options is the unclear pathophysiological mechanism of fatigue with many non-MS associated influencing factors like thyroid dysfunction and anaemia. Fatigue is also present in other inflammatory diseases, cancers and immunodeficiency syndromes. Regarding the latter patients with primary immunodeficiencies (PIDs) and common variable immunodeficiency (CVID) suffer from fatigue in 30 - 76%, which is more common than in the normal population. Studies investigating immunoglobulin replacement therapy in patients with CVID demonstrated a correlation between the frequency of infusions / s.c. applications and wear-off effect/fatigue. Immunoglobulin deficiency seems to be much more common in people with autoimmune diseases. In MS reduced serum immunglobulin G (IgG) concentrations regardless of immunotherapy affect between 8 - 26% of the patients. Nonetheless consequences of IgG hypogammaglobulinemia in MS are partly unknown. However, based on the findings in patients with CVID, fatigue might be one of them. To close this knowledge gap prospective observational studies are needed.

Official Title
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Immunoglobulin Deficiency a Treatable Cause of Fatigue in Patients With Multiple Sclerosis (MS)? - A Prospective Observational Fatigue Trial

Conditions
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Hypogammaglobulinemia, Multiple Sclerosis, Fatigue

Intervention / Treatment
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* Diagnostic Test: Laboratory test


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis of Multiple Sclerosis following McDonald 2017-Criteria Age 18-65 years Stable MS disease at inclusion (definition: no clinical relapse, no MRI activity, stable disability within the last 12 months) Unchanged immunotherapy within the last 12 months Expanded Disability Status Scale (EDSS) level <4 points indicating fully ambulatory patients. Capability of written informed consent Exclusion Criteria: Severe depression (definition: Beck Depression Index-II (BDI-II) ≥29 points) or other established psychiatric diagnosis Immunodeficiency other than hypogammaglobulinemia Immunglobulin replacement therapy or indication for immunoglobulin replacement therapy Severe Sleepiness (definition: Epworth-Sleepiness-Scale (ESS) >16 points) Fatigue aggravating factors such: liver/renal/thyroid dysfunction, substance abuse, medication (tranquilizers /antiepileptics/psychopharmaceuticals), chronic infectious disease (like hepatitis/HIV). Other neurodegenerative/autoimmune disease. Patients not able to give written consent Vulnerable patients such as children, pregnant women and prisoners

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| MS patients with IgG deficiency (serum IgG-concentration <7g/L).<br>MS patients with IgG deficiency (serum IgG-concentration <7g/L). | Diagnostic Test: Laboratory test<br>* Frequency of fatigue (defined as Fatigue Scala for Motor and Cognitive Function (FSMC) total ≥ 43 points) in MS patients with IgG-deficiency<br>* Other names: Fatigue Score;|
| MS patients with normal IgG serum concentration (serum IgG-concentration ≥7g/L).<br>MS patients with normal IgG serum concentration (serum IgG-concentration ≥7g/L). | Diagnostic Test: Laboratory test<br>* Frequency of fatigue (defined as Fatigue Scala for Motor and Cognitive Function (FSMC) total ≥ 43 points) in MS patients with IgG-deficiency<br>* Other names: Fatigue Score;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of patients with fatigue and hypogammaglobulinemia | The primary endpoint will be measured as frequency (%) of fatigue (defined as Fatigue Scala for Motor and Cognitive Function (FSMC) total ≥ 43 points) in MS patients with IgG-deficiency (IgG serum concentration <7.0 g/L) compared to those with normal IgG-serum concentration (≥ 7.0 g/L). The FSMC is an assessment of MS-related cognitive and motor fatigue. A Likert-type 5-point scale (ranging from 'does not apply at all' to 'applies completely') produces a score between 1 and 5 for each scored question. Thus minimum value is 20 (no fatigue at all) and maximum value is 100 (severest grade of fatigue) FSMC Sum Score: ≥ 43 points mild fatigue, ≥ 53 points moderate fatigue, ≥ 63 severe fatigue | 1.5 years | 
| Number of patients with fatigue without hypogammaglobulinemia | The primary endpoint will be measured as frequency (%) of fatigue (defined as Fatigue Scala for Motor and Cognitive Function (FSMC) total ≥ 43 points) in MS patients with IgG-deficiency (IgG serum concentration <7.0 g/L) compared to those with normal IgG-serum concentration (≥ 7.0 g/L). The FSMC is an assessment of MS-related cognitive and motor fatigue. A Likert-type 5-point scale (ranging from 'does not apply at all' to 'applies completely') produces a score between 1 and 5 for each scored question. Thus minimum value is 20 (no fatigue at all) and maximum value is 100 (severest grade of fatigue) FSMC Sum Score: ≥ 43 points mild fatigue, ≥ 53 points moderate fatigue, ≥ 63 severe fatigue | 1.5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Fatigue and infections | As secondary endpoint the frequency of infections (infection/months) in MS patients will be measured and compared between those with (IgG serum concentration <7.0 g/L) and without hypogammaglobulinemia (IgG serum concentration ≥ 7.0 g/L). Furthermore, the mediation of fatigue by frequency of infections* will be detailed in the cohort of MS patients with hypogammaglobulinemia. *A telephone interview with 6 questions about the frequency of infections will take place once a month. | 1.5 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Fatigue, Hypogammaglobulinemia