Talisman is global clinical study (20058N) in Multiple System Atrophy (MSA) patients. It will be conducted in two regions (China and the European Union [EU]). There will be common study objectives between China and EU regions (including prospective assessments for MSA disease progression during routine clinical visits for MSA), and this will allow for data (on common objectives) to be presented overall and stratified by region. There will also be study objectives specific to each region: 1) the clinical assessment for MSA (Unified MSA Rating Scale [UMSARS]) has not been validated using standardised methods in China, and so the psychometric properties of the Chinese version of the UMSARS will be examined in Chinese patients in this study; 2) there will be retrospective assessments and prospective protocol-mandated assessments (of Magnetic Resonance Imaging [MRI] and bloods biomarkers) and study visits for EU patients.

Because some study objectives are the same for China and the EU (i.e., prospective assessments during routine clinical visits for MSA), and other objectives are specific to each region, there will be one regional protocol for China and one regional protocol for the EU; each describing the study assessments relevant to each region.

Multiple system atrophy (MSA) is a sporadic, rapidly progressing neurodegenerative disorder. Most MSA patients are diagnosed between 50 to 60 years of age and the mean survival time is 6 to 10 years from symptom onset, with few surviving more than 15 years from symptom onset. The rapid progression and complexity of the disease, as well as its unresponsiveness to drugs, such as Levodopa for parkinsonian symptoms, makes MSA a challenging disease to treat. Based on the predominant motor features at the time of clinical evaluation, MSA is classified as either MSA with predominant parkinsonism (MSA-P) or MSA with predominant cerebellar ataxia (MSA-C).

MSA is an orphan and rare disease. The prevalence estimate of MSA is 3 to 5 per 100,000 in the general population. The prevalence estimate ranges from 2 to 5 per 100,000 in the United States and European Union (EU) and from 7 to 20 per 100,000 in Japan. MSA-P comprises approximately 70% of cases in the US and EU, whilst MSA-C comprises approximately 70% of cases in Japan.

Blood and MRI biomarkers have been evaluated in MSA patients. NfL (Neurofilament light protein) levels are increased in the cerebrospinal fluid (CSF) and plasma of patients with MSA and correlate with MSA disease severity, as measured by the unified MSA rating scale (UMSARS). An accurate estimate of NfL levels over time could help monitor MSA prognosis and help define the timepoints that could be targeted for effective treatment.

Furthermore, MSA patients with abnormal brain MRI findings have faster clinical progression of MSA, as evaluated with the UMSARS total score and UMSARS Part II (clinical examination). A recent review on the role of MRI in MSA noted that whilst MRI is a promising tool for diagnosing and monitoring disease progression; well-designed, large, prospective studies are needed before MRI biomarkers could be incorporated into a neuroimaging-supported diagnosis of MSA. The knowledge gained from this study should help improve understanding of biomarkers and other disease progression outcomes in MSA. This could allow MSA disease progression to be monitored and therefore treated more effectively. Insights into the natural course of disease in MSA patients in the EU will be combined and compared with data on the natural course of disease in MSA patients in China, as part of a larger global cohort. Specifically, the natural course of MSA will be explored in patients in China (using [Chinese versions of] the same prospective observational assessments as the current prospective protocol in the EU). This will allow for data collected prospectively during routine visits for MSA in China to be combined and compared with data collected prospectively during routine visits for MSA in the EU.

The extension part of Talisman:

The extension of Talisman will describe early MSA disease progression and mortality assessed remotely via telephone call with either the participant or care-partner in 6-month intervals up until 60 months after enrolling in extension study. The long-term extension will generate knowledge on long-term disease progression and survival in MSA.

Inclusion Criteria:

1. The patient must be aged between ≥40 and ≤75 years, at baseline.
2. The patient must be diagnosed with possible or probable MSA of the parkinsonian subtype (MSA-P) or cerebellar subtype (MSA-C), according to the Gilman criteria (version 2).
3. The patient must have an anticipated survival of at least 3 years in the opinion of the study investigator, at baseline.
4. The patient had onset of motor MSA symptoms within 5 years prior to the baseline visit in the judgement of the study investigator.
5. The patient must have an UMSARS Part I score of ≤16 (omitting question 11 on sexual function), at baseline.
6. The patient must have normal cognition (i.e., Montreal Cognitive Assessment [MoCA] score ≥22), at baseline.
7. The patient's caregiver must have approximately 3 hours per week contact with the patient and be available and able to accompany the patient to routine clinical visits throughout the study, to provide information on the patient's functional abilities.
8. The patient/patient's legally acceptable representative, and the patient's caregiver are willing to provide written voluntary informed consent.
9. The patient's treatments are prescribed according to routine clinical practice and local guidelines/regulations.

Exclusion criteria:

1. The patient has evidence (clinical or on MRI) and/or history of any serious neurological disorder, other intracranial or systemic diseases or conditions resulting in a diagnosis other than MSA.
2. The patient has two or more blood relatives with a history of MSA.
3. The patient is, in the investigator's opinion, unlikely to comply with the protocol.
4. The patient has previously been enroled in this study.
5. The patient is a member of the study personnel or of their immediate family or is a subordinate (or immediate family member of a subordinate) to any of the study personnel.

Approximately 140 patients with relatively early MSA from China and EU are expected to be enroled in this study during a 9-month enrolment.