A Study to Assess Efficacy and Safety of Adjunctive KarXT in Subjects With Inadequately Controlled Symptoms of Schizophrenia

Phase 3

Recruiting

• Conditions: Schizophrenia
• Interventions: Drug: Xanomeline and Trospium Chloride Capsules; Drug: Placebo

• Registration Number: NCT05145413
• Lead Sponsor: Karuna Therapeutics

Brief Summary

This is a Phase 3, 6-week, randomized, double-blind, placebo-controlled, multicenter, outpatient study in subjects with schizophrenia with an inadequate response to their current atypical antipsychotic treatment. The primary objective of the study is to assess the efficacy of adjunctive KarXT (a fixed dose combination of xanomeline and trospium chloride twice daily \[BID\]) versus placebo in the treatment of subjects with inadequately controlled symptoms of schizophrenia as measured by the Positive and Negative Syndrome Scale (PANSS) Total Score.

Detailed Description

Not available

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations
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Related News

Study Timeline

• Study Start: 2021-11-12
• Study First Submitted: 2021-11-23
• Study First Submitted QC: 2021-11-23
• Study First Posted: 2021-12-06
• Status Verified: 2024-12
• Last Update Submitted: 2024-12-02
• Last Update Posted: 2024-12-04
• Primary Completion: 2025-02-28
• Study Completion: 2025-02-28

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 360

Inclusion Criteria

1. Subject is aged ≥18 to <65 years at the time of randomization
2. Subject is capable of providing signed Informed Consent Form before any study assessments will be performed
3. Subject has a primary diagnosis of schizophrenia established by a comprehensive psychiatric evaluation based on the DSM-5 criteria and confirmed by Mini International Neuropsychiatric Interview for Schizophrenia and Psychotic Disorder Studies (MINI) version 7.0.2
4. Subject is currently being treated with stable dosing of monotherapy risperidone, paliperidone, aripiprazole, or their LAIs ziprasidone, lurasidone, or cariprazine and has been taking this treatment with the same dosing regimen for at least 8 weeks at the time of Day 1 (Visit 3)
5. The subject has had at least 1 previous inadequate response to above antipsychotics that was dosed appropriately (within the label) for at least 6 weeks
6. The subject has not required psychiatric hospitalization, incarceration in prison, acute crisis intervention, or other increase in the level of care due to symptom exacerbation within 8 weeks of Screening and is psychiatrically stable in the opinion of the Investigator
7. To be eligible for randomization, subjects need to have detectable levels of background antipsychotic medication (measured at Visit 1)
8. Positive and Negative Syndrome Scale (PANSS) total score ≥ 70 at Screening and randomization
9. Clinical Global Impression-Severity (CGI-S) scale with a score ≥ 4 (moderate) at Screening and randomization
10. PANSS Marder Positive symptom factor ≥ 4 on 2 (or more) items (PANSS items, delusions, hallucinations, grandiosity, suspiciousness and persecution, stereotyped thinking, somatic concern, unusual thought content or lack of judgment and insight), at Screening and randomization
11. Subjects with ≤ 20-point decrease in PANSS Total score between Visit 1 and Visit 3
12. Subject is willing and able to visit the clinic in an outpatient setting for the study duration, follow instructions, and comply with the protocol requirements
13. Body Mass Index (BMI) must be within 18 to 40 kg/m2 (inclusive of both values)
14. Subject resides in a stable living situation in the opinion of the Investigator
15. Subject has identified a reliable informant/ caregiver willing and able to assist with study activities as needed throughout the subject's participation in the study. The informant needs to be physically present at the Baseline visit, but can complete the remaining study visits assessments via phone (as needed and as per local regulations). In Bulgaria, the informant needs to physically present at the Baseline visit and should be physically present at all study visits where the Investigator determines that his/her input would be beneficial.
16. Women of childbearing potential (WOCP), or men whose sexual partners are WOCP, must be able and willing to use at least 1 highly effective method of contraception during the study and for at least 1 menstrual cycle (e.g., 30 days) after the last dose of study drug. Sperm donation is not allowed for 30 days after the final dose of the study drug. A female subject is considered to be a WOCP after menarche and until she is in a postmenopausal state for 12 months or otherwise permanently sterile (for which acceptable methods include hysterectomy, bilateral salpingectomy, or bilateral oophorectomy)

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Exclusion Criteria

1. Any primary DSM-5 disorder other than schizophrenia within 12 months before screening (confirmed using MINI version 7.0.2 at screening)

2. The subject has a history of moderate to severe substance use disorder (other than nicotine) within the past 12 months

   1. A Screening subject with mild substance use disorder within the 12 months before Screening must be discussed with the Medical Monitor before being allowed into the study
   2. Subjects who test positive for cannabis at Screening may be permitted to enroll in consultation with the Medical Monitor if the subject's pattern of use is not indicative of a moderate to severe substance use disorder

3. Subject has a history of treatment-resistant schizophrenia defined as:

   a. Failure to minimally respond to 2 adequate courses of antipsychotic drug (APD) pharmacotherapy Note: Failure to minimally respond is defined as persistence symptoms of moderate severity in 2 or more psychotic symptom domains or persistence of severe symptoms in 1 or more psychotic symptom domains despite adequate dose and duration (6 weeks or longer) of APD treatment.

4. History of symptom instability

   a. > 3 psychiatric hospitalizations over the last 12 months or 2 over the last 6 months

5. Current APD is other than aripiprazole, risperidone, paliperidone, or their LAI versions, ziprasidone, lurasidone, or cariprazine

6. Subjects who are diagnosed with schizophreniform disorder or are experiencing their first treated episode of schizophrenia

7. Significant or severe medical conditions including pulmonary, cardiovascular, hepatic, renal, hematologic, gastrointestinal, endocrine, immunologic, dermatologic, neurologic, or oncologic disease or any other condition that, in the opinion of the Investigator, could jeopardize the safety of the subject or the validity of the study results

   1. eGFR < 60 mL/min
   2. Alanine transaminase or aspartate transaminase (AST) > 1.5 x upper limit of normal (ULN)
   3. Total bilirubin > 1.5 x ULN (Subjects with Gilbert's syndrome can be included as long as direct bilirubin is ≤ 1.5 x ULN)

8. Subjects with human immunodeficiency virus (HIV), cirrhosis, biliary duct abnormalities, hepatobiliary carcinoma, and/or active hepatic viral infections as indicated by medical history, serologies or LFT results

9. History or high risk of urinary retention, gastric retention, or narrow-angle glaucoma as evaluated by the Investigator

10. History of irritable bowel syndrome (with or without constipation) or any serious constipation requiring treatment within the last 6 months

11. Risk for suicidal behavior during the study as determined by the Investigator's clinical assessment and/or C-SSRS as confirmed by the following:

    1. Answers "Yes" on items 4 or 5 (C-SSRS - ideation) with the most recent episode occurring within the 2 months before Screening or,
    2. Answers "Yes" to any of the 5 items (C-SSRS behavior) with an episode occurring within the 12 months before Screening

12. Clinically significant abnormal finding on the physical examination, medical history, ECG, or clinical laboratory results at Screening

13. Urine toxicology screen is positive for phencyclidine, amphetamines, opiates, cocaine, or alcohol (clinically significant alcohol use in the opinion of the Investigator)

14. Subject is currently taking, or plans to take while in the study, any prohibited concomitant medication.

15. Pregnant, lactating, or less than 3 months postpartum

16. If, in the opinion of the Investigator and/or Sponsor/Medical Monitor subject is unsuitable for enrollment in the study or subject has any finding that, in the view of the Investigator and/or Sponsor/Medical Monitor, may compromise the safety of the subject or affect his/her ability to adhere to the protocol visit schedule or fulfill visit requirements

17. Positive test for coronavirus (COVID-19) within 2 weeks or at Screening

18. Subjects with extreme concerns relating to global pandemics, such as COVID-19, that would obscure ratings or be expected to disrupt adherence to trial procedures

19. Unable to taper and discontinue a concomitant medication that would preclude participation in the double-blind adjunctive treatment (e.g., cannot stop anticholinergic)

20. Subjects with prior exposure to KarXT

21. Subjects who experienced any adverse effects due to xanomeline or trospium

22. Subjects who received investigational product as part of a clinical trial within 3 months of Screening

23. Risk of violent or destructive behavior as per Investigator's judgment that would interfere with subject's participation

24. Current involuntary hospitalization or incarcerationor on parole/probation

25. For all male subjects only, any one of the following:

    1. History of bladder stones
    2. History of recurrent urinary tract infections
    3. Serum prostate specific antigen (PSA) >10 ng/mL
    4. An International Prostate Symptom Score (IPSS) of 5 (almost always) on either item 1, 3, 5, or 6
    5. A sum of scores on IPSS items 1, 3, 5, and 6 of ≥9 Note: IPSS will be required only for male subjects ≥ 45 years of age. Subjects already enrolled in the study will have these assessments at their next clinic visit planned after re-consenting to determine current eligibility.

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Drug: KarXT	Xanomeline and Trospium Chloride Capsules	-
Placebo	Placebo	-

Primary Outcome Measures

Name	Time	Method
Change From Baseline in Positive and Negative Syndrome Scale (PANSS) Total Score at Week 6	Week 6	The PANSS is a medical scale used for measuring symptom severity of participants with schizophrenia. The PANSS rating form contains 7 positive symptom scales, 7 negative system scales, and 16 general psychopathology symptom scales. Participants are rated from 1 to 7 on each symptom scale. The total score is the sum of all scales with a minimum score of 30 and a maximum score of 210. A decrease in PANSS total score correlates with an improvement in schizophrenia symptoms.

Secondary Outcome Measures

Name	Time	Method
Change from Baseline in Personal Social Performance (PSP) at Week 6	Week 6	The PSP scale assesses functioning using a structured clinical interview across four dimensions: socially useful activities, personal and social relationships, self-care, and disturbing and aggressive behaviors. The PSP provides a score between 1 and 100 using a 6-point severity scale
Change from Baseline in Clinical Global Impression-Severity (CGI-S) at Week 6	Week 6	The CGI-S modified asked the clinician 1 question: "Considering your total clinical experience, how mentally ill is the participant at this time?" The clinician's answer rated on the following 7-point scale: 1 = normal, not at all ill; 2 = borderline mentally ill; 3 = mildly ill; 4 = moderately ill; 5 = markedly ill; 6 = severely ill; 7 = among the most extremely ill participants.
Change from Baseline in Positive and Negative Syndrome Scale (PANSS) Marder Positive symptom factor score at Week 6	Week 6	The Positive Marder Factor score is derived from the PANSS and consists of the sum of 4 positive symptom items (P), one negative symptom item (N) and 3 general symptom items (G) (P1. Delusions; P3. Hallucinations; P5. Grandiosity; P6. Suspiciousness and persecution; N7. Stereotyped thinking; G1. Somatic concern; G9. Unusual thought content; G12. Lack of judgment and insight).
Change from Baseline in Positive and Negative Syndrome Scale (PANSS) Marder Negative symptom factor score at Week 6	Week 6	The Negative Marder Factor score is derived from the PANSS and consists of the sum of 5 negative symptom items (N) and 2 general symptom items (G) (N1. Blunted affect; N2. Emotional withdrawal; N3. Poor rapport; N4. Passive/apathetic social withdrawal; N6. Lack of spontaneity; G7. Motor retardation; and G16. Active social avoidance), with a minimum score of 7 and a maximum score of 49.
Categorical response defined as the proportion of subjects achieving a ≥ 30% improvement in PANSS total score at Week 6	Week 6
Preference of Medication (POM) at Week 6	Week 6	The POM is a two-item questionnaire assessing the patient's and informant's preference, respectively, for the current antipsychotic as compared with the most recent pre-study antipsychotic. The POM is scored on the following scale: 1 = 'much better, I prefer this medication,' 2 = 'slightly better,' 3 = 'about the same,' 4 = 'slightly worse,' and 5 = 'much worse, I much prefer my previous medication.'

Trial Locations

Locations (163)

Local Institution - 502; 🇵🇱 Siemianowice Śląskie, Poland

Local Institution - 508; 🇵🇱 Suchy Las, Poland

Local Institution - 504; 🇵🇱 Tuszyn, Poland

Local Institution - 803; 🇷🇴 Brasov, Romania

Local Institution - 804; 🇷🇴 Bucuresti, Romania

Local Institution - 810; 🇷🇴 Bucuresti, Romania

Local Institution - 802; 🇷🇴 Bucuresti, Romania

Local Institution - 809; 🇷🇴 Bucuresti, Romania

Local Institution - 807; 🇷🇴 Bucuresti, Romania

Local Institution - 808; 🇷🇴 Craiova, Romania

Local Institution - 801; 🇷🇴 Galati, Romania

Local Institution - 806; 🇷🇴 Iasi, Romania

Local Institution - 805; 🇷🇴 Sibiu, Romania

"Clinical Center "" Dr Dragisa Misovic Dedinje"""; 🇷🇸 Belgrade, Serbia

Institute of Mental Health; 🇷🇸 Belgrade, Serbia

Local Institution - 413; 🇷🇸 Belgrade, Serbia

Local Institution - 417; 🇷🇸 Belgrade, Serbia

University Clinical Center of Serbia; 🇷🇸 Belgrade, Serbia

"Special Hospital for Psychiatric Diseases ""Kovin"""; 🇷🇸 Kovin, Serbia

Local Institution - 414; 🇷🇸 Kovin, Serbia

University Clinical Center Kragujevac; 🇷🇸 Kragujevac, Serbia

Local Institution - 415; 🇷🇸 Nis, Serbia

Special Hospital for Psychiatric Diseases Gornja Toponica; 🇷🇸 Nis, Serbia

"Special Hospital for Psychiatric Diseases ""Sveti Vracevi"""; 🇷🇸 Novi Knezevac, Serbia

Local Institution - 416; 🇷🇸 Novi Knezevac, Serbia

"Special Hospital for Psychiatric Disease ""Dr Slavoljub Bakalovic"""; 🇷🇸 Vrsac, Serbia

Local Institution - 707; 🇬🇧 Pool, Reruth, Cornwall, United Kingdom

Local Institution - 705; 🇬🇧 Brighton, East Sussex, United Kingdom

Cnri-San Diego; 🇺🇸 San Diego, California, United States

Local Institution - 192; 🇺🇸 Atlanta, Georgia, United States

CenExel iResearch, LLC; 🇺🇸 Savannah, Georgia, United States

Perceptive Pharma Research; 🇺🇸 Richmond, Texas, United States

Green Mountain Research Institute; 🇺🇸 Rutland, Vermont, United States

Local Institution - 613; 🇮🇳 Vadodara, Gujarat, India

Local Institution - 617; 🇮🇳 Belgavi, Karnataka, India

Local Institution - 614; 🇮🇳 Mangalore, Karnataka, India

Local Institution - 602; 🇮🇳 Mangalore, Karnataka, India

Local Institution - 601; 🇮🇳 Mysore, Karnataka, India

Local Institution - 611; 🇮🇳 Kozhikode, Kerala, India

Local Institution - 610; 🇮🇳 Aurangabad, Maharashtra, India

Local Institution - 619; 🇮🇳 Mumbai, Maharashtra, India

Local Institution - 603; 🇮🇳 Nagpur, Maharashtra, India

Local Institution - 608; 🇮🇳 Nashik, Maharashtra, India

Local Institution - 605; 🇮🇳 Nashik, Maharashtra, India

Local Institution - 615; 🇮🇳 Ajmer, Rajasthan, India

Local Institution - 618; 🇮🇳 Bikaner, Rajasthan, India

Local Institution - 606; 🇮🇳 Rajkot, Rajasthan, India

Local Institution - 612; 🇮🇳 Lucknow, Uttar Pradesh, India

Local Institution - 250; 🇯🇵 Toyoake, Aichi, Japan

Local Institution - 901; 🇯🇵 Toyoake, Aichi, Japan

Local Institution - 253; 🇯🇵 Meguro-ku, Tokyo, Japan

Local Institution - 252; 🇯🇵 Setagaya-ku, Tokyo, Japan

Local Institution - 251; 🇯🇵 Shibuya-ku, Tokyo, Japan

Local Institution - 910; 🇯🇵 Shibuya-ku, Tokyo, Japan

Local Institution - 506; 🇵🇱 Bialystok, Poland

Local Institution - 507; 🇵🇱 Gdansk, Poland

Local Institution - 509; 🇵🇱 Grudziadz, Poland

Local Institution - 501; 🇵🇱 Kielce, Poland

Local Institution - 503; 🇵🇱 Lodz, Poland

Local Institution - 505; 🇵🇱 Lublin, Poland

Reliable Clinical Research LLC; 🇺🇸 Hialeah, Florida, United States

Galiz Research, LLC; 🇺🇸 Hialeah, Florida, United States

At Health Texas; 🇺🇸 Richmond, Texas, United States

The Rivus Wellness & Research Institute; 🇺🇸 Oklahoma City, Oklahoma, United States

InSite Clinical Research; LLC; 🇺🇸 DeSoto, Texas, United States

JPS Health Network; 🇺🇸 Fort Worth, Texas, United States

Alea Research; 🇺🇸 Phoenix, Arizona, United States

Local Institution - 147; 🇺🇸 Phoenix, Arizona, United States

Pillar Clinical Research, LLC; 🇺🇸 Richardson, Texas, United States

Woodland International Research Group, LLC; 🇺🇸 Little Rock, Arkansas, United States

Advanced Research Center, Inc.; 🇺🇸 Anaheim, California, United States

CITrials - Bellflower; 🇺🇸 Bellflower, California, United States

Synexus Clinical Research US, Inc.; 🇺🇸 New York, New York, United States

Clinical Innovations Inc.; 🇺🇸 Costa Mesa, California, United States

Proscience Research Group; 🇺🇸 Culver City, California, United States

Omega Clinical Trials; 🇺🇸 La Habra, California, United States

Sunwise Clinical Research, LLC.; 🇺🇸 Lafayette, California, United States

Synergy Clinical Research of Escondido; 🇺🇸 Lemon Grove, California, United States

Encino Hospital Medical Center; 🇺🇸 Los Angeles, California, United States

Excell Research, Inc.; 🇺🇸 Oceanside, California, United States

Neuropsychiatric Research Center of Orange County; 🇺🇸 Orange, California, United States

CNRI - Los Angeles, LLC; 🇺🇸 Pico Rivera, California, United States

CenExel Clinical Innovations, Inc.; 🇺🇸 Riverside, California, United States

Stanford University School of Medicine; 🇺🇸 Stanford, California, United States

CenExel Collaborative Neuroscience Research; 🇺🇸 Torrance, California, United States

Larkin Community Hospital Behavioral Health Services; 🇺🇸 Hollywood, Florida, United States

San Marcus Research Clinic, Inc.; 🇺🇸 Miami Lakes, Florida, United States

Assertive Research Center; 🇺🇸 Miami Lakes, Florida, United States

South Florida Research Phase I-IV, Inc.; 🇺🇸 Miami Springs, Florida, United States

Segal Institute for Clinical Research; 🇺🇸 Miami, Florida, United States

Premier Clinical Research Institute, Inc.; 🇺🇸 Miami, Florida, United States

Local Institution - 124; 🇺🇸 Orange City, Florida, United States

Pines Care Research Center, Inc.; 🇺🇸 Pembroke Pines, Florida, United States

Interventional Psychiatry of Tampa Bay; 🇺🇸 Tampa, Florida, United States

Local Institution - 186; 🇺🇸 Tampa, Florida, United States

Grady Memorial Hospital; 🇺🇸 Atlanta, Georgia, United States

Local Institution - 135; 🇺🇸 Augusta, Georgia, United States

CenExel iResearch Atlanta; 🇺🇸 Decatur, Georgia, United States

Psych Atlanta, P.C.; 🇺🇸 Marietta, Georgia, United States

Northwestern University; 🇺🇸 Chicago, Illinois, United States

American Medical Research, Inc.; 🇺🇸 Chicago, Illinois, United States

Uptown Research Institute, LLC; 🇺🇸 Chicago, Illinois, United States

Phoenix Medical Research, Inc.; 🇺🇸 Prairie Village, Kansas, United States

St. Francis Medical Center; 🇺🇸 Monroe, Louisiana, United States

CenExel Center for Behavioral Health; 🇺🇸 Gaithersburg, Maryland, United States

Local Institution - 158; 🇺🇸 Boston, Massachusetts, United States

Local Institution - 187; 🇺🇸 Boston, Massachusetts, United States

Local Institution - 185; 🇺🇸 Worcester, Massachusetts, United States

Local Institution - 184; 🇺🇸 Ann Arbor, Michigan, United States

Western Michigan University Homer Stryker M.D. School of Medicine; 🇺🇸 Kalamazoo, Michigan, United States

Michigan State University; 🇺🇸 Lansing, Michigan, United States

Arch Clinical Trials LLC; 🇺🇸 Creve Coeur, Missouri, United States

PsychCare Consultants Research; 🇺🇸 Saint Louis, Missouri, United States

Omaha Insomnia and Psychiatric Services LLC; 🇺🇸 Omaha, Nebraska, United States

Altea Research Institute, Las Vegas; 🇺🇸 Las Vegas, Nevada, United States

CenExel Hassman Research Institute; 🇺🇸 Marlton, New Jersey, United States

Manhattan Psychiatric Center; 🇺🇸 New York, New York, United States

Manhattan Behavioral Medicine, PLLC; 🇺🇸 New York, New York, United States

Psychiatry and Alzheimer's Care of Rochester. PLLC; 🇺🇸 Rochester, New York, United States

Richmond Behavioral Associates ERG Clinical Research - New York PLLC; 🇺🇸 Staten Island, New York, United States

IMA Clinical Research Hickory; 🇺🇸 Hickory, North Carolina, United States

Insight Clinical Trials LLC; 🇺🇸 Beachwood, Ohio, United States

University of Cincinnati Medical Center; 🇺🇸 Cincinnati, Ohio, United States

Local Institution - 168; 🇺🇸 Garfield Heights, Ohio, United States

Prevention Science Institute; 🇺🇸 Eugene, Oregon, United States

Community Clinical Research, Inc.; 🇺🇸 Austin, Texas, United States

Local Institution - 183; 🇺🇸 Houston, Texas, United States

Local Institution - 180; 🇺🇸 Houston, Texas, United States

University Hills Clinical Research - Irving; 🇺🇸 Irving, Texas, United States

Northwest Clinical Research Center; 🇺🇸 Bellevue, Washington, United States

Ambulatory for Individual Practice for Specialized Medical Care in Psychiatry - Dr Ivo Natsov; 🇧🇬 Cherven Bryag, Bulgaria

Medical Centre Asklepii, OOD; 🇧🇬 Dupnitsa, Bulgaria

Medical Center Lifemed; 🇧🇬 Kardzhali, Bulgaria

MHAT Dr. Hristo Stambolski, EOOD; 🇧🇬 Kazanlak, Bulgaria

State Psychiatric Hospital Sv. Ivan Rilski, Novi Iskar; 🇧🇬 Novi Iskar, Bulgaria

Medical Center Medconsult Pleven OOD; 🇧🇬 Pleven, Bulgaria

UMHAT 'Dr. Georgi Stranski', EAD; 🇧🇬 Pleven, Bulgaria

UMHAT Sv. Georgi, EAD; 🇧🇬 Plovdiv, Bulgaria

Local Institution - 321; 🇧🇬 Plovdiv, Bulgaria

Local Institution - 313; 🇧🇬 Razgrad, Bulgaria

MHAT Dr Ivan Seliminski AD; 🇧🇬 Sliven, Bulgaria

"Medical Center ""Sv.Naum"""; 🇧🇬 Sofia, Bulgaria

MHC - Sofia, EOOD; 🇧🇬 Sofia, Bulgaria

Local Institution - 320; 🇧🇬 Sofia, Bulgaria

DCC Sv. Vrach and Sv. Sv. Kuzma and Damyan, OOD; 🇧🇬 Sofia, Bulgaria

Medical Center Akademika EOOD; 🇧🇬 Sofia, Bulgaria

Medical Center Hera EOOD; 🇧🇬 Sofia, Bulgaria

Medical Center Intermedica, OOD; 🇧🇬 Sofia, Bulgaria

Medical Center VAS OOD; 🇧🇬 Targovishte, Bulgaria

DCC Mladost M - Varna, OOD; 🇧🇬 Varna, Bulgaria

Mental Health Center-Vratsa EOOD; 🇧🇬 Vratsa, Bulgaria

Local Institution - 616; 🇮🇳 Guwahati, Assam, India

Local Institution - 607; 🇮🇳 Ahmedabad, Gujarat, India

Local Institution - 604; 🇮🇳 Ahmedabad, Gujarat, India

Local Institution - 609; 🇮🇳 Surat, Gujarat, India

Local Institution - 701; 🇬🇧 London, Greater London, United Kingdom

Local Institution - 706; 🇬🇧 Ashton Under Lyne, Greater Manchester, United Kingdom

Local Institution - 710; 🇬🇧 Manchester, Greater Manchester, United Kingdom

Local Institution - 709; 🇬🇧 Maidstone, Kent, United Kingdom

Local Institution - 708; 🇬🇧 Oxford, Oxfordshire, United Kingdom

Local Institution - 704; 🇬🇧 Glasgow, Strathclyde, United Kingdom

Local Institution - 702; 🇬🇧 Chertsey, Surrey, United Kingdom

Local Institution - 703; 🇬🇧 Birmingham, West Midlands, United Kingdom