`Multiple Sclerosis
`M. B. BORNSTEIN: A. I. MILLER: s. SLAGLE:
`R. A R N O N , ~ M. SELA,~ AND D. TEITELBAUM’
`aThe AIbert Einstein College of Medicine
`Bronx, New York 10461
`
`‘The Weizmann Institute
`Rehovot, Israel
`
`INTRODUCTION
`
`The understanding of the pathogenetic mechanisms involved in multiple sclerosis
`(MS) and the search for an effective treatment have been intimately associated with
`the laboratory model, experimental allergic encephalomyelitis (EAE). The validity of
`EAE as such a model system has been clearly and convincingly presented by Paterson
`in a series of scholarly publications.’4 Our own work in tissue cultureS also served to
`relate MS. as a naturally occurring disorder, to its laboratory counterpart, EAE.
`Organotypic cultures of mammalian C N S tissue respond with identical patterns of
`demyelination: swollen myelin sheaths,’ and eventual “sclerosis”* when exposed to
`serum from EAE (whole white matter)-affected animals and MS patients. The
`demyelinating effect is not produced by these EAE sera on cultured peripheral nerve
`which, nevertheless, are responsive to serum from animals with experimental allergic
`neuritis.’.’’ The cultures also demonstrated the capacity of mammalian CNS to
`remyelinate after being demyelinated by anti~era.~*’ These laboratory demonstrations
`provided further support for the extension to M S patients of therapeutic possibilities
`arising from animal studies.
`The synthetic polypeptide, copolymer I (COP I), was prepared from alanine,
`glutamic acid, lysine, and tyrosine (TABLE 1) as one of a series of compounds which,
`alone or in combination with various lipids, might simulate the ability of myelin basic
`protein (MBP) to induce EAE (Sela, personal communication). None of the prepara-
`tions proved to be encephalitogenic, i.e., capable of inducing EAE, but some,
`particularly COP I, did suppress EAE in animals challenged with either whole white
`matter or MBP in complete Freund’s adjuvant. The numerous laboratory investiga-
`tions of the effectiveness of COP I in EAE, involving mice, rats, guinea pigs, rabbits,
`monkeys, chimpanzees and baboons are of particular interest to the clinical trials and
`have recently been reviewed by Arnon and Teitelbaum.” In addition, extensive
`laboratory studies failed to demonstrate any toxicological or other undesirable side
`reactions in experimental animals exposed to COP I under a variety of testing
`situations (A. Meshorer, personal communication). Finally, Abramsky ef a1.’* first
`examined COP I for its effect on three patients with acute disseminated encephalo-
`myelitis (ADE) and four with terminal MS. The three ADE patients recovered rapidly
`and completely. The MS patients may have demonstrated slight improvements. What
`is more important in these first clinical studies was the absence of any significant
`undesirable side reactions.
`This report presents the data derived from a preliminary trial of the effectiveness of
`copolymer I in patients with the exacerbating-remitting (ER) and chronic progressive
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`(CP) types of MS. It will also describe the extensions of that study to pilot trials in each
`group of patients, their organizational aspects and present position.
`A preliminary trial is
`. . . conducted for the purpose of establishing dosages, studying toxicity, and obtaining a
`lead as to the possible efficacy of a new treatment which may be a new investigative
`drug . . . Different dosages with different schedules. . . are tried on a few patients who are
`very closely monitored for toxic reactions. For the assessment of therapeutic dosages, the
`patient with MS will serve as his own control. Therefore, the physician-investigator should
`be well acquainted with the medical history and past clinical course of M S in each
`patient.. . in most instances, it will not be necessary to involve more than perhaps 10
`patients in a given preliminary trial. If the preliminary trial brings forth evidence of
`therapeutic efficacy and little or no evidence of serious toxicity, it would be reasonable to
`move onto the next stage of investigation, the pilot trial.I3
`
`CONDUCT OF THE PRELIMINARY TRIAL
`
`Sixteen MS patients participated in the preliminary trial. They represented a
`broad spectrum of neurological involvement ranging from those of the chronic
`
`TABLE I. Composition of Copolymer I“
`
`N-Carboxyanhydride
`Used for Reaction
`Amino Acid
`alanine
`alanine
`benzyl glutamate
`glutamic acid
`N-trifluoroacet yl-l ysine
`lysine
`tyrosine
`tyrosine
`“Molecular weight: 23,000.
`
`Amount Used in
`the Reaction
`(mM)
`
`8.6
`6.0
`14.0
`3.0
`
`15
`23
`52
`14
`
`Molar Ratio of
`Amino Acid
`in Copolymer
`6.0
`1.9
`4.1
`I .o
`
`progressive type, some of whom were essentially bed or wheelchair bound, to those of
`the exacerbating-remitting type who were fully active and employed between attacks.
`There were four of the ER type and twelve of the C P type. All patients had been well
`known to the principal investigator (MBB) for years prior to their entry into the study.
`Some had participated as volunteers in earlier clinical and laboratory studies whereas
`others had been unsuccessfully tried on immunosuppressant therapy.
`The preliminary trial was conducted as an open s t ~ d y . ’ ~ All patients were given the
`COP I and all knew they were receiving it. The evaluating neurologist (AM) was also
`aware that this was an open study and that all patients were being treated. The initial
`dosage schedule was suggested by the group at the Weizmann Institute on the basis of
`their previous studies with laboratory animals,” such as nonhuman primates, as well as
`the brief trial that was performed by Dr. Oded Abramsky.I2 Thus, it was planned to
`prepare the COP I at a concentration of 5 mg per ml of sterile saline solution. This was
`to be given to each patient intramuscularly five times a week for the first three weeks,
`three times a week for the next three weeks, twice a week for the next three weeks, and,
`finally, once a week for the balance of a six-month period, at which time we originally
`planned to terminate the trial.
`At the time of introduction into the study, the first five patients were hospitalized
`at the General Clinical Research Center of the Albert Einstein College of Medicine.
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`They were examined and evaluated by Dr. Miller, samples of peripheral blood and
`cerebrospinal fluid were taken, and the copolymer injections were started. In the
`beginning, the patients were hospitalized during the first three weeks of treatment,
`because we had no knowledge as to whether or not there would be any significant local
`or systemic effects in patients who had multiple sclerosis. We did not, however, note
`any undesirable side reactions of any significance and soon found it unnecessary to
`keep the participants in the hospital for any period longer than was prudent following
`the lumbar puncture, usually 24 to 48 hours. The patients were seen, however, on an
`outpatient basis at the Clinical Research Center and their neurological status
`reevaluated at various times during the course of the following months.
`The specific aims of the preliminary trial were to determine the following: ( I ) Did
`COP I produce any apparent significant or undesirable side reactions? (2) Did COP I
`produce any apparent desirable effects? (3) Could a dosage schedule be established for
`further (pilot) trials should they appear to be warranted?
`
`RESULTS OF THE PRELIMINARY TRIAL
`
`During the institution of the copolymer treatment, many patients reported and, in
`fact, demonstrated early improvements in various neurological functions. As time went
`on, however, and the dosage of COP I was reduced as originally planned, these early
`improvements disappeared and most patients returned to their previous neurological
`status and continued their chronic progressive course. Over the period of the next
`months, the dosage was gradually increased in an effort to determine whether or not
`the previously observed effect was dose related. By the end of the first eighteen-month
`period, those patients who were still on the copolymer were receiving 20 mg a day in I
`ml of saline, 7 days a week. Three patients are still on this schedule, some 3-4 years
`later. This is the dosage currently being used in the pilot study.
`As for undesirable side reactions, patients occasionally reported transient slight
`pain, discomfort, itching, swelling or redness at the injection site. No systemic or
`general reactions of any kind were noted or reported during the preliminary trial.
`Examinations of urine were unremarkable. Of the sixteen patients, two of the ER type
`withdrew from the study at the time of an acute attack. One later returned. Of the
`balance, all remained in the study for at least six months as originally planned. Finally,
`three patients have been maintained to this date on 20 mg daily. In general, 1 1 of the
`16 patients demonstrated no apparent favorable effects in that they either had an
`exacerbation during the course of the study or continued their chronic progressive
`course. On the other hand, 5 of the 16 patients have demonstrated a definite change for
`the better. (See TABLE 2.)
`Nine patients received COP I for over two years, a few for over four years. No
`patient in this group has had any significant or undesirable local or systemic side
`reaction.
`
`LABORATORY DATA
`
`Laboratory examinations have included CBC, routine urinalysis and culture and
`blood chemistry analyses (SMA 6 and 12) VDRL, CSF protein and glucose and cells.
`Except for an occasional and transient eosinophilia (reaching 16% in one instance) no
`significant changes have been noted in any of these clinical tests. There has been no
`evidence of albuminuria or other evidence of altered kidney function. No pertinent
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`alteration of the patient’s serum demyelinating potency on CNS cultured tissues has
`been observed. Several sera have been examined for antibody titers against COP 1. In
`general, they have not been elevated. Lymphoblast transformation in response to
`phytohemagglutinin, MBP and COP I has not occurred.
`
`EXTENSION TO PILOT TRIALS
`
`The question now is whether or not the demonstrated improvements were, in fact,
`due to the polypeptide. As stated by Brown et u I . , ‘ ~ the aim of a pilot trial is “to
`
`TABLE 2. Results of Preliminary Trial of Copolymer I Therapy in 16 Patients with
`Multiple Sclerosis
`
`Sex
`F
`M
`F
`F
`M
`F
`
`F
`
`M
`F
`M
`
`Patient
`IY
`RH
`GT
`PP
`AT
`PM
`
`~
`
`Type
`CP”
`46
`CP
`25
`CP
`35
`E R ~
`30
`CP
`23
`CP
`39
`
`JP
`
`JW
`KJ
`CN
`
`WR
`SM
`HW
`SR
`FH
`
`JM
`
`ER
`
`CP
`CP
`ER
`
`CP
`CP
`CP
`CP
`ER
`
`CP
`
`39
`
`32
`33
`32
`
`49
`42
`36
`38
`27
`
`34
`
`“Chronic progressive.
`’Exacerbating-remitting.
`
`Date of
`Entry
`4/25/78
`511 5/78
`5/30/78
`5130178
`6/27/78
`7/ 18/78
`
`Date of
`Termination
`5/27/81
`5/29/79
`9120179
`2/5/79 (6183)
`2/8/79
`-
`
`7/ 18/78
`
`10/27/78
`
`6/5/78
`12/30/80
`5/1/82
`
`5/ 16/82
`9/20/82
`11/13/78
`1/28/80
`
`6/27/78
`7/31/78
`8/7/78
`
`10/3/78
`1 O/ 16/78
`10/24/78
`10/24/78
`11/7/78
`
`I 1 /20/78
`
`Results
`
`no effect
`no effect
`no effect
`no effect
`no effect
`arrested (not terminated)
`marked improvement
`withdrew at time of exacerba-
`tion
`no effect
`no effect
`cessation of characteristic
`attacks
`arrest (slight improvement)
`no effect
`no effect
`no effect
`cessation of characteristic
`attacks (not terminated)
`arrest and improvement
`(not terminated)
`
`determine whether a treatment that ‘looked good’ in a preliminary trial still ‘looks
`good’ when tested under more rigorously controlled conditions.” For this purpose a
`double-blind, placebo-controlled, randomized pilot trial was started about three years
`ago. Since another purpose of a pilot trial is to determine whether or not a full clinical
`trial is justified and, in addition, how it may be structured, the following brief
`description presents the current organization of the pilot trial.
`The clearly defined objectives of the pilot trial of the ER patient are (1) whether or
`not the frequency of attacks is different between the COP I and the saline-injected
`groups, and (2) whether there is a difference in the degree of disability developed after
`two years of participation in the trial.
`The patient population of 50 ER MS patients was selected from 935 volunteers to
`have at least one and preferably two attacks a year in each of the two years prior to
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`entry into the trial, to be between the ages of 20 and 35, to be ambulatory, to be
`emotionally stable, and to have had no prior treatment with immunosuppressive drugs.
`The selected patients were matched for age, sex, frequency of attacks and degree of
`disability and randomly distributed by the statistician (SS) into the placebo or COP I
`groups. All information collected is sent to the Coordinating Center where it is edited,
`coded and stored in a data base specifically designed and constructed for this study.
`The organizational structure for the pilot study includes an External Advisory
`Board, Steering Committee, Coordinating Center and Clinical Center. The External
`Advisory Board, an outside independent group which serves the trial in an advisory
`and consultative capacity, includes Dr. John Kurtzke, Professor of Neurology and
`Community Medicine, Georgetown University School of Medicine and chief of
`Neurology Service, Veterans Administration Medical Center; Dr. William Weiss,
`chief of Biometry and Field Studies at the National Institute of Neurological and
`Communicative Disorders and Stroke, NIH; and Dr. 1. Herbert Scheinberg, chair-
`man of the Clinical Investigation Committee at Albert Einstein College of Medicine.
`This group receives periodic reports from the Coordinating Center that describe the
`results of the trial to date and keep the members informed as to the conduct of the
`trial.
`The Steering Committee is composed of Murray Bornstein, M.D., principal
`investigator (who is blinded); Dr. Sylvia Wassertheil-Smoller, Ph.D., head of the
`Division of Epidemiology and Biostatistics; and Ms. Susan Slagle, M.P.H., biostatis-
`tion. It is their function to monitor the progress of the trial on an ongoing basis as well
`as to make decisions as to the design and conduct of the trial. At the Clinical Center,
`patients are examined routinely every three months and more frequently at the time of
`exacerbations. The investigating neurologists and the principal investigator, as well as
`the patients themselves, are unaware of the treatment assignments to placebo or COP
`I. This blinding of patients and examiners is maintained through the use of a
`Coordinating Center, which is a separate unit responsible for matching, randomiza-
`tion, procedures, assignment to treatment and data management.
`The pilot trial of the ER patients will end in December 1984. The code will be
`broken, the data analyzed and the results published.
`A report summarizing the status of the ER trial as of 1 January 1983 was
`submitted to the External Advisory Committee. An excerpt from this report that shows
`current enrollment status of the pilot trial is presented in TABLE 3. Based on the
`recommendations from the External Advisory Committee after reviewing the report of
`January 1 and the fact that there have been few significant undesirable side effects or
`reactions observed or reported to date, the ER pilot trial is now being extended to
`chronic progressive (CP) patients. For this purpose, 80 participants will be entered into
`the trial, varying from 25 to 55 years of age. The conduct of the multicenter C P pilot
`trial differs in some respects from the ER pilot trial.
`During a pretrial observation period, each C P patient must demonstrate a
`predetermined and sustained degree of worsening, specifically, at least two units in any
`one of Kurtzke’s eight functional groups or one unit in any two unrelated functional
`groups. Once this is demonstrated and maintained, the patient becomes eligible to
`enter the trial and will then be randomly distributed into placebo or COP I groups. The
`dosage of COP 1 will be 15 mg in 0.75 of bacteriostatic saline subcutaneously, twice a
`day. The placebo consists of 0.75 ml of bacteriostatic saline. Patients will be evaluated
`at 1.4,8, 12, 16, 20 and 24 months after admission to the trial. The evaluation will be
`the same as those listed for the current ER pilot trial. The trial will of course be
`conducted in a double-blind manner.
`The central statistic for the C P patients will be arrest of progression, which
`currently is defined as a change of not more than one unit in the eight functional groups
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`over the two-year period. Any degree of improvement will also be recorded and
`reported, but is not being used to determine the overall effectiveness of COP I. The
`essential reasons for this limitation are both theoretical and practical. Theoretically,
`COP 1 is thought to interfere with the immunological attack on the nervous system by
`promoting the development of antigen-specific suppressor T cells. Whether or not these
`cells can eventually be demonstrated in human subjects, the point is that an arrest of
`clinical progression can be interpreted as an arrest of the immunological attack. A
`number of factors of structural, biochemical or bioelectrical nature, many of which are
`unknown, may contribute to the degree of clinically manifest neuronal dysfunctions.
`Moreover, they are not only unknown, but also uncontrolled in this trial. Thus,
`although improvements in function will be noted and reported, only arrest of
`progression (as stated) will be used as the central statistic to evaluate the effectiveness
`of COP I in the C P patient.
`
`TABLE 3. Pilot Trial of COP I in ER Patients"
`Placebo
`25
`30.96
`
`10
`15
`
`13
`5
`7
`3.2
`
`2.02
`
`Number entered
`Average age
`Sexb
`males
`females
`Race
`white
`black/hispanic
`Kurtzke DSSb
`G 2
`3 4
`5 4
`mean DSS
`Previous attack rateb
`attacks/ year
`Time in study
`460
`872
`412
`total patient mos.
`38.33
`72.66
`total patient years
`34.33
`17.44
`average no. mos. in the study
`16.48
`18.40
`"Baseline characteristics of the study population and the accumulated time in the study as of 1
`January 1983.
`bMatching variables.
`
`COP I
`25
`29.96
`
`1 1
`14
`
`13
`5
`7
`3.2
`
`I .96
`
`Total
`50
`30.44
`
`21
`29
`
`48
`2
`
`26
`10
`14
`3.2
`
`1.99
`
`Meanwhile, on the basis of current data, the Steering Committee with the advice of
`the External Advisory Committee is beginning to plan a full, multicenter-probably
`internationalkAinicaI trial of COP I in the ER type of MS patient.
`If COP I should prove to be effective in arresting the progression of MS in a
`significant number of MS patients without evidence of unacceptable side reactions,
`two further possibilities may be considered.
`COP I may represent a protein component of C N S tissue acting as an encephali-
`togen. Evidence of the possible involvement of a lipid factor, galactocerebroside, as an
`antigen has been demonstrated." Proteolipid lipoprotein (PLP) may also be considered
`a candidate in this regard. A carbohydrate moiety, e.g., myelin-associated glycoprotein
`(MAG), may have similar properties. Consequently, if COP I proves to be effective in
`a given proportion of patients, the addition of other antigens such as lipid (GC and
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`PLP) and carbohydrate (MAG) substances may prove even more effective in altering
`the course of MS.
`Finally, if the synthetic polypeptide, COP I, proves valuable in MS as a disease
`involving an autoallergic mechanism, one can suggest that other synthetic polypeptides
`should be examined for their potential therapeutic effects in other diseases known or
`suspected to result from similar immunological factors.
`
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