Multiple Sclerosis: Trial
`of a Synthetic Polypeptide
`M. B. Bernstein, MD,‘ A. I. Miller, MD,‘
`D. Teitelbaum, MD,'r R. Arnon, MD,1~
`and M. Sela, MD1'
`
`
`
`A synthetic polypeptide, copolymer I (COP 1), com-
`posed of alanine, glutamic acid, lysine, and tyrosine,
`has been demonstrated to be nonencephalitogenic and
`nontoxic in laboratory animals, yet it is capable of sup-
`pressing experimental allergic encephalomyelitis. A
`preliminary open trial examined the ability of COP I
`to alter the course of disease in 12 patients with
`chronic progressive and 4 with exacerbating-remitting
`multiple sclerosis (MS). After therapy for as long as
`two years or more, no undesirable side reaction was
`noted in any patient. Three patients with chronic
`progressive MS and 2 with exacerbating-remitting dis-
`ease are better. These results, which may represent
`simply a placebo effect or may be a significant re-
`sponse, are now being examined in randomized,
`placebo-controlled, double-blind pilot trials.
`
`Bornstein MB, Miller Al, Teitelbaum D, Arnon R,
`Sela M: Multiple sclerosis: trial of a synthetic
`polypeptide. Ann Neurol 11517-319, 1982
`
`The purpose of this report is to present the results
`of a preliminary trial of a synthetic polypeptide,
`Copolymer I (COP I), on patients with multiple
`sclerosis (MS). According to the Ad Hoc Working
`Group pn the Design of Clinical Studies to Assess
`Therapeutic Efficacy in Multiple Sclerosis [3]. such a
`preliminary trial is “conducted for the purpose of es-
`tablishing dosages, studying toxicity, and obtaining a
`lead as to the possible efficacy of a new treatment for
`MS. Such a study is the first organized application of
`a new treatment, which may be a new investiga-
`tive drug .
`.
`. Difllerent dosages with different sched-
`ules .
`.
`. are tried on a few patients, who are very
`closely monitored for toxic reactions. For the assess-
`ment 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 MS in each
`patient. .
`. In most instances, it will not be necessary
`to involve more than perhaps 10 patients in a given
`
`From the ‘Albert Einstein College of Medicine of Yeshiva Univer-
`sity, l300 Morris Park Ave, Bronx, NY 10461, and the 1'Weiz-
`mann Institute, Rehovot, Israel.
`Received May 15. 1981. and in revised form July 10. Accepted for
`publication July 13. 1981.
`
`Address reprint requests ID Dr Bornstein.
`
`preliminary trial. If the preliminary trial brings forth
`evidence of therapeutic efficacy and little or no evi-
`dence of serious toxicity, it would be reasonable to
`move on to the next stage of investigation, the pilot
`trial.""
`
`Materials and Methods
`
`The synthetic polypeptide COP I, as developed by Dr
`Michael Sela of the Weizmann Institute, Rehovot, Israel,
`and supplied by the Institute,
`is composed of alanine,
`glutamic acid, lysine, and tyrosine in the molar ratios of 6.0,
`1.9, 4.7, and 1.0, respectively, and has a molecular weight
`ranging from 22,000 to 24,000. It is nonencephalitogenic
`[2] and nontoxic (Meshorer A: personal communications),
`yet is capable of suppressing experimental allergic en-
`cephalomyelitis in rabbits, guinea pigs, mice, rats, mon-
`keys, chimpanzees, and baboons [2, 4-9]. Abramsky et al
`[1] first examined COP I for its effect on human patients,
`3 with acute disseminated encephalomyelitis and 4 with
`"terminal" MS. The 3 patients with encephalomyelitis re-
`covered rapidly and completely; the MS patients may have
`demonstrated slight improvement. What is more important
`in these first clinical studies was the absence of any major
`or undesirable side reactions.
`
`Before being shipped from the Weizmann Institute, each
`preparation of COP I is tested for its biological activity of
`suppressing experimental allergic encephalomyelitis in
`guinea pigs and for immunological cross reaction with the
`basic encephalitogenic protein. On receipt in our labora-
`tory, the sterile, lyophilized COP I is stored frozen until
`use. At that time, bacteriostatic sodium chloride is injected
`into the vial to dissolve the polypeptide. The final concen-
`tration of COP I in saline has varied from 5 to its present
`concentration of 20 mg per milliliter. The solution is dis-
`tributed into sterile empty Dosette vials (Product no.
`250380, Ellrins-Sinn Inc., Cherry Hill, NJ) and recapped
`with a sterile aluminum cap that is firmly crimped into
`place. The vials. containing a single daily dose, are frozen.
`A sterility check is made of the COP 1 solution in both
`tryptic soy broth and thioglycollate. More than 700 batches
`of COP I have been prepared. Only 1 was suspect on
`sterility check and was discarded. At the time of use, a
`single-dose vial is thawed. The solution is injected sub-
`cutaneously.
`Sixteen MS patients participated in the preliminary trial.
`They represented a broad spectrum of neurological in-
`volvement, including 12 with chronic progressive disease,
`some of whom were confined to bed or to a wheelchair, and
`4 with the exacerbating-remitting type, who were fully ac-
`tive and employed between attacks. All had been well
`known to the principal investigator (M. B. B.) for years
`prior to their entry into the study. Informed consent was
`obtained.
`The preliminary trial was conducted as an open study;
`patients were given the COP I and all knew they were re-
`ceiving it. The evaluating neurologist (A. I. M.) also was
`aware that all patients were being treated. The initial dos-
`
`‘From Brown et al [3]. Neurology 29: Part 2, 1979. By permis-
`sion.
`
`EXHIBIT NO. 1014 Page 1
`0364-S134/82/030317-03301.25 © 1981 by the American Neurological Association
`317
`
`AMNEAL
`
` AMNEAL
`
`

`
`Result: of Preliminary Trial of Capo/ymer I Therapy in 16 Patient: with Multiple Sclerarir
`
`Date of
`
`Patient, Age (yr), and Sex
`MS Type
`Date of Entry
`Termination
`Result
`
`I. Y. 46, F
`R. H. 25, M
`G. T. 35, F
`P. P. 30, F
`A. T. 23, M
`P. McL. 39, F
`
`J. P. 39, F
`
`J. W. 32, M
`K. J. 33. F
`C. N. 32, M
`
`W. R. 49. M
`
`S. McC. 42, F
`H. W. 36, M
`S. R. 38, F
`P. H. 27, F
`
`J. M. 34, F
`
`C-P
`C-P
`C-P
`E-R
`C-P
`C-P
`
`E-R
`
`C-P
`C-P
`E-R
`
`C-P
`
`C-P
`C-P
`C-P
`E-R
`
`C-P
`
`4/25/78
`5/15/78
`5/30/78
`5/30/78
`6/27/78
`7/ 18/78
`
`7/18/78
`
`6/27/78
`7/31/78
`8/7/78
`
`10/5/78
`
`10/I6/78
`10/24/78
`10/24/78
`11/7/78
`
`11/20/78
`
`5/27/81
`5/29/79
`9/20/79
`.
`.
`.
`2/8/79
`
`10/27/78
`
`6/5/79
`12/30/80
`
`.
`.
`.
`11/13/78
`
`No effect
`No effect
`No effect
`No effect
`No effect
`Arrested;
`marked im-
`provement
`Withdrew at time
`of exacerbation
`
`No effect
`No effect
`Cessation of
`characteristic
`attacks
`
`Arrested; slight
`improvement
`No effect
`No effect
`No effect
`Cessation of
`characteristic
`attacks
`
`Arrest and
`improvement
`
`C-P = chronic-progressive disease; E-R = exacerbating-remitting disease.
`
`age schedule was based on studies with nonhuman primates
`[5, 7] and a brief clinical trial [1]. The COP I first was pre-
`pared at a concentration of 5 mg per milliliter of sterile
`saline solution. This was to be given to each patient in-
`ttarnuscularly 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.
`
`Results
`
`During institution of the COP 1 treatment, many pa-
`tients reported, and in fact demonstrated, early im-
`provements in various neurological functions. As
`time went on and as the dosage was reduced, these
`early improvements disappeared. Most patients re-
`turned to their previous neurological status and con-
`tinued their chronic-progressive course. During the
`ensuing months the dosage was gradually increased.
`By the end of the first eighteen—month period, those
`patients who were still on the COP I regimen were
`receiving 20 mg per day in 1 ml of saline. Eight pa-
`tients have been taking COP I for more than two
`years.
`
`As for side reactions, rarely patients reported tran-
`sient slight pain, discomfort, or itching at the injec-
`
`tion site. No local reactions of swelling or redness
`were noted. No systemic or general undesirable
`reactions of any kind were noted or reported. Exam-
`inations of urine were unremarkable. Occasionally,
`studies of peripheral blood cellular elements re-
`vealed a transient eosinophilia, reaching 16% in one
`instance. No significant change in blood chemistry
`determinations appeared. Examinations of blood
`obtained before and at various times after the in-
`
`stitution of COP I have revealed no change in lym-
`phocyte transformation in response to COP 1, myelin
`basic protein, or phytohemagglutinin. The ability of
`cells and serum alone and together, with and without
`complement, to affect central nervous system myelin
`culture was not altered.
`The observed results are listed in the Table. One
`
`of the patients with exacerbating-remitting disease
`withdrew from the study at the onset of an attack. A
`second has had a single, moderately severe exacerba-
`tion. F. H., who previously had experienced a severe
`exacerbation during the late summer to early fall
`every year for eleven years, has had no such attack in
`over two years. C. N., who was affected by moder-
`ately severe attacks four to six times a year during the
`three years prior to admission to the trial, has been
`free of such episodes. Their mild to moderate re-
`
`AMNEAL
`318 Annals of Neurology Vol 11 No 3 March 1982
`
`EXHIBIT NO. 1014 Page 2
`
` AMNEAL
`
`

`
`sidual symptoms have also decreased. Of the 12 pa-
`tients _with chronic progressive MS, 3 are arrested
`and have improved. The other 9 have continued their
`previous downhill courses.
`
`Discussion
`
`.
`
`In more than two years of the preliminary trial, no
`undesirable side reaction to COP I has occurred at
`doses ranging up to 20 mg daily. Two of 4 patients
`with exacerbating-remitting MS and 3 of 12 with
`chronic progressive disease are better. The question
`now is whether this change is due to the COP 1 or
`simply represents a placebo effect. To answer that
`question, a pilot study of patients with exacerbating-
`remitring MS was started about a year ago. It is
`planned to involve from S0 to 60 randomly distrib-
`uted patients in a placebo-controlled,double-blind
`examination of the ability of COP I at 20 mg daily to
`affect the frequency of attacks, their severity and du-
`ration, and the degree of disability demonstrated
`during a two-year period. The pilot study will soon
`be extended to a group of patients with chronic pro-
`gressive disease.
`
`Supported in part by a supplement to Grant NS 11920 from the
`National Institute of Neurological and Communicative Disorders
`and Stroke.
`
`Presented at the l0Sth Annual Meeting of the American Neu-
`rological Association, Boston, MA, Sept 8-10, 1980.
`
`References
`1. Abramsky O, Teitelbaum D, Amon R: Effect of a synthetic
`polypeptide (COP l) on patients with multiple sclerosis and
`with acute disserninated encephalornyelitis. Preliminary report.
`J Neurol Sci 31:433-438, 1977
`2. Arnon R, Teitelbaum D: Desensitization of experimental aller-
`gic encephalomyelitis with synthetic peptide analogues.
`ln
`Davison AN, Cuzner ML (eds): The Suppression of Experi-
`mental Allergic Encephalomyelitis and Multiple Sclerosis. New
`York and London, Academic, 1980, pp 105-1 17
`3. Brown JR, Beebe GW. Kurtzlte JF, Loewenson RB, Silberberg
`DH, Tourtellotte W: The design of clinical studies to assess
`therapeutic efficacy in multiple sclerosis. Neurology (NY) 29:
`Part 2, 1979
`4. Keith AB, Arnon R, Teitelbaurn D, Caspary EA, Wisniewslti
`HM: The efiect of COP l, a synthetic polypeptide, on chronic
`relapsing experimental allergic encephalomyelitis in guinea
`pigs. J Neurol Sci 42:267-274, 1979
`5. Teitelbaum D, Meshorer A, Amon R: Suppression of experi-
`mental allergic encephalomyelitis in baboons by COP I. Isrj
`Med Sci l3:l038, 1977
`6. Teitelbaum D, Meshorer A, Hirshfeld T, Arnon R, Sela M:
`Suppression of experimental allergic encephalomyelitis by a
`synthetic polypeptide. Eur] lmmunol 12242-248, 1972
`7. Teitelbaum D, Webb C, Bree M, Meshorer A, Amon R, Sela
`M: Suppression of experimental allergic encephalomyelitis in
`rhesus monkeys by a synthetic basic copolymer. Clin Immunol
`ltnmunopathol 3:2$6—262, 1974
`8. Teitelbaum D, Webb C, Meshorer A, A1-non R, Sela M: Pro-
`
`tection against experimental allergic encephalomyelitis. Nature
`240:56-4-566, 1972
`9. Teitelbaum D, Webb C, Meshorer A, Amon R, Sela M: Sup-
`pression by several synthetic polypeptides of experimental al-
`lergic encephalomyelitis induced in guinea pigs and rabbits with
`bovine and human basic encephalitogen. Eur J lmmunol
`3:273-279, 1973
`
`Valproate-Induced
`Hyperammonemia
`Mark L. Batshaw, MD, and Saul W. Brusilow, MD
`
`A patient with carbatnyl phosphate synthetase defi-
`ciency had four episodes of hyperammonemia, up to
`226 p.M, associated with valproate (VPA) treatment.
`These were accompanied by vomiting, lethargy, and
`coma. A group of epileptic patients receiving VPA
`remained asymptomatic but had significantly higher
`mean plasma ammonium levels when compared to
`epileptic Patients receiving other anticonvulsants: 33.6
`: 1.9 (SEM) versus 23.6 :t 1.5 p.M. Thus, VPA caused
`symptomatic hyperammonemia in a patient with an
`impairment in urea synthesis and resulted in mildly
`elevated ammonium levels in epileptic patients. These
`data suggest that ammonium levels should be moni-
`tored in patients receiving VPA who exhibit signs of
`vomiting or lethargy.
`
`Batshaw MI., Brusilow SW: Valproate-induced
`hyperammonemia. Ann Neurol ll:319—321, 1982
`
`As the use of sodium valproate (VPA) has increased,
`so have the reports of hyperammonemia, usually but
`not always associated with hepatic failure [5, 6, 8a,
`10, 13]. We report VPA-induced hyperammonemia
`unassociated with hepatocellular damage in a patient
`with carbamyl phosphate synthetase (CPS) deficiency
`and in a group of epileptic patients.
`
`Subjects and Methods
`The patient with partial CPS deficiency had had symp-
`tomatic hyperammonemia manifested by intermittent
`vomiting and lethargy from 13 months to 12 years of age
`[1]. From the ages of 13 to 17 years she was treated with a
`combination of essential atnino acids and keto acids [2].
`Mean plasma ammonium level obtained monthly between
`16 and 17 years ofage was 33 2: 5 PM? the normal range is
`15 to 30 p.M [1].
`
`From the Department of Pediatrics, Johns Hopkins Medical In-
`stitutions, and the John F. Kennedy Institute, 707 N Broadway,
`Baltimore, MD 21205.
`
`Received June 9, 1981, and in revised form Aug 3. Accepted for
`publication Aug 20. 1981.
`
`Address reprint requests to Dr Batshaw.
`
`AMNEAL
`EXHIBIT NO. 1014 Page 3
`0364-5 I34/82/030319-05301.0 Qty 19251 by the American Neurological Association
`319
`
` AMNEAL