European Journal of Neurology 2006, 13: 604–610
`
`doi:10.1111/j.1468-1331.2006.01292.x
`
`Oral fumaric acid esters for the treatment of active multiple sclerosis: an
`open-label, baseline-controlled pilot study
`
`S. Schimrigka,b, N. Brunea,b K. Hellwiga, C. Lukasa, B. Bellenberga, M. Rieksa,b, V. Hoffmanna,
`D. Po¨ hlaua and H. Przunteka,b
`aDepartment of Neurology and bFumarate Study Group for Multiple Sclerosis (FSGMS), St Josef Hospital, Ruhr University, Bochum,
`Germany
`
`Keywords:
`fumaric acid esters, mag-
`netic resonance imaging,
`multiple sclerosis, open-
`label study
`
`Received 22 March 2005
`Accepted 13 June 2005
`
`An exploratory, prospective, open-label study of fumaric acid esters (FAE, Fuma-
`dermÒ) was conducted in patients with relapsing–remitting multiple sclerosis
`(RRMS). The study consisted of the following four phases: 6-week baseline, 18-week
`treatment (target dose of 720 mg/day), 4-week washout, and a second 48-week
`treatment phase (target dose of 360 mg/day). Ten patients with an Expanded Dis-
`ability Status Scale (EDSS) score of 2.0–6.0 and at least one gadolinium-enhancing
`(Gd+) lesion on T1-weighted magnetic resonance imaging (MRI) brain scans parti-
`cipated in the study. Safety was assessed by adverse events (AEs), blood chemistry/
`hematology, electrocardiogram, and urinalysis. The primary efficacy outcomes were
`number and volume of Gd+ lesions. Other clinical outcomes included EDSS score,
`ambulation index (AI), and nine-hole peg test (9-HPT). Effects of FAE on intracellular
`cytokine profiles, T-cell apoptosis, and soluble adhesion molecules were also assessed.
`Three patients withdrew during the first 3 weeks of the study because of side effects,
`non-compliance, and follow-up loss. The most common AEs were gastrointestinal
`symptoms and flushing; all AEs were reported as mild and reversible. FAE produced
`significant reductions from baseline in number (P < 0.05) and volume (P < 0.01) of
`Gd+ lesions after 18 weeks of treatment; this effect persisted during the second
`treatment phase at half the target dose after the 4-week washout period. EDSS scores,
`AI, and 9-HPT remained stable or slightly improved from baseline in all patients.
`Measures of T-cell function demonstrated alterations in cytokines and circulating
`tumor necrosis factor. The results of this exploratory study suggest that further studies
`of FAE in patients with MS are warranted.
`
`Introduction
`
`Multiple sclerosis (MS), a major cause of chronic dis-
`ability in young adults, is pathologically characterized
`by focal areas of demyelination and axonal loss in the
`central nervous system (CNS). Although the etiology of
`MS is uncertain, several lines of evidence indicate that
`autoimmune response plays a central role in the
`development of MS lesions. First, myelin breakdown
`products have been detected in macrophages in MS
`lesions and in the cerebrospinal fluid (CSF) of MS pa-
`tients [1,2]. Secondly, MS lesions have many features of
`a delayed-type hypersensitivity reaction [3], and dem-
`onstrate the following: increased levels of lymphokines
`and cytokines [interferon (IFN)-c, tumor necrosis fac-
`tor (TNF)-a, interleukin (IL)-1]; activated CD4+ and
`
`Correspondence: Sebastian Schimrigk, MD, Department of Neurol-
`ogy, St Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56,
`44791 Bochum, Germany (tel.: 0049-(0)234-509-1; fax: 0049-(0)234-
`509-2740; e-mail: sebastian.k.schimrigk@rub.de).
`
`CD8+ T cells; mononuclear phagocytes (macrophages,
`microglia, and monocytes) expressing variable levels of
`class
`II major histocompatibility complex (MHC)
`antigens; and upregulation of leukocyte and vascular
`adhesion molecules (VCAM)-1 [4–7]. Thirdly, CSF of
`MS patients shows intrathecal synthesis of immuno-
`globulins with restricted heterogeneity [8] and an
`increased frequency of autoreactive T cells that secrete
`IFN-c in response to myelin proteins [9]. Fourthly,
`agents with immunomodulatory properties, such as
`IFNb have been shown to reduce lesion formation,
`decrease the frequency of relapses, and slow the pro-
`gression of disability in MS [10–12].
`Fumaric acid esters (FAE) influence several aspects
`of immune functions that are thought to be involved in
`MS. FAE therapy has been shown to induce T-helper
`(Th)2-like cytokines (e.g. IL-4, IL-5, and IL-10) [13,14]
`to induce apoptosis in activated T cells [13] and to
`downregulate
`intracellular
`adhesion molecules
`(ICAM)-1 and VCAM expression [15]. A reduction in
`these cellular adhesion molecules may lead to reduced
`
`604
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`

`

`migration of lymphocytes across endothelial barriers
`into surrounding tissues, an important event in MS [6].
`FumadermÒ (Fumapharm, Muri, Switzerland), a FAE
`formulation, is approved in Germany for the treatment
`of severe chronic plaque psoriasis [16–21]. The efficacy
`and safety of oral FAE (FumadermÒ) were investigated
`in a baseline-controlled, open-label pilot study of
`patients with relapsing–remitting MS (RRMS).
`
`Methods
`
`Patients
`
`Ten patients were enrolled in the study. Patients were
`eligible for enrollment if they were 18–55 years of age,
`had a definite diagnosis of RRMS [22], and had at least
`one relapse within the year prior to enrollment. In
`addition, patients had at least one active lesion on
`magnetic resonance imaging (MRI) brain scans and a
`baseline Expanded Disability Status Scale (EDSS) score
`of 2.0–6.0. Patients were excluded from the study if they
`had any of the following: an infection, a chronic
`inflammatory disease other than MS, a history of drug
`or alcohol abuse, a disease exacerbation or corticoster-
`oid treatment within 30 days, or immunosuppressive or
`immunomodulatory therapy within 12 weeks of enroll-
`ment. Patients who were pregnant or breastfeeding were
`also excluded. The study protocol was approved by the
`local ethics committee, and all patients were counseled
`regarding current treatment guidelines for MS, inclu-
`ding the use of IFNb and glatiramer acetate.
`
`Study design and assessments
`
`This was a prospective, open-label, baseline-controlled
`exploratory study conducted at St Josef Hospital at
`Ruhr University in Bochum, Germany. Patients were
`followed for a total of 70 weeks. The study was com-
`posed of the following four phases: a 6-week baseline
`phase (weeks )6 to 0), an 18-week treatment phase
`(weeks 0–18), a 4-week washout (no treatment) phase
`(weeks 19–22), followed by a second 48-week treatment
`phase (weeks 23–70). At the beginning of each treat-
`ment phase, the FAE dose was slowly up-titrated over
`9 weeks to minimize gastrointestinal side effects. The
`maximum daily number of tablets of FAE administered
`was six per day in the first treatment phase (720
`mg/day) and three per day (360 mg/day) in the second
`treatment phase.
`Safety was assessed by the incidence and severity of
`adverse events, physical and neurologic examinations,
`blood
`chemistry/hematology,
`electrocardiogram
`(ECG), and urinalysis. The primary efficacy outcomes
`were the number and volume of gadolinium-enhancing
`
`Ó 2006 EFNS European Journal of Neurology 13, 604–610
`
`Oral FAE for the treatment of active MS
`
`605
`
`(Gd+) lesions. Clinical outcomes included EDSS score,
`ambulation index (AI), and nine-hole peg test (9-HPT).
`The effects of FAE on intracellular cytokine profiles,
`T-cell apoptosis, and soluble adhesion molecules were
`also assessed. A physical examination, EDSS, AI, and
`9-HPT were performed at screening, baseline, and at
`weeks 3, 6, 12, 18, 22, 46, and 70. MRI brain scans were
`performed at screening, baseline, and at weeks 12, 18,
`22, 46, and 70. Adverse events were recorded through-
`out the study. Serum chemistries, ECG, and urinalysis
`were performed at screening, baseline, and at weeks
`1, 3, 6, 9, 12, 18, 22, 28, 34, 40, 46, 52, 58, 64, and 70.
`
`Study drug
`Fumaric acid ester tablets (FumadermÒ, Fumapharm,
`Muri, Switzerland) were composed of the following:
`ethylhydrogenfumarate-Ca salt 67 mg, ethylhydrogen-
`fumarate-Mg salt 5 mg, dimethylfumarate 30 mg,
`ethylhydrogenfumarate-Zn
`salt
`3 mg
`(Fumaderm
`initialÒ); and dimethylfumarate 120 mg, ethylhydro-
`genfumarate-Ca salt 87 mg, ethylhydrogenfumarate-
`Mg salt 5 mg, ethylhydrogenfumarate-Zn salt 3 mg
`(Fumaderm forteÒ).
`
`MRI protocol
`
`All MRI scans were performed using a 2-Tesla Bruker
`Tomikon S200 scanner (Bruker Medizintechnik GmbH,
`Ettlingen, Germany).
`Initial T1-weighted (time of
`repetition (TR) ¼ 800 ms, time of echo (TE) ¼ 17 ms)
`brain scans, 3-mm-thick axial slices with a spatial
`resolution of 0.98 mm, were acquired. Each scan was
`composed of 44 contiguous interwoven images. Triple
`dose (0.3 mmol/kg body weight) Gd-diethylenetriamine
`pentaacetic acid (Gd-DPTA, MagnevistÒ, Schering
`AG, Berlin, Germany) was administered for higher
`lesion detection sensitivity [23]. After a 7-min delay,
`Gd+ T1-weighted scans were then performed using the
`same parameters as for the native scan. Image data
`were converted to an 8-bit grayscale tiff-format, provi-
`ding maximum available contrast. Data analysis was
`performed using customized Image ToolÒ scripts for
`semi-automated image data utilization (UTHSCSA
`Image Tool program, University of Texas Health Sci-
`ence Center, San Antonio, TX, USA; http://ddsdx.
`uthscsa.edu/dig/itdesc.html). Two independent radiol-
`ogists detected and counted Gd+ lesions by comparing
`native T1 images to post-contrast T1 images. The
`radiologists involved in these assessments were blinded
`to the treatment status of the patients. To determine
`the approximate volume of each Gd+ lesion, a
`semi-automated local
`threshold procedure counted
`enhancing pixels to within a maximum of 1/e-of-
`
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`

`606
`
`S. Schimrigk et al.
`
`maximum contrast to non-enhancing pixels of the le-
`sion environs. Questionable cases were discussed with a
`third senior radiologist who was also blinded with
`regard to the treatment status of patients in the study.
`
`Cytokine expression and apoptotic rate
`
`The intracellular expression of IL-2, IL-4, IL-10, IFN-c,
`TNF-a, and transforming growth factor (TGF)-b was
`examined in the CD4+ lymphocyte population [24,25].
`Total T lymphocytes were prepared for flow cytometry
`and stained with anti-CD4 antibodies plus antibodies
`against one of the cytokines of interest or Annexin V as a
`marker for apoptosis. Briefly, peripheral blood mono-
`nuclear cells (PBMCs) were isolated from venous blood
`samples collected in heparinized tubes using a FICOLL
`gradient
`(FICOLLpaque,
`Pharmacia, Uppsala,
`Sweden). Cells were washed in RPMI 1640 medium with
`10% fetal calf serum (FCS) separated and cell density was
`adjusted to 2 · 106/ml. PBMCs were stimulated with
`phorbol 12-myristate 13-acetate (PMA) and ionomycin
`in the presence of monensin (ICS-KIT; Ho¨ lzel Diag-
`nostica, Laboserv GmbH, Giessen, Germany) to block
`cytokine secretion [25]. Following a 5-h incubation
`(37°C, 7% CO2), PBMCs were washed twice with Hank’s
`balance salt solution (HBSS) and fixed (4°C). Fixed
`PBMCs were washed and treated with a permeabilizing
`agent for 12 h. Intracellular staining for TNF-a, IFN-c,
`IL-2, IL-4, IL-10, and TGF-b was performed using spe-
`cific monoclonal antibodies. Cells were counter stained
`with an antibody specific for the CD4 cell surface marker
`(Becton Dickinson, Immunotech, Ho¨ lzel, Germany) to
`identify CD4+ cells. Stained cells were analyzed using a
`FACScan flow cytometer and cellquest software (Becton
`Dickinson). Expression of sICAM-1 was measured using
`an ELISA specific for sICAM (Medgenix, Laboratories,
`Rungis, France). All lymphocytes were identified by flow
`cytometry and then cells positive for both CD4 and
`cytokines of interest were quantified.
`
`Statistical analyses
`
`Number and volume of Gd+ lesions were analyzed
`using nonparametric Wilcoxon tests. Differences were
`considered statistically significant at a P-value of 0.05.
`Overall, seven MRI scans were performed per patient.
`Results from the two baseline scans were averaged.
`
`Results
`
`Patients
`
`Patient demographic and baseline characteristics are
`presented in Table 1. Of the 10 patients enrolled, six
`
`Table 1 Baseline demographic and clinical characteristics of patients
`(n ¼ 10)
`
`Characteristic
`
`Sex, n (%)
`Female
`Age (years)
`Median
`Range
`Relapse rate (preceding 12 months)
`Median
`Range
`Years since first event
`Median (years)
`Range
`EDSS
`Median
`Range
`AI
`Median
`9-HPT
`Median (right)
`Median (left)
`Number of Gd+ lesionsa
`Mean
`Range
`
`5 (50)
`
`29
`28–38
`
`2
`1–3
`
`4.5
`1–11
`
`2.0
`2.0–4.5
`
`2
`
`22
`21
`
`11
`2–39
`
`AI, Ambulation Index; EDSS, Expanded Disability Status Scale;
`9-HPT, nine-hole peg test; Gd+, gadolinium-enhancing.
`aCalculated based on n ¼ 7.
`
`completed the 70-week study. One patient was excluded
`because of an unplanned pregnancy at week 46; data
`obtained from this patient were included up to the time
`of withdrawal. Three other patients discontinued
`treatment, one each because of side effects and a lack of
`compliance; the third was lost to follow-up.
`
`Safety and tolerability
`
`The most common adverse events were gastrointestinal
`symptoms (diarrhea, cramps, nausea) and flushing
`(Table 2). Mild (6/7) to moderate (1/7) gastrointestinal
`adverse events were experienced by almost all patients
`during the initial phase of this study; however, these
`events decreased continually in all patients after
`6 weeks. Administration of antacids was necessary in
`
`Table 2 Overall adverse events (n ¼ 7)
`
`Adverse
`event
`
`Gastrointestinal
`Flushing
`Elevated liver enzyme levels
`Lymphopenia
`Vertigo
`Eosinophilia
`Headache
`Increased perspiration
`
`Number of
`patients
`
`6
`5
`4
`3
`1
`1
`1
`1
`
`Ó 2006 EFNS European Journal of Neurology 13, 604–610
`
`Sawai (IPR2019-00789), Ex. 1018, p. 003
`
`

`

`Oral FAE for the treatment of active MS
`
`607
`
`*P < 0.018 vs. baseline
`
`*
`
`*
`
`*
`
`*
`
`500
`
`400
`
`300
`
`200
`
`100
`
`0
`
`–100
`
`Lesion load (in pixel volume; 1 pixel = mm3)
`
`Baseline Week 12 Week 18
`
`Week 22
`
`Week 46
`
`Week 70
`
`Study visits
`
`Figure 2 Total lesion load of Gd+ lesions calculated for all
`lesions detected at baseline and at weeks 12, 18, 22, 46, and 70.
`Numbers presented represent total volume of Gd+ lesions
`detected on T1-weighted magnetic resonance imaging scans as
`determined following conversion of images into 8-bit grayscale
`format for quantification. Bars represent median volume of
`Gd+ lesions; at week 70, only six patients were examined.
`
`Table 3 Clinical outcomes
`
`Outcome
`
`Baseline
`
`Week
`12
`
`Week
`18
`
`Week
`22
`
`Week
`46
`
`Week
`70a
`
`EDSS (median)
`AI (median)
`9-HPT (median;
`in s; right)
`9-HPT (median;
`in s; left)
`
`2.0
`2.0
`22
`
`2.0
`2.0
`20
`
`1.5
`1.0
`20.5
`
`1.5
`1.0
`17
`
`1.5
`1.0
`18
`
`1.5
`1.0
`19
`
`21
`
`20.5
`
`20.5
`
`18
`
`19
`
`19
`
`AI, Ambulation Index; EDSS, Expanded Disability Status Scale;
`9-HPT, nine-hole peg test.
`an ¼ 6.
`
`course of the study (Table 3). Similarly, there was
`improvement in functional tests using the 9-HPT at
`18 weeks, which was sustained to 70 weeks. The AI also
`improved over the course of the study. The median AI
`score improved from 2.0 at baseline to 1.0 at 18 weeks,
`and this improvement was sustained until 70 weeks;
`however,
`these changes did not achieve statistical
`significance.
`Relapse occurred during treatment in two patients
`at weeks 18 and 46. In both cases, the EDSS score
`increased by 0.5. Both patients were treated with intra-
`venous corticosteroids (1000 mg methylprednisolone
`i.v. for 3 days), which resulted in complete remission.
`
`several cases. One patient discontinued because of the
`gastrointestinal effects of FAE. A transient elevation of
`liver enzyme levels (up to twofold) occurred in four
`patients, but these elevations were not sufficient to
`mandate withdrawal from the study. During therapy,
`one patient presented at a single visit with an eosino-
`philia of 15% of all leukocytes, which reverted to a
`slight elevation (4–6%) within the next weeks. All other
`side effects were generally mild and transient, needing
`no further treatment and decreasing within the first
`12 weeks of treatment.
`
`MRI
`
`A significant reduction in the number of Gd+ lesions
`was already observed following 18 weeks of FAE
`treatment, with a further reduction after 70 weeks of
`treatment (Fig. 1). The mean number of Gd+ lesions
`decreased from 11.28 (range 2–39) at baseline to 0.28
`(range 0–1) at the end of the 70-week study (P < 0.02).
`The mean number of lesions at weeks 12, 18, and 22 was
`4.3 (range 0–10), 1.5 (range 0–4), and 0.57 (range 0–3),
`respectively. Similarly, median Gd+ lesion volume was
`significantly decreased from 244.5 mm3 (range 25–649)
`at baseline to 26.1 mm3 (range 0–57) after 18 weeks of
`FAE therapy (P < 0.018) (Fig. 2). The lesion volume
`continued to decrease to 8.6 mm3 (range 0–56) at
`22 weeks, and this
`reduction was maintained to
`2.14 mm3 (range 0–9) at 70 weeks (P < 0.018).
`
`Clinical outcomes
`
`The six patients who completed the study demonstrated
`a stable or slightly improved EDSS score over the
`
`*P < 0.02 vs. baseline
`
`*
`
`*
`
`*
`
`*
`
`Week 22
`Baseline Week 12 Week 18
`Study visits
`
`Week 46
`
`Week 70
`
`16
`
`14
`
`12
`
`10
`
`8 6 4 2 0
`
`–2
`
`Number of Gd+ lesions
`
`Figure 1 Mean number of Gd+ lesions from T1-weighted mag-
`netic resonance imaging scans performed at baseline and at weeks
`12, 18, 22, 46, and 70.
`
`in
`The expression of Th2 cytokine, such as IL-10,
`CD4+ lymphocytes,
`increased during
`treatment
`
`Cytokine expression and apoptosis
`
`Ó 2006 EFNS European Journal of Neurology 13, 604–610
`
`Sawai (IPR2019-00789), Ex. 1018, p. 004
`
`

`

`608
`
`S. Schimrigk et al.
`
`Figure 4 Rate of apoptosis in CD4+ T-cell population over the
`course of the study. *P < 0.05 vs. baseline.
`
`Discussion
`
`This report describes the first evaluation of FAE for the
`treatment of patients with RRMS. The study period
`included more than 3400 patient-days of observation.
`Treatment of psoriasis with FAE has been associated
`with mild to moderate gastrointestinal side effects [19],
`although in patients with psoriasis these effects are
`generally mild and subside with time on therapy. In this
`preliminary study, FAE therapy was well tolerated by
`patients with MS. Side effects were similar to those
`experienced by patients treated with FAE for psoriasis
`and included gastrointestinal
`symptoms
`(diarrhea,
`cramps) and flushing.
`A significant decrease from baseline was seen in
`both the number and volume of Gd+ lesions starting
`after 18 weeks of
`treatment. All clinical measures
`(EDSS, AI, and 9-HPT) either remained stable or
`showed improvement during the study, which further
`supports the MRI findings. However, the interpret-
`ation of these results is limited by the small number of
`patients in this study. The fact that FAE treatment
`reduced brain lesions to a degree that reached statis-
`tical significance in a study with a small number of
`patients is encouraging and suggests that larger trials
`to determine the efficacy of FAE in patients with MS
`should be conducted. Additional MRI measurements
`to detect brain atrophy and new MRI techniques that
`provide greater sensitivity for the detection of brain
`lesions [26] may provide insight into the potential ef-
`fects of FAE on disease activity in patients with
`RRMS. Given the baseline-controlled nature of this
`study,
`the possibility that patients were recruited
`during a period of high disease activity must be
`
`Ó 2006 EFNS European Journal of Neurology 13, 604–610
`
`Figure 3 Expression of Th1- and Th2-like cytokines examined in
`CD4+ T cells by flow cytometry. (a) Expression levels of inter-
`leukin-10 over the course of the study. *P < 0.05 vs. baseline. (b)
`Expression levels of interferon-c over the course of the study. No
`significant differences from baseline levels were observed at any
`time point.
`
`(Fig. 3a). Increases in IL-10 levels at weeks 24 and
`(P < 0.05)
`28 were
`statistically significant
`com-
`pared with baseline. In contrast, the expression of
`Th1-type cytokines such as IFN-c was not significantly
`affected (Fig. 3b). The rate of apoptosis increased
`in both the total lymphocyte population and CD4+
`lymphocyte population, from 7% at baseline to 11%
`at week 6 (Fig. 4). In the total lymphocyte population
`the apoptotic rate was 12% at baseline and increased
`to 17% at week 6 (not shown). The increases in
`apoptotic rates were not sustained, and by week 12 the
`rate of apoptosis had returned to baseline levels in
`lymphocyte population and CD4+
`both the total
`population.
`
`Sawai (IPR2019-00789), Ex. 1018, p. 005
`
`

`

`considered. A 6-week baseline period was included to
`control for this possibility. The fact that EDSS scores
`were stable throughout the study suggests that patients
`did not experience a period of at least clinically high
`disease activity during the baseline phase where all
`patients were clinically stable and have had a mini-
`mum of 30 days without corticosteroid treatment at
`study entry.
`Commonalities exist between MS and psoriasis in
`terms of immune function changes that may explain
`the efficacy of FAE in both psoriasis and MS. For
`example, the balance between the production of pro-
`inflammatory and anti-inflammatory cytokines may be
`important to both diseases. In this regard, it is inter-
`esting to note that treatments beneficial to both dis-
`eases also affect this balance. In one study, the clinical
`benefits of FAE in psoriasis, as measured by the Pso-
`riasis Area and Severity Index, were associated with
`reductions in IFN-c and leukocytes [27]. In vitro sti-
`mulation of T cells in the presence of monomethyl-
`fumarate, the metabolic product of dimethylfumarate,
`enhanced IL-4 production in primed CD4/CD45RO+
`T cells [13]. Cytokines play a central role in the
`immune-mediated processes that contribute to axonal
`degeneration and neuronal dysfunction in MS [28]. The
`evaluation of
`intracellular cytokine expression in
`CD4+ T cells in the present study suggests that FAE
`therapy may shift cytokine responses, increasing the
`production of potentially beneficial cytokines such as
`IL-10. Although there was a significant limitation in
`the present study due to the relatively small number of
`patients involved, the changes observed in IL-10 and
`apoptotic rates suggest that FAE therapy may posi-
`tively influence cytokine responses in CD4+ cells. This
`possibility is also supported by recent results that FAE
`therapy has shown positive results in an animal model
`of MS, experimental autoimmune encephalomyelitis
`(EAE) [29].
`In summary, FAE treatment was well tolerated in
`patients with MS and a reduction in disease activity, as
`measured by MRI brain scans and a beneficial shift in
`cytokine expression in the CD4+ lymphocyte popula-
`tion, was observed. These results suggest that further
`studies using larger patient populations are warranted
`to evaluate the efficacy of FAE alone, or as add-on to
`current therapy, on relapse rate and disease progression
`in patients with MS.
`
`AuthorsÕ contributions
`
`SS wrote the first draft of the article, which was circu-
`lated to the other authors. All authors checked the
`pertinent references and contributed to the scientific
`content of the article.
`
`Ó 2006 EFNS European Journal of Neurology 13, 604–610
`
`Oral FAE for the treatment of active MS
`
`609
`
`Conflict of interest
`
`The study was supported by Fumapharm AG, Switzer-
`land, in the form of unconditional research grants.
`
`References
`
`1. Cohen SR, Herndon RM, McKhann GM. Radioimmu-
`noassay of myelin basic protein in spinal fluid. An index
`of active demyelination. New England Journal of Medicine
`1976; 295: 1455–1457.
`2. Prineas JW, Kwon EE, Goldenberg PZ, Cho ES, Sharer
`LR. Interaction of astrocytes and newly formed oligo-
`dendrocytes
`in resolving multiple
`sclerosis
`lesions.
`Laboratory Investigation 1990; 63: 624–636.
`3. Traugott U, Reinherz EL, Raine CS. Multiple sclerosis.
`Distribution of T cells, T cell subsets and Ia-positive
`macrophages in lesions of different ages. Journal of Neuro-
`immunology 1983; 4: 201–221.
`4. ffrench-Constant C. Pathogenesis of multiple sclerosis.
`Lancet 1994; 29: 271–275.
`5. Hartung HP, Reiners K, Archelos JJ, et al. Circulating
`adhesion molecules and tumor necrosis factor receptor in
`multiple sclerosis: correlation with magnetic resonance
`imaging. Annals of Neurology 1995; 38: 186–193.
`6. Noseworthy JH, Lucchinetti C, Rodriguez M, Weins-
`henker BG. Multiple sclerosis. New England Journal of
`Medicine 2000; 343: 938–952.
`7. Lassmann H, Ransohoff RM. The CD4-Th1 model for
`in
`re-appraisal. Trends
`multiple sclerosis: a crucial
`Immunology 2004; 23: 132–137.
`8. Walsh MJ, Tourtellotte WW. Temporal invariance and
`clonal uniformity of brain and cerebrospinal IgG, IgA,
`and IgM in multiple sclerosis. Journal of Experimental
`Medicine 1986; 163: 41–53.
`9. So¨ derstro¨ m M, Link H, Sun JB, et al. T cells recognizing
`multiple peptides of myelin basic protein are found in
`blood and enriched in cerebrospinal fluid in optic neuritis
`and multiple sclerosis. Scandinavian Journal of Immuno-
`logy 1993; 37: 355–368.
`10. The IFNB Multiple Sclerosis Study Group. Interferon
`beta-1b is effective in relapsing-remitting multiple scler-
`osis. I. Clinical results of a multicenter, randomized,
`double-blind, placebo-controlled trial. Neurology 1993;
`43: 655–661.
`11. Jacobs LD, Cookfair DL, Rudick RA, et al. Intramuscular
`interferon beta-1a for disease progression in relapsing
`multiple sclerosis. Annals of Neurology 1996; 39: 285–294.
`12. PRISMS (Prevention of Relapses and Disability by
`Interferon b-1a Subcutaneously in Multiple Sclerosis)
`Study Group. Randomised
`double-blind
`placebo-
`controlled study of interferon b-1a in relapsing/remitting
`multiple sclerosis. Lancet 1998; 352: 1498–1504.
`13. de Jong R, Bezemer AC, Zomerdijk TP, van de Pouw-
`Kraan T, Ottenhoff TH, Nibbering PH. Selective stimu-
`lation of T helper 2 cytokine responses by anti-psoriasis
`Journal
`of
`agent monomethylfumarate. European
`Immunology 1996; 26: 2067–2074.
`14. Ockenfels HM, Schultewolter T, Ockenfels G, Funk R,
`Goos M. The antipsoriatic agent dimethylfumarate im-
`munomodulates T-cell cytokine secretion and inhibits
`cytokines of the psoriatic cytokine network. British Jour-
`nal of Dermatology 1998; 139: 390–395.
`
`Sawai (IPR2019-00789), Ex. 1018, p. 006
`
`

`

`610
`
`S. Schimrigk et al.
`
`15. Vandermeeren M, Janssens S, Borgers M, Geysen J. Di-
`methylfumarate is an inhibitor of cytokine-induced E-
`selectin, VCAM-1 and ICAM-1 expression in human
`endothelial cells. Biochemical and Biophysical Research
`Communications 1997; 234: 19–23.
`16. Bayard W, Hunziker T, Krebs A, Speiser P, Joshi R.
`Peroral long-term treatment of psoriasis using fumaric
`acid derivatives. Hautarzt 1987; 38: 279–285.
`17. Kolbach DN, Nieboer C. Fumaric acid therapy in psori-
`asis: results and side effects of 2 years of treatment.
`Journal of the American Academy of Dermatology 1992;
`27: 769–771.
`18. Altmeyer PJ, Matthes U, Pawlak F, et al. Antipsoriatic
`effect of fumaric acid derivates. Results of a multi-
`center double-blind study in 100 patients. Journal of
`the American Academy of Dermatology 1994; 30:
`977–981.
`19. Altmeyer P, Hartwig R, Matthes U. Efficacy and
`safety profile of fumaric acid esters in oral
`long-term
`therapy with severe
`treatment
`refractory psoriasis
`vulgaris. A study of 83 patients. Hautarzt 1996; 47:
`190–196.
`20. Mrowietz U, Christophers E, Altmeyer P. Treatment of
`psoriasis with fumaric acid esters: results of a prospective
`multicentre study. British Journal of Dermatology 1998;
`138: 456–460.
`21. Prinz JC. The role of T cells in psoriasis. Journal of the
`European Academy of Dermatology and Venereology 2003;
`17: 257–270.
`
`22. Poser CM, Paty DW, Scheinberg L, et al. New diagnostic
`criteria for multiple sclerosis: guidelines for research
`protocols. Annals of Neurology 1983; 13: 227–231.
`23. Filippi M, Yousry T, Campi A, et al. Comparison of triple
`dose versus standard dose gadolinium-DTPA for detec-
`tion of MRI enhancing lesions in patients with MS.
`Neurology 1996; 46: 379–384.
`24. Andersson U, Hallden G, Persson U, Hed J, Moller G,
`DeLey M. Enumeration of IFN-gamma-producing cells by
`flow cytometry. Comparison with fluorescence microscopy.
`Journal of Immunological Methods 1988; 112: 139–142.
`25. Jung T, Schauer U, Heusser C, Neumann C, Reiger C.
`Detection of intracellular cytokines by flow cytometry.
`Journal of Immunological Methods 1993; 159: 197–207.
`26. Zivadinov R, Bakshi R. Role of MRI in multiple sclerosis
`I: inflammation and lesions. Frontiers in Bioscience 2004;
`9: 665–683.
`27. Litjens NHR, Nibbering PH, Barrois AJ, et al. Beneficial
`effects of fumarate therapy in psoriasis vulgaris patients
`coincide with downregulation of type 1 cytokines. British
`Journal of Dermatology 2003; 148: 444–451.
`28. Imitola J, Chitnis T, Khoury SJ. Cytokines in multiple
`from bench to bedside. Pharmacology and
`sclerosis:
`therapeutics 2005; 106: 163–177.
`29. Gold R, StadelmannC, Linker R, Diem R, Ba¨ hr M, Bru¨ ck
`W. Neue Erkenntnisse zur Pathogenese der multiplen
`Sklerose. Potential fu¨ r die Erweiterung der therapeutis-
`chen Optionen. Deutsches Arzteblatt 2005; 102: A1204–
`A1210.
`
`Ó 2006 EFNS European Journal of Neurology 13, 604–610
`
`Sawai (IPR2019-00789), Ex. 1018, p. 007
`
`