Relapsing Remitting Multiple Sclerosis Clinical Trial
Official title:
Phase II Study of High Dose Cyclophosphamide Followed by Glatiramer Acetate in the Treatment of Relapsing Remitting Multiple Sclerosis
The purpose of this study is to determine if high-dose cyclophosphamide followed by a maintenance dose of glatiramer acetate is safe in patients with relapsing remitting multiple sclerosis (MS). The investigators hypothesize that institution of glatiramer acetate treatment following high-dose cyclophosphamide treatment will extend the period of disease free activity and further reduce the disability in patients with relapsing remitting multiple sclerosis. The investigators plan to investigate the properties of glatiramer acetate against the recurrence of MS disease activity following high dose cyclophosphamide induced cessation detectable autoimmunity. The investigators hypothesize that glatiramer acetate, given in the phase of immune reconstitution after high-dose cyclophosphamide, may bias the immune system to a more tolerated state, thus leading to more stable and potentially permanent remissions.
Multiple sclerosis (MS) is an autoimmune disease characterized by progressive immune-mediated
destruction of myelin and axons within the CNS. Despite the development, approval and
clinical utilization of several medicines for patients with MS, most patients continue to
accrue progressive disability. High-dose cyclophosphamide is chemotherapy treatment option
for severe, refractory, immune-mediated illnesses such as MS. There is growing evidence that
high dose cyclophosphamide is well tolerated and effective in MS. Our experience with 9
patients who underwent treatment at the Johns Hopkins Hospital yielded impressive results
with a significant 40% reduction in baseline disability and an 81% reduction in MRI
gadolinium enhancing lesions. Five out of 9 patients had recurrence of new brain MRI lesions
during 24 months of follow-up, recurring in 4 patients during the first year of follow-up.
Our findings suggest that high-dose cyclophosphamide holds promise in inducing remission and
reducing disability in relapsing remitting MS however the recurrence of MS disease activity
(evidenced by worsening disability, clinical exacerbations or ongoing MRI evidence of new
lesions) suggests that high-dose cyclophosphamide given as a treatment on its own, is not
sufficient to induce long-term remission.
Glatiramer acetate has been shown to be a more general suppressor of autoimmune disease,
inhibiting the onset of experimental animal models of uveoretinitis, rheumatoid arthritis,
immune rejection of grafts against host and host against graft disease, and inflammatory
bowel disease. Glatiramer acetate was originally developed based on the observation that it
inhibited the onset of clinical disease in an animal model of multiple sclerosis,
experimental autoimmune encephalomyelitis (EAE). Glatiramer acetate suppression of EAE was
found to be a general phenomenon not restricted to a particular species, disease type or
encephalitogen used for the induction of EAE. A unique feature of glatiramer acetate is its
promiscuous binding with high affinity to various class II MHC molecules and it potent
induction of Th2 regulatory T cells. Moreover glatiramer acetate has subsequently been shown
to be a more general suppressor of autoimmune disease, inhibiting the onset of experimental
uveoretinitis, immune rejection of grafts against host and host against graft disease, and
experimental inflammatory bowel disease.
We plan to investigate the properties of glatiramer acetate against the recurrence of MS
disease activity following high dose cyclophosphamide induced cessation detectable
autoimmunity. This study is a prospective, open-label two-year follow-up study in 12 patients
with relapsing-remitting MS who are unable to tolerate or have failed to optimally respond to
conventional therapy and are at high risk of disease progression and loss of function.
Patients who elect to enter the study will be given a single course of high-dose,
cyclophosphamide regimen without transplantation. Patients will then receive 20 mg of
glatiramer acetate subcutaneously 4 to 6 weeks after the last dose of high-dose
cyclophosphamide, to allow the immune system to have time to begin to reconstitute without
glatiramer acetate but still provide sufficient time for glatiramer acetate to vaccinate
against recurrence of MS disease activity.
The primary outcome of this pilot study will be to determine if high followed by a
maintenance dose of glatiramer acetate is safe in this patient population. We hypothesize
that institution of glatiramer acetate treatment following high-dose cyclophosphamide
treatment will extend the period of disease free activity and further reduce the disability
in patients with relapsing remitting MS.
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