Biomarkers in Multiple Sclerosis

OBJECTIVE: To identify biomarkers (by gene- and protein expression profiling, single
nucleotide polymorphism (SNP) haplotype determination, HLA typing) and link these with
clinical- and MRI phenotypes in a large cohort of relapsing-remitting (RR-) MS patients. To
identify biomarkers that separate MS patients and healthy, matched controls.

STUDY POPULATION: Up to 1000 patients who are enrolled in and treated under a multi-center
trial of combination therapy (MS-CombiRx) using two approved disease-modifying therapies
(interferon-beta, IFN-b, Avonex; glatiramer-acetate, GA) as single treatments or in
combination. 200 healthy, matched control individuals.

DESIGN: Samples of serum and white blood cells will be obtained on each patient prior to
randomization in the MS-CombiRx study and then at 6 months 1, and 3 years following
randomization. Samples will be analyzed for SNP haplotype, gene and protein expression, and
HLA haplotype. Samples from controls will be analyzed in the same fashion, however, only one
time point will be analyzed, and there will be no treatment of controls.

OUTCOME MEASURES: The results of the biomarker studies will be assessed in relationship to
both the clinical and MRI phenotype at baseline and to change in disability, relapse rate,
response to therapy and change in MRI measures of disease during the 3-year treatment period.
Each of the biomarker study components will be analyzed with respect to biomarkers that
discriminate between MS patients and controls.

SIGNIFICANCE: Similar to rheumatoid arthritis or autoimmune diabetes multiple sclerosis (MS)
is considered a complex disease with autoimmune pathogenesis as well as vulnerability of the
target tissue, i.e. the central nervous system (CNS). The results of the biomarker study
should provide a better understanding of the disease pathogenesis, of the inter-individual
disease heterogeneity, and finally identify biomarkers such as gene- and protein expression
signatures and individual genes and proteins that are correlated with responsiveness or
non-responsiveness to single drug treatment or the combination of the two drugs. The three
years duration of the combination therapy trial will further allow us to gather information
on the longitudinal evolution of the identified biomarkers under treatment of MS.

- INCLUSION CRITERIA - PATIENTS:

To be eligible for entry into this study, candidates must meet the following eligibility
criteria at the time of enrollment:

Between the ages of 18 and 60 years, inclusive.

Diagnosis of Relapsing-Remitting MS.

Expanded Disability Status Scale (EDSS) score between 0 and 5.5, inclusive.

At least 2 exacerbations in the prior three years; one exacerbation may utilize the
McDonald MRI criteria for dissemination in time (a new Gd-enhancing lesion demonstrated on
a scan done at least 3 months following onset of a clinical attack or a new T2 lesion or
Gd-enhancing lesions on a follow-up scan after an additional 3 months).

Give written informed consent prior to any testing under this protocol, including screening
tests and evaluations that are not considered part of the subject's routine care.

EXCLUSION CRITERIA - PATIENTS:

Candidates will be excluded from study entry if any of the following exclusion criteria
exist at the time of screening (prior to randomization):

Prior use of interferon beta or glatiramer acetate.

Acute exacerbation within 30 days of screening.

Steroids for acute exacerbations (greater than 100 mg/day) within 30 days of study entrance
or chronic systemic steroid use.

Evidence of progressive MS.

Use of immunosuppressive or chemotherapeutic agents or IVIg.

Inability to perform the MSFC (Time 25-Foot Walk, 9HPT, and PASAT3).

Inability to undergo baseline MRI scan.

History of any significant cardiac, hepatic, pulmonary, or renal disease; immune
deficiency; or other medical conditions that would preclude therapy with interferon beta or
glatiramer acetate.

Known history of sensitivity to gadopentate dimeglumine or mannitol.

History of a seizure within the 3 months prior to randomization.

History of suicidal ideation or an episode of severe depression within the 3 months prior
to randomization.

Abnormal screening blood tests exceeding any of the limits defined below:

Alanine transaminase (ALT) or aspartate transaminase (AST) greater than two times the upper
limit of normal (i.e., greater than 2 times the ULN).

Total white blood cell count less than 2,300/mm(3).

Platelet count less than 80,000/mm(3).

Creatinine greater than 2 times the ULN.

Participation in another experimental clinical trial, without formal approval.

Previous participation after randomization in this study.

History of alcohol or drug abuse within the 2 years prior to randomization.

Female subjects who are currently pregnant, breast-feeding, or plan to become pregnant.

For female subjects, unless postmenopausal or surgically sterile, unwillingness to practice
effective contraception, as defined by the investigator, during the study. The rhythm
method is not to be used as the sole method of contraception.

Unwillingness or inability to comply with the requirements of this protocol including the
presence of any condition that is likely to affect the subject's returning for scheduled
follow-up visits on schedule (any physical, mental, or social condition, including history
of any episode of suicidal ideation or severe depression defined as any episode that
required hospitalization within the previous 3 months).

INCLUSION CRITERIA - CONTROLS:

18 to 60 years inclusive.

EXCLUSION CRITERIA - CONTROLS:

Any significant acute or chronic illness, particularly no autoimmune or chronic
inflammatory, -infectious disease.

HIV positive.

No treatment with immunomodulatory, immunosuppressive or chemotherapeutic drugs.

Pregnancy.

Nursing mothers.