Adrenocorticotropic Hormone (ACTH) Effects on Myelination in Subjects With MS

This pilot study proposal is designed to perform a chronological measurement of MWF in new
contrast-enhancing lesions in subjects treated with ACTH during an acute exacerbation of MS.

The initial course of ACTH (H.P. Acthar®) will be administered as recommended in the package
insert, a subcutaneous daily dose of 80-120mg units daily for 2-3 weeks. However, as
recommended in the package insert, the dosage may be individualized according to the medical
condition of each subject. Therefore, the frequency and dose of the drug may be determined by
considering the severity of the disease and the initial response of the subject. The typical
dosing for an MS exacerbation is 80mg/day for 3-5 days and it is expected that this will be
the initial dosing for the majority of thesubjects.

MS subjects enrolled in this study will be randomized into:

Group A: 80mg/day ACTH for 3-5 days (The dose could be adjusted based on the individual needs
of the subjects up to 80-120mg units daily for 2-3 weeks.)

Group B: 80mg/day ACTH for 3-5 days (The dose could be adjusted based on the individual needs
of the the subjects up to 80-120mg units daily for 2-3 weeks.), followed by monthly 80 mg/day
ACTH for 3 days for up to 12 months of treatment.

The Judith Jaffe Multiple Sclerosis Center currently has over 1000 subjects in a clinical and
MRI database. The subjects who have signed consent for the database will have their standard
of care MRI scans monitored for new enhancing lesions; this will only have to be repeated if
initial scan is not completed at our MS center with our current clinical protocol. All RRMS
subjects with new enhancing lesions will be considered for the study and approached regarding
participation subjects that are considered candidates and consent for the study, subjects
will then be randomized (1:1) to receive one course of ACTH followed by monthly pulses vs.
receiving only one course of ACTH treatment. All subjects will have follow-up MRI¿s are 3
months, 6 months and 12 months post lesion onset for a total of 3 additional scans. If a
patient is identified as having an enhancing lesion from MRI scan not obtained through our
database, an additional scan will be obtained through the study and serve as the baseline
MRI. All subjects will receive the first course of ACTH within 4 weeks of new lesion
detection.

Multiple sclerosis (MS) is a very dynamic disease both biologically and clinically, which is
characterized by a temporally complex pattern of inflammation, demyelination/remyelination,
and axonal loss. The cycle of demyelination and remyelination has been shown to occur in MS
lesions (1,2). High dose corticosteroids have been a mainstay of treatment for MS relapses.
Corticosteroid treatment shortens time to recovery from relapses, presumably at least in part
due to their anti-inflammatory effects. Despite their anti-inflammatory properties,
corticosteroids have been shown to impair and delay remyelination in animal models of MS
(3,4) and there is little clinical evidence of a longer-term beneficial effect.
Adrenocorticotropic hormone (ACTH) gel, a long-acting formulation of the full sequence ACTH
that includes other pro-opiomelanocortin (POMC) peptides, is considered an alternative to
corticosteroids in the treatment of relapses (currently FDA approved for this indication).
ACTH gel exerts direct anti-inflammatory and immune-modulating effects within the central
nervous system (CNS). These effects are mediated not only via induction of endogenous
corticosteroid production but also via effects on melanocortin receptors (5). Studies have
shown that ACTH and other melanocortins may reduce neuroinflammatory responses (6), and ACTH
has been shown to protect mature oligodendrocytes from inflammation-related damage and
excitotoxicity (7). Currently however, there is a paucity of studies using more advanced MRI
metrics to determine if ACTH may have reparative and neuroprotective properties in subjects
with MS. We propose to study monthly courses of ACTH in subjects with new lesions and
compared to the one-time treatment course of ACTH for new activity. We hypothesize that
continued exposure to the anti-inflammatory effects of ACTH on new lesions would be superior
to promoting remyelination as compared to a one-time treatment course. Given that the
majority of endogenous remyelination is felt to begin within months after lesion development
and likely to be most prominent in the few months following, a one year study is most likely
sufficient to measure this process.

T2 relaxometry is a MR imaging technique in which a series of T2-weighted images at different
echo times are obtained and the contribution of water associated with myelin and other tissue
compartments can be differentiated using T2 decay curve analysis(8). The relative
contribution of the myelin water, represented as the myelin water fraction (MWF), has been
shown to highly correlate with histological myelin measurement in animal models (9) and
ex-vivo brain (10,11), and has been applied to MS the subjects (12). The histological
correlation of T2 relaxometry with myelin content makes it an excellent candidate as a
biomarker for myelin content and it has been found to be reproducible and sensitive marker to
change over time (13-16). Through the application a multi-slice 2D T2prep spiral gradient
echo (GRE) imaging, T2 data can be efficiently acquired (17,18) and we have further optimized
a 3D T2prep GRE sequence at 3T for which full brain coverage can be achieved within 10
minutes (19). One of the main advantages of using T2 relaxometry and MWF as a surrogate for
myelin over other advanced MR modalities lies in the T2 spectrum (the T2 decay curve
analysis). Both MWF and the extracellular T2 component (the intermediate peak) within the T2
spectrum) can increase with edema (20), thus once the extracellular pool stabilizes, we can
ensure that any change in MWF is a true reflection of myelination.

The primary objective of this study is to determine if monthly pulse doses of a three-day
course ACTH (H.P. Acthar®) is more effective at recovering myelin at 12 months, as measured
by MWF, in new multiple sclerosis lesions as compared to one course of treatment.

The main secondary objective is to utilize every three-month MWF measurements to determine
the peak time of remyelination in new multiple sclerosis lesions when followed over the
course of 12 months.

Inclusion Criteria:

- Patients with RRMS or SPMS with new contrast-enhancing lesions who will start as part
of their standard of care ACTH.

Exclusion Criteria:

- Patients having received oral or IV corticosteroids within one month prior to initial
scan demonstrating contrast enhancing lesion

- Patients with known or new allergy to ACTH

- Patients being treated with Natalizumab, Rituximab, and Cyclophosphamide

- Patients unwilling to have serial MRI exams

- Patients unable to undergo MRI imaging because of having an artificial heart valve,
metal plate, pin, or other metallic objects in their body or is unable to complete all
the MRI scans required for this study

- Patients with acute or chronic renal disease in whom administration of gadolinium may
pose risk of nephrogenic systemic fibrosis

- Patients that are pregnant

- Premenopausal woman not willing to use at least one form of contraception

- Patients with a known history of diabetes mellitus

- Patients with a known history of osteoporosis or bone density values in the
osteoporosis range at screening

- Progressive neurological disorder other than RRMS or SPMS

- Clinically significant cardiovascular disease, including myocardial infarct within
last 6 months, unstable ischemic heart disease, congestive heart failure, or angina

- Subjects on chronic steroid therapy for treatment of MS or other systematic disease

- Subject currently has a significant medical condition (other than MS) including the
following: neurological, psychiatric, metabolic, hepatic, renal, hematological,
pulmonary, cardiovascular (including uncontrolled hypertension), gastrointestinal,
urological disorder, or central nervous system (CNS) infection that would pose a risk
to the subject if they were to participate in the study or that might confound the
results of the study

o Note: Active medical conditions that are minor or well-controlled are not
exclusionary if, in the judgment of the Primary Investigator, they do not affect risk
or the subject or the study results.

- Subject is unable to cooperate with any study procedures, unlikely to adhere to the
study procedures and keep appointments, in the opinion of the Investigator, or was
planning to relocate during the study