Impact of Tecfidera on Gut Microbiota

This will be an open-label prospective study design with respect to MS immunomodulatory
therapy choice. Study group will be defined as subjects with a relapsing form of multiple
sclerosis as defined by the McDonald criteria choosing to begin dimethyl fumarate (DMF)
therapy. Blinding of the principal investigator and study subject to microbiota analysis
results will be maintained until the planned end of study. Subjects who receive at least one
dose of DMF and subsequently discontinue therapy will be invited to complete the study on
alternative immunomodulatory therapy or no therapy. Data from subjects who have received at
least one dose of DMF and who withdraw early from the study will be included in analysis as
last visit carried forward. A goal has been set to enroll 25 subjects for this study.

Gut microbiota will be characterized using a commercial service, Second Genome, utilizing
bacterial DNA extraction from stool samples and 16S ribosomal RNA gene amplification,
followed by high-throughput sequencing. Taxonomic profiling on the Illumina MiSeq system is
cycled to generate paired 250-bp reads in Second Genome's protocols. These longer read
lengths provide high-quality full length-reads of the gene to ensure the most accurate
classification available through sequencing technologies. Next generation sequencing has
emerged as a powerful tool for investigating microbial communities in large sample sets.

Serial stool samples will be collected from each subject, and sent to Second Genome for
analysis. The first stool sample will be collected prior to the initial dose of DMF, with
subsequent collections at defined time points over the course of the study. A more intensive
analysis will focus on the first 12 weeks of treatment, a time during which development and
resolution of gastrointestinal side effects typically take place on therapy.
Treatment-emergent flushing severity will be recorded during this time using a 5-point
Likert scale flushing severity survey. Gastrointestinal (G.I.) symptoms will be assessed
using the Gastrointestinal Symptoms Rating Scale (GSRS) questionnaire, a validated,
self-administered questionnaire that includes 15 questions, which assess severity of G.I.
symptoms using a 7-point Likert scale in five domains: indigestion, diarrhea, constipation,
abdominal pain and reflux. The severity of symptoms reported in the GSRS increases with
increasing score. Other variables which potentially may alter the gastrointestinal
microbiota and secondarily DMF tolerance will be assessed, including the identification of
subjects predisposed to functional bowel disorders via use of the Rome III functional bowel
survey, a validated clinical tool to identify at-risk individuals, diet composition,
antibiotic exposure, steroid treatments for neurological relapses, use of prebiotic ,
probiotic, or vitamin D supplements, and H2 blocker or proton pump inhibitor (PPI) therapy,
as gut pH changes impact the gut flora composition.Additional data on mood change over 24
weeks of DMF therapy, using the Hamilton Anxiety Measurement (HAM) Rating Scale and Patient
Health Questionnaire-9 (PHQ-9) Depression Scale, will be collected and correlated to
DMF-emergent G.I. disturbances, and to changes in bacterial and archaeal species in the gut
flora.

Inclusion Criteria:

- Confirmed diagnosis of a relapsing form of multiple sclerosis by McDonald criteria.

- Age 18 years or older.

- Able to provide informed consent.

- Treatment naïve to DMF, Fumaderm or other fumarate containing compound.

- Neurologically stable within 4 weeks prior to screening.

- Stable gross diet composition type (Western, vegetarian with dairy, vegan,
gluten-limited, Paleo) within 12 weeks of screening visit.

- Able to complete study specific questionnaires and demographic information via HIPAA
compliant secure internet based portal.

- No oral antibiotics within 4 weeks of screening.

- Able to abide by safety surveillance monitoring and management as part of standard of
care.

- Able and willing to comply with the protocol requirements for the duration of the
study.

Exclusion Criteria:

- Treatment with immunosuppressive therapies (other than steroids) within 12 months of
screening, experimental or FDA approved cell trafficking modulators, experimental
immune cell vaccines, or stem cell therapy.

- G.I. diagnostic or therapeutic procedure within 24 weeks of screening visit, or at
any time during participation in the study.

- Steroid therapy (oral or intravenous) within 4 weeks of screening visit.

- Chronic use of a proton pump inhibitor therapy (daily use for greater than 4 weeks)
within 3 months of screening.

- Chronic use (i.e. daily use for greater than 4 weeks) of laxatives other than Colace
within 6 months of screening.

- Intravenous antimicrobial therapy within 24 weeks of screening.

- Oral antimicrobial therapy within 4 weeks of screening.

- Dental procedure within 4 weeks of screening visit.

- Total parenteral nutrition (TPN) within 12 months of screening.

- History of Crohns disease, ulcerative colitis, biliary cirrhosis, celiac disease,
chronic pancreatitis, gastric lap-band procedure, gastric or colon cancer, bowel
resection, colitis within past 6 months.

- Women who are pregnant, breastfeeding, planning pregnancy, or potentially fertile and
not willing to abide by effective contraception while being treated with DMF.