Promoting and measuring remyelination and neuroprotection in clinical trials of people with multiple sclerosis

Abstract

The most tractable strategy to delay or prevent the progressive phase of MS is to promote endogenous remyelination; doing so restores nerve conduction and prevents demyelinated axons from degenerating. The rate-limiting stage in this process is differentiation of oligodendrocyte progenitor cells (OPCs) into mature, myelinating, oligodendrocytes. In animals, agonism of the retinoid X receptor (RXR)-γ enhances remyelination in this way. Metformin also promotes remyelination, this time by overcoming an age-associated block to the responsiveness of OPCs to pro-differentiation factors.

In this PhD I show that bexarotene, a non-selective agonist of the RXR receptor, promotes remyelination in people with relapsing remitting multiple sclerosis. Converging evidence from electrophysiology and neuroimaging in a phase II clinical trial (CCMR One) demonstrate that this occurs in demyelinated lesions and is greatest in lesions located in grey matter regions of the brain. I additionally conducted analyses which suggest an age-dependency of bexarotene’s remyelinating effect and led a follow-up sub study of the trial participants which showed the treatment effect afforded by bexarotene is sustained, years after treatment. Unfortunately, bexarotene was poorly tolerated, and so the legacy of this trial will likely be one of shaping the framework for future assessments of remyelinating therapies. As such, I designed, obtained funding and secured approvals for a clinical trial to test the remyelinating effect of the combination of metformin with clemastine (CCMR Two), implementing lessons from CCMR One in the trial design; this is due to commence participant recruitment in 2021.

In exploring treatments for progressive forms of MS, not limited to the process of remyelination, I worked with the MS Society to develop and implement a rigorous, expert-led, evidence-based approach to the selection of licensed drugs for repurposing and testing in clinical trials of people with progressive MS. I reviewed the preclinical and clinical literature for a list of compounds and condensed these into a database of summary documents. These were presented to a panel of experts and people affected by MS, ultimately leading to four treatments being recommended for immediate testing in progressive MS trials: R-α-lipoic acid, metformin, the combination treatment of R-α-lipoic acid and metformin, and niacin.

Regrettably, much of my research has been halted by the COVID-19 pandemic. In this PhD I had additionally sought to evaluate electrophysiological techniques for quantifying remyelination and neuroprotection – multifocal VEP and saccadometry – in cohorts of people with MS and in the setting of the CCMR Two trial. Instead, when these studies were delayed, I embraced an opportunity to help the Cambridge COVID-19 research effort, working on the RECOVERY trial in the first wave, and leading my own project to analyse enrolment to treatment trials, ultimately describing the barriers to, and implications of, low recruitment rates in advance of the subsequent waves. Consequently, further exploratory research with electrophysiology and the CCMR Two trial will be the subject of post-doctoral research.