Intranasal Insulin for Improving Cognitive Function in Multiple Sclerosis
Phase: PHASE1
Conditions: Multiple Sclerosis, Relapsing-Remitting, Multiple Sclerosis, Secondary Progressive, Multiple Sclerosis, Primary Progressive
Sponsor: Johns Hopkins University

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
1 
 
 
PROTOCOL TITLE: INTRANASAL INSULIN FOR IMPROVING COGNITIVE FUNCTION IN 
MULTIPLE SCLEROSIS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DATE: November 20, 2020 
 
 
 
 
 
 
 
VERSION: 2.4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
2 
 
 
 
 
 
 
SYNOPSIS 
 
This will be a randomized, double-blind, placebo-controlled phase I/II pilot study. Participants will be 
randomized to intranasal insulin 10 international units (IU) twice a day, 20 IU twice a day, or placebo for 24 
weeks. Insulin will be administered intranasally using the novel  ViaNaseTM controlled particle dispersion 
system, allowing for direct delivery of the medication to the nasal epithelium, leading to maximal transport to 
the CNS (Kurve Technology, Lynnwood, WA).34 Cognitive assessments will occur at baseline and throughout 
the 24-week trial, as well as for a period of 24 weeks after discontinuation of the intervention, to evaluate the 
impact of insulin on cognitive performance as well as the longevity of the treatment response. Biomarkers of 
cellular stress, neuronal injury, oxidative stress, inflammation, and energy metabolism will be assessed at 
baseline and at subsequent visits. Stored specimens will be acquired for more detailed future mechanistic 
studies if intranasal insulin does appear to be safe and effective.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
3 
 
 
 
 
 
INTRODUCTION 
 
Cognitive impairment is common in and devastating to people with MS. MS is a common, chronic, central 
nervous system (CNS) disease characterized by inflammation, demyelination, and neurodegeneration. One of 
the most devastating symptoms of this disease is impaired cognitive function, which is common and present in 
over 60% of individuals with MS.1-3 MS-related cognitive impairment is associated with lowered quality of life 
4 and reduced functional capacity, including loss of employment,4-7 impaired social relationships,8 compromised 
driving safety,7 and poor adherence to treatment.9 Impaired cognitive functioning has been observed early in the 
disease, sometimes even before diagnosis,10 and cognitive function has been shown to decline longitudinally, 
both over the short- and long-term.11-13 Several cognitive domains are impacted in people with MS, including 
attention, memory, executive functioning, and especially processing speed.2, 10, 14-18  
To date, multiple pharmacologic interventions have been assessed with disappointing results. There was no 
significant difference between treatment and placebo for cognition in randomized control trials of donepezil,19  
aminopyridines,20 gingko biloba,21 and memantine.22 Psychostimulants demonstrated some efficacy, but only in 
secondary outcome measures.23 Behavioral interventions show promise but are understudied.24 Furthermore, 
cognitive rehabilitation is often time consuming, costly, and not universally available. Hence, there is an 
urgent need to identify or develop novel therapies that can help improve cognitive function in MS.  
 
Insulin is critical for helping with regulation of multiple CNS functions including brain metabolism, 
neurite outgrowth, neurotransmitter channel activity, neuronal survival, and learning and memory.25 ,26 
There are insulin receptors throughout the brain, with robust concentrations located in eloquent areas including 
the olfactory bulb, hippocampus, cerebral cortex, and cerebellum. Insulin is present at high levels in the brain 
and when these levels are decreased, there may be learning and memory impairments.25, 27, 28 The cognitive 
impairment that can ensue in the context of low brain insulin levels may be related to its ability to protect 
neurons from various insults including oxidative stress, ischemia, and glutamate-related excitotoxicity.25 
Moreover, insulin’s anti-inflammatory effects, as detailed below, 
may also impact brain health via suppressing concentrations of 
chemokines, cytokines, and other molecules that may provoke 
ongoing CNS inflammation and damage in disease states.   
 
Insulin has biologically relevant anti-inflammatory and 
neuroprotective CNS effects. At the cellular level, insulin 
regulates various neuronal functions including receptor 
expression, trafficking, and survival pathway activation. 
Insulin signaling in neurons exerts a neuroprotective effect, 
especially under oxidative stress, via the phosphoinositide-3 
kinase (PI3K/AKT) pathway (Figure 1) which, downstream, 
induces the cAMP response element binding protein (CREB). 
CREB regulates the expression of several genes that are crucial 
for learning and memory, including brain derived neurotrophic 
factor (BDNF),29 an important promoter of neuronal survival 
pathways, resulting in regulating learning and memory. This 
neuroprotective effect has been seen in models of Alzheimer’s, 
Parkinson’s, and Huntington’s Diseases.30 Insulin also exerts anti-inflammatory effects on peripheral blood 
Figure 1.  Neuroprotective signaling associated with insulin. 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
4 
 
mononuclear cells (PBMCs) by altering inflammatory markers (e.g. monocyte chemoattractant protein-1, 
chemokine receptor-5) that could ultimately help minimize ongoing nervous system injury.25  
 
Insulin’s ability to regulate energy metabolism could also result in a protective effect on neurons via 
impacting oxidative stress and excessive energy demands. Insulin appears to directly mediate brain glucose 
metabolism maximally within the cortex, and with any disturbance in the communication between insulin and 
neuronal glucose metabolism, there may be impaired adenosine triphosphate (ATP) synthesis followed by 
neuronal apoptosis.31, 32 Moreover, the oxidative stress that results from excessive energy demand leads not only 
to the production of reactive oxygen species (ROS), but also to ceramide production. These signaling pathways 
are connected and may be altered upstream by insulin’s impact on brain glucose metabolism. For example, 
several apoptosis-inducing treatments both activate the sphingomyelin (SM)-ceramide pathway and generate 
oxidative stress.33 Inflammatory cytokines relevant to MS (e.g. tumor necrosis factor [TNF]-α) can also induce 
ceramide formation and ROS. Chemical scavengers prevent elevations in ROS and also SM-ceramide pathway 
activation. Finally, the use of pyrrolidine dithiocarbamate or N-acetyl cysteine, both antioxidants, restricts 
ceramide formation and cell death due to TNF-α in rat astrocytes or human breast carcinoma cells.  
 
The impact of insulin in the nervous system, especially as it relates to cognitive health, deserves more attention, 
as it may be a treatment for disease that cause CNS dysfunction from several pathologies, including MS.  
 
Insulin administration has been shown to improve memory and learning in healthy people and in those 
with neurodegenerative diseases (see Table 1). Intranasal insulin has shown to have neuroprotective and 
restorative effects in several human clinical trials. In a recent randomized, double-blind, placebo-controlled 
study with over 100 people suffering from amnestic mild cognitive impairment or Alzheimer’s Disease, 
intranasal insulin preserved cognitive function in both selective cognitive domains and more globally compared 
to placebo.34 The insulin-treated patients also did not show a decline in measures of brain metabolism, whereas 
the placebo-treated participants did show decreases in fluorodeoxyglucose 18F uptake in various lobes 
(parietotemporal, frontal, precuneus, and cuneus). Further, improvements in episodic memory persisted for 
several weeks after treatment cessation. Overall, these findings suggest that intranasal insulin not only affects 
cognitive function acutely, but that over time, there may be associated structural changes that lead to a more 
permanent treatment benefit. Since cognitive dysfunction is very common in MS and can be devastating, a 
treatment intervention (i.e., intranasal insulin) that can help both acutely and longitudinally is worth pursuing.   
 
Table 1. Summary of past and ongoing human intranasal insulin trials. Adapted from 34-50 
 
REF. 
INTRANASAL 
INSULIN DOSE 
SUBJECTS 
ASSESSMENT 
Benedict 2004 
160 IU (long-term) 
Healthy 
Word list (immediate, delayed recall 
Reger 2006 
20 or 40 IU (acute) 
Probable AD or 
MCI vs. healthy 
Story recall (immediate, delayed recall) 
Word list (immediate, delayed recall) 
Benedict 2007 
20 IU Aspart vs. 20 IU 
Regular (long term) 
Healthy men 
Word list (immediate recall) 
Word list (delayed recall) 
Benedict 2008 
160 IU (acute) 
Healthy, normal 
weight, no meds  
Digit span, object location (immediate recall) 
Mirror tracing (immediate recall) 
Hallschmid 
2008 
160 IU (long-term) 
Obese men 
Word list (delayed recall) 
Word list (immediate recall) 
Reger 2008 
20 IU (long term) 
AD or MCI 
Memory score (immediate/ delayed recall ratio) 
Voice onset time (immediate/delayed recall ratio) 
Reger 2008 
10, 20, 40, 60 IU 
(acute) 
AD or MCI 
vs. healthy 
Story recall (immediate recall or delayed recall) 
Word list learning (immediate & delayed recall) 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
5 
 
Krug 2010 
160 IU (acute) 
Healthy women  Digit span (immediate recall) 
Object location(immediate recall) 
Fan 2012 
I40 IU (acute) 
Schizophrenic 
Hopkins Verbal Learning Test 
Craft 2012 
10 or 20 IU BID 
AD or MCI 
Verbal Memory Composite 
Craft 2012 
20 or 40 IU 
AD or MCI 
Story recall (delayed recall) 
McIntyre 
2012 
40 IU (long term) 
Euthymic with 
bipolar disorder 
California Verbal Learning Test, second edition 
Process Dissociation Task 
Burns 2012 
40 IU (acute) 
Early AD 
Functional MRI activation; cognitive battery 
Novak 2013 
40 IU (long term) 
Diabetic 
Brief Visuo-spatial Memory Test-Revised 
Verbal fluency measures 
Fan 2013 
40 IU (long term) 
Schizophrenic 
Cognitive battery 
Craft 2013 
20 IU BID 
AD or MCI 
Cognitive battery 
Haley 2013 
20 IU 
AD 
Cerebral glutamate levels; cognitive battery 
AD= Alzheimer’s Disease; MCI=mild cognitive impairment; IU=international units; BID=twice daily 
 
Intranasal insulin is extremely safe and tolerable in other populations, allowing for concentrated delivery 
to the nervous system. Intranasal insulin has a long-standing safety track record that spans more than a decade. 
No significant adverse events were reported in the largest intranasal insulin study to date or in any other study 
that has used intranasal insulin (see Table 1). An intranasal delivery system provides a non-invasive way to 
bypass the blood-brain barrier and allow rapid delivery of a medication to the CNS via the olfactory and 
trigeminal perivascular channels.34 The main advantage of the delivery system is reducing systemic side effects 
via limiting a medication’s exposure to peripheral organs and tissues. In addition, first-pass metabolism is 
avoided. Intranasal insulin, as seen in previous human studies, does not adversely affect systemic (blood) 
glucose or insulin, and it increases CSF insulin to biologically protective concentrations within 30-40 minutes.51   
 
Intranasal Insulin for Cognition in MS is an Innovative Treatment Approach-Summary 
Insulin appears to activate biologically relevant pathways within the nervous system for regulating and 
improving learning and memory. The direct and indirect effects of insulin on energy metabolism, oxidative 
stress, and modulation of inflammatory and neuronal pathways, along with the data from clinical trials 
in people with other neurodegenerative disorders, prove the rationale for investigating it in people with 
MS who suffer with cognitive impairment. As noted above, reduced levels of insulin and/or insulin activity 
may contribute to a number of pathological processes that may ultimately lead to long-term disability in 
neurodegenerative diseases. Restoring brain insulin to normal levels and increasing insulin sensitivity in the 
brain may provide therapeutic benefit to people with MS. Herein, we thus propose the first clinical trial in MS 
to determine the safety and tolerability as well as the effectiveness of intranasal insulin as a therapeutic 
intervention for cognitive dysfunction. Our study will investigate associated changes in putative biomarkers (see 
Preliminary Data below) that may corroborate clinical outcomes and provide data regarding the mechanisms by 
which insulin acts. These measures, along with neuropsychological testing, will be incorporated with safety data 
in order to accurately assess the potential utility of intranasal insulin for MS cognitive impairment. 
 
OBJECTIVES/AIMS 
 
Primary Objective: To evaluate the safety and tolerability of intranasal insulin in people with MS 
 
Secondary Objectives: The main secondary objective is to evaluate if intranasal insulin improves cognition in 
people with MS, as assessed by the SDMT. Additional secondary objectives are to determine if intranasal 
insulin is associated with changes in additional components of the Minimal Assessment of Cognitive Function 
in MS (MACFIMS), the Multiple Sclerosis Functional Composite (MSFC) score, health-related quality of life 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
6 
 
(Functional Assessment of Multiple Sclerosis [FAMS]), the Expanded Disability Status Scale (EDSS) score, 
and changes in biomarkers of oxidative stress, neuronal injury, cellular stress, and metabolism. 
 
Aim 1. To evaluate the safety and tolerability of intranasal insulin in people with MS. 
Hypothesis: Intranasal insulin has been shown to be safe in a pilot clinical trial of patients with mild cognitive 
impairment and Alzheimer’s Disease, but its safety and tolerability in MS patients are unknown. We 
hypothesize that intranasal insulin will be safe and tolerable for people with MS. 
 
Aim 2. To evaluate if intranasal insulin improves cognition in people with MS. 
Hypothesis: Intranasal insulin has been shown to improve multiple aspects of cognition in several randomized, 
blinded clinical trials of healthy people and in those with mild cognitive impairment and Alzheimer’s Disease. 
We hypothesize that intranasal insulin will improve cognition in MS patients who are cognitively impaired. 
 
Aim 3. To evaluate the impact of intranasal insulin on measures of oxidative stress, axonal injury, 
cellular stress, and energy metabolism in MS. 
Hypothesis: Although there is not a single biomarker for MS, there are some surrogate measures of interest that 
may well be impacted by treatment with insulin. We will perform an exploratory analysis to evaluate the effect 
that intranasal insulin has on these measures, with the hypothesis that intranasal insulin will improve markers of 
oxidative and cellular stress, neuronal injury, metabolism, and inflammation in people with MS. 
 
 
 
STUDY DESIGN 
 
Design: The design of this phase II, randomized, double-blind, placebo-controlled trial is as follows: 
 
Participants: The eligibility criteria for the trial are provided in the table below: 
Eligibility Criteria 
Rationale 
Meets 2010 criteria for multiple sclerosis 
Study is focused on individuals with MS 
No relapse in past 3 months 
To avoid relapse-induced cognition 
confounding 
Age 18-70 years 
To ensure results generalizable 
At least mild cognitive impairment (1.0 standard deviation 
or greater below the published mean SDMT z-score, or a 
score of <34 on the processing speed test [PST] 
To ensure that we are able to detect 
improvements in cognition if insulin does in 
fact have this effect 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
7 
 
Capacity to learn and self-administer intranasal insulin, or 
presence of a caregiver with such capacity who is willing 
to do it for the duration of the trial 
To ensure that subjects are able to take the 
medication as prescribed 
Untreated/on the same MS therapy for at least 2 months, 
with no anticipated change in the next year 
To avoid change in measures due to change in 
medication 
No current, active major depression 
May impact results of cognitive testing 
If on tricyclic antidepressant or anticonvulsant, on stable 
dose for 6 weeks or more; if on oxybutynin or tolterodine, 
on stable dose for > 6 months without plans for changing 
dose in next year 
May impact results of cognitive testing 
 
If taking selective serotonin (± norepinephrine) reuptake 
inhibitors, pregabalin, gabapentin, sympathomimetic, 
monoamine oxidase inhibitor, antipsychotic, amantadine, 
cholinesterase inhibitor, memantine, modafanil, 
armodafinil, or evening short-acting benzodiazepines, on  
stable dose for 6 weeks or greater 
To minimize impact on cognitive testing 
without  impairing recruitment/limiting 
generalizability (MS patients use these therapies  
commonly) 
Not pregnant or nursing, and willing to prevent pregnancy 
during study if of childbearing potential 
Risks of intervention to developing fetus or 
breastfeeding infant unknown 
No or stable THC use in past 6 weeks; no other illicit drug 
or alcohol abuse in past 3 months* 
To ensure participants can adhere to treatment/ 
avoid impact of substances on cognitive testing 
No known history of diabetes mellitus or insulin resistance  To avoid confounding due to global glucose 
dysregulation or use of systemic insulin 
No active liver disease, stage IV/V kidney disease or 
severe metabolic derangements 
To prevent differential metabolism of insulin 
No CNS disorder other than MS or headache 
To avoid confounding due to insulin effect on 
other disorder 
No issue making participation not in best interest of patient To prevent any undue harm to patient 
During COVID-19 pandemic and related periods of 
slowdown or shutdown, willing to comply with state/local 
recommended social distancing and other suggested 
COVID-19 related safety measures. Additionally, if female 
of childbearing potential, to prevent pregnancy 
To ensure minimization of risks to participants 
 
 
Recruitment: Eligible subjects with MS will be recruited from the Johns Hopkins MS Center, at which over 
3,000 MS patients, who come from diverse racial/ethnic and socioeconomic backgrounds and from a wide 
catchment area, are seen annually. We will also screen potentially eligible subjects using an IRB-approved 
Telephone Screening Script. This will allow us to screen patients who may or may not meet the study’s 
eligibility criteria. If a patient meets the eligibility criteria via telephone screening, we will schedule the patient 
to come in for a baseline visit. The study coordinator will call only patients of physicians on the study team. 
Patients interested in participating will be emailed or mailed the written consent form to review in advance.  
 
Since we began routinely administering the iPAD-based correlate of the SDMT, the Processing Speed Test 
(PST) for all MS Center patients since early 2017 and impaired cognition based on the SDMT is one of the 
main eligibility criteria, we will quickly be able to focus recruitment efforts on those who have evidence of mild 
cognitive impairment, eliminating the need for an extra screening visit.  More than 80 people with MS who are 
currently enrolled in various studies in the center already have SDMT data and thus will also be easily screened 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
8 
 
for eligibility, even if they haven’t had a recent clinic visit. For MS Center patients that have not taken an 
SDMT or PST test, we will use an oral consent process to administer the SDMT test and determine eligibility. 
SDMT or PST test results obtained within 3 months of the baseline visit will be considered as proof of 
eligibility for the study and may be screened in person or by phone. The study coordinator will only approach 
MS Center patients of physicians on the study team or those referred by their treating physician. In addition to 
the above recruitment strategies, we will obtain home-based PST screening test for our MS patients that have 
iPADs (Air, Air 2, and iPAD 2017), as the PST app is now available. This will allow for remotely screening 
potential subjects that have transportation and/or mobility limitations.  If at any time point, enrollment is less 
than 85% of the target, we will interview subjects who have declined to participate to determine the deterrents 
to enrollment; we will then implement alterations in recruitment needed to enhance enrollment. 
 
 
Study Treatment: Intranasal insulin (Novolin R, Novo Nordisk, Princeton, NJ) will be evaluated in two doses 
(10 IU twice a day, 20 IU twice a day) and compared to the sterile diluent (Eli Lilly and Company – 
NDC:00002-0800) (1:1:1 randomization, stratified by relapsing versus progressive MS). The 20 IU dose will 
consist of insulin. The 10 IU dose will be a diluted mixture comprised of normal saline and insulin. The study 
drug, insulin, has a distinct smell. In order to preserve study blinding, we will use the Lilly sterile diluent, which 
has a similar odor as the insulin, to preserve blinding. The study drug and placebo (Lilly diluent) will be 
prepared by the Johns Hopkins Investigational Drug Service and will appear identical to maintain blinding. A 
nasal drug delivery device (Kurve Technology, Lynnwood, WA) will be utilized to ensure optimal exposure of 
the olfactory epithelium. The treatment regimen was chosen to match that of a recent successful pilot study in 
Alzheimer’s Disease.34 Evaluating two doses will allow for the possibility that any benefit of insulin may be 
non-linear. 
 
Treatment Preparation: The study pharmacist will transfer either insulin; sterile diluent (placebo); or normal 
saline into 10cc empty syringes to preserve study blinding. The syringes will be labeled syringe A or syringe B, 
respectively. At the baseline visit, subjects and/or caregivers will be instructed on how to fill the cartridges by 
adding one A and one B syringe to the cartridge; gently mix the contents and be shown how to administer the 
doses using the ViaNase device.  Due to the 28-day shelf life of the insulin/diluent, the subjects need to know 
how to refill their own study products prior to their next study visit.  
 
Methods to Maximize Adherence: Given data from prior studies, it is anticipated that adverse events will not 
reduce adherence. The study coordinator will help each participant set reminder alarms on watches or phones; 
those who do not have access to such devices will be given a medication alarm watch for use during the study. 
Study staff will also identify a patient advocate and to educate that person to help the study participant maintain 
adherence. To maximize visit adherence, patients will receive a reminder in the week prior to the appointment.   
 
Accountability of Medication:  A sufficient amount of medication will be supplied at the baselineand week 12 
visits to ensure the supply will last until the next study visit, otherwise, refills will be mailed to the participants. 
Participants will be asked to return unused medication at each study visit for adherence assessment. The Johns 
Hopkins Investigational Drug Unit will maintain adequate records of the disposition of the study drug and 
accounts of any destroyed study drug.  
 
Study Personnel: All personnel (except the statistician) will be blinded to treatment assignment. The treating 
physician will assess eligibility criteria, obtain informed consent, obtain and maintain the medical history and 
medication record, monitor patients’ safety, conduct the physical examination, and evaluate and report adverse 
events. The examining physician will perform the blinded EDSS. The blinded study neuropsychologist will 
administer the MACFIMS to participants. The blinded study coordinator will be responsible for the study’s 
administrative duties, obtaining vital signs, conducting the MSFC and administering the depression, suicidality, 
and health-related quality of life measures, and drawing and processing blood samples as well as urine 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
9 
 
pregnancy testing, when indicated. The laboratory technician will conduct the biomarker analyses for Aim 3. 
Other personnel include Drs. Haughey and Calabresi, who will interpret biomarker data. A statistician from the 
Johns Hopkins School of Public Health will create the randomization schedule and perform final data analyses. 
 
Study Visits: The visit schedule is detailed below. Visits will take place within ± 5 days of the target date. 
 
Week 0  
Week 6 Week 12 Week 24 
Week 36 
Week 48 
Written consent 
X 
 
 
 
 
 
Verify eligibility 
X 
 
 
 
 
 
Teaching and First dose 
administration and observation 
X 
 
 
 
 
 
Medical history, relapse assessment 
X 
X 
X 
X 
X 
X 
Medication review 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
Physical, neurologic (EDSS) exams 
X 
 
X* 
X* 
 
X* 
MS Functional Composite 
X 
X 
X 
X 
X 
X 
Adverse event assessment 
 
X 
X 
X 
X 
X 
Biomarker evaluation 
X 
X 
X 
X 
X 
X 
Stored blood for future studies 
X 
X 
X 
X 
X 
X 
DXA scan 
X 
 
 
 
 
 
A pregnancy test (if woman of 
childbearing potential) 
X 
X 
X 
X 
 
 
MACFIMS battery 
X 
 
X 
X 
X 
X 
Sleep questionnaires 
X 
 
X 
X 
 
X 
Depression and quality of life  
X 
X 
X 
X 
X 
X 
Suicidality evaluation 
X 
X 
X 
X 
X 
X 
 
*EDSS only 
 
Schedule Modification during COVID-19 (will be in effect unless JHU operations have returned to normal, a 
COVID-19 vaccine has been developed, or evidence of substantial likelihood of herd immunity from COVID-
19 due to a high proportion of previously-infected individuals). Additionally, due to COVID-19 and staffing 
shortages during the holiday season, we will allow study visits within ± 10 days of the target date if needed to 
ensure the safety of the participants.   
 
 
Week 0  
Week 
6: 
Virtual 
Week 
12** 
Week 24 
Week 
36: 
Virtual 
Week 48: 
Virtual% 
Written consent& 
X 
 
 
 
 
 
Verify eligibility 
X 
 
 
 
 
 
Teaching and First dose 
administration and observation 
X 
 
 
 
 
 
Medical history, relapse 
assessment 
X 
X 
X 
X 
X 
X 
Medication review 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
 
X 
X 
 
 
Neurologic (EDSS) exam 
X 
 
 
 
 
 
MS Functional Composite 
X 
 
X*** 
X*** 
 
 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
10 
 
Adverse event assessment 
 
X 
X 
X 
X 
X 
Biomarker evaluation 
X 
 
X 
X 
 
 
Stored blood for future studies 
X$ 
 
X$ 
X$ 
 
 
DXA scan 
X 
 
 
 
 
 
Pregnancy assessment* 
X* 
X 
X 
X 
 
 
MACFIMS battery 
X 
 
X 
X 
 
X 
Sleep questionnaires 
X 
 
X 
X 
 
X 
Depression and quality of life  
X 
X 
X 
X 
X 
X 
Suicidality evaluation 
X 
X 
X 
X 
X 
X 
*Pregnancy test at baseline; document last menstrual period/adequate pregnancy prevention plan at virtual 
follow-ups (for women of childbearing potential) 
**will convert to virtual follow-up with activities equal to week 6 if stay-at-home orders recur 
Items that are in bold will be done either virtually or in-person until operations are fully normalized with 
respect to COVID-19 pandemic; in addition, some aspects of the MACFIMS neuropsychological battery can 
(and will) be done virtually as well 
***timed 25-foot walk only 
&Consent will be reviewed at length virtually within the week prior to the day of the visit, with all questions 
asked at that time. At the baseline visit, patients will be given the opportunity to ask any remaining questions 
and can sign during the teleconsent, if capable, or will sign at the time of the baseline visit. 
% if COVID-19 pandemic is lifted, we will still complete this visit in-person; we will accept a study window 
that extends 3 months beyond week 48 if there is indication at that time, even if the pandemic is still affecting 
safety, that it will soon be safe again (e.g. vaccine developed or clear evidence of critical percentage of 
population has already been infected, fully operational at JHU) 
 
If a severe COVID-19 outbreak occurs again such as occurred in the spring of 2020, we will conduct all follow-
up assessments by video or phone until such time as it is safe to pursue the modified schedule, as above, or 
resume the originally-planned schedule. 
 
All study visits will be scheduled for the morning to reduce variability in cognitive function related to the time 
of day. At baseline, fasting laboratory testing will be performed, including a hemoglobin A1c test and insulin 
level.  All subjects will then be given breakfast prior to completing cognitive testing. For follow-up visits, all 
subjects will complete the MACFIMS battery after eating a usual meal (if the participant came without having 
eaten, breakfast will be provided to them) and prior to taking the morning dose of study treatment. Unscheduled 
visits will occur if any safety issue arises. 
 
In order to ensure subjects (or their responsible caregivers) are able to use the medication as instructed, all 
subjects and caregivers (when relevant) will be instructed on the use of the inhaler and will be observed by a 
health care provider when performing their first dose administration at the time of the first visit. 
 
 
Risks 
 
Intranasal insulin 
Intranasal insulin has been shown to be safe and tolerable in other populations and patient groups, but it has 
never been studied in people with MS. The most common side effects related to irritation of the nasal passages. 
Giving insulin through the nose did not result in lower circulating glucose levels in other studies, but the first 15 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
11 
 
people in this study will be monitored for this potential risk by testing a fingerstick blood glucose level 
periodically for 90 minutes after the first dose of intranasal insulin (see Safety section under Outcomes on page 
10). 
Insulin, given by the more traditional subcutaneous route, has the following potential risks: 
Hypoglycemia: Common symptoms of hypoglycemia include sweating, dizziness or lightheadedness, 
shakiness, hunger, a fast heartbeat, tingling of the hands, feet, lips or tongue, trouble concentrating, 
confusion, blurry vision, slurred speech, anxiety, irritability, or mood changes, or headache. Very low 
blood sugar can cause loss of consciousness, seizures, or temporary or permanent brain problems or 
death.  Mild hypoglycemia can be treated by drinking or eating something sugary right away (fruit juice, 
sugar candies, or glucose tablets).  
 
 
Hypokalemia: Hypokalemia can lead to breathing problems, low heartbeat, or death. 
 
 
Allergic reaction: Common symptoms of an allergic reaction include a rash all over the body, trouble 
breathing, a fast heartbeat, sweating, and feeling faint. 
 
 
Weight gain or swelling of the arms and legs. 
 
While these are all risks potentially associated with subcutaneous administration of insulin, none of these risks 
has been demonstrated to be the case in the published trials of intranasal insulin. Thus, by avoiding the 
traditional route of administration, it is anticipated that these risks will be minimized. 
 
Blood Draw  
Taking blood may cause discomfort, bleeding or bruising where the needle enters the body. In rare cases, it may 
result in fainting. There is a small risk of infection. To minimize the risks, blood will be drawn by a trained 
study team member/phlebotomist. 
 
Confidentiality  
Despite the best efforts of the research team, there may still be a risk if information about participants were to 
become known to people outside of this study.  
 
Questionnaires  
Participants may get tired or bored when we are asking questions or they are completing questionnaires. They 
do not have to answer any question they do not want to answer. 
  
DXA scan 
DXA testing is painless and involves exposure to radiation. This research study includes exposure to radiation 
from x-rays or gamma rays. This radiation exposure is for research purposes only and is not part of the 
participant’s medical care. X-rays and gamma rays can damage cells, but at low doses, the body is usually able 
to repair these cells.  
 
The radiation exposure that participants will get in this research study is 0.001 rem. This is less than the 0.3 rem 
that the average person in the United States gets each year from natural sources like the sun, outer space, air, 
food, and soil. The risk from the radiation exposure in this research study is very small. The radiation exposure 
described here is what participants will get from this research study only. It does not include any exposure 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
12 
 
participants may have received or will receive from other medical tests outside of this study that are a part of 
their medical care. 
  
Benefits 
There is no known benefit of intranasal insulin, and thus there is no known risk of being in the placebo group. 
All patients who are already on a medication for MS will be allowed to continue that medication during the 
study. 
Payment and Remuneration 
Participants will receive a parking coupon at each visit.   
 
Costs 
There are no costs to participants for taking part in this study. 
 
 
Outcomes:  
 
Safety Since this medication was extremely well-tolerated in several published studies,34-50 we anticipate the 
same will be true for people with MS. In prior studies, there was no effect of intranasal insulin on serum glucose 
levels. However, we will monitor the first 15 participants for a period of 90 minutes after their first dose of the 
medication to evaluate serial finger stick blood glucose levels. If there is a clinically significant reduction in 
these levels, we will convene a Data Safety Monitoring Board (DSMB) meeting to adjust the protocol. We will 
also record and, when appropriate, report all patient-reported adverse events, as described below. Subjects and 
their caregivers will be required to keep an electronic diary of adverse events, which will be reviewed at each 
study visit. As mandated by the FDA, the Columbia Suicide Severity Rating Scale will be administered at each 
study visit. 
 
Cognitive Assessments  The MACFIMS battery includes the following: The Symbol Digit Modalities Test 
(SDMT) is commonly used in MS to assess processing speed.1, 52-54 The oral version of the test is recommended 
for MS since the written version may be confounded by upper extremity weakness.53, 55, 56 There are three 
alternate versions of this test with strong psychometric properties.37 A 3.5-4 point raw score difference on the 
SDMT has been identified as clinically meaningful.6, 57 The Controlled Oral Word Association Test (COWAT) 
measures phonemic fluency.58 The California Verbal Learning Test, Second Edition (CVLT-II) is a verbal 
learning and memory test.55, 59 The Brief Visuospatial Memory Test – Revised (BVMT-R) is a visual, nonverbal 
test of learning and memory.60 The Rao-version of the Paced Auditory Serial Addition Test (PASAT) evaluates 
processing speed, working memory, and basic addition skills.58 Visual-spatial abilities are assessed with the 
Judgement of Line Orientation Test (JLO).58, 61 The Delis-Kaplan Executive Function System (DKEFS) tests 
executive functioning, concept formation, and cognitive flexibility. 
 
 
  
Exploratory Biomarkers Plasma and/or PBMCs will be collected at baseline, week 12, and week 24 visits 
(except if COVID-19 related shutdown does not permit follow-up blood collection or lab-based processing) and 
will be isolated and cryopreserved for batch analyses in the labs of Dr. Haughey or Calabresi. Inflammatory 
(cytokines, lymphocyte subsets), metabolic (Kreb’s cycle substrate, fatty acids), cellular stress (ceramides, 
sphingomyelin) and neurotrophic (BDNF) measures, as well as markers of oxidative stress (protein carbonyls, 
8-isoprostane, nitrotyrosine, and 4-hydroxynonenal adducts [lysine and histidine]), will be quantified. Since our 
data show oxidative stress biomarkers and elevated ceramides in plasma of MS patients and recent work shows 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
13 
 
the brain has lymphatics, explaining how brain metabolites return to the periphery, blood biomarkers are a 
relevant and convenient way to monitor CNS metabolism.62  
 
Additional Outcomes and Assessment of Covariates In order to identify and, if needed, adjust for comorbid 
depression, the Beck Depression Inventory will be administered at each study visit. Health-related quality of life 
will also be assessed utilizing the FAMS. We will also evaluate how overall sleep quality in people with MS 
impacts health-related quality of life. We will also evaluate for occult insulin resistance or differences in 
metabolism in several ways. We will evaluate dual-energy x-ray absorptiometry (DXA) at baseline, which will 
help determine body composition, in particular bone density. We will also calculate an insulin resistance index, 
the homeostatic model assessment (HOMA-IR),63 using baseline fasting glucose and insulin. Statistical models 
exploring these body composition and insulin resistance parameters as potential confounders or mediators will 
be evaluated. Finally, the MACFIMS, safety, depression, and health-related quality of life outcomes will be 
monitored after discontinuation of the insulin (or placebo) to evaluate for any decline in cognitive function 
associated with medication discontinuation.  
 
Safety/Adverse Event Monitoring  An adverse event (AE) is any occurrence or worsening of an undesirable or 
unintended sign, symptom (or abnormal laboratory test), or disease temporally associated with the use of a 
medicinal product or intervention, whether or not it is considered related to the product/intervention. We will 
use the National Cancer Institute’s Common Terminology Criteria for Adverse Events version 4.0 to report and 
grade all adverse events, whether or not they are related to disease progression or treatment. The relationship 
between an AE and the intervention will be determined by the blinded study physician and recorded on the 
appropriate form. The investigator will record all study adverse events in the chart and will treat participants 
with AEs appropriately, observing them until they resolve or stabilize. AEs will be collected from the start of 
the study until a participant terminates from the study; those that are unresolved at the time of termination will 
be followed until they resolve or up to 30 days. An adverse event is considered unexpected when its nature or 
severity is not consistent with the product information (e.g. protocol or the informed consent form). Serious 
AEs will be collected from informed consent signing until 30 days after study completion or until 30 days after 
a participant withdraws from the study. The following process for reporting a serious AE will ensure 
compliance with the International Conference on Harmonisation guidelines: the Institutional Review Board 
(IRB) and DSMB will be notified in two business days of a serious AE that is medication-related and 
unexpected, and standard reporting (15 calendar days) will occur if the event is serious, expected and 
medication-related, serious, expected and not medication-related, or serious, unexpected and not medication-
related. Life-threatening events will be reported within 7 calendar days. Any pregnancy will be reported to the 
IRB and DSMB, and pregnancies will be followed to their conclusion. Female participants who become 
pregnant will stop the study intervention. The investigator will report pregnancies to the IRB within two 
business days. The study medication will be discontinued if an AE grade 3 or higher occurs and is at least 
possibly related to the medication or if the subject cannot tolerate the medication/ wants to discontinue it. Any 
death that is at least possibly related to the study will put the study on hold until the DSMB evaluates it.  
 
DSMB: The DSMB consists of an independent neurologist, an endocrinologist, and a statistician. It will 
convene any time an adverse event ≥ grade 3 occurs and routinely at 25%, 50%, 75%, and 100% enrollment. 
All serious adverse events will be promptly and simultaneously reported to the IRB, the DSMB and the 
Independent Research Monitor. Only serious adverse events (SAEs) that would also meet the definition of an 
Unanticipated Problem Involving Risks to Subjects or Others (UPIRTSOs) that are related to the protocol will 
be promptly reported to the United States Army Medical Research and Materiel Command Office of Research 
Protections Human Research Protection Office HRPO (USAMRC ORP HRPO). 
 
Independent Research Monitor: The PI, Dr. Mowry, has appointed Dr. Anne Damian, a trained neurologist, as 
the Independent Research Monitor.  Dr. Damian will provide independent safety review and will have the 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
14 
 
authority to stop the research study; remove an individual subject from the research study; and will take any 
steps to protect the safety and well-being of the subjects until the IRB can assess the problem or event. The 
independent research monitor must review all unanticipated problems involving risks to subjects or others 
(UPIRTSO), but not all SAEs.  The monitor will review the SAEs if they also meet the definition of a 
UPIRTSO and will provide an unbiased written report of the event.  The Research Monitor will comment on the 
outcomes of the event or problem and the relationship to participation in the study. Additionally, the research 
monitor will indicate whether she concurs with the details of the report provided by the principal investigator.  
 
 
Analytic Plan 
 
Aim 1. Safety data will be analyzed as they are captured in real time. Assessments will focus on AEs (including 
study treatment tolerability assessments, laboratory evaluations, vital signs, and physical examination). The 
incidence rate of AEs will be recorded by system organ class, severity, and by relationship to the study 
treatment. Tolerability analysis will be based on the number (%) of subjects who failed to complete the study 
due to adverse events. Lab values for each parameter will be summarized by shift tables. For quantitative 
parameters, summary statistics for actual values and change from baseline will be presented. Changes in the 
first 24 weeks will be compared between groups using mixed effects regression analyses to account for the 
longitudinal nature of the data using random subject-specific intercepts and slopes. 
 
Aim 2. Summary statistics (mean ± standard deviation, median and interquartile range, or number and 
percentages) will be used to characterize the outcomes. For each cognitive outcome, to evaluate variability in 
the estimated means across groups, assuming that the within-group means are normally distributed, a one-way 
ANOVA will be conducted at the follow-up visits during the first 24 weeks. If the within-group data are 
strongly non-Gaussian, a Kruskal-Wallis test will be used. A mixed effects longitudinal model will also be used 
to test whether any differences across groups exist at the follow-up visits within the first 24 weeks. Further, 
models accounting for covariates of interest, including the HOMA-IR, body composition, body mass index, age, 
sex and depression, will be evaluated. For within-person changes in measures at follow-up compared to 
baseline, paired t-tests will be used. We will also evaluate the SDMT at each study visit and other MACFIMS 
outcomes at week48 to establish the longevity of any therapeutic response to insulin. 
 
Aim 3. For the biomarker outcomes, to evaluate variability in the estimated means across groups, assuming that 
the within-group means are normally distributed, a one-way ANOVA will be conducted at the follow-up visits 
during the active treatment phase. If the within-group data are strongly non-Gaussian, a Kruskal-Wallis test will 
be used. A mixed effects longitudinal model will also be used to test if differences across groups exist at follow-
up visits. For within-person changes in measures at follow-up compared to baseline or before versus after 
calorie restriction days, paired t-tests will be used. Correlations between the biomarkers will be assessed. A 
bootstrap of subjects will be used to obtain 95% equal confidence intervals for these measures. We will also 
evaluate the biomarker changes after study therapy ends. 
 
Sample Size and Power: Sample size estimates are difficult given the novelty of the project but are based on 
the goal of detecting a benefit of insulin on cognition. In a pivotal study of two doses of intranasal insulin 
versus placebo in participants with mild cognitive impairment or mild to moderate Alzheimer’s Disease, the 
Dementia Severity Rating Scale score improved over the four-month treatment course in those receiving 
intranasal insulin.34 Using the scores in the 10 IU twice a day group, given a two-sided alpha of 0.05 and beta 
0.20 (80% power), assuming 3 follow-up cognitive tests and a correlation between baseline and follow-up 
results of 0.5, 29 subjects per group are required. To account for drop-outs and for the three-arm design, a total 
of 35 subjects per group is planned. With SDMT as the outcome, for a two-arm design, this sample size confers 
80% power (assuming SDMT standard deviation of 9 points and two-sided alpha of 0.05) to detect a 6-point 
improvement in SDMT which seems reasonable considering that transcranial stimulation with cognitive training 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
15 
 
improved SDMT by an average of more than 8 points compared to cognitive training alone in a pilot study of 20 
subjects.64 We do not expect that this study will provide conclusive evidence of efficacy for cognition, but it 
will provide estimates of the mean and standard deviation of the distribution in change in cognitive tests that 
will inform the design of definitive, phase III trials. Aim 3 is exploratory, but given the relative abundance 
differences in MS versus controls in our preliminary data in C22:1, and assuming a similar absolute C22:1 
concentration as in women aged 55-64 years,65 with 35 subjects in a two-arm study of 35 subjects/arm and a 2-
sided alpha of 0.05, we will have 80% power to detect a 10 ng/mL difference in ceramide levels.  
 
 
 
 
 
 
REFERENCES CITED 
 
1. Benedict RH, et al. Validity of the minimal assessment of cognitive function in multiple sclerosis 
(MACFIMS). J Int Neuropsychol Soc 2006;12:549-558.  
2. DeLuca J. What we know about cognitive changes in multiple sclerosis. In: LaRocca N, Kalb R, eds. 
Multiple Sclerosis: Understanding the Cognitive Challenges. New York: Demos Health; 2006: 17-40. 
3. Rao S. Cognitive Function in Patients with Multiple Sclerosis: Impairment and Treatment. IJMSC 2004;1:9-
22. 
4. Ruet A, Deloire M, Hamel D, Ouallet JC, Petry K, Brochet B. Cognitive impairment, health-related 
quality of life and vocational status at early stages of multiple sclerosis: a 7-year longitudinal study. J 
Neurol 2013;260(3):776-84. 
5. Strober LB, Christodoulou C, Benedict RH, Westervelt HJ, Melville P, Scherl WF et al. Unemployment in 
multiple sclerosis: the contribution of personality and disease. Mult Scler 2012;18(5):647-53. 
6. Morrow SA, Drake A, Zivadinov R, Munschauer F, Weinstock-Guttman B, Benedict RH. Predicting loss of 
employment over three years in multiple sclerosis: clinically meaningful cognitive decline. Clin 
Neuropsychol 2010;24(7):1131-45. 
7. Schultheis MT, Weisser V, Ang J, Elovic E, Nead R, Sestito N et al. Examining the relationship between 
cognition and driving performance in multiple sclerosis. Arch Phys Med Rehabil 2010;91(3):465-73. 
8. Patti F. Optimizing the benefit of multiple sclerosis therapy: the importance of treatment adherence. Patient 
Prefer Adherence 2010;4:1-9. 
9. Chiaravalloti ND, DeLuca J. Cognitive impairment in multiple sclerosis. Lancet Neurol 2008; 7(12):1139-
1151.  
10. Rao SM et al. Cognitive dysfunction in multiple sclerosis. II. Impact on employment and social functioning. 
Neurology. 1991;42:692-696. 
11. Amato MP, Razzolini L, Goretti B, Stromillo ML, Rossi F, Giorgio A et al. Cognitive reserve and cortical 
atrophy in multiple sclerosis: a longitudinal study. Neurology 2013;80(19):1728-33. 
12. Amato MP, Ponziani G, Siracusa G, Sorbi S. Cognitive dysfunction in early-onset multiple sclerosis: a 
reappraisal after 10 years. Arch Neurol 2001;58(10):1602-6. 
13. Lacy M, Hauser M, Pliskin N, Assuras S, Valentine MO, Reder A. The effects of long-term interferon-beta-
1b treatment on cognitive functioning in multiple sclerosis: a 16-year longitudinal study. Mult Scler 
2013;19(13):1765-72. 
14. Deluca J, Barbieriberger S, Johnson SK. The nature of memory impairments in multiple sclerosis- 
acquisition versus retrieval. Journal of Clinical and Experimental Neuropsychology 1994;16(2):183-9. 
15. DeLuca J, Gaudino EA, Diamond BJ, Christodoulou C, Engel RA. Acquisition and storage deficits in 
multiple sclerosis. Journal of Clinical and Experimental Neuropsychology 1998;20(3):376-90. 
16. Thornton AE, Raz N, Tucker KA. Memory in multiple sclerosis: Contextual encoding deficits. Journal of 
the International Neuropsychological Society 2002;8(3):395-409. 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
16 
 
17. DeLuca J, Chelune GJ, Tulsky DS, Lengenfelder J, Chiaravalloti ND. Is speed of processing or working 
memory the primary information processing deficit in multiple sclerosis? J Clin Exp Neuropsychol 
2004;26(4):550-62. 
18. Demaree HA, DeLuca J, Gaudino EA, Diamond BJ. Speed of information processing as a key deficit in 
multiple sclerosis: implications for rehabilitation. J Neurol Neurosurg Psychiatry 1999;67(5):661-3. 
19. Krupp LB, et al. Multicenter randomized clinical trial of donepezil for memory impairment in multiple 
sclerosis. Neurology. 2011;76(17):1500-1507. 
20. Solari A, Uitdehaag B, Giuliani G, Pucci E, Taus C. Aminopyridines for symptomatic treatment in multiple 
sclerosis. Cochrane Database Syst Rev 2001(4):Cd001330. 
21. Lovera JF, Kim E, Heriza E, Fitzpatrick M, Hunziker J, Turner AP et al. Ginkgo biloba does not improve 
cognitive function in MS: a randomized placebo-controlled trial. Neurology 2012;79(12):1278-84. 
22. Lovera JF, Frohman E, Brown TR, Bandari D, Nguyen L, Yadav V et al. Memantine for cognitive 
impairment in multiple sclerosis: a randomized placebo-controlled trial. Mult Scler 2010;16(6):715-23. 
23. Morrow SA, Kaushik T, Zarevics P, Erlanger D, Bear MF, Munschauer FE et al. The effects of L-
amphetamine sulfate on cognition in MS patients: results of a randomized controlled trial. J Neurol 
2009;256(7):1095-102. 
24. Mitolo M, Venneri A, Wilkinson ID, Sharrack B. Cognitive rehabilitation in multiple sclerosis: A 
systematic review. J Neurol Sci 2015;354(1-2):1-9. 
25. Duarte AI, Moreira PI, Oliveira CR. Insulin in Central Nervous System: More than Just a Peripheral 
Hormome. J Aging Res. 2012;2012:384017. 
26. Apostolatos A, Song S, Acosta S, et al. Insulin promotes neuronal survival via the alternatively spliced 
protein kinase CδII isoform. J Biol Chem 2012 Mar 16;287(12):9299-310. 
27. Schechter R, Whitmire J, Holtzclaw L, George M, Harlow R, Devaskar SU. Developmental regulation of 
insulin in the mammalian central nervous system. Brain Research, vol. 582, no. 1, pp. 27–37, 1992.  
28. LeRoith E. CNS regulation of carbohydrate metabolism in Advances in Metabolic Disorders, A. Szabo, Ed., 
vol. 10, pp. 304–340, Academic Press, 1983. 
29. Altarejos JY, Montminy M. CREB and the CRTC co-activators: Sensors for hormonal and metabolic 
signals. Nat Rev Mol Cell Biol 2011;12:141-151. 
30. Duan W, Guo Z, Jiang H, Ware M, Li XJ, Mattson MP. Dietary restriction normalizes glucose metabolism 
and BDNF levels, slows disease progression, and increases survival in huntingtin mutant mice. Proc Natl 
Acad Sci U S A 2003;100:2911-2916. 
31. Bingham EM, Hopkins D, Smith D et al. The role of insulin in human brain glucose metabolism: an 
18fluorodeoxyglucose positron emission tomography study. Diabetes 2002;51:3384-3390.  
32. Russell JW, Golovoy D, Vincent AM, et al. High glucoseinduced oxidative stress and mitochondrial 
dysfunction in neurons. FASEB J 2002;16:1738–1748.  
33. Andrieu-Abadie N, Gouaze V, Salvayre R, Levade T. Ceramide in apoptosis signaling: relationship with 
oxidative stress. Free radical biology & medicine 2001;31:717-728. 
34. Craft S, Baker LD, Montine TJ, et al. Intranasal insulin therapy for Alzheimer Disease and amnestic mild 
cognitive impairment. Arch Neurol 2012;69:29-38. 
35. Benedict C, Hallschmid M, Hatke A, et al. Intranasal insulin improves memory in humans. 
Psychoneuroendocrinology 2004;29:1326-1334. 
36. Benedict C, Hallscmid M, Schmitz K, et al. Intranasal insulin improves memory in humans: superiority of 
insulin aspart. Neuropsychopharmacology 2007;32:239-243. 
37. Benedict C, Kern W, Schultes B, Born J, Hallschmid M. Differential sensitivity of men and women to 
anorexigenic and memory-improving effects of intranasal insulin. J Clin Endocrinol Metab 2008;93:1339-
1344. 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
17 
 
38. Hallschmid M, Benedict C, Schultes B, Born J, Kern W. Obese men respond to cognitive but not to 
catabolic brain insulin signaling. Int J Obes 2008;32:275-282. 
39. Reger MA, Watson GS, Frey WH, et al. Effects of intranasal insulin on cognition in memory-impaired older 
adults: modulation by APOE genotype. Neurobiol Aging 2006;27:451-458. 
40. Reger MA, Watson GS, Green PS, et al. Intranasal insulin improves cognition and modulates beta-amyloid 
in early AD. Neurology 2008;70:440-448. 
41. Reger MA, Watson GS, Green PS, et al. Intranasal insulin administration dose-dependently modulates 
verbal memory and plasma amyloid-beta in memory-impaired older adults. J Alzheimers Dis 2008;13:323-
331. 
42. Krug R, Benedict C, Born J, Hallschmid M. Comparable sensitivity of postmenopausal and young women 
to the effects of intranasal insulin on food intake and working memory. J Clin Endocrinol Metab 
2010;95:E468-E472. 
43. Fan X, Copeland PM, Liu EY, et al. No effect of single-dose intranasal insulin treatment on verbal memory 
and sustained attention in patients with schizophrenia. J Clin Psychopharmacol 2011;31:231-234. 
44. Fan X, Liu E, Freudenreich O, et al. No effect of adjunctive, repeated-dose intranasal insulin treatment on 
psychopathology and cognition in patients with schizophrenia. J Clin Psychopharmacol 2013;33:226-230. 
45. McIntyre RS, Soczynska JK, Woldeyohannes HO, Miranda A, Vaccarino A, Macqueen G, Lewis GF, 
Kennedy SH. A randomized, double-blind, controlled trial evaluating the effect of intranasal insulin on 
neurocognitive function in euthymic patients with bipolar disorder. Bipolar Disord 2012;14:697-706. 
46. https://www.clinicaltrials.gov/ct2/show/NCT01547169?term=intranasal+insulin+verbal+memory&rank=1. 
Accessed July 30, 2015. 
47. https://www.clinicaltrials.gov/ct2/show/NCT00581867?term=intranasal+insulin+burns&rank=1. Accessed 
July 30, 2015. 
48. Novak V, Milberg W, Hao Y, et al. Enhancement of vasoreactivity and cognition by intranasal insulin in 
type 2 diabetes. Diabetes Care 2014;37:751-759. 
49. https://www.clinicaltrials.gov/ct2/show/NCT01595646?term=craft+intranasal+insulin&rank=3. Accessed 
July 30, 2015. 
50. https://www.clinicaltrials.gov/ct2/show/NCT01145482?term=intranasal+insulin+haley&rank=1. Accessed 
July 30, 2015. 
51. Born J, Lange T, Kern W, McGregor GP, Bickel U, Fehm HL. Sniffing neuropeptides: A transnasal 
approach to the human brain. Nat Neurosci 2002;5:514-516. 
52. D’hooghe MB, Cleynhens K, D’hooge M, Haelewyck MC, DeKeyser J, Nagels G. The Symbol Digit 
Modalities Test as a sentinel test for cognitive impairment. Eur J Neurol 2014;21:1219-1225. 
53. Benedict RH, Duquin JA, Jurgensen S, Rudick RA, Feitcher J, Munschauer FE et al. Repeated assessment 
of neuropsychological deficits in multiple sclerosis using the Symbol Digit Modalities Test and the MS 
Neuropsychological Screening Questionnaire. Mult Scler 2008;14(7):940-6. 
54. Benedict RH SA, Parikh R, Rodgers J, Cadavid D, Erlanger D. Reliability and equivalence of alternate 
forms for the Symbol Digit Modalities Test: implications for multiple sclerosis clinical trials. Mult Scler 
2012;18(9):1320-5. 
55. Langdon DW, Amato MP, Boringa J, Brochet B, Foley F, Fredrikson S et al. Recommendations for a Brief 
International Cognitive Assessment for Multiple Sclerosis (BICAMS). Mult Scler 2012;18(6):891-8. 
56. Brochet B, Deloire MS, Bonnet M, Salort-Campana E, Ouallet JC, Petry KG et al. Should SDMT substitute 
for PASAT in MSFC? A 5-year longitudinal study. Mult Scler 2008;14(9):1242-9. 
57. Benedict RH, Morrow S, Rodgers J, Hojnacki D, Bucello MA, Zivadinov R et al. Characterizing 
cognitive function during relapse in multiple sclerosis. Mult Scler 2014;20(13):1745-52. 
58. Benedict RH FJ, Archibald CJ, Arnett PA, Beatty WW, Bobholz J, Chelune GJ, Fisk JD, Langdon DW, 
Caruso L, Foley F, LaRocca NG, Vowels L, Weinstein A, DeLuca J, Rao SM, Munschauer F. Minimal 

Date: November 20, 2020 
PI: Ellen M. Mowry, M.D., M.C.R. 
Application #: IRB00095554 
18 
 
neuropsychological assessment of MS patients: a consensus approach. Clin Neuropsychol 
2002;16(3):381-97. 
59. Panou T, Mastorodemos V, Papadaki E, Simos PG, Plaitakis A. Early signs of memory impairment among 
multiple sclerosis patients with clinically isolated syndrome. Behav Neurol. 2012;25(4):311-26. 
60. Benedict R. Brief Visuospatial Memory Test-Revised: Professional manual. Lutz, FL: Psychological 
Assessment Resources, Inc. 
61. Benton AL, Sivan AB, Hamsher Kd, Varney NR, Spreen O. Contributions to Neuropsychological 
Assessment: A Clinical Manual. Oxford University Press; 1994. 
62. Louveau A, Smirnov I, Keyes TJ et al. Structural and functional features of central nervous system 
lymphatic vessels. Nature 2015;523:337-341. 
63. Willette AA, Bendlin BB, Starks EJ, et al. Association of insulin resistance with cerebral glucose uptake in 
late middle-aged adults at risk for Alzheimer Disease. JAMA Neurol 2015 (in press). 
64. Mattioli F, Bellomi F, Stampatori C, Capra R, Miniussi C. Neuroenhancement through cognitive training 
and anodal tDCS in multiple sclerosis. Mult Scler J 2015 (in press). 
65. Mielke MM, bandaru VV, Han D, et al. Demographic and clinical variables affecting mid- to late-life 
trajectories of plasma ceramide and dihydroceramide species. Aging Cell 2015 (in press). 
 

Trial Protocol for:  
Intranasal Insulin for Improving Cognitive Function in Multiple Sclerosis (NCT02988401) 
Date of Protocol 11/20/2020