Oral Cladribine B-cell Study
Conditions: Multiple Sclerosis
Sponsor: Queen Mary University of London

 
 
 
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JRMO Research Protocol for  
Interventional Studies  
 
 
 
 
Full Title  
Oral Cladribine B-cell study 
 
Short Title 
Clad-B study 
 
Sponsor 
Barts Health NHS Trust 
 
 
Contact person: 
 
Dr Mays Jawad 
Research & Development Governance 
Operations Manager 
Joint Research Management Office 
 
5 Walden Street 
 
London 
 
E1 2EF 
 
Phone: 020 7882 7275/6574 
 
Email: sponsorsrep@bartshealth.nhs.uk 
 
 
IRAS Number 
262436 
 
REC Reference 
<REC Reference number> 
 
Chief Investigator 
Dr Sharmilee Gnanapavan 
Consultant Neurologist & Honorary Senior 
Clinical Lecturer 
Dept of Neuroscience and Trauma, Blizard 
Institute, 4 Newark St., London E1 2AT 
020 7377 7000 Ext. 42157 
Sharmilee.Gnanapavan@bartshealth.nhs.uk  
 
List of sites 
The Royal London Hospital  
                                                          Barts Health NHS Trust 
                                                          Whitechapel Road  
                                                          London E1 1BB 
 
List of laboratories 
Dept Neuroscience and Trauma, Blizard Insitute 
Dr David Holden 
4 Newark St., London E1 2AT 
+44 20 7882 2327 
d.w.holden@qmul.ac.uk 
 
 
 

 
 
 
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1. Contents 
 
1. 
Contents 
2 
2. 
Glossary 
4 
3. 
Signature page 
5 
4. 
Summary and synopsis 
6 
5. 
Introduction 
8 
5.1 
Background 
8 
5.2 
Preclinical data 
10 
5.3 
Rationale 
12 
5.4 
Risks / benefits 
13 
6. 
Study objectives 
13 
6.1 
Primary objective 
13 
6.2 
Secondary objective 
13 
6.3 
Tertiary objective 
14 
6.4 
Primary endpoint 
14 
6.5 
Secondary endpoint 
14 
6.6 
Tertiary endpoint 
14 
7. 
Study population 
15 
7.1 
Inclusion criteria 
15 
7.2 
Exclusion criteria 
15 
8. 
Study design 
15 
9. 
Study procedures 
16 
10. 
Assessment and management of risk 
18 
11. 
Statistical considerations 
18 
11.1 Sample size 
18 
11.2 Method of analysis 
19 
12. 
Ethics 
19 
13. 
Public Involvement 
19 
14. 
Data handling and record keeping 
19 
14.1 Data management 
19 
14.2 Source data 
20 
14.3 Confidentiality 
20 
14.4 Record Retention and Archiving 
20 
15. 
Laboratories 
20 
15.1 Central and local laboratories 
20 
15.2 Sample collection and preparation 
21 
15.3 Laboratory procedures 
21 
15.4 Sample storage and transfer 
21 

 
 
 
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16. 
Interventions and tools 
22 
16.1 Medicinal product 
22 
17. 
Safety reporting 
22 
17.1 Adverse Events (AEs) 
22 
17.2 Adverse Reaction (ARs) 
22 
17.3 Notification and reporting of Adverse Events and Reactions 
23 
17.4 Serious Adverse Events (SAEs) or reactions 
23 
17.5 Notification and reporting of Serious Adverse Events 
23 
17.6 Urgent Safety Measures 
23 
17.7 Annual Safety Reporting 
24 
17.8 Overview of the Safety Reporting responsibilities 
24 
18. 
Monitoring and auditing 
24 
19. 
Trial committees 
24 
20. 
Finance and funding 
24 
21. 
Indemnity 
24 
22. 
Dissemination of research findings 
25 
23. 
References 
25 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
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2. Glossary 
 
9-HPT  
 
 
9-Hole Peg Test 
AE 
 
 
 
Adverse Event 
AR 
 
 
 
Adverse Reaction 
BBB 
 
 
 
Blood Brain Barrier 
CD 
 
 
 
Cluster Differentiation 
CI 
 
 
 
Chief Investigator 
Clad 
 
 
 
Cladribine 
CRF 
 
 
 
Case Report Form 
CSF 
 
 
 
Cerebrospinal Fluid 
CXCL-13 
 
 
Chemokine-13 
EDSS  
 
 
Expanded Disability Status Scale 
FACS  
 
 
Fluorescence-activated cell sorting 
FBC 
 
 
 
Full blood count 
FLC 
 
 
 
Free Light Chains 
GAP-43 
 
 
Growth Associated Protein-43 
GFAP  
 
 
Glial Fibrillary Acidic Protein 
IgG 
 
 
 
Immunoglobulin G 
JRMO  
 
 
Joint Research Management Office 
LFT 
 
 
 
Liver Function Test 
MSFC  
 
 
Multiple Sclerosis Functional Composite 
MSIS-29 
 
 
Multiple Sclerosis Impact Scale-29 
NCAM  
 
 
Neural Cell Adhesion Molecule 
NEDA  
 
 
No Evidence of Disease Activity 
NF 
 
 
 
Neurofilament 
OCB 
 
 
 
Oligoclonal Bands 
PROMS 
 
 
Patient reported outcome measures 
PBMC  
 
 
Peripheral Blood Mononuclear Cells 
REC 
 
 
 
Research Ethics Committee 
RRMS  
 
 
Relapsing Remitting Multiple Sclerosis 
SAE 
 
 
 
Serious Adverse Event 
SAP 
 
 
 
Statistical analysis plan 
SAR 
 
 
 
Serious Adverse Reaction 
SDMT  
 
 
Single Digit Modalities Test 
SOP 
 
 
 
Standard Operating Procedure 
SUSAR 
 
 
Suspected Unexpected Serious Adverse Reaction 
T25FW 
 
 
Timed 25 Foot Walk 
U&E 
 
 
 
Urea & Electrolytes 
WCC  
 
 
White Cell Count 

 
 
 
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3. Signature page 
 
 
 
 

 
 
 
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4. Summary and synopsis 
 
Short title 
Clad-B Study 
Methodology 
Longitudinal study 
Research sites 
Barts Health NHS Trust 
Queen Mary, University of London 
Objectives / aims 
Primary: To quantify the temporal changes of memory B 
cells (CD19+/CD27+/IgD-/+), plasmablasts (CD19-
/CD138+/CD38+) and T cells (CD4/CD45RA-/+, CCR7-/+, 
CD8+/CD45RA-/+/CCR7-/+), Tregs 
(CD4/CD8)/CD25+/CD127-/Fox3 P+) in the peripheral 
venous blood of pwMS with RRMS over 96w of treatment 
with oral cladribine.  
These will be compared to the populations of non-memory 
or class-switched B cells (immature/transitional B cells 
CD10+/CD38+/CD19+, immature regulatory B cells 
CD10+/CD38+/CD19+/CD24+/IL-10+, mature B cells CD10-
/CD38+/CD19+).  
 
 
Secondary:  
1. To study the effects of oral cladribine on: 
a. CSF OCBs and free immunoglobulin kappa 
and lambda light chain levels (FLC).  
b. CSF markers of inflammation, in particular 
CXCL-13 and urine markers of inflammation 
(neopterin). 
c. CSF markers of neuroaxonal damage, in 
particular free neurofilament light chains. 
d. On the peripheral repertoire B-cells 
(immunoglobulin) and T-cells (T cell 
receptor) and plasma cells (soluble 
receptors). 
 
2. To compare CSF OCB positivity and CSF light chain 
levels with a contemporary control group of 
alemtuzumab treated pwMS (historical data). 
 
Tertiary: 
1. To compare B and T cell repertoire with a 
contemporary control group of alemtuzumab treated 
pwMS (historical data). 
 
2. To evaluate the effect of changes in the immune cell 
profile on clinical measures of disability, MRI activity 
and PROMS. 
 
Number of 
participants 
13 
Inclusion and 
exclusion criteria 
Inclusion: 
● Patients with RRMS who are being treated with oral 
cladribine at Barts Health NHS Trust 

 
 
 
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● Patients must be willing and able to undergo lumbar 
punctures 
● Patients who are OCB positive in their CSF (from 
previous diagnostic lumbar puncture)  
Exclusion: 
● Ineligible for oral cladribine under NHS England 
prescribing guidelines and those participating in 
MAGNIFY-MS study (cladribine tablets in active MS) 
● Unsuitable to have a lumbar puncture (e.g. spinal 
deformity, tethered cord syndrome, or the use of 
aspirin or anticoagulants), and those unable to 
comply with study requirements, including frequency 
of visits and lumbar punctures 
● Presence of comorbidities in which administration of 
cladribine is contraindicated 
● Abnormal baseline investigations (WCC<3 x 10*9/l, 
neutrophil count < 1.5 x 10*9/l, platelet count < 100 x 
10*9/l, haemoglobin < 110 g/l, LFT >/= 3x upper limit 
of normal site reference ranges, potassium < 2.8 
mmol/l or  > 5.5 mmol/l, sodium <125 mmol/l, 
creatinine > 130 umol/l 
Statistical 
methodology and 
analysis (if 
applicable) 
Changes in total immune cell counts will be analysed using 
descriptive statistics, including reduction relative to baseline 
and absolute reduction in numbers. Time to nadir and 
recovery will be done using best-fit modelling. 
Total blood IgG and free kappa and lambda light chain 
levels will be normalised to albumin levels. McNemar’s test 
will be used to compare differences in OCB status between 
baseline, year one or year two. The association between 
different biomarkers, clinical and imaging parameters will be 
analysed using multiple regression. 
Study duration 
96 weeks. 
 

 
 
 
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5. Introduction 
 
There is emerging data that suggests that B cells, in particularly memory B cells, and 
intrathecal plasma cell responses in multiple sclerosis (MS) are pathogenic and the 
intrathecal component is one of the proposed mechanisms that drives delayed non-
relapsing progressive MS. As cladribine penetrates the central nervous system, and 
might have activity against both B-cells and plasma cells, we hypothesise that 
cladribine may be superior to other disease-modifying therapies by targeting 
pathogenic intrathecal B-cells and plasma cells. We are particularly interested in see 
if cladribine targets the intrathecal long-lived plasma cells and the oligoclonal IgG 
bands (OCBs) they produce, since OCBs have, to date, proven resistant to current 
treatments including high efficacy treatments such as alemtuzumab. In addition, we 
will study the effect of cladribine on intrathecal inflammatory (CXCL13) and 
neurodegenerative (neurofilament light chain) markers. As recent evidence supports 
the hypothesis that cladribine is working via memory B cells, we will therefore assess 
the impact of oral cladribine on the kinetics of different peripheral B and T cell 
depletion and repopulation rates. Finally we will assess the impact of oral cladribine 
on both the B-cell (immunoglobulin) and T-cell (T cell receptor) repertoire. 
 
 
 
5.1 Background  
 
Multiple sclerosis (MS) is invariably associated with an intrathecal oligoclonal IgG 
response or oligoclonal bands (OCBs) (Giovannoni 2014). This response is not 
specific to MS and also occurs in central nervous system (CNS) infections and other 
CNS-specific autoimmune diseases, in particular the paraneoplastic syndromes 
(McLean, Luxton, and Thompson 1990). Even when the neuroinfectious diseases are 
successfully treated OCBs persist (van Eijk et al. 1987). In neurosyphilis, for 
example, OCBs are found a decade, or longer, after successful treatment with 
antibiotics (“Proteins of the Cerebrospinal Fluid - ScienceDirect” 2016). The 
persistence of the OCBs has been put down to longevity of long-lived plasma cells 
(Meinl, Krumbholz, and Hohlfeld 2006). In the case of infections these OCBs target 
the inciting pathogen and most bands can be removed using antigen-specific 
immunoadsorption (Luxton et al. 1995). In a putative autoimmune diseases such as 
MS these OCBs may be targeting self-antigens and may therefore be responsible for 
driving progressive MS pathology, which theoretically could become independent of 
autoimmune T-cell help (Meinl, Krumbholz, and Hohlfeld 2006; Giovannoni 2014). 
Pathological studies have shown that the presence of B-cell-like follicles in the 
meninges of people with MS (pwMS); these structures are associated with earlier 
age of onset of progressive disease and earlier age of death (Magliozzi et al. 2007). 
Recent data has linked the subpial cortical MS lesion with antibody deposition and 
complement activation (Wolfgang Bruck, 2015; personal communication), similar to 
that what has been described in the so called type 2 acute MS lesion (Lucchinetti et 
al. 1996). CSF from pwMS is gliotoxic and neurotoxic in vitro (Øren, White, and Aasly 
2001) and in vivo; this toxicity may be antibody mediated. Based on these 
observations OCBs are likely to be pathogenic in MS. To the best of our knowledge 
none of the currently licensed disease-modifying therapies have been convincingly 
shown to eliminate the intrathecal OCBs in pwMS, with the possible exception of 
natalizumab (von Glehn et al. 2012). There have been a few small case series 
showing the loss of OCBs in a proportion of patients treated with natalizumab 
(Mancuso et al. 2014; von Glehn et al. 2012; Krasulová et al. 2007). However, this 

 
 
 
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observation was not confirmed in a larger, more definitive, German study (Harrer et 
al. 2013). It is important to note that in pwMS treated with alemtuzumab intrathecal 
oligoclonal bands persist (Hill-Cawthorne et al. 2012).  In comparison, in the Scripps 
chronic progressive cladribine trial, patients treated with cladribine had a significant 
decline in the number of oligoclonal bands (Sipe et al. 1994). Although the OCBs did 
not disappear this study used agarose gel electrophoresis, a technique that is not 
specific for detecting immunoglobulins and is now obsolete (Freedman et al. 2005).  
 
We hypothesise that it will be important to target intrathecal plasma cells 
therapeutically to delay the onset, or slow down, the clinically-apparent progressive 
phase of MS. Most licensed DMTs are effective, to a greater or lesser extent, at 
suppressing relapses and focal MRI activity (new T2 or Gd-enhancing lesions), 
however, none of the treatments have yet been shown to prevent the onset of non-
relapsing progressive disease. Why? If the non-relapsing progressive phase of the 
disease is driven by intrathecal OCBs, the resistance of long-lived plasma cells to 
current therapeutic intervention may explain why this phase of the disease is so 
resistant to treatment. To successfully treat, or prevent, progressive MS intrathecal 
plasma cells may need to be eliminated to prevent antibody mediated mechanisms 
that underlie the progressive phase of MS. We are thus actively exploring treatments 
that target intrathecal plasma cells; for example, we are proposing that cladribine (2-
chlorodeoxyadenosine) a nucleoside analogue penetrates the blood-brain barrier 
(BBB) and has been shown to have biological activity against myeloma cells, or 
malignant plasma cells, albeit in combination with a STAT3 inhibitor (Ma et al. 2011).  
 
This suggests that cladribine may target both peripheral and central anti-
inflammatory mechanisms including pathogenic intrathecal plasma cells. We 
hypothesise therefore that cladribine will be effective as a treatment for progressive 
MS; cladribine by targeting intrathecal plasma cells in MS will reduce intrathecal IgG 
and free light chain production and may result in the disappearance of intrathecal 
OCBs. We are therefore proposing an intensive B-cell biomarker study (CLAD-B 
study) to explore the effect of cladribine on peripheral and intrathecal B cells and 
plasma cells. As cladribine has a greater impact on peripheral B cells, in particularly 
memory B cells (B. Ceronie, M. Zhifeng, F. Ammoscato, H. Lock, H.J. Longhurst, G. 
Giovannoni, D. Baker, K. Schmierer 2017),  and to look at  the differential effect of 
cladribine on both the T & B cell repertoire.  
 
We have recently hypothesised that all effective MS DMTs, particularly high-efficacy 
DMTs, work via targeting the peripheral memory B-cell population and suggested 
that cladribine may be preferentially working as semi-selective B-cell agent (Baker et 
al. 2017). We now have cross-sectional pilot data from patients treated with 
parenteral cladribine showing prolonged peripheral memory B-cell depletion of a 
similar magnitude to alemtuzumab-treated patients (Baker et al. 2017; B. Ceronie, M. 
Zhifeng, F. Ammoscato, H. Lock, H.J. Longhurst, G. Giovannoni, D. Baker, K. 
Schmierer 2017). As part of this study we propose defining in detail the changes in 
peripheral lymphocyte subsets in both the depletion and repopulation phases after 
oral cladribine. In addition, we will study the effects of oral cladribine on the 
peripheral blood B and T cell repertoire by studying the immunoglobulin and T-cell 
receptor diversity.  
 
 
 
 

 
 
 
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5.2 Preclinical data  
 
Intrathecal plasma cell and B cell biology 
 
In MS both quantitative and qualitative assays are used to assess pathological 
intrathecal IgG production, which is an indicator of intrathecal B cell and plasma cells 
activity. From a diagnostic perspective qualitative assays are more sensitive being 
abnormal in 95-98% of patients with clinically definite MS. The Ig-Index, and other 
similar indices, are less sensitive only being abnormal in ~70% of people clinically-
definite MS. However, these indices do provide a proxy of the intrathecal B and 
plasma cell activity. The downside of using IgG as a marker of activity is its long 
circulating peripheral half-life of IgG that results in the equilibration of levels between 
the blood and intrathecal compartments. The equilibration ratio is very sensitive to 
any disruptions in blood-brain-barrier (BBB) hence the need to adjust CSF:plasma 
IgG ratio with the albumin quotient, an index of BBB integrity. In comparison free 
immunoglobulin light chains (FLCs), both kappa and lambda, have a very short 
circulating half-life due to their high fractional excretion rate in the kidney and 
catabolism. As a result levels of FLCs between the blood and CSF don’t equilibrate. 
Therefore, CSF FLC levels are a very good proxy of intrathecal B-cell and plasma 
cell activity. Therefore, any drug that reduces activity of B-cells and/or plasma cells 
will lower FLC levels. Unfortunately, FLCs don’t differentiate between B-cells and 
plasma cells. We are not aware of any specific soluble CSF biomarker, apart from 
FACs analysis of free cells in the CSF that can reliably differentiate between B-cells 
and plasma cells.  
 
The molecular mechanisms underlying terminal differentiation of B cells into plasma 
cells, and long-lived plasma cells, are partially understood and involve both 
transcriptional and epigenomic changes. As B cells differentiate into plasmablasts 
there is a committal step in which an S phase-synchronized differentiation switch is 
associated with an extensive DNA demethylation and local acquisition of 5-
hydroxymethylcytosine at enhancers and genes related to plasma cell identity (Caron 
et al. 2015). Downregulation of both TGFb1/SMAD3 signaling and p53 pathway 
support this final step, allowing the emergence of a CD23-negative subpopulation in 
transition from B cells to plasma cells. Hydroxymethylation of PRDM1, a gene 
essential for plasma cell fate, is coupled to progression in S phase. DNA methylation 
patterns can potentially be used to study the B cell maturation process in the context 
of MS (Kulis et al. 2015) and we propose exploratory epigenetic studies in the future 
(samples from this study will be stored for this).  
 
 
B-cells  
 
Preliminary evidence from therapeutic studies suggests that the memory B cell pool 
might play a crucial role in the disease pathogenesis (Baker, D., Marta, M., Pryce, G., 
Giovannoni, G., Schmierer, K. 2016). Limited evidence has shown that the memory B 
cell pool is suppressed by several of the disease modifying therapy (DMT) agents 
used in RRMS (Kasper et al. 2014)(Thompson et al. 2010)(Rieckmann 2009; 
Palanichamy et al. 2014). This appears to correlate with disease suppression and the 
desired clinical outcome of no evidence of disease activity (NEDA)(Coles et al. 2012; 
Leist et al. 2014; Bar-Or et al. 2008). This suggests that memory B cells may have a 
role in the mechanisms underlying demyelination in RRMS. It also suggests that they 
might have utility as a marker for disease suppression. However, the suppression of 

 
 
 
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memory B cells by DMT, and their contribution to pathogenesis in MS, remains 
unclear. 
 
The maxim that CD4 Th17 cells play an important role in RRMS pathogenesis is 
largely based on animal models (Rostami and Ciric 2013; Volpe, Battistini, and 
Borsellino 2015). However, this failed to be demonstrated in human subjects, where 
their suppression in clinical trials has only produced marginal benefits (Deiß et al. 
2013). It is clear then that other mechanisms must play a crucial role in demyelination 
and relapse. 
 
Alemtuzumab is an anti-CD52 monoclonal antibody that is one of the most clinically 
efficacious DMT agents, capable of inducing long-term disease suppression (Coles 
et al. 2012). Studies of the B cell pool have shown that, while immature B cells 
rapidly repopulate after therapy, CD19+/CD27+ memory B cells are significantly 
depleted for up to 30 months following treatment(Coles et al. 2012; Kasper et al. 
2014; Thompson et al. 2010). While alemtuzumab also suppresses CD4+ and CD8+ 
T cells, changes in the T cell pool do not correlate with disease activity (Bar-Or et al. 
2008). Cladribine is a drug originally licensed for hairy cell and B-cell chronic 
lymphocytic leukaemia. It has also been shown to be highly effective in suppressing 
disease activity in RRMS (Leist et al. 2014). One report has suggested that it 
preferentially depletes the CD19 B cell pool, with only modest effects on CD4 and 
CD8 cells (Leist et al. 2014; Rieckmann 2009). Rituximab is anti-CD20 monoclonal 
antibody that suppresses T cells by approximately 20-25% (Palanichamy et al. 2014). 
However, it also produces a sustained depletion in memory B cells that lasts for up to 
a year, which parallels disease activity (Palanichamy et al. 2014; Bar-Or et al. 2008).  
 
Taken together, these studies suggest that some of the most clinical effective DMT 
agents MS seem to target the memory B cell pool (CD19+/CD27+), which advocates 
for the role of these cells in disease activity (Baker et al. 2017). However, their 
degree of depletion, what subsets may be implicated, and the exact mechanisms by 
which they might contribute to pathogenesis, remains to be explored. While the 
limited reports do suggest the memory B cell pool may be affected, no studies have 
compared alemtuzumab and cladribine directly in terms of their effect on the 
compartment, and whether there may be more specific effects of specific subset 
depletion within the compartment. 
 
Several studies causing B cell augmentation seem to worsen disease activity in MS. 
Atacicept is a homodimeric fusion protein that stimulates B cell numbers, activation 
and antibody production (Palanichamy et al. 2014; Bar-Or et al. 2008; Gatto 2008). It 
was reported to precipitate CNS inflammation and progression to clinically definite 
MS in a trial of optic neuritis(Sergott et al. 2015) and a clinical study in MS was 
discontinued after worsening of disease (Sergott et al. 2015; Kappos et al. 2014). 
Similarly, TNF inhibitors have been shown to augment memory B cell populations in 
trials of rheumatoid arthritis, sometimes leading to development of CNS 
demyelinating disease (Roll et al. 2012; Souto-Carneiro et al. 2009). TNF inhibitors 
have further been shown to worsen the disease course of MS (van Oosten et al. 
1997). These data provide some indirect evidence that memory B cells may have an 
important function the manifestation of disease in RRMS (Baker et al. 2017). 
 
It is unclear what the precise role of memory B cells is in driving CNS inflammation, 
as they are a heterogeneous population with many different functions.  In the 
progression of disease activity there is a shift in the makeup of unswitched and naïve 
B cells towards CD19+/CD27+ memory cells (van Oosten et al. 1997; Haas et al. 

 
 
 
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2011). It is known that they express co-stimulatory molecules and major 
histocompatibility (MHC) proteins and can present myelin antigens (Michel et al. 
2015; Harp et al. 2010). Given this, it has been posited that they may act as 
important antigen presenting cells to drive T cell mediated mechanisms of 
inflammation (Baker, D., Marta, M., Pryce, G., Giovannoni, G., Schmierer, K. 2016). If 
particular, a subset of CD19+/CD27+/CD25+ memory B cells, which express the 
Interleukin 2A Receptor, are increased intrathecally in MS (de Andrés et al. 2014), 
and appear to have a regulatory function on CD4+ T cells (Kessel et al. 2012).  If they 
play a crucial role in the pathogenic mechanisms of MS, and their activity correlates 
with disease activity, they might serve as a useful biomarker of disease activity in 
response to DMT (Baker, D., Marta, M., Pryce, G., Giovannoni, G., Schmierer, K. 
2016; Komori et al. 2015). Thus, it is of great clinical interest to characterise which of 
these cells and their myriad subsets are most closely related to disease suppression. 
 
Memory B cells are a heterogeneous group of lymphocytes (Michel et al. 2015). 
Which specific subsets are most closely related to disease activity requires greater 
elucidation. Important subsets include the class-switched IgD+ and non class-
switched 
IgD- 
subtypes. 
Circulating 
plasmablasts, 
which 
co-express 
the 
CD19+/CD27+/CD38+ marker set, may also be of clinical importance, as their levels 
are increased throughout the course of MS (Michel et al. 2015; Cepok 2005). Only 
one study has examined a pathogenic subset of CD27+/CD38low memory B cells in 
MS, which are increased in untreated disease (Li et al. 2015). However, no previous 
study has examined the activity of memory B cell subsets in response to therapy. We 
would therefore like to characterise not only the general CD19+/CD27+ pool, but also 
subsets of IgD± and CD25± memory B cells and CD38+ plasmablasts. This may give 
us greater insight into the effects of DMT and the role of B cells subsets in RRMS. 
 
Limited therapeutic evidence supports the notion that CD19+/27+ memory B cells may 
play a vital role in contributing to the disease pathophysiology of MS (Kasper et al. 
2014) (Thompson et al. 2010; Rieckmann 2009; Palanichamy et al. 2014). Moreover, 
CD27 is associated with immunoglobulin index in cerebrospinal fluid in MS (Komori 
et al. 2015). Their association with disease activity, and suppression by effective 
DMT, suggests that they might play a vital role in MS pathogenesis. If CD19+/CD27+ 
memory B cells are proven to be key protagonists in the disease process, they might 
be valuable targets for the development of novel therapeutic agents that specifically 
target the memory B cell pool.  
 
 
5.3 Rationale 
 
 
Study objectives: To study the impact of cladribine on peripheral and intrathecal B-
cell, plasma cells, T cells and Tregs.  
 
While some treatments have been shown to affect this pool, it is not clear to what 
degree, or if there are specific pathogenic subsets that might be interesting drug 
targets, in order to maximise clinical efficacy while minimising adverse effects. This 
study will therefore attempt to explore the memory B cell pool and related subsets, 
plasmablasts and T cell family in order to further characterise their response to 
therapy. 
 
 
 

 
 
 
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Hypotheses  
 
1. Oral cladribine preferentially targets memory B cells and that the repopulation 
of B-cells is driven initially be immature and subsequently mature B-cells, but 
not memory B cells.  
2. In people with MS (pwMS) the administration of cladribine will reduce CSF 
biomarkers of both B cell and plasma cell activity (OCBs and absolute free 
light chain levels) and markers of CNS inflammation (CXCL-13) and 
neuroaxonal damage (neurofilament light chain).  
3. The administration of oral cladribine to be pwMS will result in changes, or 
rejuvenation, of immune repertoire at both a B-cell (immunoglobulin) and T-
cell (T cell receptor) level.   
 
5.4 Risks / benefits  
 
There are small risks associated with venepuncture and lumbar puncture that will 
form the main method of sample collection. These include haematoma formation, 
infection, nerve damage, haemoconcentration, extravasations, syncope and fainting, 
petechiae, excessive bleeding, oedema, fear and phobia, thrombosis, arterial 
puncture, pain and allergy (Campbell, Carrington, and Limber 1999). However, these 
risks are rare if performed competently. There are no direct benefits to the 
participants taking part in the study. However, there may be a future benefit to 
current or future MS patients, depending on the results of the study.  
6. Study objectives 
 
6.1 Primary objective 
 
To quantify the temporal changes of memory B cells (CD19+/CD27+/IgD-/+), 
plasmablasts (CD19-/CD138+/CD38+) and T cells (CD4/CD45RA-/+, CCR7-/+, 
CD8+/CD45RA-/+/CCR7-/+), Tregs (CD4/CD8)/CD25+/CD127-/Fox3 P+) in the 
peripheral venous blood of pwMS with RRMS over 96w of treatment with oral 
cladribine. These will be compared to the populations of non-memory or class-
switched B cells (immature/transitional B cells CD10+/CD38+/CD19+, immature 
regulatory B cells CD10+/CD38+/CD19+/CD24+/IL-10+, mature B cells CD10-
/CD38+/CD19+).  
 
 
6.2 Secondary objective 
 
1. To study the effects of oral cladribine on: 
 
a. CSF OCBs and free immunoglobulin kappa and lambda light chain 
levels (FLC).  
b. CSF markers of inflammation, in particular CXCL-13 and urine 
markers of inflammation (neopterin). 
c. CSF markers of neuroaxonal damage, in particular free neurofilament 
light chains. 
d. On the peripheral repertoire B-cells (immunoglobulin) and T-cells (T 
cell receptor) and plasma cells (soluble receptors). 
 
2. To compare CSF OCB positivity and CSF light chain levels with a 
contemporary control group of alemtuzumab treated pwMS (historical data). 

 
 
 
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6.3 
Tertiary objective 
 
1. To compare B and T cell repertoire with a contemporary control group of 
alemtuzumab treated pwMS (historical data). 
 
2. To evaluate the effect of changes in the immune cell profile on clinical 
measures of disability, MRI activity and PROMS. 
 
6.4 Primary endpoint 
 
 
The time course of B, plasmablast and T cell depletion and re-population over 
96w to see if any particular population of cells is more susceptible to cladribine, 
i.e. memory B-cells (CD19+/CD27+). These changes will be compared to 
populations of naïve B cells. 
 
6.5 Secondary endpoint 
 
1. a. Relative change in CSF OCB pre- and post-cladribine (baseline vs 48w and 
96w). 
b. Relative change in CSF cytokines and chemokines (baseline vs 48 w and 96w 
period), in particular CXCL-13 pre- and post-cladribine and urine neopterin 
levels. 
c. Relative change in CSF neurofilament light chain pre-and post-cladribine 
(baseline vs 48w and 96w).  
d. Relative change in blood immunoglobulin levels and T cell receptor levels 
(baseline vs 48 w and 96w period) pre-and post-cladribine and urine 
immunoglobulin levels. 
2. Relative change in CSF soluble CD138 (plasma cell marker) pre- and post-
cladribine (baseline vs. 48w and 96w). 
3. Occurrence of CSF OCB positivity and relative change in CSF FLC post-
cladribine versus historical data post-alemtuzumab (baseline vs. 48w and 96w). 
 
6.6 
Tertiary endpoint 
 
1. Relative change in B and T cell repertoire post-cladribine versus historical 
data post-alemtuzumab. 
 
2. Correlation between baseline, 48w and 96w immune cell profiles and 
baseline, 48w and 96w EDSS, MSFC, T2 lesion load and gadolinium 
enhancement, MSIS-29 and their changes. 
 
 
 
 
 
 
 
 

 
 
 
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7. Study population 
 
This longitudinal study over 96 weeks will examine peripheral venous blood samples, 
CSF and urine of pwMS with RRMS who are treated with oral cladribine tablets under 
the NHS in Barts Health. Only those able to give consent to participate in the study 
will be included.  
 
 
 
7.1 Inclusion criteria 
 
1. Patients with MS who are being treated with oral cladribine at Barts Health 
NHS Trust will be approached to participate in this study. 
2. Patients must be willing and able to undergo lumbar punctures.  
3. Patients who are OCB positive in their CSF (previous diagnostic lumbar 
puncture). 
  
 
7.2 Exclusion criteria 
 
1. Ineligible for oral cladrabine under NHS England prescribing guidelines and 
those participating in MAGNIFY-MS study (cladribine tablets in active MS). 
2. Unsuitable to have a lumbar puncture, for example spinal deformity, tethered 
cord syndrome or the use of aspirin or anticoagulants, and those unable to 
comply with study requirements, including frequency of visits and lumbar 
punctures.  
3. Presence of comorbidities in which the administration of cladribine is 
contraindicated. 
4. Abnormal baseline investigations (WBC<3 x 10*9/l, lymphocytes <1.0 x 
10*9/l, neutrophil count <1.5 x 10*9/l, platelet count <100 x 10*9, 
haemoglobin <110g/l, LFT>/3x upper limit of normal of site reference ranges, 
potassium <2.8mmol/l or >5.5mmol/l, sodium <125 mmol/l, creatinine >130 
umol/l).  
 
8. Study design 
 
 
Patients will be required to give consent for 15mL of peripheral venous blood (plasma 
and serum), urine and CSF to be collected at multiple time points over 96 weeks.   
These samples will be collected in addition to those collected for routine clinical 
monitoring. They will be informed that their decision to consent for their blood 
products to be used in research will have no impact on their current or future 
treatment, and it should not affect their decision to start, continue or discontinue their 
MS therapy.   
 
Venous blood samples will be analysed by flow cytometry. B cell populations will be 
determined using specific markers for B cell populations including CD10, CD19, 
CD25, CD27, CD38 and IgD. This will allow the analysis of the number of memory B 
cells 
(CD19+/CD27+), 
memory 
B 
cell 
subsets 
(CD19+/CD27+/IgD-/+ 
and 
CD19+/CD27+/CD25-/+) and  plasmablasts (CD19+/CD27+/CD38+) in the subject’s 
blood samples. As controls, naive B cells CD19+/CD27- and T cells (CD19-

 
 
 
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/CD3+/CD4+/CD8+) will also be examined. Whole blood for DNA extraction will be 
collected and stored for deep sequencing to analyse the B and T cell repertoire using 
Adaptive Biotechnologies’ immunoSEQ technology; these assays can identify 
millions of T- and B-cell receptors in a single sample. Using this technology will allow 
us to compare the impact of cladribine on the adaptive immune system over time and 
to compare it with similar data from alemtuzumab treated subjects from Prof. Heinz 
Wiendl’s laboratory in Munster.  
 
CSF will be collected using an atraumatic needle. CSF will be processed for routine 
biochemistry and aliquots will be stored for OCBs, FLC, B cells: soluble CD19 and 
plasma cells: soluble CD138; inflammatory markers: urine neopterin and multiplex 
cytokine profile; and neurodegenerative markers: NF, GFAP, NCAM, GAP-43 and 
S100B levels. 
 
Study subjects will also be examined annually, have a routine annual MRI T2 lesion 
load and gadolinium enhancement, and the following outcome measures assessed 
EDSS, 9-HPT, T25FW, MSIS-29 and other routine clinical outcome measures at 24 
weekly intervals.  
 
Historical control data from 12 post-alemtuzumab treated subjects (Barts Health) for 
secondary endpoints (CSF OCB & FLC) and tertiary endpoints (B and T cell 
repertoires) will be used as comparators. 
9. Study procedures 
 
Participants will be counselled on the risks of the treatment and any study 
procedures (bloods, urine sampling and lumbar punctures) when obtaining full 
informed consent, and will specifically exclude those who may be vulnerable to these 
risks. Informed consent to participate in the study will be taken by the research 
fellow, treating neurologist or the study CI (Dr Sharmilee Gnanapavan). It will be 
explained to all participants that they are free to withdraw their consent at any time 
without needing to provide an explanation, and their medical care will not be affected 
in any way if they decide not to participate. The data collected up to the point of 
withdrawal will be included in the analysis at the end. 
 
All serious adverse events will be reported to the Sponsor and the research ethics 
committee by the project manager and PI (see Section 17: safety reporting). Clinical 
databases will be maintained by the project manager and access to personal data 
will be limited to the study team, and all other data will otherwise be anonymised. 
Day to day management of the study including MRI evaluation will be handled by the 
research fellow in conjunction with the neuroradiology department at Barts Health 
NHS Trust. Clinical scores, EDSS and timed 25 foot walk, and lumbar punctures will 
be performed by the research fellow or another trained neurologist listed on the 
delegation log. 
 
Lumbar punctures will be performed using atraumatic needles to minimise the risk of 
post-puncture headaches at Barts Health NHS Trust day unit in accordance with 
routine clinical practice. Sample processing and storage (including freezer 
maintenance) will be performed by the laboratory technician in accordance with 
Departmental standard operating procedures (SOPs). Laboratory analysis will be 
performed by the research fellow, as well as the data analysis in conjunction with the 
study statistician.  
 

 
 
 
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Schedule of study interventions: 
 
 

 
 
 
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10. Assessment and management of risk 
 
 
Blood tests are a safe procedure, but there can be complications, such as bruising at 
the site of puncture and excessive bleeding. There is also the risk of needle stick 
injury to the person performing the test. We will minimise the risk of complications by 
having a trained staff member perform the blood extraction in accordance with 
infection control guidelines. 
 
Lumbar puncture will be an aseptic procedure under local anaesthetic performed by 
a neurologist with experience to minimise the risk of infection and to maintain 
comfort. Atraumatic needles will be used to reduce the incidence of headache post 
lumbar puncture secondary to CSF leak. Potential but rare risk of lumbar puncture 
(approximately 1/10,000) is bleeding and nerve damage. Measures will be taken to 
minimise bleeding complications by applying pressure to the lumbar puncture site 
after the needle is removed and by not performing lumbar punctures on those on 
blood thinners (including aspirin, warfarin or heparin). The use of landmarks to 
identify site of the lumbar puncture beforehand, as well as partly withdrawing the 
introducer to check if there is CSF and that needle is in the subarachnoid space will 
minimise the incidence of nerve injuries. Telephone contact details will be provided 
as part of aftercare, for either the subject or their partner to access a member of the 
study team if there are any possible safety concerns. 
 
Samples will be processed according to laboratory SOPs and COSHH procedures to 
minimise the risk of sample mismanagement and infection risk. 
 
 
11. Statistical considerations 
 
11.1 
Sample size 
 
 
This is an exploratory study and all analyses are descriptive. The primary endpoint of 
this study will be to look at the effect of oral cladribine on peripheral immunological 
markers over time. However, to explore the intrathecal effect of cladribine we will 
assess its impact on the disappearance of OCBs from the CSF. Based on published 
data none of the patients with MS will be expected to lose OCBs over 2 years of the 
study. With a power of 80%, and an alpha of 5%, we will only need 11 subjects to 
show a significant result if at least 50% of subjects on cladribine become OCB 
negative compared to a comparator group. Allowing for a 20% dropout rate we would 
only need to recruit 13 subjects.  
 
 
 
 
 

 
 
 
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11.2 Method of analysis  
 
 
Depletion and re-population kinetics of B and T cell subsets will be analysed using 
descriptive statistics. An interim analysis of the year 1 data is planned, and a further 
analysis of the whole data will be performed at the end of the study. These will be 
calculated as a reduction relative to baseline counts and the absolute reduction in 
numbers. Time to nadir and recovery will be done using best-fit modelling. 
Categorical data based on absolute cut-offs will be presented as proportions, e.g. for 
absolute lymphocyte counts this will use the WHO boundaries.   
 
Total blood IgG and free kappa and lambda light chain levels will be normalised to 
albumin levels. McNemar’s test will be used to compare differences in OCB status 
between baseline and year one CSF or year two CSF. Differences in CSF and blood 
biomarkers, clinical and imaging parameters between baseline and 48w and 96w  will 
be analysed using multiple regression. A detailed SAP will be prepared and approved 
during the recruitment period well before data becomes available. 
 
 
12. Ethics 
 
 
The Principal Investigator will ensure that the study is carried out in accordance with 
the ethical principles in the Research Governance Framework for Health and Social 
Care, Second Edition, 2005 and its subsequent amendments as applicable and 
applicable legal and regulatory requirements. A favourable opinion will be sought 
from NHS REC.  
 
 
13. Public Involvement 
 
 
The therapeutic strategy and concept employed in this trial have been discussed with 
service users and pwMS during Patient Engagement and focus group events. 
Results of the study will be shared within these events and also on the MS research 
blogspot: http://multiple-sclerosis-research.blogspot.com/. 
 
14. Data handling and record keeping 
 
 
14.1 
Data management 
 
 
Study data will be captured in source documents such as the hospital medical notes, 
laboratory reports, ECG print-outs and study-specific source document worksheets. 
Data will be entered into the case report form (CRF) by delegated members of the 
study team. All data generated by the study will be stored securely with a full audit 
trail. 
 

 
 
 
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14.2 
Source data 
 
 
Data will be recorded from a variety of sources including participant-reported 
information, physical examination findings, and print-outs from equipment, recording 
results from electronic displays, laboratory reports and validated questionnaires.  All 
efforts will be made to maximise completeness of data e.g. telephoning subjects. All 
interactions with participants will be documented (e.g. telephone conversations). 
Questionnaires will be completed by participants and that every questionnaire should 
be data and signed by the person completing it. The CI/delegate will keep records of 
all participants (sufficient information to link records e.g., CRFs, hospital records and 
samples), all original signed informed consent forms and copies of the CRF pages. 
All data generated by the study will be stored securely with a full audit trail. 
 
 
14.3 
Confidentiality 
 
 
Information related to participants should be kept confidential and managed in 
accordance with the Data Protection Act, NHS Caldecott Principles, The Research 
Governance Framework for Health and Social Care, and the conditions of Research 
Ethics Committee Approval. 
 
 
14.4 
Record Retention and Archiving 
 
 
When the research trial is complete, it is a requirement of the Research Governance 
Framework and Trust Policy that the records are kept for a further 20 years. For trials 
involving BH Trust patients, undertaken by Trust staff, or sponsored by BH or QMUL, 
the approved repository for long-term storage of local records is the Trust Corporate 
Records Centre. All research documentation will be archived in physical form.  
 
 
15. Laboratories  
 
 
15.1 
Central and local laboratories 
 
 
Specimen collection and processing: standard operating procedures will be in place 
outlining CSF, blood and urine and collection, transport, processing and storage 
either to the relevant Barts Health NHS Trust laboratory for routine specimens or to 
the Blizard Institute research laboratories for research samples. 
 
 
 

 
 
 
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15.2 
Sample collection and preparation 
 
 
Specimen collection, handling and processing will be performed in accordance with 
written SOPs. Because the adequacy of the specimen will affect the accuracy and 
usefulness of the biomarker results, all CSF will be processed within an hour of 
collection, whilst the quality of the blood specimen will be assessed for general 
interferences, such as haemolysis and lipemia by RLH Pathology Labs. Samples will 
have a unique identifier with participant details anonymized and stored at -80C until 
required for analysis. 
 
 
15.3 
Laboratory procedures  
 
Four (serum, whole blood and cells) additional samples of venous blood will be taken 
during the venepuncture to obtain their routine clinical blood tests. The whole blood 
will be stored for future ImmunoSEQ analysis. The CSF collection and urine 
collection would also be an additional tests. Because the adequacy of the specimen 
will affect the accuracy and usefulness of the biomarker results, all CSF will be 
processed within an hour of collection, whilst the quality of the blood specimen will be 
assessed for general interferences, such as haemolysis and lipemia by Barts Health 
NHS Trust Pathology Labs. Samples will have a unique identifier with participant 
details anonymized. 
 
PBMC Preparation: Peripheral blood mononuclear cells (PBMCs) will be obtained 
from venous blood by density gradient centrifugation using Ficoll (Invitrogen). Briefly 
the blood will be diluted 1:1 in PBS (without Ca2+, Mg2+) and 25ml loaded on Ficoll 
in a 1:1 ratio. Tubes will then be centrifuged for 30min at 1500rpm at 20oC. The buffy 
coat will be collected in a 50ml tube and washed twice in PBS. Finally the pellet will 
be resuspended in 1ml PBS and cells counted with haemocytomer. 
 
Extracellular Staining: Cells will be washed twice with 500ul of FACS buffer (2% FBS, 
2mM EDTA in PBS). Cells with then be blocked for 20 minutes in the dark with 100ul 
of blocking solution (FACS buffer). Cells will then be labelled with antibodies of 
interest (anti-live, anti-CD3, anti-CD10, anti-CD19, anti-CD25, anti-CD27, anti-CD38, 
anti-IgD; BD). They will be left for 30 minutes on ice before being washed twice with 
FACS, then centrifuged for 5 minutes at 1300 and 4oC. The pellet will be 
resuspended in 200ul of FACS buffer. They will then be analysed. 
 
 
15.4 
Sample storage and transfer 
 
 
The routine blood tests will be sent to the NHS pathology laboratory at the Royal 
London Hospital. The additional sample will be transferred by hand to the laboratory 
at the Blizard Institute. Aside from the PBMCs (see above), samples will be stored at 
-80C awaiting analysis. 
 
 

 
 
 
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16.  Interventions and tools  
 
16.1 
Medicinal product  
 
 
Participants will receive oral cladribine based on licensed indication for cladribine 
(Mavenclad, Merck Serono) in RRMS (NICE TA493) under the NHS. In the summary 
of product characteristics the recommended cumulative dose is 3.5 mg/kg body 
weight over 2 years, taken as 1 treatment course of 1.75 mg/kg per year. Each 
treatment course consists of 2 treatment weeks, 1 at the beginning of the first month 
and 1 at the beginning of the second month of the respective treatment year. Each 
treatment week consists of 4 or 5 days on which a patient takes 10 mg or 20 mg (1 or 
2 tablets) as a single daily dose, depending on body weight. Following completion of 
the 2 treatment courses, no further cladribine treatment is required in years 3 and 4. 
Cladribine will be stored and dispensed by the Barts Health NHS Trust pharmacy. 
 
 
17. Safety reporting  
 
 
Adverse Events (AEs) and Adverse Reactions (ARs) will be recorded. Serious 
Adverse Events (SAEs) and Serious Adverse Reactions (SARs) will be reported to 
the CI as medical assessor for the sponsor and coordinating team. All unexpected 
SARs (SUSARs) will be reported to the JRMO and REC. 
 
 
17.1 
Adverse Events (AEs) 
 
 
An AE is any untoward medical occurrence in a participant to whom an intervention 
has been administered, including occurrences which are not necessarily caused by 
or related to that intervention. An AE can therefore be any unfavourable or 
unintended sign (including an abnormal laboratory finding), symptom or disease 
temporally associated with study activities. 
 
 
17.2 
Adverse Reaction (ARs)  
 
 
An AR is any untoward and unintended response in a participant to an intervention.  
All adverse events judged by either the reporting investigator or the sponsor as 
having a reasonable causal relationship to the intervention qualify as adverse 
reactions. The expression ‘reasonable causal relationship’ means in general that 
there is evidence or an argument to suggest a causal relationship. 
 
 
 
 

 
 
 
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17.3 
Notification and reporting of Adverse Events and Reactions 
 
 
If the AE is not defined as serious, the AE will be recorded in the study documents 
and the participant followed up by the research team. The AE will be documented in 
the participants’ source documents, the Case Report Form (CRF), and, where 
appropriate, medical records. 
 
 
17.4 
Serious Adverse Events (SAEs) or reactions 
 
 
A serious adverse event (SAE) is defined as an untoward occurrence that: 
● Results in death, 
● Is life-threatening, 
● Requires hospitalisation or prolongation of existing hospitalisation, 
● Results in persistent or significant disability or incapacity, 
● Consists of a congenital anomaly or birth defect, or 
● Is otherwise considered medically significant by the investigator. 
 
SARs will be reported to the REC where in the opinion of the Chief Investigator the 
event was serious and: 
● Related (it may have resulted from administration of any of the research 
interventions), and 
● Unexpected (the type of event is not listed in the protocol or other Reference 
Safety Information as an expected occurrence). 
 
 
17.5 
Notification and reporting of Serious Adverse Events  
 
 
Serious Adverse Events (SAEs) that are considered to be ‘related’ and ‘unexpected’ 
will be reported to the sponsor and the funder of the studied medicinal product within 
24 hours of learning of the event, and to the REC within 15 days in line with the 
required timeframe.  
 
 
17.6 
Urgent Safety Measures 
 
 
The CI will take urgent safety measures if necessary to ensure the safety and 
protection of the clinical study participant from immediate hazards to their health and 
safety. The measures will be taken immediately. The approval of the REC prior to 
implementing urgent safety measures is not required. However the CI will inform the 
sponsor and Research Ethics Committee (via telephone) of this event immediately.  
 
The CI will inform the REC in writing within 3 days, in the form of a substantial 
amendment. The sponsor (Joint Research Management Office (JRMO)) will be sent 
a copy of the correspondence with regards to this matter.  
 
 

 
 
 
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17.7 
Annual Safety Reporting 
 
 
The CI will send the Annual Progress Report to the REC using the HRA template (the 
anniversary date is the date on the REC “favourable opinion” letter) and to the 
sponsor.  
 
 
17.8 
Overview of the Safety Reporting responsibilities 
 
 
The CI is the medical assessor on behalf on the sponsor and will review all events 
reported. The CI will ensure that safety monitoring and reporting is conducted in 
accordance with the sponsor’s requirements.  
 
 
 
18. Monitoring and auditing 
 
 
The sponsor or delegate retains the right to audit any study, study site, or central 
facility. Any part of the study may be audited by the funders, where applicable. 
 
Study will be monitored as per sponsors SOPs and internal audits may be conducted 
by the sponsor. Monitoring will include source data verification. 
 
 
 
19. Trial committees 
 
There will be regular meetings between the PI, and research fellow as part of study 
management. The safety committee will comprise of the PI and co-investigators 
(Barts Health NHS Trust neurologists) who will address any safety issues that may 
arise in the study. 
 
 
 
20. Finance and funding 
 
 
The study is funded by Merck Serono Ltd. (Bedfort Cross, Stanwell Road, Feltham, 
TW14 8NX, UK). 
 
 
 
21. Indemnity 
 
 
NHS indemnity scheme will apply. It provides cover for the design, management, and 
conduct of the study. 
 

 
 
 
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22. Dissemination of research findings 
 
 
Patients will be asked at the time of consent whether they would like to be informed 
of the study outcome. If they request to be informed, they will contacted by post with 
a lay summary of the trial findings.  
 
Depending on the study outcome, it may be published in a peer-reviewed scientific 
journal, and the conclusions disseminated through poster presentation at an 
international conference. 
 
 
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