Dimethyl Fumarate Treatment of Primary Progressive Multiple Sclerosis
Phase: PHASE2
Conditions: Primary Progressive Multiple Sclerosis
Sponsor: Rigshospitalet, Denmark

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Clinical trial protocol 
 
 
Dimethyl 
fumarate 
treatment 
of 
primary 
progressive multiple sclerosis 
(FUMAPMS) 
 
 
 
 
 
 
Study title: 
Dimethyl 
fumarate 
treatment 
of 
primary 
progressive multiple sclerosis 
Study abbreviation: 
FUMAPMS 
Study type: 
Phase 2, single center, RCT  
Version: 
Version 5 
Date: 
January 28th, 2020 
Test drug: 
Dimethyl fumarate 
EudraCT-number: 
2016-000283-41 
Ethical committee number: 
H-16032162 
 
  
 
 
 

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Table of Contents   
Abbreviations ................................................................................................................................ 8 
1 
PROTOCOL SUMMARY ........................................................................................................ 10 
2 
 FLOW CHART ...................................................................................................................... 13 
3  
 BACKGROUND ................................................................................................................. 13 
3.1 PRIMARY PROGRESSIVE MULTIPLE SCLEROSIS ........................................................... 13 
3.2 DIMETHYL FUMARATE ............................................................................................... 14 
3.3 OUTCOME MEASURES .............................................................................................. 15 
3.4 STUDY RATIONALE ................................................................................................... 16 
4  
 AIM OF THE STUDY ......................................................................................................... 16 
4.1 PRIMARY OUTCOME MEASURE .................................................................................. 16 
4.2 
SECONDARY OUTCOME MEASURES ....................................................................... 16 
4.3 TERTIARY (EXPLORATORY) OUTCOME MEASURES ...................................................... 17 
4.4 OPEN-LABEL PHASE OUTCOME (WEEK 48-96) ............................................................ 18 
4.5 ADDITIONAL EXPLORATORY OUTCOME ....................................................................... 19 
5  
 PATIENT POPULATION .................................................................................................... 19 
5.1 INCLUSION CRITERIA ................................................................................................ 19 
5.2 EXCLUSION CRITERIA ............................................................................................... 20 
5.3 TREATMENT DISCONTINUATION ................................................................................. 21 
6  
 TRIAL DESIGN .................................................................................................................. 21 
6.1 TRIAL TYPE .............................................................................................................. 21 
6.2 STUDY ENDPOINTS ................................................................................................... 21 
6.3 TIME PLAN FOR THE TRIAL ........................................................................................ 21 
6.4 RELAPSES ............................................................................................................... 22 
7 
 METHODS AND OUTCOME MEASURES ............................................................................ 22 
7.1 STUDY VISIT PROCEDURES ....................................................................................... 22 
7.1.1 TREATMENT IN THE OPEN-LABEL PHASE.................................................................. 22 
7.1.2 CUT OFF LEVEL OF NFL......................................................................................... 23 
7.1.3 QUALITY ASSURANCE OF NFL MEASUREMENTS....................................................... 23 
7.1.4 SCREENING VISIT (WEEK –6 TO WEEK –2) ............................................................... 23 
7.1.5 BASELINE VISIT ..................................................................................................... 24 
7.1.6 STUDY VISIT TYPE 1 (WEEK 12, 36, 60, 84) ............................................................. 24 

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7.1.7 STUDY VISIT TYPE 2 (WEEK 24 AND 72) .................................................................. 25 
7.1.8 STUDY VISIT WEEK 48 ........................................................................................... 25 
7.1.9 STUDY VISIT WEEK 96 ........................................................................................... 26 
7.1.10 UNSCHEDULED VISITS ......................................................................................... 26 
7.2 Outcome measures ............................................................................................................... 26 
7.2.1 CSF CONCENTRATION OF NEUROFILAMENT LIGHT CHAIN ......................................... 26 
7.2.2 NEUROLOGICAL EXAMINATION WITH EXPANDED DISABILITY STATUS SCALE (EDSS), TIMED 25-
FOOT WALK (T25FW), NINE-HOLE PEG TEST (9HPT) , BICAMS, FSMC, UID AND  MSIS-2927 
7.2.2.1 ASSESSMENT OF DISEASE PROGRESSION ............................................................ 27 
7.2.3 TIMED 25-FOOT WALK TEST (T25FW) .................................................................... 27 
7.2.4 NINE-HOLE PEG TEST (9HPT) ............................................................................... 27 
7.2.5 BRIEF INTERNATIONAL COGNITIVE ASSESSMENT FOR MS (BICAMS) ....................... 27 
7.2.6 MULTIPLE SCLEROSIS IMPACT SCALE (MSIS-29) .................................................... 27 
7.2.7 URINARY DISTRESS INVENTORY (UDI) ................................................................... 27 
7.2.8 FATIGUE SCALE FOR MOTOR AND COGNITIVE FUNCTION (FSMC) ............................ 27 
7.2.9 CSF CONCENTRATION OF CHITINASE-3-LIKE-1 (CHI3L1) ........................................ 28 
7.2.10 CSF CONCENTRATIONS OF SOLUBLE CD14 AND CD27, . ...................................... 28 
7.2.11 CSF CONCENTRATION OF SOLUBLE BCMA (TNFRSF17) ...................................... 28 
7.2.12 SERUM CONCENTRATIONS OF NEUROFILAMENT LIGHT CHAIN ................................. 28 
7.2.13 MYELIN BASIC PROTEIN (MBP) ............................................................................ 28 
7.2.14 MRI WITH GADOLINIUM (GD) ENHANCING LESIONS ................................................ 28 
7.2.15 LESIONS ON T2 WEIGHTED MRI ........................................................................... 29 
7.2.16 PERCENTAGE BRAIN VOLUME CHANGE (PBVC) ..................................................... 29 
7.2.17 CHANGE IN VOLUME OF T2 LESIONS, CORTICAL GREY MATTER (CGM)  NORMAL-APPEARING 
WHITE MATTER (NAWM), PUTAMEN AND THALAMUS ....................................................... 29 
7.2.18 CHANGE IN MAGNETIZATION TRANSFER RATIO (MTR) OF T2 LESIONS, PUTAMEN, THALAMUS, 
CGM AND NAWM ......................................................................................................... 29 
7.2.19 CHANGE IN DIFFUSION TENSOR IMAGING (DTI) MEASURES (FRACTIONAL ANISOTROPY AND 
MEAN DIFFUSIVITY) OF T2 LESIONS, CGM AND NAWM, PUTAMEN AND THALAMUS ............. 29 
7.2.20 CROSS SECTIONAL AREA AT THE C2 LEVEL OF THE SPINAL CORD ........................... 29 
7.2.21 CIRCLE DRAWING TEST ........................................................................................ 30 
7.3 SAFETY STUDIES...................................................................................................... 30 

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7.3.1 NEUROLOGICAL EXAMINATION ............................................................................... 30 
7.3.2 PREGNANCY TEST ................................................................................................. 30 
7.3.3 ROUTINE PHYSICAL EXAMINATION .......................................................................... 30 
7.4 STUDY PERSONNEL, SAMPLE HANDLING AND STUDY BIOBANK ..................................... 30 
7.5 RISK ASSESSMENT FOR STUDY PROCEDURES ............................................................ 31 
7.5.1 LUMBAR PUNCTURE .............................................................................................. 31 
7.5.2 MRI SCAN ............................................................................................................ 31 
7.5.3 BLOOD SAMPLES ................................................................................................... 32 
8  
 STUDY MEDICATION........................................................................................................ 32 
8.1 DIMETHYL FUMARATE AND PLACEBO ......................................................................... 32 
8.1.1 STUDY MEDICATION .............................................................................................. 32 
8.1.2 INITIAL DOSING AND DOSE REDUCTION .................................................................... 33 
8.1.3 DOSING OF THE STUDY DRUG ................................................................................ 33 
8.1.4 SIDE EFFECTS ...................................................................................................... 33 
8.1.5 PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY (PML) ................................... 33 
8.1.6 DELIVERY, PACKING, LABELLING AND RANDOMIZATION OF STUDY DRUG .................... 34 
8.1.7 STORAGE AND BREAKAGE OF THE RANDOMIZATION CODE ........................................ 34 
8.1.8 COMPLIANCE ........................................................................................................ 34 
9  
CONCOMITANT DISEASES AND CONCOMITANT MEDICATION ................................... 34 
9.1 DEFINITIONS ............................................................................................................ 34 
9.2 BASELINE CONCOMITANT DISEASES AND CONCOMITANT USE OF MEDICATION ............... 35 
9.3 CONCOMITANT DISEASE AND CONCOMITANT MEDICATION DURING THE TRIAL ............... 35 
9.4 PRECAUTIONS/OVERDOSE ........................................................................................ 35 
9.5 RESCUE MEDICINE ................................................................................................... 35 
9.6 SYMPTOMS IN PROGRESSIVE MS .............................................................................. 35 
10  
ADVERSE EVENTS, ADVERSE RECTIONS, SERIOUS ADVERSE EVENTS OR 
REACTIONS AND SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTION .................. 35 
10.1 DEFINITIONS .......................................................................................................... 36 
TABLE 10.1 INTENSITY OF EVENTS .................................................................................. 37 
10.2 RELATEDNESS: CAUSAL CONNECTION BETWEEN EVENT AND TRIAL MEDICATION ......... 37 
10.3 CATEGORIES AND DEFINITIONS OF THE OUTCOME OF AN EVENT ................................ 38 
10.4 REGISTRATION OF EVENTS ..................................................................................... 38 

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10.5 REPORTING SERIOUS ADVERSE EVENTS AND REACTIONS (SAE/SAR) AND SUSPECTED 
UNEXPECTED SERIOUS ADVERSE REACTIONS (SUSAR) ................................................... 39 
10.6 PREGNANCY AND CONTRACEPTION ......................................................................... 40 
10.7 FOLLOW UP............................................................................................................ 40 
11  
CASE REPORT FORM (CRF) ............................................................................................ 40 
11.1 INVESTIGATOR STUDY FILE AND ARCHIVES ............................................................... 40 
12  
MONITORING AND CONTROL VISITS .............................................................................. 40 
13  
DATABASE HANDLING ..................................................................................................... 41 
14  
STATISTICAL CONSIDERATIONS .................................................................................... 41 
14.1 SAMPLE SIZE ESTIMATION ....................................................................................... 41 
14.2 STATISTICAL METHODS ........................................................................................... 41 
14.3 SENSITIVITY ANALYSES .......................................................................................... 46 
14.4 STATISTICAL DESCRIPTION OF ANALYSIS ON DATA OBTAINED AFTER END OF THE OPEN-LABEL 
PHASE .......................................................................................................................... 46 
15  
ETHICAL CONSIDERATIONS ............................................................................................ 47 
15.1 RECRUITMENT, INFORMED CONSENT, POWER OF ATTORNEY AND PATIENT INFORMATION47 
15.2 THE REGIONAL SCIENTIFIC ETHICAL COMMITTEE ..................................................... 48 
15.3 THE DANISH DATA PROTECTION AGENCY ................................................................ 48 
15.4 THE DANISH MEDICINE AGENCY ............................................................................. 48 
15.5 FINANCING AND INSURANCE .................................................................................... 49 
16 
STUDY RESPONSIBILITY ................................................................................................. 49 
17 
 BIOBANK .......................................................................................................................... 49 
18  
DATA AND PUBLICATIONS .............................................................................................. 50 
19 
STORAGE OF CLINICAL TRIAL DOCUMENTS ................................................................ 51 
20  
INSURANCE ....................................................................................................................... 51 
21 
Appendix A: Study outline ................................................................................................ 52 
22 
Appendix B ........................................................................................................................ 53 
23 
Appendix C ........................................................................................................................ 54 
23.1 
HANDLING AND ANALYSES OF BIOLOGICAL MATERIAL ........................................... 54 
23.2 
LUMBAR PUNCTURE .......................................................................................... 54 
23.2.1 PROCEDURE ....................................................................................................... 54 
23.2.2 CONTRAINDICATION FOR LUMBAR PUNCTURE ........................................................ 54 
23.2.3 HANDLING OF THE CEREBROSPINAL FLUID (CSF) .................................................. 54 
23.3 
Cerebrospinal fluid analyses ......................................................................................... 54 
23.3.1 CSF ANALYSES AT THE DEPARTMENT OF CLINICAL BIOCHEMISTRY ......................... 54 
23.3.2 CSF AND SERUM ANALYSES DONE IN THE LABORATORY OF NEUROIMMUNOLOGY .... 54 
23.3.3 NEUROFILAMENT LIGHT CHAIN ELISA ANALYSES................................................... 54 

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23.3.4 SERUM NFL ANALYSES ....................................................................................... 55 
23.3.5 CHITINASE-3-LIKE-1 ANALYSES ............................................................................ 55 
23.3.6 SCD14 ANALYSES ............................................................................................... 55 
23.3.7 SCD27 ANALYSES ............................................................................................... 55 
23.3.8 MYELIN BASIC PROTEIN (MBP) ANALYSES ............................................................ 55 
BCMA (TNFRSF17) ANALYSES ..................................................................................... 55 
23.4 
Blood samples ............................................................................................................... 55 
Appendix D .................................................................................................................................. 56 
24  
 REFERENCES .................................................................................................. 63 
 
 
 

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Abbreviations 
 
AE 
 
 
Adverse event 
ALAT 
 
 
Alanine Amino Transferase 
Anti-HBsAG  
 
Anti Hepatitis B surface antigen 
Anti-HCV 
 
 
Anti Hepatitis C Virus  
Anti-HIV 
 
 
Anti Human Immunodeficiency Virus 
AR 
 
 
Adverse reaction 
BCMA (TNFRSF17) 
B-cell maturation antigen (tumor necrosis factor receptor 
superfamily member 17) 
BID 
 
 
“Bis in die” from Latin meaning twice a day 
BICAMS 
 
 
Brief International Cognitive Assessment for MS 
CGM 
 
 
Cortical grey matter 
CH13L1 
 
 
Chitinase 3 like 1 
CNS 
 
 
Central nervous system 
CRP 
 
 
C-reactive protein 
CSF 
 
 
Cerebrospinal fluid 
C2 
 
 
Cervical vertebrae number 2  
DMF 
 
 
Dimethyl Fumarate 
DTI 
 
 
Diffusion tensor imaging 
EDSS 
 
 
Expanded Disability Status Scale 
ELISA 
 
 
Enzyme-linked immunosorbent assay 
EMA 
 
 
European Medical Association 
FA 
 
 
Fractional anisotropy 
FAE 
 
 
Fumaric acid esters 
FSMC 
 
 
Fatigue Scale for Motor and Cognitive Functions 
GCP 
 
 
Good Clinical Practice 
Gd 
 
 
Gadolinium 
HBsAG 
 
 
Hepatitis B surface antigen 
hCG 
 
 
Human Chorionic Gonadotropin 
HIV 
 
 
Human Immunodeficiency Virus 
9HPT 
 
 
Nine-Hole Peg Test 

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IgG 
 
 
Immunoglobulin  
INR 
 
 
International Normalized Ratio 
JCV 
 
 
John Cunningham Virus 
MBP 
 
 
Myelin basic protein 
MD 
 
 
Mean Diffusivity 
MCV 
 
 
Mean Cell Volume 
MRI 
 
 
Magnetic resonance imaging  
MS 
 
 
Multiple Sclerosis 
MSIS-29 
 
 
Multiple Sclerosis Impact Scale 29 
MTR 
 
 
Magnetization Transfer Ratio 
NAGM 
 
 
Normal Appearing Grey Matter 
NAWM 
 
 
Normal-appearing white matter 
NFL 
 
 
Neurofilament light chain 
NFkB 
 
 
Nuclear Factor Kappa Beta 
NPCs 
 
 
Neural stem/progenitor cells 
Nrf2 
 
 
Nuclear factor (erythroid-derived 2)-Related Factor 2 
PBVC 
 
 
Percentage Brain volume change 
PML 
 
 
Progressive multifocal leukoencephalopathy 
 
PPMS 
 
 
Primary progressive multiple sclerosis 
RRMS 
 
 
Relapsing remitting multiple sclerosis 
SAE 
 
 
Serious Adverse Event 
SAR 
 
 
Serious Adverse Reaction 
sCD14 
 
 
Soluble CD14 
sCD27 
 
 
Soluble CD27 
SDMT 
 
 
Symbol Digit Modalities Test 
sNFL 
 
 
Serum neurofilament light chain 
SPMS 
 
 
Secondary progressive multiple sclerosis  
SUSAR 
 
 
Suspected unexpected serious adverse reaction 
 
TMF 
 
 
Trial Master File 
T25FW 
 
 
Timed 25-Foot Walk 
UDI 
 
 
Urinary Distress Inventory 
 

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1 
PROTOCOL SUMMARY 
 
 
Title:  
Dimethyl fumarate treatment of primary progressive multiple sclerosis 
Study aim:  
The aim of the study is to evaluate the efficacy and safety of dimethyl fumarate 
(DMF) treatment in primary progressive multiple sclerosis (PPMS). Patients 
fulfilling the inclusion criteria are randomized to treatment with dimethyl 
fumarate or placebo for 48 weeks followed by an open-label treatment phase 
where all patients are treated with dimethyl fumarate for an additional 48 
weeks. 
The primary endpoint of the study is to assess the effect of treatment with 
dimethyl fumarate on: 
 
• 
Change in the cerebrospinal fluid (CSF) concentration of neurofilament 
light chain (NFL) in patients treated with Dimethyl fumarate or placebo 
for 48 weeks 
 
Secondary endpoints are: 
• 
Clinical endpoints: comparison of change from screening to week 48 
in patients treated with dimethyl fumarate and placebo for the following 
variables: 
 
Expanded Disability Status Scale 
 
Timed 25-Foot Walk  
 
Nine-Hole Peg Test  
 
Brief International Cognitive Assessment for MS (BICAMS) 
 
Symbol Digit Modalities Test  
• 
CSF endpoints: comparison of change from screening to week 48 in 
patients treated with dimethyl fumarate and placebo for the following 
variables: 
 
IgG-index 
 
CSF-serum albumin quotient 
 
Concentrations of: chitinase-3-like-1, sCD14, sCD27, BCMA 
(TNFRSF17) and myelin basic protein 
 
• 
Magnetic resonance imaging (MRI) endpoints: comparison of change 
from screening to week 48 in patients treated with dimethyl fumarate 
and placebo for the following variables: 

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 
Number of new or enlarged T2 lesions 
 
Fractional anisotropy (FA) in Normal Appearing White Matter 
(NAWM) 
 
Lesion volume 
 
Magnetization transfer ratio (MTR) in lesions 
 
Thalamic volume 
 
Percentage brain volume change 
 
Tertiary endpoints are: 
 
• 
Clinical endpoints: comparison of change from screening to week 48 
in patients treated with dimethyl fumarate and placebo for the following 
variables: 
 
 Brief International Cognitive Assessment for MS (BICAMS) 
 
Brief Visuospatial Memory Test Revised  
 
California Verbal Learning Test 2  
 
• 
MRI endpoints: comparison of change from screening to week 48 in 
patients treated with dimethyl fumarate and placebo for the following 
variables: 
 
Number of Gd enhancing lesions 
 
Total number of lesions 
 
Volume of Cortical Grey Matter (CGM), NAWM and the 
putamen nuclei   
 
MTR of CGM, NAWM, the putamen and thalamic nuclei 
 
Diffusion tensor imaging (DTI) measures (FA and mean 
diffusivity) of CGM, NAWM (except FA in NAWM), lesions, the 
putamen and thalamic nuclei 
 
Cross sectional area at C2 level of the cervical spinal cord 
 
• 
Self-reported outcome measures: comparison of change from 
screening to week 48 in patients treated with dimethyl fumarate and 
placebo for the following variables 
 
Urinary Distress Inventory  

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 
Fatigue Scale for Motor and Cognitive Functions  
 
Multiple Sclerosis Impact Scale 29  
 
• 
Safety: 
 
Records of adverse events (AE), serious adverse events (SAE) 
and serious unexpected serious adverse reaction (SUSAR)  
 
Safety blood samples 
 
Tertiary (exploratory) outcome measures from the open label phase (week 48-
96) are analyzed separately for patients initially randomized to treatment with 
DMF or placebo and patients initially not randomized due to low 
concentrations of NFL. Patients with lower CSF concentrations than required 
for randomization at screening will be asked to be followed-up per protocol 
after 48 weeks, and if they show evidence of clinical disease progression at 
the week 48 visit, they can be treated with dimethyl fumarate from week 48-
96. For these patients the outcome measures are comparisons of changes in 
clinical and self-reported measures and MRI endpoints from week 0-48 and 
from week 48-96.  
 
Research plan: 
The trial is a single center phase 2A proof-of-concept study. Participating 
patients will be treated with DMF or placebo for 48 weeks followed by an open-
label treatment phase where all patients, initially enrolled in the study, are 
treated with dimethyl fumarate for an additional 48 weeks. Clinical studies are 
conducted at the screening visit (week –6 to –2), week 48 and week 96. 
Lumbar puncture is conducted at the screening visit and week 48. Safety 
blood samples are taken at the screening visit, baseline visit, week 12, 24, 36, 
48, 60, 72, 84 and week 96. Pregnancy test will be performed as a measure 
of serum hCG on all women of childbearing age at every visit. MRI is 
conducted at the screening visit, week 48 and week 96.  
Trial population: 
Patients eligible for randomization have PPMS with or without superimposed 
relapses with an EDSS score of 6.5 points or less and have a high CSF 
concentration of NFL at screening above 380ng/l. Patients completing the 
screening visit but not randomized due to CSF concentration of NFL <380ng/l 
will be followed up after 48 weeks. 
Sample size: 
54patients with PPMS fulfilling the inclusion criteria will be randomized to 
active or placebo treatment.  
Trial medication: 
Dimethyl fumarate 240 mg BID for 48 weeks or matching placebo (week 0-48) 
and open-label treatment with dimethyl fumarate 240 mg BID for 48 weeks 
(week 48-96).  
 

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2 
 
FLOW CHART 
 
See appendix A. 
 
3  
 
BACKGROUND 
 
3.1 Primary progressive multiple sclerosis  
Multiple sclerosis (MS) is a chronic, inflammatory disease of the central nervous system (CNS), and 
is presumed to be caused by T cell-mediated autoimmune processes 1. Denmark has a high 
prevalence of MS, and with approximately 14,000 patients, it is the second most common cause of 
disability in young adults. Two onset forms of MS exist: relapsing-remitting MS (RRMS, 85%) and 
primary progressive MS (PPMS, 15%) 2.  During the course of the disease, the majority of patients 
with RRMS will eventually convert to a secondary progressive disease course (SPMS). Progressive 
MS forms account for at least half of all patients with MS. 
 
Clinically RRMS is characterized by relapses with neurological symptoms that last from a few days 
to several months but subsequently improve or remit completely. The pathological correlate is focal, 
inflammatory lesions in the optic nerve, brain or spinal cord with infiltrating leukocytes, activated 
macrophages, loss of myelin (demyelination) and damage to axons and neurons3,4. The focal lesions 
can be visualized on magnetic resonance imaging (MRI) as hyperintense areas on T2-weighted 
images and show evidence of blood-brain barrier disruption when Gadolinium (Gd)-contrast is 
administered.  
 
Progressive forms of MS are characterized clinically by gradual symptom development. 
Superimposed relapses may occur, and progressive MS with superimposed relapses or 
development of new or Gd-enhancing MRI lesions is classified as active progressive MS 2. 
Superimposed relapses do not, however, influence the disease course, and the overall disease 
course is comparable in PPMS and SPMS 5. In the past decade there has been immense interest in 
neurodegenerative processes as the primary pathophysiological substrate for disease progression 
in MS, and it has been argued that PPMS is a purely neurodegenerative form of MS 6. Pathology 
studies do, however, indicate that inflammation is also a key feature of PPMS, but inflammation in 
progressive MS is more diffuse than in RRMS 4,7. Furthermore, patients with progressive MS show 
evidence of ongoing inflammation, which correlates with demyelination and neuroaxonal damage in 
CSF biomarker studies 8. Most recently, it has been suggested that oxidative damage induced by 
inflammation may play a key role in the pathogenesis of MS 9–11. 
 
Treatment options for patients with PPMS are very limited. Prophylactic treatment with interferon-β 
and glatiramer acetate did not show statistically significant efficacy in randomized, controlled trials 
12,13. Furthermore, a recent phase 3 study comparing treatment with fingolimod and placebo in PPMS 
found no effect on disease progression 14. A previous phase 2B study with the B cell-depleting 
monoclonal antibody rituximab found no statistically significant effect of treatment in PPMS, whereas 
a recent phase 3 study found a statistically significant effect of the B cell-depleting monoclonal 

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antibody ocrelizumab in PPMS (Hauser, ECTRIMS 2015). The effect was, however, marginal, and 
it is uncertain whether it is primarily driven by a subgroup of patients with active PPMS. Ocrelizumab 
is, however, not marketed, and if eventually approved by the EMA, will not be marketed earlier than 
2017.  
We previously completed a phase 2A proof-of-concept study (the NAPMS study) investigating the 
effect of the monoclonal antibody natalizumab in patients with PPMS or SPMS. This study showed 
that treatment resulted in significant decreases in the primary outcome measure (the CSF 
concentration of osteopontin) and in many secondary outcome measures 15.  The improvement in 
the primary outcome measure was statistically significant even for the subgroup of patients with 
PPMS alone and was associated with lower levels of NFL and increases in magnetization transfer 
ratios, which are indicative of improvements in CNS tissue integrity, presumably due to increases in 
myelination or decreases in diffuse CNS inflammation. A recent phase 3 study comparing treatment 
with natalizumab and placebo in SPMS did not find a statistically significant effect on the primary 
outcome measure of progression (Biogen press release 2015). The study did, however, find a 
statistically significant effect on progression of upper limb dexterity and disease activity in terms of 
relapses and MRI disease activity. These results are consistent with the findings from our phase 2A 
study, where we found that CSF concentrations of MMP-9 and CXCL13, which are both known to 
be associated with disease activity, normalized upon treatment with natalizumab. In contrast, 
osteopontin and NFL concentrations were lowered but not normalized, which we interpret as being 
consistent with the limited clinical efficacy of treatment in the recent phase 3 study.          
In conclusion, the results of the NAPMS study as well as another phase 2A study of monthly 
methylprednisolone treatment of progressive MS indicates that it is feasible to conduct phase 2A 
trials with CSF measures as the primary outcome in PPMS 16. 
 
3.2 Dimethyl fumarate 
Fumarates have long been known to have disease-attenuating effects in psoriasis. They have been 
in routine use in dermatology in Germany for several decades, and initial studies indicated that 
fumarates might also have beneficial effects in MS 17,18. DMF has the interesting property of 
combining immunological effects, at least partly mediated by interference with nuclear factor κB and 
other transcription factors, and also anti-oxidative and neuroprotective effects mediated by activation 
of the transcription factor Nuclear factor (erythroid-derived 2)-Related Factor 2 (NRF2) 19,20. More 
recently, the surface receptor HCA2 was reported to be essential for the effect of DMF in an animal 
model of MS 21. DMF is currently approved for treatment of RRMS by the EMA in a dose of 240 mg 
BID. The effect of treatment has been documented in two phase 3 randomized, controlled trials in 
RRMS 22,23. Treatment with dimethyl fumarate was not associated with severe adverse events during 
up to two years of treatment in clinical trials in MS. This is in line with the experience with fumarate 
treatment in dermatology. Gastrointestinal side effects and flushing occurred more frequently in 
patients treated with dimethyl fumarate than in patients treated with placebo but resolved within the 
first month of treatment in the majority of patients. The development of the severe opportunistic 
infection progressive multifocal leukoencephalopathy (PML) has, however, been reported in rare 
cases, usually with long lasting, marked lymphopenia, during long-term treatment with fumarates 

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including DMF. This has led to an update of the summary of medicinal product characteristics 
(SMPC) by the EMA, with detailed recommendations on lymphocyte monitoring.  
A small study comparing treatment with two types of fumarate in progressive MS showed that DMF 
was well tolerated and that there was no safety issues occurring 24. Only 26 patients participated, 
and the study was not a randomized clinical trial but it warrants further investigation into the possible 
treatment effect of DMF in progressive MS patients.  
 
3.3 Outcome measures 
The diffuse inflammation observed in PPMS is better reflected by the study of biomarkers in CSF 
than by the conventional measure Gd-enhancing MRI lesions 8,25. CSF concentrations of NFL 
correlate with inflammation in patients with progressive MS 8, improve upon treatment with 
natalizumab in progressive MS and RRMS and are associated with Magnetization Transfer Ratio 
(MTR) measures of tissue integrity in progressive MS 15,26. As NFL has emerged as a treatment-
responsive biomarker, and has been associated with the long-term prognosis in MS 27,28, we have 
chosen to use change in this biomarker as the primary outcome measure in the present study. Based 
on the results of previous studies we have chosen to use changes in BCMA (TNFRSF17), soluble 
CD14 (sCD14), soluble CD27 (sCD27), Chitinase-3-like-1 (CHI3L1) and Myelin Basic protein (MBP)  
as secondary outcome measures of intrathecal inflammation.  
MRI is a routine method in MS research. In addition to the assessment of focal T2 lesions and active 
Gd-enhancing lesions, MRI measures such as MTR, Diffusion Tensor Imaging (DTI) and brain 
atrophy measurements are increasingly used in MS research 29. Brain atrophy and MTR are 
associated with the long-term prognosis in PPMS 30–33, and DTI provides additional information about 
tissue integrity and was used as outcome measure in a recent phase 2 study in patients with PPMS 
34. Based on these studies and other studies in the literature, we have chosen to use the occurrence 
of new or enlarged T2 lesions, fractional anisotropy (FA) of normal appearing white matter (NAWM) 
from DTI, lesion volume, MTR of lesions, thalamic volume and percentage brain volume change 
(PBVC)  as secondary MRI outcome in the present study. Furthermore, we include the value from 
the Symbol Digit Modalities Test (SDMT) from the Brief International Cognitive Assessment for 
Multiple Sclerosis (BICAMS) panel as secondary outcome measures alongside values from the 
Expanded Disability Status Scale, the 9-hole-pege test and the Timed 25-foot Walk. The study will 
also explore the differences between the treatment and placebo group on additional measures from 
MRI, clinical (two further measures from the BICAMS panel) and self-reported outcome measures.  
To examine the relationship between changes in neuroaxonal damage and changes in clinical and 
inflammatory disease characteristics, we will study the relationship between changes in the primary 
endpoint (CSF NFL concentrations) and changes in secondary endpoints (clinical measures, MRI 
measures and inflammatory biomarkers in the CSF. For further information about statistical analysis 
see section 14. 
Data from the open-label phase (W48 to W96) explore the effects of prolonged treatment with 
dimethyl fumarate. Data from this phase of the study are analyzed independently and will describe 
time effects of DMF treatment by including all DMF-treated patients during the 96 weeks  study 
phase. Concentrations of serum-NFL from screening, week 48 and week 96 will be analyzed 35, see 
section 14.  

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3.4 Study rationale 
At present, there are no treatments available for patients with PPMS. In the past decade, much focus 
in progressive MS research has been based on a hypothetic role of neurodegenerative processes. 
However, until now there is no evidence that neuroprotective therapy is efficacious in progressive 
MS. In contrast, there is ample evidence that patients with progressive MS show evidence of 
systemic immune activation. In a recent study we reported that patients with PPMS have increased 
activation of circulating, pro-inflammatory T lymphocytes 36 and another study from our group 
provided evidence of comparable levels of immune activation in blood cells in RRMS, SPMS and 
PPMS 37. The role of these cells in the pathogenesis of progressive MS is supported by our study of 
the effect of natalizumab, which blocks the migration of pathogenic immune cells to the CNS, and 
was associated with a decrease in inflammation, demyelination and neuroaxonal damage in PPMS 
and SPMS 15. Treatment with natalizumab did not, however, normalize neuroaxonal damage, which 
is in contrast to the effect seen in RRMS 26. 
Since DMF may exert a combination of anti-inflammatory, neuroprotective and anti-oxidative effects, 
we hypothesize that treatment with dimethyl fumarate may decrease neuroaxonal damage in PPMS. 
We also hypothesize that this is the result of beneficial effects on inflammatory processes in the 
brain and spinal cord as well as anti-oxidative effects, and that this is associated with beneficial 
effects on MRI and clinical measures of disease severity.  
 
4  
 
AIM OF THE STUDY 
 
The primary aim of the study is to investigate whether 48 weeks of treatment with dimethyl fumarate 
can reduce neuroaxonal damage as assessed by the CSF concentration of NFL in patients with 
PPMS. Secondary endpoints investigate the effects on other CSF measures of demyelination and 
inflammation and investigate the effects of treatment on clinical and MRI outcome from screening to 
week 48. Tertiary outcome are the MRI measurements not used as secondary outcome, two 
outcome measures from the BICAMS panel and the self-reported questionnaires.  
 
 
4.1 Primary outcome measure 
The primary aim of the study is to assess whether 48 weeks of treatment with dimethyl fumarate can 
decrease neuroaxonal damage in PPMS as assessed by: 
• 
Difference in change in the CSF concentration of NFL from screening to week 48 
in PPMS patients treated with dimethyl fumarate or placebo 
 
4.2 Secondary outcome measures 
 
• 
Clinical endpoints: comparison of change from screening to week 48 
in patients treated with dimethyl fumarate and placebo for the following 
variables: 
 
Expanded Disability Status Scale (EDSS) 

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 
Timed 25-Foot Walk (T25FW) 
 
Nine-Hole Peg Test (9HPT) 
 
Brief International Cognitive Assessment for MS (BICAMS) 
 
Symbol Digit Modalities Test (SDMT) 
 
• 
CSF endpoints: comparison of change from screening to week 48 in 
patients treated with dimethyl fumarate and placebo for the following 
variables: 
 
IgG-index 
 
CSF-serum albumin quotient 
 
Concentrations of: chitinase-3-like-1, sCD14, sCD27, BCMA 
(TNFRSF17) and myelin basic protein (MBP) 
• 
Magnetic resonance imaging (MRI) endpoints: comparison of change 
from screening to week 48 in patients treated with dimethyl fumarate 
and placebo for the following variables: 
 
Number of new or enlarged T2 lesions 
 
Fractional anisotropy (FA) in Normal Appearing White Matter 
(NAWM) 
 
Lesion volume 
 
Magnetization Transfer Ratio (MTR) in lesions 
 
Thalamic volume 
 
Percentage brain volume change (PBVC) 
 
 
4.3 Tertiary (exploratory) outcome measures  
 
• 
Clinical endpoints: comparison of change from screening to week 48 
in patients treated with dimethyl fumarate and placebo for the following 
variables: 
• 
Brief International Cognitive Assessment for MS (BICAMS) 
• 
Brief Visuospatial Memory Test Revised (BVMTR) 
• 
California Verbal Learning Test 2 (CVLT-II) 
 
• 
MRI endpoints: comparison of change from screening to week 48 in 
patients treated with dimethyl fumarate and placebo for the following 
variables: 

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 
Number of Gd enhancing lesions 
 
Total number of lesions 
 
Volume of Cortical Grey Matter (CGM), NAWM and the 
putamen nuclei   
 
Change in MTR of CGM, NAWM, the putamen and thalamic 
nuclei 
 
Change in diffusion tensor imaging (DTI) measures (FA and 
mean diffusivity) of CGM, NAWM (except FA in NAWM), 
lesions, the putamen and thalamic nuclei 
 
Cross sectional area at C2 level of the cervical spinal cord 
 
• 
Self-reported outcome measures: comparison of change from 
screening to week 48 in patients treated with dimethyl fumarate and 
placebo for the following variables 
 
Urinary Distress Inventory (UDI)  
 
Fatigue Scale for Motor and Cognitive Functions (FSMC) 
 
Multiple Sclerosis Impact Scale 29 (MSIS-29) 
 
 
4.4 Open-label phase outcome (week 48-96) 
 
▪ 
Clinical, self-reported, MRI and serum outcome week 48-96 (including 
screening regarding serum-NFL): 
 
EDSS 
 
T25FW 
 
9HPT 
 
BICAMS (SDMT, BVLTR, CVLT-II) 
 
UDI  
 
FSMC  
 
MSIS-29 
 
Number of Gd enhancing lesions 
 
Total number of lesions 
 
New or enlarged T2 lesions  

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 
Percentage brain volume change (PBVC) 
 
Volume: lesions, CGM, NAWM , the putamen and thalamic nuclei 
 
MTR: in lesions, CGM, NAWM and, the putamen and thalamic nuclei  
 
DTI (fractional anisotropy and mean diffusivity): lesions, CGM, NAWM 
and the putamen and thalamic nuclei  
 
Cross sectional area at C2 level of the cervical spinal cord 
 
Serum endpoint 
▪ 
Concentrations of neurofilament light chain (NFL) in serum 
from screening, W48, and W96 (SIMOA (Quanterix, 
commercially available)) 
 
 
4.5 Additional exploratory outcome 
At the time of MRI (screening, week 48 and week 96) a circle drawing test will be performed.  
 
5  
 
PATIENT POPULATION 
 
Patients are recruited at the Danish Multiple Sclerosis Center at Rigshospitalet, University of 
Copenhagen. Patients are eligible for inclusion in the study if they have PPMS according to the 2010 
revision of the McDonald criteria for MS and the 2014 revision of the Lublin criteria for the clinical 
course of MS. Patients are selected for the screening visit based on a list of inclusion and exclusion 
criteria, and must have evidence of disease activity as assessed by the CSF concentration of NFL 
at the screening visit. 
Patients eligible for the study based on the inclusion and exclusion criteria, but not fulfilling the CSF 
criterion for disease activity, can be followed up after 48 weeks. If such patients show evidence of 
clinical disease progression after 48 weeks, they are eligible for inclusion in the open-label active 
treatment phase of the study.  
 
5.1 Inclusion criteria 
• 
Age 18 to 65 years 
• 
PPMS according to the McDonald (2010) and Lublin (2014) criteria 
• 
Disease duration at least one year 
• 
EDSS  6.5 
• 
Written informed consent  
• 
No other signs of significant disease judged by the investigator 
• 
Eligible for randomization to active treatment or placebo as assessed by CSF 
NFL levels above 380ng/L 

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• 
Not eligible for randomization as assessed by CSF biomarker studies but accepts 
follow-up and open-label treatment per protocol 
• 
Patients not eligible for randomization due to low NFL concentrations in CSF at 
screening can be followed up after 48 weeks, and are eligible for open-label 
treatment if they fulfil one of the following clinical criteria of disease progression: 
• 
1 point increase in EDSS score from screening to week 48 if screening 
EDSS <6 
• 
0.5 point increase in EDSS score from screening to week 48 if 
screening EDSS>5.5 
• 
2 point increase in a physical functional system 
• 
Worsening in SDMT, 9HPT or T25FW >20% from screening to week 
48 
 
5.2 Exclusion criteria 
• 
Pregnancy or breast feeding  
• 
Lack of effective contraception for women of child-bearing potential 
• 
Relapse within 6 months of inclusion  
• 
Methylprednisolone treatment within 3 months of inclusion 
• 
Treatment with interferon-beta, glatiramer acetate, immunoglobulin G or other 
immunomodulatory treatment within 6 months of inclusion 
• 
Treatment with mitoxantrone, cyclophosphamide, azathioprine or other 
immunosuppressive treatment within 6 months of inclusion 
• 
Findings on the screening MRI judged to preclude participation by the treating 
physician 
• 
Other diseases associated with immunodeficiency 
• 
Other diseases judged to be relevant by the treating physician 
• 
Anticoagulant therapy other than platelet inhibitors 
• 
Active malignant disease in the previous 5 years 
• 
Renal insufficiency or blood creatinine > 150 μmol/l 
• 
Present or chronic infection with hepatitis B virus, hepatitis C virus, HIV (tested in 
the screening blood samples) or other infections found to be relevant by the 
treating physician.  
• 
Psychiatric disorders or other disorders impairing the patient’s ability to 
participate in the trial 
• 
Contraindication to MRI  
• 
Known allergy or hypersensitivity to dimethyl fumarate 
 
 

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5.3 Treatment discontinuation 
 
Patients will be informed about their right to withdraw from the study and that this will have no 
negative consequences for their future treatment in the department.                                    
Treatment with the trial medication will be discontinued in case of: 
• 
Withdrawal of informed consent 
• 
Pregnancy, pregnancy wish or lack of effective contraception (for women of child-
bearing potential) 
• 
Poor compliance, e.g. not showing up for scheduled visits 
• 
Treatment with other disease-modifying therapies or immunosuppressive drugs 
• 
At the request of the investigator or sponsor 
 
If treatment is discontinued the patient will, if possible, be seen at an unscheduled visit for clinical 
assessment and safety blood samples as described in 7.1.4 (screening visit) within 4 weeks unless 
informed consent has been withdrawn.  
 
6  
 
TRIAL DESIGN 
 
6.1 Trial type 
The trial is a single-center, parallel group, randomized, 48 weeks placebo-controlled trial with a 48 
weeks open-label treatment extension phase.  
 
6.2 Study endpoints 
The primary endpoint of the study is the change in CSF concentrations of NFL from screening to 
week 48. Secondary and tertiary endpoints are described in detail in section 4.  
Safety endpoints include standard measures such as a routine physical examination, pulse, blood 
pressure, and monitoring of adverse events (AE), serious adverse events (SAE) and serious 
unexpected serious adverse reaction (SUSAR) 
 
6.3 Time plan for the trial 
The study includes a screening phase (2-6 weeks before randomization) with a screening visit 
divided over 2-3 days (see section 7.1.4), a randomized treatment phase (48 weeks) with a baseline 
visit (week 0) and 4 study visits (week 12, 24, 36, 48) and an open-label extension phase with 4 
study visits (week 60, 72, 84 and 96). It is expected than 1-2 patients will be screened per week, and 
that 1 patient per week can be randomized.   
                             
Plan for patient inclusion:                                                                                                                     
Planned inclusion of the first patient: 
 
September 2016                                                       
Planned period of recruitment: 
 
September 2017                                                          
Planned end of trial: 
 
 
December 2020 

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6.4 Relapses 
The patient is asked to contact the clinic within 3 days from the onset of a suspected relapse and 
should be examined by the study physician within 10 days from onset of the suspected relapse. If 
the physician finds that the relapse results in significant impairment, methylprednisolone pulse 
therapy can be administered (section 9.5). 
 
7 
 
METHODS AND OUTCOME MEASURES 
 
The treating physician (investigator) is clinically responsible, and will prescribe the study drug, 
conduct the clinical procedures (lumbar puncture and quantitative neurological examinations). The 
study coordinator will assist with the quantitative neurological examinations, study drug 
administration and blood samples.  
 
7.1 Study visit procedures 
All patients will complete a screening visit. If they fulfil all inclusion criteria and no exclusion criteria 
at the screening visit, they will enter the randomized part of the study and complete a baseline visit 
and study visits at week 12, 24, 36, 48, 60, 72, 84 and 96. For full overview of content of each visit 
see Appendix B 
 
7.1.1 Treatment in the open-label phase 
Patients who do not show evidence of disease activity in the screening lumbar puncture, measured 
as NFL below 380ng/L, can be followed up with a study visit at week 48 if they accept to do so. They 
are eligible for open-label treatment from week 48 to 96, if there is evidence of clinical disease 
progression (section 5.1) and will be followed with study visits at week 60, 72, 84 and 96.  
As described in the next section, patients with increased CSF concentration of NFL at the screening 
visit are eligible for randomization to treatment with DMF or placebo for 48 weeks followed by the 48 
week open-label extension phase. Open-label treatment extension phases are widely used in MS 
research in order to obtain additional data on efficacy and adverse events. 
 
The rationale for allowing open-label treatment of patients not eligible for randomization but still 
showing significant clinical worsening 48 weeks after the screening visit is that this will allow us to 
collect preliminary data on efficacy in this patient subgroup. Although efficacy of DMF in PPMS has 
not been established, preliminary evidence support that DMF treatment is safe and well tolerated 
also in progressive MS 24. Furthermore, the systematic follow-up of patients not eligible for 
randomization at baseline will provide further scientific evidence to support the use of NFL 
measurements for selecting PPMS patients for clinical trials. The threshold for clinical disease 
progression used to establish eligibility for open-label treatment is based on thresholds validated in 
previous clinical trials in progressive MS 38.  
 
Although prone to bias from the unblinded administration of the study drug, valid data can still be 
obtained from the open-label study design since the MRI studies conducted will not be prone to the 

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same bias. This notion is supported by the treatment effects observed in MRI studies in two previous 
unblinded phase 2 studies from our group 15,16.   
 
7.1.2 Cut off level of NFL   
All patients eligible for inclusion in the study will have a lumbar puncture done at the screening visit. 
If the level of NFL is increased above 380ng/l, the patient is eligible for randomization, which will 
take place at the baseline visit. The measurement of NFL in CSF is done using the NF-Light® ELISA 
assay from Uman Diagnostics (see Appendix D). This is a commercially available kit developed in 
Sweden and used in most research with NFL as an outcome measure 8,39,40. The cut-off level of 
380ng/l correspond to the previously established upper limit in young adults established for this 
assay 41. The same assay has been used in several previous studies from our group8,15,16,28. These 
studies confirm that increased NFL levels predict a poor prognosis in MS, that PPMS patients on 
average have increased CSF levels of NFL, that NFL concentrations in general are stable over 1 
year, and that the use of NFL levels as an inclusion criterion is supported by exploratory reanalyses 
of data from our previous phase 2 clinical trials in patients with progressive MS 15,16.  
  
7.1.3 Quality assurance of NFL measurements 
The NFL immunoreactivity detected with the NF-Light® assay from Uman Diagnostics is highly 
stable 42. The assay is used for routine analysis by Statens Serum Institut in Copenhagen and is 
currently being implemented for routine analysis at the Neuroimmunology laboratory at 
Rigshospitalet, where the ELISA for this study is conducted.  
Quality assurance of each assay run is done by running reference samples containing NFL in a high 
and low concentration alongside the sample from the patient and having a negative control in each 
assay run. All samples are run in duplicate in order to allow assessment of the assay coefficient of 
variation (CV).  
Intra-assay CV for the assay is generally below 5% and inter-assay CV is generally below 9%. If a 
sample has a CV above 15% it will be reanalyzed.  
For more information about the NFL kit kindly see appendix D. 
7.1.4 Screening visit (week –6 to week –2)                                                                                
Patients eligible for the study will go through the following procedures. The screening visit may be 
divided into two-three separate visits. MRI can be performed on the same day as the initial visit but 
can also be done on a separate day. Lumbar puncture will always be performed on a day separate 
from the initial visit and MRI. 
 
On day one the participants complete the following elements: 
• 
Written informed consent of participation 
• 
Inclusion and exclusion criteria are reviewed for the patient 
• 
Data on the MS history, previous treatment and other diseases are collected 
• 
Routine physical examination, pulse, blood pressure, weight, height 

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• 
Neurological examination with EDSS 
• 
T25FW, 9HPT, and BICAMS (SMDT, BVLTR and CVLT-II)  
• 
MSIS-29 
• 
UDI  
• 
FSMC  
• 
Safety blood tests: 
 Hematology: hemoglobin, MCV, thrombocytes, leukocytes with differential 
count 
 
Biochemistry: creatinine, sodium, potassium, ALAT, LDH, bilirubin, basic 
phosphatase, INR, CRP 
 
Anti-HBsAg, HBsAG, anti-HCV, anti-HIV 
 
Pregnancy test (in women of child-bearing potential) via serum hCG 
 
On day one or two the participants complete the following elements: 
• 
MRI with Gd contrast (performed at Hvidovre Hospital within two weeks)Circle drawing 
test at the time of the MRI 
 
On day two or three the participants complete the following elements: 
 
• 
Lumbar puncture for NFL analysis and other CSF outcome measures 
 
For full overview of study visit content see appendix B.  
 
7.1.5 Baseline visit 
• 
Study drug administration 
• 
Pregnancy test (in women of child-bearing potential) via serum hCG 
• 
T25FW, 9HPT, SDMT 
 
For full overview of study visit content see appendix B. 
 
7.1.6 Study visit type 1 (week 12, 36, 60, 84)  
• 
Study drug administration and accountability 
• 
Pregnancy test (in women of child-bearing potential) via serum hCG 
• 
Safety blood tests: 
 Hematology: hemoglobin, MCV, thrombocytes, leukocytes with differential 
count 
 
Biochemistry: creatinine, sodium, potassium, ALAT, LDH, bilirubin, basic 
phosphatase, INR, CRP 
 
For full overview of study visit content see appendix B. 

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7.1.7 Study visit type 2 (week 24 and 72) 
• 
Neurological examination with EDSS 
• 
9HPT and T25FW (only week 24) 
• 
Study drug administration and accountability 
• 
Pregnancy test (in women of child-bearing potential) via serum hCG 
• 
Safety blood tests: 
 Hematology: hemoglobin, MCV, thrombocytes, leukocytes with differential 
count 
 
Biochemistry: creatinine, sodium, potassium, ALAT, LDH, bilirubin, basic 
phosphatase, INR, CRP 
 
For full overview of study visit content see appendix B. 
 
 
7.1.8 Study visit week 48 
The week 48 visit may be divided into two-three separate visits. MRI can be performed on the same 
day as the clinical visit but can also be done on a separate day. Lumbar puncture will always be 
performed on a day separate from the clinical visit and MRI. 
 
• 
Routine physical examination, pulse, blood pressure 
• 
Neurological examination with EDSS 
• 
T25FW, 9HPT, SDMT and BICAMS (SMDT, BVLTR and CVLT-II) 
• 
MSIS-29 
• 
UDI  
• 
FSMC 
• 
Study drug administration and accountability 
• 
Pregnancy test (in women of child-bearing potential) via serum hCG 
• 
Safety blood tests: 
 Hematology: hemoglobin, MCV, thrombocytes, leukocytes with differential 
count 
 
Biochemistry: creatinine, sodium, potassium, ALAT, LDH, bilirubin, basic 
phosphatase, INR, CRP 
 
• 
MRI with Gd contrast (performed at Hvidovre Hospital week 47 or 48) 
• 
Circle drawing test at the time of the MRI 
• 
Lumbar puncture for CSF outcome measures 
 
For full overview of study visit content see appendix B. 
 

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7.1.9 Study visit week 96  
The week 96 visit may be divided into two separate visits. MRI can be performed on the same day 
as the clinical visit but can also be done on a separate day.  
 
• 
Routine physical examination, pulse, blood pressure 
• 
Neurological examination with EDSS 
• 
T25FW, 9HPT, SDMT, and BICAMS  
• 
MSIS-29 
• 
UID  
• 
FSMC 
• 
Study drug accountability 
• 
Pregnancy test (in women of child-bearing potential) via serum hCG 
• 
Safety blood tests: 
 Hematology: hemoglobin, MCV, thrombocytes, leukocytes with differential 
count 
 
Biochemistry: creatinine, sodium, potassium, ALAT, LDH, bilirubin, basic 
phosphatase, INR, CRP 
 
• 
MRI with Gd contrast (performed at Hvidovre Hospital week 95 or 96) 
• 
Circle drawing test at the time of the MRI 
 
For full overview of study visit content see appendix B. 
 
7.1.10 Unscheduled visits 
Patients are informed to contact the treating physician if they develop new symptoms or worsening 
that may constitute a relapse. The treating physician will decide whether the patient has a relapse 
or, and whether this should be treated with methylprednisolone, or whether there is another cause 
of the worsening.  
 
If symptoms of other disease occur the treating physician will register this as an AE or SAE, decide 
whether it is related to the study drug, and whether the study drug should be withdrawn. 
  
7.2 Outcome measures 
 
7.2.1 CSF concentration of neurofilament light chain 
NFL is aa cytoskeletal constituent of intermediate filaments and reflect neuronal and axonal death 
when appearing in CSF. The concentration of NFL is often elevated in CSF of progressive MS 
patients. NFL is a treatment responsive biomarker and has been associated with long-term prognosis 
in MS 27. In this study NFL is measured by ELISA technique as a biomarker of intrathecal 
neuroaxonal damage (see Appendix C, D and section 7.1.3). 
 

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7.2.2 Neurological examination with Expanded Disability Status Scale (EDSS), Timed 25-foot 
Walk (T25FW), Nine-Hole Peg Test (9HPT) , BICAMS, FSMC, UID and  MSIS-29  
EDSS will be rated at the screening visit, at week 24, 48, 72 and 96. EDSS assessment is done by 
standardized neurological examination (neurostatus 03/09). T25FW, 9HPT, SDMT, , BICAMS, 
FSMC, UID and MSIS-29 will be conducted at the screening visit, week 48 and week 96, except 
9HPT and T25FW that will also be performed at week 24.  
 
7.2.2.1 Assessment of disease progression 
The patients will routinely be assessed by full neurological examination and EDSS scoring. Disease 
progression is evaluated from this and patient history. The patients are instructed to contact the 
treating doctor if new symptoms develop between two routine examinations.  
 
7.2.3 Timed 25-foot walk test (T25FW) 
The T25FW is a quantitative mobility and leg function performance test. The patient is directed to 
one end of a clearly marked 25-foot course and is instructed to walk 25 feet as quickly as possible. 
Patients may use assistive devices when performing this task 43. 
  
7.2.4 Nine-Hole Peg test (9HPT) 
The 9-HPT is a brief, standardized, quantitative test of upper extremity function. Both the dominant 
and non-dominant hands are tested. It has great sensitivity to detect minor impairments of hand 
function 44. 
 
7.2.5 Brief International Cognitive Assessment for MS (BICAMS) 
BICAMS is an international validated assessment tool for the cognitive impairment seen in MS 
patients. It consists of 3 individual test: Symbol Digit Modalities test (SDMT), Brief Visuospatial 
Memory Learning Test Revised (BVMTR) and California Verbal Learning Test 2 (CVLT-II)45.  
 
7.2.6 Multiple Sclerosis Impact Scale (MSIS-29) 
MSIS-29 is a measure of the physical and physiological impact of multiple sclerosis from the patient’s 
perspective 46. It consists of 29 items of which 20 evaluate physical impact and 9 evaluate 
psychological impact.  
 
7.2.7 Urinary Distress Inventory (UDI) 
UDI is a questionnaire describing to which degree a person is bothered by different symptoms of  
bladder incontinent47.  
 
7.2.8 Fatigue Scale for Motor and Cognitive function (FSMC) 
FSMC has undergone validation and provides differential quantification and graduation of cognitive 
and motor fatigue in MS patients. Fatigue is one of the core symptoms in MS 48. 
 

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7.2.9 CSF concentration of Chitinase-3-like-1 (CHI3L1) 
CHI3L1 is a member of the glycoside hydrolase 18 Chitinase family and are expressed by inflamed 
tissues in numerous chronic inflammatory conditions. It has been detected in the human brain in 
several central nervous system (CNS) diseases, including MS. It has been suggested that astrocytes 
are the principal brain cell population that expresses CHI3L1, corroborating in vitro studies, which 
has identified CHI3L1 as one of the most abundant proteins released by cultured astrocytes upon 
exposure to pro-inflammatory components49. CHI3L1 will be analyzed by a validated in-house 
Luminex assay (R&D Systems). 
7.2.10 CSF concentrations of soluble CD14 and CD27, .  
sCD27 is primarily secreted by activated T-cells and has been proved to be superior to other CSF 
markers in diagnosing patients with intrathecal inflammation, furthermore it has shown good 
correlations with NFL, and may be more specific for patients with progressive MS. sCD14 is secreted 
by activated mononuclear phagocytes and provides information about innate immune activation in 
the CNS50,51. Soluble CD14 and soluble CD27 will be analyzed by a validated in-house Luminex 
assay (R&D Systems). 
7.2.11 CSF concentration of soluble BCMA (TNFRSF17) 
BCMA is a cell surface receptor found on mature B-cells and plasma cells. It acts as a receptor for 
the ligands B-cell activating factor (BAFF) and a proliferating-inducing factor (APRIL). BCMA 
receptor antagonists suppress EAE in mice, and BCMA may be a strong indicator of disease activity 
in progressive MS according to a large recent study of proteins in the CSF of progressive MS 
patients52. Also, B-cells are known to play an important role in inducing and sustaining intrathecal 
inflammation. Soluble BCMA (TNFRSF17) will be analyzed by a validated in-house Luminex assay 
(R&D Systems). 
7.2.12 Serum concentrations of neurofilament light chain  
Is done retrospectively as an explorative analysis after the completion of week 96. Analysis is done 
on stored serum samples from screening, week 48 and week 96. Patients do not undergo lumbar 
puncture for CSF NFL analysis at week 96. Concentrations of NFL in serum have been shown to be 
an excellent marker of neuronal damage in multiple sclerosis. Furthermore, the correlation between 
NFL in CSF and NFL in serum has been good in previous studies35 . Serum NFL will be measured 
using single-molecule array analysis (Quanterix) (appendix C). 
 
7.2.13 Myelin Basic Protein (MBP) 
MBP is a major protein in CNS myelin. The CSF concentration of MBP is increased in MS patients 
53. MBP will be measured in CSF using ELISA technique (R&D Systems) and is used as an 
intrathecal biomarker of demyelination (see appendix C). 
 
7.2.14 MRI with Gadolinium (Gd) enhancing lesions 
Gd enhancing lesions is the most frequently used marker of inflammation in MS patients. It reflects 
focal inflammation. Focal inflammation is seen in progressive MS and natalizumab treatment has 
been shown to reduce inflammation in SPMS 54.  

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7.2.15 Lesions on T2 weighted MRI  
Active demyelinating lesions, chronic inactive lesions and gliosis contributes to T2 weighted lesions. 
The volume of T2 lesions is a marker for accumulated disease activity in a given study period. The 
number or increase in volume of lesions is a measure for disease activity. This study uses the volume 
and the number of new T2 weighted lesions as a marker of disease activity by comparison of MRI 
before and after treatment.  
 
7.2.16 Percentage brain volume change (PBVC) 
Atrophy can be estimated on MRI by normalized brain volume (NBV). There is a good correlation 
between clinical disease progression and these measures 55. The degree of atrophy is a well-
established measurement of neuronal and axonal damage with great reproducibility in different 
studies of MS treatment 56 and can be measured over a short period. The rate of atrophy can be 
used as a measure of treatment effect. 
 
7.2.17 Change in volume of T2 lesions, cortical grey matter (CGM)  Normal-Appearing White 
Matter (NAWM), putamen and thalamus 
MRI measures in T2 weighted images are used to detect possible changes in these measures 
during the trial. 
7.2.18 Change in magnetization transfer ratio (MTR) of T2 lesions, putamen, thalamus, CGM 
and NAWM 
MTR is an indirect measurement of the content of macromolecules in a given tissue. MTR is a way 
of estimating the degree of demyelination and axonal loss in MS. Pathological studies have shown 
that a low MTR value represents low content of myelinated axons in both focal lesions and in NAWM. 
A low MTR value in normal-appearing grey matter (NAGM) is one of the best correlations between 
MRI and the clinical findings 31,57 in patients suffering from progressive MS. In this study, we measure 
the MTR value for T2 lesions, putamen, thalamus, CGM and NAWM. 
 
7.2.19 Change in diffusion tensor imaging (DTI) measures (fractional anisotropy and mean 
diffusivity) of T2 lesions, CGM and NAWM, putamen and thalamus  
DTI, like MTR, gives a measurement of the integrity of the tissue by measuring the movement of 
water molecules. DTI is measured in mean diffusivity (MD) and fractional anisotropy (FA). Changes 
in DTI have been shown to precede the development of Gd enhancing lesions 58 and has in NAWM 
and NAGM been show to correlate with disease progression in MS patients 59,60. In this study we will 
examine DTI values in lesions, putamen, thalamus, CGM and NAWM.  
 
 
7.2.20 Cross sectional area at the C2 level of the spinal cord 
Measures atrophy at this level of the spinal cord. 
 

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7.2.21 Circle drawing test 
The circle-drawing test is a patient performed task done at the time of the MRI at Hvidovre Hospital. 
Participants continuously draw superimposed circles (for several seconds) with their right and left 
hand in a normal handwriting position with the hand resting on the table while drawing. It is done as 
an exploratory analysis and will not be reported as an outcome at week 48.  
 
7.3 Safety studies 
Standard safety measures include full neurological examination, pregnancy test of all women of 
childbearing age, routine physical examination, hematology and biochemical parameters in blood, 
monitoring of adverse events and reactions (AE/AR), serious adverse events and reactions 
(SAE/SAR) and serious unexpected serious adverse reaction (SUSAR). 
 
7.3.1 Neurological examination 
A full neurological examination will be performed at the screening visit, week 24, 48,72 and 96 by 
adherence to neurostatus 03/09. 
 
7.3.2 Pregnancy test 
Serum-hCG will be measured on all female patients of childbearing age at every study visit. 
 
7.3.3 Routine physical examination 
Routine physical examination consists of examination of the cardiovascular system, the respiratory 
system, the gastrointestinal system, the musculoskeletal system, the urogenital system, 
dermatologically and HEENT: head, eyes, ears, nose and throat. This examination is performed at 
the screening visit and when required. 
 
7.4 Study personnel, sample handling and study biobank 
Blood samples and CSF samples will be taken at the multiple sclerosis clinic at Rigshospitalet. An 
experienced medical doctor from the multiple sclerosis clinic will perform the lumbar puncture.  
Safety blood samples are analyzed at the department of clinical biochemistry at Rigshospitalet and 
hereafter destroyed in accordance to standardized guidelines for Rigshospitalet. Analyzes of CSF is 
done at department of clinical biochemistry and the Neuroimmunology laboratory (which is a part of 
the department of multiple sclerosis at Rigshospitalet) and hereafter destroyed in accordance to 
standardized guidelines for Rigshospitalet.                        
For further detail about execution and handling of the lumbar puncture at CSF kindly, see appendix 
C.                                                                                                                                                        
All MRI scans are performed at the MRI department at Hvidovre Hospital.  
 
 
 
 
 

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The Danish Multiple Sclerosis Center will report the establishment of a biobank for the study itself 
and a distinct biobank to The Regional Scientific Ethical Committee and the Danish Data Protection 
Agency with regards to the storage of CSF samples for analyzes described in this study and for 
future research purposes.  
 
 
7.5 Risk assessment for study procedures 
 
7.5.1 Lumbar puncture 
The procedure of a lumbar puncture is associated with some degree of discomfort, and the patient 
will be offered local anesthesia to reduce it. Lumbar puncture involves the risk of post lumbar 
headache, which is seen in approximately 13-36%. This type of headache usually subsides within a 
couple of days but can in some instances require an epidural blood patch 61. Patients with PPMS are 
generally older than patients with relapsing-remitting MS and older people have a reduced risk of 
developing headache after lumbar puncture. The risk of headache is further reduced using 
atraumatic needle/technique.  
Lumbar puncture is also associated with a risk of serious complications namely post lumbar puncture 
infection (meningitis) and bleeding in the cavity surrounding the spinal cord, but these complications 
are extremely rare.  
 
7.5.2 MRI scan 
MRI does not entail any risk when the right precautions are taken. It is a non-invasive technique, that 
produce detailed images of the body´s internal structure. MRI systems use a strong static magnetic 
field, a pulsed gradient magnetic field and radiofrequency energy to obtain the images in selected 
plains of the body. The subject is placed in a strong magnetic field created by a superconducting 
magnet surrounding the core of the scanner. The subject lying in the scanner is exposed to brief 

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pulses of non-ionized radiofrequency radiation from a transmission coil. Grey and white matter can 
be distinguished whit brain MRI and accurate calculations of the different brain volumes ban be 
performed.  
Certain metallic implants are not MRI compatible and eliminates the patient from having MRI done. 
The scanner is noisy, and all subjects will therefore be provided with earplugs or earmuffs.                   
The contrast medium used for an MRI scan is gadolinium (Gd). It can have side effects such as 
nausea, headache, a sensation of warmth and a metallic taste. Allergic reactions are extremely rare.                   
To ensure that there is no risk of development of nephrogenic systemic fibrosis all patients must 
have normal renal function, which is entailed in the safety blood analyzes.                                    Some 
patients can get claustrophobic during the MRI. This is easily counteracted by a light sedative i.e. 
Alprazolam 0,5mg taken 30-60 minutes before the scan is performed.  
The MRI will be described clinically by a specialist at Hvidovre Hospital within 7-14 days. If by any 
reason this description give rise to elimination of a patient from the study the patient will be contacted 
by phone and if necessary be invited to a consultation with a doctor for detailed explanation and 
perhaps further examinations and tests if needed.  
 
7.5.3 Blood samples 
Having a blood sample done can induces a slight discomfort when the needle penetrates the skin. 
Bleeding under the skin can occur. Infection is rare.  
 
8  
 
STUDY MEDICATION 
    
8.1 Dimethyl fumarate and placebo 
Fumarates exert pleiotropic immunomodulatory effects. Multiple pathways have been implied in 
mediating these effects. 
Fumaric acid esters (FAE) have been used in treating psoriasis since 1959. Tecfidera is an oral 
formulation of FAE containing the active metabolite dimethyl fumarate (DMF) used for treating MS. 
Studies of the properties of DMF in rats have shown that the drug possesses neuroprotective abilities 
and protects different neuronal cell types including neural stem/progenitor cells (NPCs) and 
differentiated neurons (motor neurons) from oxidative damage. This occurs through increased 
expression of the transcription factor nuclear factor-erythroid 2-related factor 2 (Nrf2) pathway and 
subsequently induction of the expression of anti-oxidative proteins 62. DMF inhibits pro inflammatory 
cytokine production through inhibition of nuclear transcription factor kappa B (NFκB) independently 
of Nrf2 pathways (68)63. Inflammation but also oxidative stress/damage play a part in both secondary 
and primary progressive MS. Biomarkers of oxidative stress is significantly elevated in these patients 
8.  
 
8.1.1 Study medication 
Treatment medication (DMF) is distributed from the Danish Multiple Sclerosis Center, University 
Hospital Rigshospitalet, Copenhagen. Patients will receive active medication (dimethyl fumarate 120 
mg capsules) or identically looking placebo capsules to be taken at a final dosage of 240 mg twice 

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daily. Patients will be instructed to take the capsules with food to minimize gastrointestinal side 
effects.  
 
8.1.2 Initial dosing and dose reduction 
In order to reduce the side effects of DMF, which usually resolve within the first four weeks of 
treatment, the study drug is administered as one capsule once daily the first week. Then the dosage 
is increased to one capsule twice daily the second week, two capsules in the morning and one in the 
evening the third week, and two capsules twice daily from week 4 to 48. The patient and the study 
coordinator will document study drug use. 
 
 
Morning 
 
Evening 
Week 1 
1 capsule 
 
 
Week 2 
1 capsule 
 
1 capsule 
Week 3 
2 capsules 
 
1 capsule 
Week 4 
2 capsules 
 
2 capsules 
 
8.1.3 Dosing of the study drug 
In order to prevent common side effects the dosing of the treatment drug is gradually increased over 
the span of 4 weeks until full daily dosage of 240mg twice a day has been reached. Patients will be 
given written information on how to take the medicine. 
The dosage can be reduced from this time schedule for up to four weeks at the discretion of the 
treating physician. If the full dosage of two capsules of study medication twice daily cannot be 
resumed after four weeks of dose reduction, the patient must be withdrawn from the study. 
 
8.1.4 Side effects 
Very common side effects (>10%) include abdominal pain, diarrhea, nausea, flushing and ketones 
in the urine.                                                                                                                                          
Common side effects (1-10%) include lymphopenia, lymphocytosis, leucopenia, skin rash, skin 
itching, redness, vomiting, gastroenteritis, gastritis, increased liver transaminases, hot flashes, 
hyperesthesia, hypersensitivity, albuminuria and proteinuria.  
 
8.1.5 Progressive multifocal leukoencephalopathy (PML) 
PML is a rare but severe opportunistic infection caused by John Cunningham virus (JCV). PML can 
be deadly or result in severe disability.                                                                            
Lymphopenia is a known risk factor for development of PML and Dimethyl fumarate can cause a 
mean lymphocyte count decrease of approximately 30% 64.There has been case reports of PML 

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induced by Dimethyl fumarate in both MS patients 65 and psoriasis patients 66.                                                     
In order to minimize this risk all patients will undergo blood test for hematology parameters every 
12 weeks and will routinely be examined by a physician at the screening visit, week 24, 48, 72 and 
96. All patients are further encouraged to contact the treating physician or study nurses with any 
new symptoms of disease. Estimation of the risk of PML during DMF treatment cannot be made as 
it is extremely rare and only case reports of it exist.  
 
8.1.6 Delivery, packing, labelling and randomization of study drug 
Both the active study medication (DMF) and the placebo capsules are provided from the manufacture 
– Biogen. The capsules are sent from Biogen UK and capsules containing DMF and placebo are 
sent approximately 2 days apart to avoid mix up upon delivery. The delivery of both DMF capsules 
and placebo capsules are to the Regional Capital Pharmacy in Herlev. The pharmacy handles all 
packaging according to standard guidelines and they develop the randomization code and deliver 
the codes in sealed envelopes to the Danish Multiple Sclerosis Centre under the Department of 
Neurology.   
Distribution of the capsules is done from the Danish Multiple Sclerosis Center, Rigshospitalet, 
University of Copenhagen.        
                                                                  
8.1.7 Storage and breakage of the randomization code 
The sealed envelopes containing the randomization codes are held in a locked cabinet in a lockable 
office at the Department of Neurology. The key to the office is held by trained researched nurses. 
The two research nurses, the sponsor, the primary investigator and persons authorized by these 
persons are the only personal who can gain access to the locked cabinet. The randomization code 
will be broken if it is deemed necessary by the sponsor or primary investigator (or other persons 
authorized by sponsor or the primary investigator) to ensure the safety of the patient or in case a 
patient withdraws consent and request to know the treatment allocation. 
 
8.1.8 Compliance 
The capsules are distributed to the patients at the Danish Multiple Sclerosis Center under the 
Department of Neurology. The exact number of capsules handed out to any one patient is recorded. 
All patients are encouraged to keep a detailed diary of their medicinal intake and any discomfort 
and/or side effects and to bring any leftover medication in addition to the diary at every visit. Trained 
research nurses keep count of medicine handed out and medicine left over in order to assess 
compliance.   
 
9  
CONCOMITANT DISEASES AND CONCOMITANT MEDICATION 
 
9.1 Definitions 
Concomitant disease is any disease present at the screening visit that continues unaltered.               
Concomitant medication is any medication, besides the study drug, taken by the patient during the 
trial inclusive at the screening visit.  

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9.2 Baseline concomitant diseases and concomitant use of medication 
Details regarding concomitant diseases and use of medication, other than the study drug, will be 
noted in the case report form (CRF) with description of dosage, start and stop date, and reason for 
the usage. Any other diagnostic or therapeutic intervention, occurring in the trial period is also 
reported in the CRF. The patients may not take any kind of immunosuppressive or immune-
modulating substances when entering the trial and a patient whom begins such a treatment during 
the trial will be excluded from any further participation (see section 5.2).  
 
9.3 Concomitant disease and concomitant medication during the trial 
Medication that is considered necessary for the patient and do not interact with the treatment with 
DMF can be prescribed by the investigator after assessment. Any preexisting symptomatic 
treatment, i.e. antispasmodic, must be optimized before trial initiation with the aim of continuing an 
unaltered dosage throughout the trial period.                                                                                  
Changes in concomitant medication or treatment procedures must be reported in the patients’ 
medical charts and the CRF at every visit. The sponsor must be contacted if the changes 
influences on the patients’ possibility of continuing the trial.                                                            
Any worsening of concomitant disease compared to the level at the screening visit as well as any 
concomitant disease occurring during the trial will be considered as a possible side effect (see 
section 10) to the trial drug and will be reported as such even when the concomitant disease is 
judged to have no linkage to the trial medication.   
 
9.4 Precautions/overdose 
The patient will receive the necessary symptomatic treatment after assessment by the investigator 
in case of overdose or suspected overdose. 
 
9.5 Rescue medicine 
The patient is asked to contact the clinic within 3 days from the onset of a suspected relapse and 
should be examined by the study physician within 10 days from onset of the suspected relapse. If 
the physician finds that the relapse results in significant impairment, methylprednisolone pulse 
therapy can be administered.  
 
9.6 Symptoms in progressive MS 
Symptoms attributed to the condition of primary progressive MS need not be described in detail at 
the screening visit. It is likewise not necessary to report the naturally occurring fluctuations in 
progressive MS during the trial as concomitant disease or side effects (see section 10.1). 
 
 
 
10  
ADVERSE EVENTS, ADVERSE RECTIONS, SERIOUS ADVERSE EVENTS OR 
REACTIONS AND SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTION  
 

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10.1 Definitions 
 
 
• 
Adverse event (AE):  
Any untoward medical occurrence in a study participant that does not necessarily have a 
causal relationship with the allocated treatment. It can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the experimental treatment or product, whether or not the event is considered 
causally related to the treatment 
 
• 
Serious adverse event (SAE) 
If an AE meets any of the following criteria, it must be reported to the sponsor as a serious 
AE (SAE) within 24 hours of the investigator being made aware of it: 
o Results in death 
o Is life-threatening (note: the term life-threatening refers to an event in which the 
patient was at risk of death at the time of the event; it does not refer to an event which 
hypothetically might have caused death if it was more severe) 
o Requires inpatient hospitalization or extension of existing/preplanned hospitalization 
o Results in persistent or significant disability/incapacity 
o Is a congenital abnormality/birth defect 
o Is a medically important event 
 
• 
Adverse reaction (AR):  
Any untoward and unintended response to an investigational medicinal product related to 
any dose administered.  
 
• 
Serious adverse reaction (SAR): 
An SAE for which a causal relationship to the investigational medicinal product is at least 
possible i.e. a causal relationship is conceivable and cannot be dismissed 
 
• 
Suspected unexpected serious adverse reaction (SUSAR):  
An adverse reaction that is both unexpected (not consistent with the applicable product 
information) and also meets the definition of a Serious Adverse Reaction SAR).  
 
Any adverse event must be registered from the first day of administered trial drug but do not include 
diseases or other preexisting conditions revealed during the screening procedure. All events must 
be evaluated with regard to relatedness, intensity and seriousness. The intensity of the events will 
be reported in accordance to table 10.1 and relatedness will be evaluated in accordance to table 
10.2. Seriousness is defined above in “10.1 Definitions” under “Serious adverse events”. Symptoms 
that are due to progressive MS and that do not have substantial fluctuations besides the normal for 
this category of patients is not considered as an adverse event. Progressive neurological symptoms 

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are a part of the natural course in patients with PPMS but may also reflect progressive multifocal 
leukoencephalopathy (PML). PML must always be excluded as the course of the progressing 
neurological symptoms before the symptom can be attributed to the natural course of progressive 
MS. Relapses is not considered an adverse event and should not be reported as such even if the 
patient needs hospitalization, unless the treating physician (investigator) deem the symptoms not to 
be an occurrence of the natural history of evolving progressive MS. A preplanned hospitalization is 
not considered an adverse event and will not be reported as such, but extension of pre-planned 
hospitalization, i.e. due to unforeseen complications, must be considered a serious adverse event 
and consequently be reported as such.  
 
Table 10.1 Intensity of events  
 
Intensity 
Definition 
 
Mild 
Aware of signs or symptoms but they are easily tolerated. The event 
is often transient, treatment is not necessary, and the event does not 
hinder the patient’s daily activities 
 
Moderate 
Noticeable symptoms, moderately hindering the patients’ daily 
activities, but still acceptable. Can usually be alleviated by simple 
therapeutic treatments 
 
Severe 
Significant inconvenience and a hinder of the patients´ daily activities. 
Unacceptable and usually requires medication or other type of 
treatment 
 
 
 
10.2 Relatedness: Causal connection between event and trial medication 
The causal connection between trial medication and events must be examined via following 
definitions:  
 
Likely 
• 
Good reasons and sufficient documentation to assume a 
causal connection 
 
Possible 
• 
A causal connection is reasonable and cannot be ruled out 
 
Unlikely 
 
• 
The event is most likely related to an etiology other than the 
trial medication 
 

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Unknown 
• 
It is impossible to determine, i.e. due to insufficient evidence, 
inconsistency in data or poor documentation  
 
 
 
10.3 Categories and definitions of the outcome of an event 
 
Recovered 
 
• 
Fully recovered after the event with medical or surgical 
assistance or recovered to a level observed at the first trial 
related activity after signing the written consent form 
   
Stabilized 
• 
This term should only be used in cases of cancer or chronic 
conditions that cannot be normalized with medical or surgical 
intervention. Should furthermore only be used when the patient 
has completed the trial period 
 
Recovered 
with 
sequelae 
• 
When the patient suffers from lasting and significant invalidity 
or incapacity for work due to an event occurring during the trial, 
i.e. been paralyzed, gone blind or deaf.  
Any event recovered but with sequelae should be considered 
a serious adverse event 
 
Clinical laboratory 
event 
 
• 
A laboratory event is classified as such, if a lab answer is 
outside the normal range and investigator judges it to be 
clinically significant 
 
 
10.4 Registration of events  
The patients are encouraged to report any new or worsened symptoms or medical incidences at 
every visit or via other forms of contact after the screening visit. This will continue until week 96 or 
until the patient is no longer in the trial setting for any reason. All events observed by the investigator 
or reported by the patient must be evaluated by the investigator and be reported in the CRF. All 
serious adverse events or reactions (SAE/SAR) will immediately be reported to the sponsor (see 
section 10.5). Investigator will perform all necessary measures to examine and possibly cure the 
event. To help examine whether an event or reaction is expected or unexpected the Summary of 
Product Characteristics from the European Medicine Agency (EMA) will be used.  
For every event, the investigator will report the following variables: 
• 
Description of the event 
• 
Start and stop date 
• 
Intensity 
• 
Severity 

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• 
Relatedness  
• 
Precautions taken with regard to dimethyl fumarate  
• 
Outcome 
 
Any necessary medical treatment of the event must be reported in the section about concomitant 
medication in the CRF. If more than one event occurs for one patient, they must be reported 
separately. If the intensity of an event increases, then it must be reported as a separate event.  
 
10.5 Reporting serious adverse events and reactions (SAE/SAR) and suspected unexpected 
serious adverse reactions (SUSAR)  
Events that require immediate reporting to sponsor within 24 hours of investigator being made aware 
of it are the following:  
• 
Serious adverse events (SAE) or reactions (SAR) including death (see table 10.1) 
• 
Any adverse event that results in permanent disruption from the trial even when the event is 
not considered to be a SAE or SAR 
 
The form for reporting an SAE/SAR and/or the form for discontinuation of the trial (trial 
discontinuation form) will be sent or delivered by the investigator to: 
 
 
 
All adverse events and reactions that take place during the trial must be reported in the CRF.     The 
sponsor reports to the Danish Medicine Agency and the Regional Scientific Ethical Committee if the 
SAE/SAR is deemed to be a SUSAR. If the SUSAR results in death or is life-threatening the report 
must be sent to the Danish Medicine Agency and the Regional Scientific Ethical Committee within 7 
days. A SUSAR that does not cause death and is not life threatening must be reported to the Danish 
Medicine Agency and the Regional Scientific Ethical Committee within 15 days.                                      
After the end of the trial all AE/AR, SAE/SAR and SUSAR´s will be reported in the final safety 
summary report and sent to the Danish Medicine Agency and the Regional Scientific Ethical 
Committee. All SAR will be reported annually in a safety report to the Danish Medicine Agency and 
the Regional Scientific Ethical Committee. All SAE will be reported in the final report after the trial is 
completed. The final results of the trial will be reported in the EudraCT (see section 18). All events 
and side effect will be summarized using MedDRA terminology. 
 
 
 

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10.6 Pregnancy and contraception 
There are no or limited amount of data from the use of DMF in pregnant women. Animal studies 
have shown reproductive toxicity. DMF is not recommended during pregnancy and in women of 
childbearing potential not using appropriate contraception. Patients that become pregnant or seize 
to use appropriate contraception during the trial must stop taking the trial medicine and are 
eliminated from further participation. If the patient has been pregnant during the trial, she will be 
asked to be seen at follow up visits and the result of the pregnancy including reports on the health 
and development of the baby will be followed until 8-12 weeks postpartum. The investigator will fill 
in a form on the pregnancy (pregnancy form). Participating female patients of child baring age must 
use contraception in the form of either an intrauterine device or hormonal contraceptives during the 
trial. The terminal half-life of monomethyl fumarate, which is the active component of dimethyl 
fumarate, is approximately 1 hour and no circulating monomethyl fumarate is present at 24 hours in 
the majority of individuals. Accumulation of parent drug or monomethyl fumarate does not occur with 
multiple doses of dimethyl fumarate at the therapeutic regimen. 
 
10.7 follow up 
Any serious events that occur during the trial and continues after must be followed up until the 
condition ceases or it is judged clinically that the condition is stable. The patient will be seen 
approximately 4 weeks past week 96, if there are any trial related problems at week 96 and continue 
to be evaluated for as long as it is clinically judged to be necessary. 
 
11  
CASE REPORT FORM (CRF)  
 
The CRF will be consistent with the protocol and be established ahead of the trial. The CRF will 
include all the relevant data as described in the protocol with exception of MRI and CSF information.                   
Investigator is responsible for the data being recorded in the CRF and that all other reports are 
accurate and complete. In the CRF, a patient will be identifiable by an identification number 
(screening number) and initials. Investigator must keep copies of the CRF for 10 years after 
cessation of the trial.  
 
11.1 Investigator study file and archives 
The investigator has a trial master file (TMF) from the beginning of the trial. The files in the TMF 
entail all relevant documents for carrying out the trial. The investigator must keep the TMF a minimum 
of 5 years after cessation of the trial. Patient files must be kept a minimum of 5 years or longer 
according to hospital policies. All information regarding the trial must be kept in a secure and lockable 
facility. Approval of this trial from the Regional Scientific Ethical Committee, the Danish Data 
Protection Agency and the Danish Medicine Agency will be located in the TMF.  
 
12  
MONITORING AND CONTROL VISITS 
 
The GCP Unit of Copenhagen University Hospital monitors the trial. During the course of the trial, 
the monitor will visit the MS Clinic at regular intervals and can be contacted by e-mail or phone if 

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needed. The purpose of the monitoring visits is to ensure that the CRF is filled out correctly, that the 
study protocol is adhered to, and that drug accountability is ensured. Monitor will not have direct 
access to the patient’s electronical medical files. The signed consent form from the patient entails 
that information regarding health-related issues, private affairs and other confidential information can 
be passed on to monitor if needed for monitoring visits. 
The Danish Medicine Agency will not have direct access to the electronical patient file but can be 
handed the same kind of information as stated above upon control visits. The mentioned information 
can only be handed to the GCP-unit and the Danish Medicine Agency by the responsible treating 
physician. The patients will be made aware that a signed informed consent form entails these issues.  
 
 
 
 
13  
DATABASE HANDLING 
 
Staff from the Danish Multiple Sclerosis Center handles the database. 
 
14  
STATISTICAL CONSIDERATIONS 
 
14.1 Sample size estimation 
The study aims to have 95% power to detect a 30% difference in the CSF concentration of NFL 
between patients treated with DMF and patients treated with placebo at a two-sided significance 
level of p=0.05. This requires 21 patients in each treatment arm if the study is enriched with patients 
who have ongoing neuroaxonal damage. This is ensured by including only patients with increased 
CSF concentrations of NFL at screening (>380 ng/L). The power calculation is based on the 
assumption that the standard deviation of change in NFL concentrations is approximately 30% in 
both arms, and that there is no significant regression towards the mean. These assumptions are 
supported by our observations in a serial study of patients with progressive MS; the results of the 
NAPMS study and the COMTIMS study. In order to account for a dropout rate of up to 20% (as 
observed in some clinical trials in RRMS), we plan to include 54 patients in the study.  
 
14.2 Statistical methods 
Analysis will be performed on the changes in the cerebrospinal fluid, clinical, self-reported and MRI 
outcome measures described in section 4.4. Descriptive statistics will be presented separately for 
patients randomized to treatment with dimethyl fumarate or placebo (numbers and percentages; 

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mean, standard deviation; and median, inter-quartile range for data not following a normal 
distribution). The analyses are performed on the change in each outcome measure over the span of 
48 weeks using a general linear model with treatment allocation as factor and the baseline value of 
each variable as covariate.  
Analyses will be done using intention to treat analysis of raw data and using multiple imputation (MI) 
of missing data. Results will be given with 95% confidence intervals and unadjusted p-values from 
the MI analyses. A total of 25 datasets will be produced. In case of variables that cannot be 
appropriately analyzed by a general linear model, logarithmic transformation of data will be applied. 
If this is still not successful, data in the two treatment arms will be compared by a nonparametric 
method (Mann-Whitney U-test).  
The results of the statistical analyzes will be reported as advised in ICH E3 guidelines regarding 
structure and content in clinical study reports. A p-value of 0.05 will be used without correction for 
multiplicity.  
 
1. Primary endpoint 
 
• 
Change from screening in the concentration of neurofilament light chain (NFL) 
measured in the cerebrospinal fluid (CSF)  
At screening visit and week 48 visit, we will measure the concentration of neurofilament 
light chain (NFL) in the CSF by the use of a commercially available ELISA kit (UMAN 
diagnostics, see appendix D). The primary efficacy measure will be the difference in 
change of the concentration of NFL in the CSF between the treatment and placebo group 
from screening to week 48. The aim of the statistical analysis is to test the null hypothesis 
that the observed difference in the change of NFL between the treatment group and the 
placebo group is caused by the random allocation of patients. We will use a general linear 
model with treatment allocation as factor and baseline concentrations of neurofilament 
light chain as covariate. We will report the difference in change at the week 48 visit with 
95% confidence intervals and a p-value. Change from screening will be reported in 
absolute values (ng/L) in compliance with the CONSORT statements67.  
 
 
2. Secondary Endpoints 
 
2.1. Cerebrospinal Fluid (CSF) endpoints 
 
2.1.1. Change from screening in myelin basic protein (MBP) concentration in the CSF 
We will analyze the difference in change in MBP concentration from screening visit to 
week 48 between the treatment and placebo group using a general linear model with 
treatment allocation as factor and screening MBP concentration as covariate. 
 
2.1.2. Change from screening in sCD27 concentration in the CSF 

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We will analyze the difference in change in sCD27 concentration from screening visit 
to week 48 between the treatment and placebo group using a general linear model 
with treatment allocation as factor and screening sCD27 concentration as covariate  
 
2.1.3. Change from screening in BCMA concentration in the CSF 
We will analyze the difference in change in BCMA concentration from screening visit 
to week 48 between the treatment and placebo group using a general linear model 
with treatment allocation as factor and screening BCMA concentration as covariate. 
 
2.1.4. Change from screening in sCD14 concentration in the CSF 
We will analyze the difference in change in sCD14 concentration from screening visit 
to week 48 between the treatment and placebo group using a general linear model 
with treatment allocation as factor and screening sCD14 concentration as covariate  
 
2.1.5. Change from screening in CHI3L1 concentration in the CSF 
We will analyze the difference in change in CHI3L1 concentration from screening visit 
to week 48 visit between the treatment and placebo group using a general linear 
model with treatment allocation as factor and screening CHI3L1 concentration as 
covariate 
 
2.1.6. Change from screening in IgG-index 
We will analyze the difference in change in IgG-index from screening visit to week 48 
between the treatment and placebo group using a general linear model with treatment 
allocation as factor and screening IgG-index as covariate  
 
2.1.7. Change from screening in CSF-serum albumin quotient 
We will analyze the difference in change in CSF-serum albumin quotient from 
screening visit to week 48 between the treatment and placebo group using a general 
linear model with treatment allocation as factor and screening CSF-Serum albumin 
quotient as covariate. 
 
 
2.2. Magnetic Resonance Imaging (MRI) Endpoints 
2.2.1. Number of new or enlarging T2 lesions 
We will analyze the number of new or enlarging T2 lesions from screening visit to 
W48 between the treatment and placebo group using negative binomial regression 
with the number of lesions at baseline as covariate. 
 
2.2.2. Percent brain volume change (PBVC) 
We will analyze the difference in percentage change in brain volume from screening 
visit to week 48 between the treatment and placebo group using a general linear 

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model with treatment allocation as factor and screening normalized brain volume as 
covariate. 
 
2.2.3. Change from screening in fractional anisotropy (FA) in normal appearing white 
matter (NAWM) 
We will analyze the difference in change from screening to W48 of FA in NAWM 
between the treatment and placebo group using a general linear model with treatment 
allocation as factor and the screening value of FA in NAWM as covariate.  
 
2.2.4. Change from screening in in magnetization transfer ratio (MTR) of T2 lesions 
We will analyze the difference in change from screening to W48 in MTR of T2 lesions 
between the treatment and placebo group using a general linear model with treatment 
allocation as factor and screening MTR of T2 lesions as covariate. 
 
2.2.5. Change from screening in thalamic volume 
We will analyze the difference in change from screening to W48 of thalamic volume 
between the treatment and placebo group using a general linear model with treatment 
allocation as factor and screening thalamic volume as covariate. 
 
2.3. Clinical Endpoints: 
2.3.1. Change from screening in Expanded Disability Status Scale (EDSS) 
We will initially analyze the difference in EDSS change from screening visit to week 
48 between the treatment and placebo group using a general linear model with 
treatment allocation as factor and screening EDSS as covariate.  
 
2.3.2. Change from screening in Timed 25-Foot Walk (T25FW). 
We will analyze the difference in T25FW change from screening visit to week 48 
between the treatment and placebo group using a general linear model with treatment 
allocation as factor and the screening T25FW value as covariate.  
 
2.3.3. Change from screening in Nine-Hole Peg Test (9HPT). 
We will analyze the difference in 9HPT change from screening visit to week 48 
between the treatment and placebo group using a general linear model with treatment 
allocation as factor and the screening 9HPT value as covariate.  
 
2.3.4. SDMT (from the Brief International Cognitive Assessment for MS (BICAMS) 
panel) 
We will analyze the difference in the SDMT change from screening visit to week 48 
between the treatment and placebo group using a general linear model with treatment 
allocation as factor and the screening SDMT value as covariate.  
 
 

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3. Exploratory endpoints 
The data will be analyzed separately for patients randomized to treatment with dimethyl fumarate or 
placebo. The analyses are performed on the change in each outcome measures over the span of 
48 weeks using a general linear model (negative binomial regression for lesion numbers) adjusting 
for the baseline value of each factor.  
Analyses will be done on raw data and using multiple imputation (MI). A total of 25 datasets will be 
produced. Results will be given with 95% confidence intervals and unadjusted p-values from the MI 
analyses.  
 
3.1 Clinical endpoints 
• 
Change from screening for Brief Visuospatial Memory Test Revised (BVMTR)  
• 
Change from screening for California Verbal Learning Test 2 (CVLT-II) 
o Both tests are from the BICAMS panel. Each generates one outcome that will be 
analyzed separately  
 
3.2 MRI-derived Endpoints 
 
• 
Change from screening in number of Gd-enhancing lesions. 
• 
Number of T2 new lesions 
• 
Number of enlarging T2 lesions  
• 
Change from screening in volume of cortical grey matter (CGM), normal 
appearing white matter (NAWM), and putamen volume 
• 
Change in Magnetization Transfer Ratio (MTR) of CGM, NAWM, the putamen 
and thalamic nuclei 
• 
Change in diffusion tensor imaging (DTI) measures (FA and mean diffusivity) of 
CGM, NAWM (except FA in NAWM), lesions, the putamen and thalamic nuclei 
• 
Cross sectional area at C2 level of the cervical spinal cord 
 
3.3 Self-reported outcome measures 
• 
Urinary Distress Inventory (UDI) 
• 
Fatigue Scale for Motor and Cognitive Function (FSMC) 
• 
Multiple Sclerosis Impact Scale 29 (MSIS-29) 
 
3.4 Correlation analyses of changes in primary and secondary outcome measures 
The relationship between changes in primary and secondary outcome measures will be analyzed by 
exploratory Spearman rank correlation analyses. We will conduct these analyses separately for the 
DMF and placebo groups as well as for the combined group. Rank correlation coefficients lower than 
0.5 are classified as low, 0.5-0.71 as moderate, and above 0.71 as high in the correlation analyses.  
                                                                        

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14.3 Sensitivity analyses 
To test the robustness of the analyses we will conduct primary and secondary outcome analysis with 
unadjusted linear models, and we will test for highly statistically significant (P<0.01) heterogeneity 
between the compared groups; and adjust for such variable(s) in a linear model. We will compare 
the unadjusted analyses with the adjusted analyses to estimate the influence of covariates and 
thereby the robustness of the models. 
The possible influence of missing data and extreme values (outliers) will be assessed by comparing 
analysis of the multiple imputation data set and the raw data and by exclusion of outliers from the 
analysis. A per protocol analysis will be conducted for participants who have taken at least 60% and 
80% of the study medication. Furthermore, we will conduct analyses of the raw data in order to 
address whether these results differ from the results of the analyses based on multiple imputation. 
 
14.4 Statistical description of analysis on data obtained after end of the open-label phase 
Analysis will be performed on the changes in the clinical, self-reported and MRI outcome measures 
described in section 4.4. In addition, we will measure the changes in serum concentrations of 
neurofilament light chain (NFL). 
The data will be analyzed separately for patients randomized to treatment with dimethyl fumarate, 
placebo and the initially non-randomized patients (included at week 48 due to >20% worsening in 
one or more clinical outcome measures. See section 5.1). This will yield two groups: one group with 
patients that has received DMF for 96 weeks and one where DMF treatment has been given for 48 
weeks. Analysis will focus on the changes in outcome measures using a general linear model 
adjusting for the baseline value of each factor. Non-adjusted p-values will be used. In addition, focus 
will be on tolerability and safety of the study medication.   
• 
Description of the effect of treatment with DMF from week 48-96 in patients randomized to 
placebo or DMF at baseline 
• 
Description of the disease course from baseline to week 48 in patients fulfilling all inclusion 
criteria except the CSF NFL concentration criterion at screening  
• 
Description of the effect of treatment with DMF from week 48-96 in those patients who show 
evidence of disease progression in spite of having a low NFL concentration in CSF at 
screening 
• 
Description of serum NFL measures from screening, week 48 and week 96  
• 
Time to EDSS worsening confirmed after 24 weeks and persisting at week 96 (performed 
every 24 weeks for patients enrolled at baseline) 
 
14.4.1 Endpoints measured at week 96 (analyzed as difference in changes) 
 
o Serum endpoints 
▪ 
Concentration of serum NFL at screening, week 48 and 96 
 
 
 

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15  
ETHICAL CONSIDERATIONS 
 
Dimethyl fumarate (DMF) is approved for treatment of MS. It is generally well tolerated, and side 
effects are rarely severe. Progressive multifocal leukoencephalopathy (PML) is seen extremely 
rarely during treatment with DMF but is most often described in the literature after longtime treatment 
and alongside severe lymphopenia. Safety hematology parameters will routinely be measured every 
12 weeks and patients will be e neurologically examined for EDSS scoring every 24 weeks. All 
patients will be asked about new symptoms at visits and encouraged to contact the treating physician 
regarding 
new 
symptoms 
or 
suspected 
side 
effects 
outside 
trial 
visits.                   
In this trial, the placebo group will have the possibility of being treated with DMF to also gain the 
possible positive effects of treatment from week 48-96. There is no approved treatment for primary 
progressive MS other than symptomatic treatment. A positive outcome of this study will therefore 
have great impact on the treatment of these patients and the development of new-targeted 
treatments. Likewise, will a negative result also influence and help develop new treatment strategies. 
The trial will supply much needed information about patients with primary progressive MS, which is 
a group of patients not often considered in research. 
All participant of the study will be thoroughly informed about the risk of known side effects, PML and 
the risk of unforeseen side effects when participating in a medical trial. The participants can at any 
time pull out of the study without any reprisals. The study is done in accordance with the Helsinki 
Declaration for medical research involving humans, ICH-GCP and after approval of the protocol from 
the Danish Medicine Agency and the Regional Scientific Ethical Committee. The possible beneficial 
effects of DMF treatment in primary progressive MS patients are estimated to outweigh the possible 
side effects. The rationale behind this study is underlined by the fact that there is no effective 
treatment for progressive MS and the result will be greatly beneficial no matter the outcome. There 
are no ethical arguments against the execution of this study.  
 
15.1 Recruitment, informed consent, power of attorney and patient information 
 
Recruitment happens through the responsible treating physicians from every MS clinic in Denmark. 
If a patient is interested in possibly participating in the trial and gives consent to have his or her 
contact information handed over to the sponsor or investigator for this trial then contact to the patient 
may follow. All trial related activity takes place at Rigshospitalet or Hvidovre Hospital (only MRI 
scans). 
Ahead of any trial related activity, the investigator must inform the patient in word and in writing about 
the trial and make sure the patient understands the information. Patients will be contacted via letter 
containing the request form for participation in the trial and the participation information form. The 
pamphlet called “before you decide” from the Regional Scientific Ethical Committee and the 
document concerning the rights of patients participating in medical trials is also in the letter. 
The letter contains information on how to reach the doctor responsible for the trial. If the patient is 
interested in participation or hearing more about the trial a meeting will be set. At the meeting the 
patient will be given oral information from a doctor about the trial and have ample opportunity to ask 
any questions that might have arisen. The information will be given by the doctor responsible for the 

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trial or an appointed doctor. If the patient feels that the information level is sufficient the written 
consent form can be signed. The written consent form will also be signed by the doctor who has 
given the oral information and the patient will be given a copy of the double signed consent form. 
Patients will be thoroughly informed that they have the right to further consideration of at least 24 
hours before signing the consent form.  
Investigator must make sure that the patient is fully aware and fully informed about the purpose of 
the trial, the procedures, the potential risks, foreseen discomforts and possible expected benefits.                   
The information interview will take place in an interview room at the multiple sclerosis clinic and the 
patient will be encouraged to have another person with them for support.                                      
Investigator will make sure to inform the patient that signing the informed consent entail that the 
GCP-unit and the Danish Medicine Agency can be handed information from their electronical medical 
files if necessary upon monitoring visits from the GCP-unit and upon control visits from the Danish 
Medicine Agency (see section 12 for detailed information). 
It must be stated that the trial is done on a voluntarily basis and that the patient at any time can 
withdraw their written consent without any negative consequences to the further treatment at the 
multiple sclerosis center. The patient must voluntarily give informed consent and sign a consent form 
before any trial related procedure. Written consent will be obtained at the screening visit. 
Patients are reinforced that they at all time can withdraw their consent without any negative reflection 
on their further treatment at the multiple sclerosis department.  
A separate consent form for the biobank for future research purposes must also be signed by the 
patient and the doctor who gives the information.   
Patients with progressive multiple sclerosis are easily fatigued. By sending al written material in one 
letter we enable the process to be with one less visit to the clinic. If the patient however, feels that 
he or she needs time to consider before signing the informed consent form one more visit most be 
established.   
 
15.2 The Regional Scientific Ethical Committee 
The Regional Scientific Ethical Committee must approve the protocol, the consent form and the 
patient information form before the trial is initiated.                                                                                                 
The Regional Scientific Ethical Committee must approve any supplements to the protocol. It is 
investigators responsibility to obtain the necessary approvals and to store all reports to and 
correspondences with the committee in the Investigator File.                                                                                 
The agency will receive reports on serious adverse events, reactions (SAE/SAR) and SUSAR´s   
according to normal procedures during the trial. 
 
15.3 The Danish Data Protection Agency 
Investigator is responsible for getting approval from the Danish Data Protection Agency. 
 
15.4 The Danish Medicine Agency 
Sponsor must send the protocol to the Danish Medicine Agency. The agency must approve the 
protocol and any additional material before the trial is commenced. The agency will receive reports 

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on serious adverse events, reactions (SAE/SAR) and SUSAR´s according to normal procedures 
during the trial.  
 
15.5 Financing and insurance 
Biogen finances the trial with the amount of 6.678.875kr. The funds are used for compensation of 
medical staff, laboratory technicians and to pay for expenses of laboratory analyzes, other analyzes 
and MRI scans. Specific amount can be seen below. Biogen delivers the trial medication and the 
placebo. The finances are transferred from Biogen to a research account held by the department of 
neurology. Sponsor, investigator or any other staff involved in the trial will receive no compensatory 
payments and have no financial interest in Biogen. No personal fees are paid by Biogen to the 
involved staff. Biogen have no influence on the conduct, analyses or methods used in the trial. The 
patients in the trial are protected by law by: “Bekendtgørelse af lov om klage- og erstatningsadgang 
inden for sundhedsvæsenet” and: ”Bekendtgørelse af lov om produktansvar”. 
 
Specifications of funds: 
 
3%  
laboratory analyses kits  
 
 
 
 
3% 
medicine management and possibly data management  
32% 
MRI scans 
62% 
Salary for personal in the laboratory, the doctors, study coordinator and 
project nurses 
 
16 
STUDY RESPONSIBILITY 
 
Sponsor and investigator are responsible for: 
• 
Development of the CRF 
• 
Handling of data 
• 
Statistical analyzes 
• 
Development and submission of application to the Regional Scientific Ethical Committee 
• 
Development and submission of application to the Danish Medicine Agency 
• 
Development and submission of application to The Danish Data Protection Agency 
• 
Archiving all essential documents in the TMF 
 
The GCP-unit is responsible for: 
• 
Monitoring of the trial 
 
 
17 
 BIOBANK 
 

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A research biobank will be applied for in connection with this protocol. The application will be sent to 
the Regional Scientific Ethical Committee and the Danish Data Protection Agency.                   
The purpose of the biobank is extracting and storing CSF during the project. The CSF will be used 
for analyzes of trial measures. 
In addition to the trial related biobank a biobank for future research purposes will be established. 
This biobank for future research purposes will consist of the CSF that was not used for trial related 
measures.   
 
Amount of CSF: 
 
• 
Cerebrospinal fluid: 12ml. Taken twice during the study  
 
12 ml is the amount of spinal fluid necessary to obtain a correct measurement of spinal protein levels 
68. 
Approximately 2ml of CSF will be used for trial related analysis and the rest will be transferred to the 
biobank for future research purposes. The patients will be asked to sign an independent consent 
form regarding the biobank for future research purposes.  
The Regional Scientific Ethical Committee must grant permission before any analyses can be 
performed on material in the biobank for future research purposes. The material in this biobank will 
be kept for 10 years.   
The CSF in the trial related biobank will be kept until all trial related analysis has been completed. 
Any leftover CSF can at that time be transferred to the biobank for future research purposes but only 
if the patient has signed the informed consent regarding this specific biobank. If the CSF cannot be 
transferred to the future biobank it will be destroyed in accordance to standardized procedures at 
Rigshospitalet.   
  
 
18  
DATA AND PUBLICATIONS 
 
The trial is a single center trial and the results are analyzed and published by sponsor, investigator 
and other collaborating authors.                                                                                                       
Sponsor and investigator have all the intellectual property rights of the data and will make sure that 
both negative, positive and inconclusive results are published.                                                                             
The sponsor, all investigators and collaborating authors will have the possibility of reading and 
commenting on any script before a publication.                                                                                         
All data not published are considered confidential.                                                                                
Upon cessation of the trial, the sponsor must report this to the Danish Medicine Agency and the 
Regional Scientific Ethical Committee within 90 days. For the Danish medicine Agency, the 
EudraCT file “End of Trial” is used and for the Regional Scientific Ethical Committee the "Skema til 
afrapportering ved afslutning af forsøg" will be used.                                                                                              
The Danish Medicine Agency and the Regional Scientific Ethical Committee must be notified within 

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15 days if the trial is stop before scheduled.                                                                                                 
The result of the trial must be entered in the EudraCT within 1 year after trial cessation. After this, 
the data will be released at www.clinicaltrialsregister.eu. This replaces the need for a trial report to 
the Danish Medicine Agency but a full report can be requested by the agency.                                             
The report must be sent to the Regional Scientific Ethical Committee if it is listed as a requirement 
in the approval of the trial from this agency.  
 
19 
STORAGE OF CLINICAL TRIAL DOCUMENTS 
 
Sponsor and investigator are responsible for storage of the list of patient identification and patient 
files for 10 years after cessation of the trial. Other documents related to the trial must be archived in 
the Investigator File and be kept for 10 years after cession of the trial. Likewise, all MRI scans are 
preserved for 10 years.   
An access logged electronical file has been established by CIMT (Center for It, Medico og Telefoni). 
Only people from the neurological department at Rigshospitalet with permission from the investigator 
can be granted access. The data contained on paper is stored in a lockable office in a lock cabinet.  
 
20  
INSURANCE 
 
Participating patients in this trial are insured by: “Bekendtgørelse af lov om klage- og 
erstatningsadgang inden for sundhedsvæsenet” and: ”Bekendtgørelse af lov om produktansvar”. 
 
 

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21 
Appendix A: Study outline 
 
                                
                    
 
 

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22 
Appendix B 
 
 
Screening 
Week -6 to -
2 
Baseline 
Week 0 
 
Week 
12 
 
Week 
24 
 
Week 
36 
 
Week 
48 
e 
 
Week 
72 
 
Week 
84 
 
Week 
96 
MRI 
x 
 
 
 
 
x 
 
 
 
x 
Lumbar 
puncture 
x 
 
 
 
 
x 
 
 
 
 
T25FW *2 
x 
x 
 
x 
 
x 
 
 
 
x 
9HPT*2 
x 
x 
 
x 
 
x 
 
 
 
x 
BICAMS*1 
X 
 
 
 
 
 
x 
 
 
 
x 
SDMT 
x 
2 
random 
SDMT keys 
1-3 
x 
The 
lacking 
key 
from 
screening 
and 
then 
fixed 
key 
no. 4 
 
 
 
x 
Fixed 
key 
no. 5 
 
 
 
x 
Fixed 
key 
no. 6 
 
 
 
 
 
 
 
 
 
 
 
UDI 
x 
 
 
 
 
x 
 
 
 
x 
FSMC 
x 
 
 
 
 
x 
 
 
 
x 
MSIS-29 
x 
 
 
 
 
x 
 
 
 
x 
EDSS 
x 
 
 
x 
 
x 
 
x 
 
x 
Blood 
samples 
x 
x 
(only 
s-
hCG) 
x 
x 
x 
x 
x 
x 
x 
x 
 
 

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23 
Appendix C 
 
23.1 
Handling and analyses of biological material 
 
23.2 
Lumbar puncture 
 
23.2.1 Procedure 
The lumbar puncture is performed by an experienced medical doctor at the screening visit. It is done 
using sterile technique with a 0.7mm syringe. The patient will be offered local anesthesia or this will 
be administered at the treating physician judgment. 
 
23.2.2 Contraindication for lumbar puncture 
The lumbar puncture cannot be performed if any of the following contra indications are present: 
 
• 
Clinical suspicion of increases intracerebral pressure 
• 
Suspected infection in the area of the puncture or clinical significant physical disease 
• 
INR > 1,3 
• 
Platelets < 100 million per ml blood 
• 
The use of antithrombotic treatment other than platelet inhibitors 
 
23.2.3 Handling of the cerebrospinal fluid (CSF) 
12 ml of CSF is taken during the lumbar puncture. It is contained in a tube and iced. 1ml is send to 
analysis for cell count, albumin determination and IgG-index at the department of clinical 
biochemistry.  
The rest of the CSF is handled in the laboratory of Neuroimmunology, where it is centrifuged. The 
cell free part of the CSF is divided into portions of 0,5ml and stored at minus 80 degrees. 
Cells from the CSF are stored for the purpose of possible supplementary analyses as a biobank for 
future research purposes.  
 
23.3 
Cerebrospinal fluid analyses 
 
23.3.1 CSF analyses at the department of clinical biochemistry  
Routine analyses of cell count (white blood cells), determination of albumin content and IgG-index 
 
23.3.2 CSF and serum analyses done in the laboratory of Neuroimmunology 
Oligoclonal bands, CSF and serum neurofilament light chain (NFL), Chitinase-3-like-1 (CHI3L1), 
BCMA (TNFRSF17) sCD14, sCD27, and myelin basic protein (MBP) 
 
23.3.3 Neurofilament light chain ELISA analyses 
The concentration of neurofilament light chain (NFL) in CSF is analyzed by ELISA technique using 
a commercially available kit from Uman Diagnostics, Umeå, Sweden (NF-light® (Neurofilament light) 
ELISA). See Appendix D. 

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23.3.4 Serum NFL analyses 
Concentrations of Neurofilament Light Chain is measured in serum using single-molecule array 
(SIMOA) analysis (Quanterix, USA, cat. no. 102258).  
 
23.3.5 Chitinase-3-like-1 analyses 
Chitinase-3-like-1 is tested in CSF using a validated in-house Luminex assay (R&D Systems). 
 
23.3.6 sCD14 analyses 
sCD14 is tested in the CSF using a validated in-house Luminex assay (R&D Systems). 
 
23.3.7 sCD27 analyses 
sCD27 is tested in the CSF using a validated in-house Luminex assay (R&D Systems). 
 
23.3.8 Myelin basic protein (MBP) analyses 
MBP is tested in CSF using a  validated in-house ELISA (R&D Systems). 
 
BCMA (TNFRSF17) analyses 
BCMA is analyzed in the CSF using a validated in-house Luminex assay (R&D Systems). 
 
23.4 
Blood samples 
Blood samples are taken 10 times during the trial. The safety blood samples are analyzed at 
department of clinical biochemistry at Rigshospitalet and hereafter destroyed in accordance to local 
standardized guidelines.  
 
 
 
 

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Appendix D 
 

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24  
 
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