PET Imaging of Cyclooxygenases in Multiple Sclerosis
Phase: PHASE2
Conditions: Multiple Sclerosis
Sponsor: National Institute of Mental Health (NIMH)

1
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
Abbreviated Title: COXes in MS
NIH IRB #: 00483
Version Date:  04/20/23
Title: PET Imaging of Cyclooxygenases in Multiple Sclerosis
NIH Principal Investigator:
Robert Innis, M.D., Ph.D.
Molecular Imaging Branch
NIMH
Building 10, Rm B2D47
9000 Rockville Pike
Bethesda, MD 20892
Phone: 301.594.1368
E-mail: robert.innis@nih.gov
Name of the Coordinating Center: National Institutes of Mental Health (NIMH) will be the 
Coordinating Center for this multi-institutional study. 
Investigational Agent:
Drug Name:
[11C]PS13
[11C]MC1
IND Number:
136241 
142872
Sponsor:
NIMH IRP
NIMH IRP
Manufacturer:
NIMH IRP
NIMH IRP

2
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
TABLE OF CONTENTS 
STATEMENT OF COMPLIANCE ................................................................................................6
1
PROTOCOL SUMMARY.......................................................................................................7
1.1
Synopsis ............................................................................................................................7
1.2
Schema..............................................................................................................................8
1.3
Schedule of Activities (SOA) ...........................................................................................9
2
INTRODUCTION .................................................................................................................10
2.1
Study Rationale...............................................................................................................10
2.2
Background .....................................................................................................................11
2.3
Risk/Benefit Assessment.................................................................................................17
2.3.1
Known Potential Risks ............................................................................................17
2.3.2
Known Potential Benefits........................................................................................20
2.3.3
Assessment of Potential Risks and Benefits............................................................20
3
OBJECTIVES AND ENDPOINTS.......................................................................................21
4
STUDY DESIGN ..................................................................................................................21
4.1
Overall Design ................................................................................................................21
4.2
Scientific Rationale for Study Design.............................................................................21
4.3
Justification for Dose ......................................................................................................21
5
STUDY POPULATION........................................................................................................22
5.1
Inclusion Criteria.............................................................................................................22
5.2
Exclusion Criteria ...........................................................................................................22
5.2.1 
Exclusion of Children..............................................................................................23
5.2.2 
Exclusion of Pregnant or Breastfeeding Women.....................................................23
5.2.3 
Exclusion of Participants who are HIV Positive .....................................................23
5.2.4
Exclusion of Participation of NIH Staff or family members of study team members
23
5.3
Inclusion of Vulnerable Participant ................................................................................23
5.4
Lifestyle Considerations .................................................................................................23
5.5
Screen Failures................................................................................................................23
5.6
Strategies for Recruitment and Retention .......................................................................24
5.6.1
Costs ........................................................................................................................24

3
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
5.6.2
Compensation ..........................................................................................................24
6
STUDY INTERVENTION ...................................................................................................25
6.1
Study Interventions(s) Administration............................................................................25
6.1.1
Study Intervention Description................................................................................25
6.1.2
Dosing and Administration......................................................................................25
6.2
Preparation/Handling/Storage/Accountability................................................................26
6.2.1
Acquisition and Accountability ...............................................................................26
6.2.2
Formulation, Appearance, Packaging, and Labeling...............................................26
6.2.3
Product Storage and Stability ..................................................................................26
6.2.4
Preparation...............................................................................................................27
6.3
Measures to Minimize Bias: Randomization and Blinding ............................................27
6.4
Study Intervention Compliance ......................................................................................27
6.5
Concomitant Therapy......................................................................................................27
7
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL .....................................................................................27
7.1
Discontinuation of Study Intervention............................................................................27
7.2
Participant Discontinuation/Withdrawal from the Study................................................27
7.3
Lost to Follow-up............................................................................................................28
8
STUDY ASSESSMENTS AND PROCEDURES.................................................................28
8.1
Screening Procedures......................................................................................................28
8.1.1
Screening activities performed prior to obtaining informed consent ......................28
8.1.2
Screening activities performed after a consent for screening has been signed........29
8.2
Efficacy Assessments......................................................................................................29
8.2.1
PET Procedures .......................................................................................................29
8.2.2
Biospecimen Evaluations.........................................................................................30
8.2.3
Correlative Studies for Research/Pharmacokinetic Studies ....................................30
8.2.4
Samples for Genetic/Genomic Analysis..................................................................30
8.3
Safety and Other Assessments ........................................................................................30
8.4
Adverse Events and Serious Adverse Events .................................................................31
8.4.1
Definition of Adverse Event....................................................................................31
8.4.2
Definition of Serious Adverse Events (SAE) ..........................................................31
8.4.3
Classification of an Adverse Event..........................................................................31

4
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
8.4.4
Time Period and Frequency for Event Assessment and Follow-Up........................32
8.4.5
Adverse Event Reporting.........................................................................................33
8.4.6
Serious Adverse Event Reporting............................................................................33
8.4.7
Events of Special Interest ........................................................................................34
8.4.8
Reporting of Pregnancy ...........................................................................................34
8.5
Unanticipated Problems ..................................................................................................34
8.5.1
Definition of Unanticipated Problems (UP) ............................................................34
8.5.2
Unanticipated Problem Reporting ...........................................................................34
8.5.3
NIH Intramural IRB Reporting of IND Safety Reports...........................................34
9
STATISTICAL CONSIDERATIONS ..................................................................................34
9.1
Statistical Hypothesis......................................................................................................34
9.2
Sample Size Determination.............................................................................................35
9.3
Populations for Analyses ................................................................................................35
9.3.1
Evaluable for toxicity ..............................................................................................35
9.3.2
Evaluable for objective response.............................................................................36
9.3.3
Evaluable Non-Target Disease Response................................................................36
9.4
Statistical Analyses .........................................................................................................36
9.4.1
General Approach....................................................................................................36
9.4.2
Analysis of the Primary Endpoints..........................................................................36
9.4.3
Analysis of the Secondary Endpoint(s) ...................................................................36
9.4.4
Safety Analyses .......................................................................................................36
9.4.5
Baseline Descriptive Statistics.................................................................................36
9.4.6
Planned Interim Analyses........................................................................................36
9.4.7
Sub-Group Analyses................................................................................................36
9.4.8
Tabulation of individual Participant Data................................................................36
9.4.9
Exploratory Analyses...............................................................................................36
10
REGULATORY AND OPERATIONAL CONSIDERATIONS..........................................37
10.1
Informed Consent Process...........................................................................................37
10.1.1
Consent/Assent Procedures and Documentation.....................................................37
10.1.2
Consent for minors when they reach the age of majority........................................37
10.1.3
Considerations for Consent of NIH staff, or family members of study team 
members.................................................................................................................................37

5
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
10.1.4
Consent of Subjects who are, or become, decisionally impaired ............................38
10.2
Study Discontinuation and Closure.............................................................................38
10.3
Confidentiality and Privacy.........................................................................................38
10.4
Future use of Stored Specimens and Data...................................................................39
10.5
Safety Oversight..........................................................................................................39
10.6
Clinical Monitoring .....................................................................................................39
10.7
Quality Assurance and Quality Control ......................................................................40
10.8
Data Handling and Record Keeping............................................................................40
10.8.1
Data Collection and Management Responsibilities.................................................40
10.8.2
Study Records Retention .........................................................................................40
10.9
Protocol Deviations and Non-Compliance..................................................................41
10.9.1
NIH Definition of Protocol Deviation .....................................................................41
10.10
Publication and Data Sharing Policy...........................................................................41
10.10.1 Human Data Sharing Plan .......................................................................................41
10.10.2 Genomic Data Sharing Plan.....................................................................................41
10.11
Collaborative Agreements...........................................................................................41
10.12
Conflict of Interest Policy ...........................................................................................42
11
ABBREVIATIONS ...............................................................................................................42
12
REFERENCES ......................................................................................................................44

6
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Conference on Harmonization Good 
Clinical Practice (ICH GCP) and the following: 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812) 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled.  Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; an 
IRB determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.

7
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
1
PROTOCOL SUMMARY
1.1
SYNOPSIS
Title:
PET Imaging of Cyclooxygenases in Multiple Sclerosis
Study Description:
This study will examine whether cyclooxygenase 1 (COX-1) and 
cyclooxygenase 2 (COX-2) are elevated in the brain of individuals 
with Multiple Sclerosis (MS)
 
Objectives:
To determine whether COX-1 and COX-2 are detectable in the brains 
of individuals with MS.
Endpoints:
Primary endpoint: Calculation of COX-1 and COX-2 densities from 
[11C]PS13 and [11C]MC1 PET scans, respectively, using baseline 
scans and scans after blockade with ketoprofen and celecoxib, 
respectively.
Secondary endpoint: 1) Comparison of [11C]PS13 and [11C]MC1 
specific uptake in different types of MS lesions (active, chronic 
active, inactive) and in normal white matter. 2) Comparison of 
[11C]PS13 and [11C]MC1 specific uptake in the brain lesions of the 
same subjects
Study Population:
Sixteen (16) participants with MS will be recruited. Participants may 
be male or female, 18 years or older and enrolled in the HP-
00079860 protocol at the University of Maryland in Baltimore 
(UMB).
Phase:
2
Description of 
Sites/Facilities 
Enrolling Participants:
This is a multisite protocol that will enroll patients from University 
of Maryland and screening and PET imaging will be performed at the 
NIH Clinical Center. 
Description of Study 
Intervention:
Participants will be intravenously injected with up to 20 mCi of 
[11C]PS13 and [11C]MC1 twice, once at baseline and once after 
blockade by ketoprofen and celecoxib, respectively.
Study Duration:
36 months.
Participant Duration:
2-5 days.
1.2
SCHEMA

8
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
Visit 1
Time Point 
Visit 2-3
Time Point 
Visit 3-5
Time Point 
Obtain informed consent. General medical history 
and examination, and laboratory testing)
Day hospital visits:
1 IV, pre-lab EKG
           
PET scan #1 at baseline with one tracer
PET scan #2 after blockade
Post-labs 
Follow-up phone call
Day hospital visits:
1 IV, pre-lab EKG
           
PET scan #1 at baseline with the other tracer
PET scan #2 after blockade
Post-labs 
Follow-up phone call

9
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
1.3
SCHEDULE OF ACTIVITIES (SOA)
 
This study will require one to five visits, including the initial evaluation (1 day) and four 
PET scans (1-4 days); two PET scans for each radioligand. The screening evaluations during the 
initial visit will take 4-6 hours and will typically be performed in one day. Those who agree to 
join the study on an outpatient basis will adhere to the following schedule: during the first visit, 
the participant will give informed consent and complete the screening, which includes a history 
and physical exam. The screening evaluation will include screening labs and EKG and will 
typically be done on the same day. The two PET scans with each radioligand will typically occur 
on the same day, but they may be done on separate days. 
These patients enrolled will have already been recruited under protocol HP-00079860 (In 
vivo assessment of meningeal inflammation and its clinical impact in multiple sclerosis by 7 
Tesla MRI) at the University of Maryland, Baltimore (UMB; PI: Daniel Harrison). Participants 
will have already undergone the study activities involved in UMB protocol HP-00079860, which 
includes a 7T MRI of the brain. The 7T MRI acquired under the UMB protocol will later be used 
for co-registration of PET, so MRI does not need to be repeated under this protocol. 
Table 1
1st Visit / 
Screen
2nd
 Visit
3rd 
Visit
4th 
Visit
5th 
Visit
Informed consent
X
History and physical 
exam
X
Screening lab tests*
X
EKG
X
On each visit with PET scan
Brain PET scans 
Up to two at each visit, no more than four total
Safety tests for PET 
scans**
On each visit with PET scan
'If a blocker is given, the following set of PET scans with the other blocker must not be done earlier than 
two days after. The PET scans should be completed within a timeframe of two months.
*The screening lab tests are described in Section 5.2.
** Safety tests for each PET scan are described in Section 8.3.

10
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
2
 INTRODUCTION
2.1
STUDY RATIONALE
Our laboratory developed two novel radioligands, [11C]PS13 and [11C]MC1 for PET 
imaging of cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), respectively. COX-1 
and COX-2 are two isoforms of COX enzyme which play a key rate limiting step in the 
conversion of arachidonic acid (AA) into pro-inflammatory lipid metabolites called 
prostaglandins (PGs). COX-1 is constitutively expressed in most brain tissues whereas COX-2 is 
induced by inflammatory stimuli. We recently found that COX-2 was elevated and measurable in 
the currently symptomatic joints of patients with rheumatoid arthritis [1]. We now seek to 
determine whether COX-2 is measurable in the brains of participants with MS, in particular in 
the MS plaques. 
Although MS provides the technical advantage of local areas of active inflammation, it 
also entails the technical disadvantage of a breakdown of the blood-brain barrier surrounding 
active plaques. Thus, the uptake could reflect both parent radioligand binding to COX-1 and 
COX-2 as well as inactive, polar radiometabolites that can spill into the compromised tissue. To 
address this problem, a COX-1 and COX-2 blocking agent, ketoprofen and celecoxib, will be 
given. Radioligand specific uptake will be blocked by ketoprofen and celecoxib, whereas the 
activity due to radiometabolites won’t be affected.
In this way, the outcome measure will be a comparison of brain lesions at baseline and 
after blockade, normalized to a reference region such as the contralateral mirror image of the 
lesion, and thus does not require absolute quantitation with arterial plasma samples. Of course, 
this ratio would not determine whether COX-1 or COX-2 are globally increased in MS brain, in 
addition to any local increases associated with active plaques. However, arterial blood sampling 
seems excessively burdensome for an exploratory study. Expressed in other terms, if COX-1 or 
COX-2 do not detect any specific binding in MS lesions, then it’s unlikely to detect a global 
increase compared to healthy subjects.
A reference region will be selected based on the PET scan blocked by celecoxib or 
ketoprofen. A true reference region has no specific/blockable binding, and a pseudo-reference 
region has a small amount of specific binding.  The cerebellum might not be the most 
appropriate choice because the cerebellum is affected by diffuse inflammation in MS. This is 
however a problem common to all regions, since MS affects the whole brain. A more accurate 
reference region might be the mirror image of the ROI in the opposite hemisphere because, even 
if affected by generalized inflammation, the contralateral ROI would more accurately reflect the 
amount of nonspecific binding of the target region. A comparison with the contralateral region 
would track the change in COX-1 and COX-2 binding after blockade with sufficient accuracy, 
without the need of an arterial input function.
The MS lesions will be identified anatomically by a 7T MRI, acquired under a specific 
protocol of UMB (PI: Daniel Harrison). The 7T MRI images include the following brain 
sequences: MP2RAGE (magnetization prepared 2 rapid acquisition gradient echo), MPRAGE 
(magnetization prepared rapid acquisition gradient echo), FLAIR (fluid attenuated inversion 
recovery), and a ME-GRE (multi-echo gradient recalled echo). All are 3D acquisitions and 
acquired both pre- and post-gadolinium contrast. All 7T MRI images will be co-registered to the 
pre-contrast MP2RAGE T1-weighted image at 0.5 mm3 resolution. MRI images will undergo 
both manual processing for MS lesion identification and classification, along with use of 

11
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
automated and semi-automated tools for brain structure/tissue segmentation. PET images will 
also be co-registered to the pre-contrast T1-weighted MP2RAGE image, allowing interrogation 
of PET signal in various lesion types and brain structures. Every effort will be made to have PET 
study visits occur as close to the date of the 7T MRI as possible. In order to account for logistical 
problems, PET will be performed within 180 days before or after MRI. Similarly, the 
baseline/blocked scans will be performed within two months of each other. An interval of at least 
two days will be respected between the administration of the two blockers (ketoprofen and 
celecoxib). Lesions will be identified on MRI independently of the PET scans and by 
investigators blinded to the PET scans.
As a secondary endpoint, we will explore whether different types of MS lesions display 
different amounts of COX-1 and COX-2 binding. In particular, active lesions will be identified 
as those that show contrast enhancement with administration of gadolinium. Chronic-active 
lesions will be identified as those who have a paramagnetic outer rim identified on ME-GRE 
images that have been processed for quantitative susceptibility maps (QSM). Inactive lesions 
will be white matter lesions that do not meet criteria for active or chronic-active. Normal 
appearing white matter will be all white matter minus lesioned white matter, as determined by 
automated segmentation. We hypothesize that COX-1 and COX-2 binding positively correlates 
with the activity of the lesion.
Finally, we will determine whether the expressions of COX-1 and COX-2 are correlated 
by analyzing the uptake of the two tracers within the lesions of the same subjects.
2.2
BACKGROUND 
Multiple sclerosis (MS) is an autoimmune disease whose pathogenesis is characterized by 
neuroinflammation. The socioeconomic impact of MS is considerable in terms of healthcare 
costs and individual disability. The clinical presentation of MS is highly heterogeneous. 
Typically, the onset of the disease is characterized by acute worsening of neurological symptoms 
followed by a full or partial recovery. On average 10 years after disease, secondary progressive 
MS leads to irreversible and progressive disability [2]
Although the progression of the disease can be slowed down to some extent with disease-
modifying therapies, there is no curative treatment, especially to prevent the cumulative 
disability in the more progressive forms of the disease. Thus, more research is clearly needed to 
understand the pathophysiology, to develop alternative biomarkers for the evaluation of disease 
activity, and to seek alternative pathways for therapeutic development in the treatment of 
progressive MS.
Neuroinflammation and axonal loss occur during all stages of MS [3]. Thus, by studying 
inflammation, one may gain important insights about the physiopathological course of the 
disease, especially for its degenerative component.
MRI and MS
Magnetic resonance imaging (MRI) is the main diagnostic and prognostic tool used in the 
study and treatment of patients with multiple sclerosis (MS). Visualization of MS pathology by 
MRI has brought about substantial advances in MS care, including earlier and more accurate 

12
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
diagnoses and the ability to monitor the effects of treatment and visualize subclinical disease 
activity. MS, especially after contrast enhancement, can assess the activity of lesions. Active 
lesions are those that show contrast enhancement with administration of gadolinium. Chronic-
active lesions are those who have a paramagnetic outer rim, and inactive lesions are white matter 
lesions that do not meet criteria for active or chronic-active.
Despite these diagnostic assets, standard clinical MRI fails to visualize much of MS-
related pathology.[4, 5] Although current MRI performs well as a tool to measure white matter 
(WM) inflammation in MS, it has been less successful as a tool to quantify gray matter (GM) 
pathology, meningeal inflammation, neurodegeneration, chronic inflammatory changes, and 
myelin tissue content. For this reason, researchers continue to strive towards development of new 
imaging technologies – hoping to bring us closer to in vivo quantification of MS disease 
processes akin to postmortem histopathology. 
PET and MS
Contrarily to MRI, positron emission tomography (PET) imaging enables molecular and 
neuroreceptor imaging in vivo. Particularly relevant for the study of MS is PET imaging of 
activated microglia. Traditionally, imaging of microglia has been achieved with radioligands 
binding to the 18 kDa translocator protein (TSPO)—a protein structure expressed on the outer 
mitochondrial membrane of activated, but not resting microglia [6].
The first TSPO-PET studies in MS patients were done with the prototypical radioligand 
[11C] (R)-PK11195. These early studies were able to show for example that TSPO was increased 
in acute lesions but was low in chronic lesions [7] or that increased TSPO was associated to 
areas related to demyelinating lesions in MRI [8]. [11C] (R)-PK11195, however, has issues of 
high non-specific binding and poor signal-to-noise ratio. Newly developed TSPO radioligands, 
such as 11C-PBR28 [9] and 11C-ER176 [10], have much higher specific binding, but are more 
sensitive to different binding affinities in the presence of a single nucleotide polymorphism in the 
TSPO gene. This polymorphism divides populations into three genetic groups: high-affinity 
binders (HABs), mixed-affinity binders (MABs), and low-affinity binders (LABs). While an in-
human study showed consistently quantifiable distribution volume for TSPO with [11C]ER-176 
than its predecessor in all three genetic groups, there was still some genetic preference for HABs 
as compared to MABs or LABs [11].
Given the limitations of TSPO radioligands, PET radioligands aimed at different targets 
have been tried. These include Purinoreceptor P2X7, which has been linked to microglia-
mediated neuroprotection via activation of the receptors by ATP [12], the cannabinoid receptor 
2, which is also expressed in activated microglia [80], and [11C]TMSX-PET, a tracer for 
adenosine receptors, which has been used to study the pathologic alterations in the white matter 
associated with progressive MS disease [13]
The role of COX in MS
Cyclo-oxygenase receptors are involved in neuroinflammation and appear as interesting 
targets for PET imaging of MS. This enzyme plays a key role in the conversion of arachidonic 
acid to essential cell-signaling eicosanoids which is accompanied by the production of reactive 
oxygen species. It is believed that oxidative stress might be responsible for brain inflammatory 
disorders causing deleterious effects during CNS pathogenesis. What is more, oxidative stress 

13
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
can activate several intracellular signaling cascades that can have deleterious effects on the 
cellular homeostasis [14].
COX-1 is almost exclusively localized in microglia which play a complex role in MS 
pathophysiology  [2, 18]. Microglia produce proinflammatory mediators in activated states and 
play a key role in neuroinflammation. COX-1 expression is elevated in activated microglia and 
facilitates oxidative stress and proinflammatory processes that ultimately leads to neuronal loss 
and neurodegeneration.
The role of COX-1 in the neuroinflammatory pathway has been postulated primarily 
using genetic modulation of COX-1 in rodents as well as neuroinflammation models in animals. 
For instance, genetic knockout of COX-1 in mice reduced oxidative stress and neuronal damage 
compared to wild-type mice. In a neuroinflammation model in monkeys, COX-1 expression was 
increased globally in activated microglia as well as macrophages [19]. Taken together, the 
evidence suggests that COX-1 is a promising biomarker for studying neuroinflammatory 
processes.
COX-2 is extensively expressed in MS lesions. COX-2 was found near regions showing 
active demyelination suggesting that these inducible enzymes could contribute to the pathology 
of MS [15]. In addition, evidence from genetic and pharmacological studies indicate that 
increased COX-2 expression and activity contributes to neuronal excitotoxic cell death. 
Therefore, COX-2 could contribute to excitotoxic death of oligodendrocytes and damage of 
axons leading to disease progression in MS [15].
Development of PET Radioligands Selective for COX-1 and COX-2
Over the past years, our laboratory developed the first radioligands to image COX-1 and 
COX-2. These radioligands—[11C]PS13 for COX-1 and [11C]MC1 for COX-2—are potent and 
selective for each isoform and have shown promising results in monkeys (Fig. 1) and humans 
(Fig 2). We found that COX-1 is expressed constitutively (i.e., under healthy conditions) in 
several organs, including brain, spleen, kidney, and GI tract. The binding of the COX-1 
radioligand was selective for its targeted isozyme, as it could be blocked by COX-1-selective 
inhibitors in both monkeys and humans, but not by COX-2-selective inhibitors. 

14
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
Figure 1. The maximum intensity projection 
images in rhesus macaque after injection of 
[11C]PS13 under baseline conditions (A) and 
after injection of PS13 (0.3 mg/kg) (B).
High uptake was observed in the brain, spleen 
(upper arrow), gastrointestinal tract, and kidney 
medulla (lower arrow) at baseline. Uptake was 
blocked by pharmacological doses of PS13 
[16].
Figure 2. The whole-body maximum 
intensity projection images with [11C]PS13 
under baseline conditions (A) and after oral 
administration of ketoprofen 75 mg (B) in a 
healthy volunteer. Ketoprofen, a selective 
COX-1 inhibitor, blocked 50−80% of uptake in 
spleen (upper arrow) and gastrointestinal tract 
(lower arrow) [17]
COX-1 was found in all areas of brain, but was particularly high in the pericentral cortex, 
occipital cortex, and hippocampus (Fig. 3). This regional distribution of COX-1 protein 
measured with PET in brain is consistent with that of the mRNA for PTGS1, the gene that 
encodes the COX-2 protein (Allen Brain Atlas).
Development of a radioligand selective for COX-2 was more challenging because COX-2 
is expressed at very low concentrations under healthy conditions. To evaluate [11C]MC1, we first 
had to upregulate COX-2 in monkey brain using intracerebral injection of the inflammogen 
lipopolysaccharide (LPS). Under baseline/healthy conditions, [11C]MC1 detected no COX-2 in 
brain. However, after LPS injection, [11C]MC1 clearly visualized areas of elevated COX-2 and 
showed appropriate subtype selectivity (Fig. 4). Our interpretation was that [11C]MC1 lacked the 
sensitivity to measure low baseline concentrations of COX-2 but could detect the enzyme after 
upregulation, which can be a 10- to 20-fold effect. To determine whether [11C]MC1 can detect 
COX-2 in human participants, we studied individuals with rheumatoid arthritis (RA), as COX-2 
is upregulated in affected joints. In the four participants studied to date, symptomatic joints had 

15
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
increased uptake of [11C]MC1 that was blocked by celecoxib (Fig. 5) [1]. These preliminary 
results confirmed that [11C]MC1 is capable of imaging COX-2 in humans if COX-2 
concentrations are adequately elevated by peripheral inflammation.
Figure 3. Parametric total 
distribution volume (VT) images 
calculated by the Logan graphical 
analysis method. MRI is from a 
representative participant, and PET 
images are averaged from 20 scans in 
10 participants. Arrows represent 
notable [11C]PS13 binding in the 
pericentral cortex, occipital cortex, 
and hippocampus [17].
Figure 4. Parametric distribution 
volume (VT) images of [11C]MC1 
uptake on Day 1 after the second LPS 
injection in a monkey. Upper row: 
[11C]MC1 uptake was markedly 
increased surrounding the injection area 
in the right putamen. Bottom row: MC1 
blocked radioligand binding to COX-2 at 
the injection site (marked by red arrow) 
to a level lower than that in the 
remainder of the brain [1]. 

16
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
Figure 5. Human PET images of COX-2 in 
an individual with rheumatoid arthritis and 
a healthy control. Increased [11C]MC1 uptake 
in the bilateral hand joints reflected increased 
COX-2 binding in a participant with rheumatoid 
arthritis compared to the healthy volunteer. The 
increased [11C]MC1 uptake in the individual 
with rheumatoid arthritis was partially blocked 
by celecoxib (400 mg) but may be completely 
blocked by higher doses [1]. 
We scanned six new healthy participants under protocol 19-M-0079 (Evaluation of novel 
PET radioligands as inflammatory biomarkers in rheumatoid arthritis and myositis). The 
brain scans were fully quantitative and had an arterial input function, acquired at baseline 
and after blockade by 600 mg of celecoxib, a preferential COX-2 inhibitor. All subjects 
showed a small amount (10-20%) of displaceable COX-2 signal in the brain, measured as 
total distribution volume corrected for plasma free fraction of the parent radioligand. This 
measure of enzyme density (VT/fp) was 95 ± 9.5 mL/cm-3 at baseline and 76 ± 4.7 
mL/cm-3 after blockade (Fig 6).

17
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
Figure 6: VT/fp at baseline and after blockade with 600mg celecoxib in 6 healthy subjects. A 
small displaceable binding (10-20%) is seen in each subject.
These quantitative brain studies demonstrate that our COX-2 radioligand, [11C]MC1, has the 
sensitivity necessary to measure the low densities of COX-2 present in healthy human brain. 
These studies in healthy participants complement our prior finding that [11C]MC1 can detect 
elevated COX-2 in symptomatic, but not asymptomatic, joints in participants with rheumatoid 
arthritis (Shrestha et al. 2020).
Given that the same target, COX-2, is expressed in MS lesions, we expect that [11C]MC1 will be 
able to detect an increase of COX-2 concentrations also in this population of subjects.
2.3
RISK/BENEFIT ASSESSMENT
2.3.1
Known Potential Risks
Risks include those associated with: a) medical examinations including laboratory testing 
that may reveal previously undiagnosed medical disorders, b) placement of a venous line, c) 
venous blood sampling, d) radiation exposure from 11C-PS13 and 11C-MC1 and the transmission 
scans, e) PET scanning, f) celecoxib administration, and g) ketoprofen administration.
a.
Examination and laboratory testing
Medical examinations are associated with minimal risks. We will first explain and 
familiarize the subjects with the laboratory testing to minimize discomfort, if any, during testing. 
In the present protocol, all subjects have already been diagnosed under the UMB protocol, and 
the only lab tests done under this protocol are the safety lab tests. 
b. Venous catheterization
Venous catheter insertion can be associated with bruising, infection, or clot formation. 
Using proper placement techniques will minimize these risks.

18
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
c.
Venous sampling
Subjects will have venous blood sampling of no more than 150 mL during the entire 
course of the study. This includes approximately 75 mL for laboratory tests. Blood sampling may 
lead to the formation of a small subcutaneous hematoma caused by blood leaking from a 
punctured blood vessel. This hematoma causes only minor discomfort. It is not dangerous and 
requires no treatment other than reassuring the patient. There is also a small risk of infection at 
the site of the needle puncture, which can be readily treated with antibiotic therapy.
d. Radiation exposure risks
Whole-body imaging with [11C]MC1 in one male and one female healthy participant 
under protocol 19-M-0079 showed that the radiation exposure (rem) from a 20 mCi injection of 
[11C]MC1 had an effective dose of 0.34. Liver (1.33), gallbladder wall (1.26), and kidneys (0.50) 
were the three organs with the highest exposures.
We calculated the radiation exposure of [11C]PS13 from whole-body imaging in 15 
healthy subjects. The radiation exposure (rem) from a 20 mCi injection, which is a typical dose 
for brain imaging, was: effective dose (0.34). Spleen (2.06), liver (0.74), and lungs (0.53) were 
the three organs with the highest levels.
With regard to exposure from the transmission scan, the PET Department recently 
implemented Dr. Innis’s suggestion to decrease the current (amperage) and, thus, overall 
radiation from the CT scan. We do not need a high resolution (high current) image for 
attenuation correction; a low-resolution scan, like that obtained from a line source, is perfectly 
adequate to correct attenuation in the PET emission scan. With the lowered current, the exposure 
to the lens of the eye is now 0.26 rem, about one-third of the previous value. 
We routinely include the dose from two transmission scans in the event that it must be 
repeated in any given participant. The effective doses for two head transmission scans from a 
PET/CT are ~ 0.04 rem. Thus, the total effective dose in each [11C]MC1 or [11C]PS13 PET scan 
is 0.38 rem. Because each participant may undergo up to two [11C]PS13 and two [11C]MC1 PET 
scans under this protocol, the total effective dose is estimated as 1.52 rem. The estimated annual 
effective dose of 1.52 is well below the limit of 5 rem per year established by the NIH’s 
Radiation Safety Committee. All participants will be asked about any prior research participation 
involving radiation exposure so that the total exposure, in combination with the present study, 
will not exceed an effective dose of 5 rem per year.
e.
PET scan
PET scanning, which detects injected radioactivity within the body, is associated with no 
known physical hazards to the subject lying on the table. We routinely use a series of procedures 
to minimize the risk for discomfort during scanning sessions. Namely, the procedures are 
conducted in the presence of trained health professionals to whom subjects will have ready 
access, should they experience any problems. Subjects can communicate with the trained health 
professionals while in the scanner and can withdraw from the study at any time if they wish to do 
so. The head of the subjects may be constrained by a head-holder or a thermoplastic mask, which 
are usually well-tolerated.
Occasionally subjects become anxious during the scan. In that case, subjects can request 
the operator of the PET to stop the scan.

19
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
f.
Celecoxib administration
Participants will receive a single dose of celecoxib (up to 600 mg) before the second PET 
scan. This dose is beyond the normal therapeutic range (100- 200 mg BID), but we feel it is safe 
based on prior experience. Celecoxib will be administered only short-term – i.e., one dose. 
Prior Experience
a) Although the typical dose of celecoxib is 100-200 mg BID, the FDA-approved package 
insert (page 1) allows 400 mg BID for diseases like acute pain or primary dysmenorrhea.  
(https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/020998s050lbl.pdf)
b) Doses up to 2,400 mg/day for up to 10 days in 12 participants did not result in serious 
toxicity. See page 9 of celecoxib’s package insert, which has been uploaded in iRIS.
c) In one large clinical trial of 8,059 individuals with RA, those enrolled in the celecoxib 
arm took celecoxib (400 mg BID) for six months (participants in the other two arms took 
either ibuprofen or diclofenac) [18]. This study found a decrease in GI toxicity among 
participants using celecoxib but no increase in cardiovascular events [18].
d) Our collaborator (James Katz, MD, NIAMS) has used up to 600 mg as a single dose in 
patients with RA on another protocol (19-M-0079) and observed no untoward effects.
e) We have been using a dose of 600 mg for our protocol 19-M-0079, in order to block 11C-
MC1 scans in a manner similar to the one envisioned in this protocol, without any 
untoward effects. To date, about ten subjects have received this blocking dose under this 
protocol.
Short-Term Use 
Few studies have examined whether increased cardiac risk is associated with short-term 
use of celecoxib. In two randomized, double-blind studies, participants received 200 mg of 
celecoxib daily for six weeks without a significant increase in cardiovascular adverse events [19, 
20]. Another study found that celecoxib had a superior safety and tolerability profile compared to 
diclofenac [19]. A seven-day trial of 200 mg celecoxib twice daily actually improved outcomes 
in myocardial injury in elective percutaneous intervention for stable angina [21]. To more 
thoroughly investigate this, a retrospective analysis conducted using the Veterans Integrated 
Service Network (VISN) 17 database found that although long-term celecoxib use was 
associated with increased cardiovascular risk, short-term use did not carry this risk [22]. 
Common reactions to repeated doses of celecoxib are: headache, upset stomach, upper 
respiratory infection, diarrhea, abdominal pain, nausea, vomiting, rash, gas, swelling in the legs, 
dizziness, elevated liver enzymes, impaired kidney function, and sensitivity to sunlight. In 
addition, the Food and Drug Administration (FDA) has placed a "Black Box Warning" for 
celecoxib that the drug might rarely lead to death, heart attack, or stroke. The “Black Box 
Warning” also describes that all non-steroidal anti-inflammatory drugs (NSAIDs), which 
includes celecoxib, are associated with an increased risk of ulcers or tear in the lining of the 
stomach or intestines, which may cause bleeding or increased risk of infection. We feel that the 
risk of serious reactions is low as we are giving a single dose of celecoxib. Participants will be 
monitored for adverse reactions. Rarely, a participant will have an allergic reaction to their very 
first dose. Because there are possible teratogenic or nonteratogenic effects of celecoxib on 
pregnancy, participants of child-bearing potential will be required to use contraception from the 
time they are enrolled until three days after the last administration of celecoxib. Urine pregnancy 
testing will be also done before each administration of celecoxib. This drug has been approved 

20
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
by the U.S. Food and Drug Administration (FDA); it is not FDA approved for the off-label use in 
this study. However, the FDA is allowing its use in this study.
g. Ketoprofen administration
Participants will receive a single dose of ketoprofen of 75 mg before the second COX-1 
PET scan. This dosing range is within the normal therapeutic dosing range for ketoprofen 
administration and is below the maximum therapeutic dose of ketoprofen which is 300 mg/day. 
Common reactions to ketoprofen administration include: dyspepsia, nausea, abdominal pain, 
constipation, headache, dizziness, somnolence, rash, AST/ALT elevation, peripheral edema, 
fluid retention, tinnitus, ecchymosis, photosensitivity, and delayed ovulation. Rare but serious 
reactions associated with ketoprofen administration include: gastrointestinal bleeding, 
perforation, or ulcer, myocardial infarction, stroke, thromboembolism, hypertension, congestive 
heart failure, renal papillary necrosis, nephrotoxicity, hepatotoxicity, anaphylaxis, 
bronchospasm, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis, 
erythema multiform, anemia, blood dyscrasias, and prolonged bleeding time 
(https://online.epocrates.com/rxmain  accessed 12/8/2017). We feel that the risks of serious 
reactions are low as we are giving a single dose of ketoprofen within the recommended dose 
range in healthy volunteers. Subjects will be monitored for adverse reactions. Rarely, a subject 
will have an allergic reaction to their very first dose. This drug has been approved by the U.S. 
Food and Drug Administration (FDA); it is not FDA approved for the off-label use in this study. 
However, the FDA is allowing its use in this study.
Prior Experience
a) The maximum therapeutic dose of ketoprofen is 300 mg/day, and previous 
clinical trials in pain control with single dose of 150-225 mg reported of no 
serious adverse events. Most of the reported adverse effects were nausea, 
vomiting, and GI discomfort, but otherwise were well-tolerated (Gaskell et al, 
2017; Sunshine and Olson, 1988; Turek and Baird, 1988).
b) Under protocol 17-M-0179, we administered blocking doses of ketoprofen in 8 
subjects, with doses up to 75 mg. Despite evidence of substantial blockade of the 
organ uptake, especially in the spleen, no pharmacological side effects were 
noted.
2.3.2
Known Potential Benefits
This study offers no direct benefit to individual subjects but will lead to generalizable 
knowledge regarding the usefulness of COX-1 and COX-2 as potential biomarker of MS.
2.3.3
Assessment of Potential Risks and Benefits
This study will determine whether COX-1 and COX-2 are detectable in the brains of 
subjects with MS. If the results are positive, such PET imaging may be used to explore the 
pathophysiological role of inflammation in MS. This valuable information may then help guide 
future trials with anti-inflammatory drugs, a benefit to future patients that justifies the risks to the 
current participants.
With regard to how the study design sought to minimize risks, please see each risk listed 
above (Section 2.3).

21
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
3
OBJECTIVES AND ENDPOINTS
4
STUDY DESIGN
4.1
OVERALL DESIGN
Subjects will undergo medical history and general medical examination, 11C-PS13 and 
11C-MC1 PET scans at baseline and after blockade by ketoprofen and celecoxib, and laboratory 
testing.
4.2
SCIENTIFIC RATIONALE FOR STUDY DESIGN
To determine whether COX-1 and COX-2 is detectable in the brains of individuals with 
MS, whether COX-1 and COX-2 binding is correlated with the activity of the lesion as measured 
by MRI, and whether COX-1 and COX-2 are correlated in the brain lesions of the same 
individuals.
4.3
JUSTIFICATION FOR DOSE
The FDA has allowed a dose up to 20 mCi of 11C-PS13 and 11C-MC1 to be used for research 
purposes. 
Celecoxib 600 mg PO.
Ketoprofen 75 mg PO.
Objectives
Endpoints
Justification for Endpoints
Primary
To determine whether 
COX-1 and COX-2 are 
detectable in the brains of 
participants with MS.
PET scans with [11C]PS13 and 
[11C]MC1 with and without 
blockade by ketoprofen and 
celecoxib.
We previously demonstrated that 
these radioligands are selective 
for COX-1 and COX-2.
Secondary
To determine whether 
COX-1 and COX-2 differ 
in various types of MS 
lesions (active, chronic 
active, inactive) compared 
to normal white matter.
To determine whether the 
expressions of COX-1 and 
COX-2 are correlated in 
the lesions of the same 
subjects
PET scans with [11C]PS13 and 
[11C]MC1 with and without 
blockade by ketoprofen and 
celecoxib.
PET scans with [11C]PS13 and 
[11C]MC1 with and without 
blockade by ketoprofen and 
celecoxib.
We previously demonstrated that 
these radioligands are selective 
for COX-1 and COX-2.
We previously demonstrated that 
these radioligands are selective 
for COX-1 and COX-2.

22
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
5
STUDY POPULATION
Patients with MS will be recruited by referral from the PI at UMB, with subjects being those 
who are currently enrolled under UMB protocol HP-00079860 and who have signed a clause in 
the UMB consent document allowing contact for future research. 
Healthy subjects won’t be needed for this study because MS subjects scanned at baseline will be 
their own controls for the scans after blockade.
5.1
INCLUSION CRITERIA
1. Aged 18 years and older.
2. Female participants of childbearing potential must be using a medically acceptable 
means of contraception.
3. Able to provide informed consent.
4. In good general health as evidenced by medical history and physical examination.
5. Enrolled under UMB protocol HP-00079860 (In vivo assessment of meningeal 
inflammation and its clinical impact in multiple sclerosis by 7 Tesla MRI), P.I. Daniel 
Harrison and have agreed to contact for future research.
5.2
EXCLUSION CRITERIA
1. Any medical contraindication to the procedures performed in the study, or any current 
severe medical or psychiatric illness other than MS. This includes contraindications to 
Celecoxib, such as aspirin sensitive asthma, and contraindications to ketoprofen, such 
as hypersensitivity to ketoprofen or history of upper or lower gastrointestinal 
bleeding.
2. Behavioral symptoms that would preclude the gathering of data for the study, or 
advanced disease such that subjects cannot provide assent.
3. Clinically significant abnormalities on EKG or safety labs. This includes CBC; acute 
care panel (Na, K, Cl, CO2, creatinine, glucose, urea nitrogen); hepatic panel 
(alkaline phosphatase, ALT, AST, bilirubin total, and bilirubin direct); mineral panel 
(albumin, calcium, magnesium, phosphorus).
4. MRI performed >180 days before or after the PET scan
5. Have taken NSAIDs for two weeks prior to the PET scan. Have taken aspirin, 
corticosteroids (except for topical creams), or immunosuppressants (except for FDA-
approved disease-modifying therapy for MS) in the prior month.
6. Have other major neurological or medical diseases that may cause cognitive 
dysfunction, such as structural brain diseases, metabolic diseases, paraneoplastic 
syndromes, infectious diseases, or other significant neurological abnormalities. 
7. Have an unstable medical condition that, in the opinion of the investigators, makes 
participation unsafe (e.g., an active infection or untreated malignancy).
8. Are unable to travel to the NIH.
9. Have recent exposure to radiation related to research (e.g., PET from other research) 
that, when combined with this study, would be above the allowable limits.
10. Have an inability to lie flat and/or lie still on the camera bed for at least two hours, 
including claustrophobia, overweight greater than the maximum for the scanner, and 

23
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
uncontrollable behavioral symptoms, which will be screened by an interview with the 
patient and/or caregiver during the screening visit. 
11. Pregnancy
12. HIV infection
13. Be NIMH staff or an NIH employee who is a subordinate/relative/co-worker of the 
investigators.
5.2.1 Exclusion of Children 
Because this protocol has more than minimal risk from radiation exposure without 
possibility of direct benefit, inclusion of children is not appropriate.
5.2.2 Exclusion of Pregnant or Breastfeeding Women
Pregnant women will be excluded because this protocol involves exposure to ionizing 
radiation. Lactating women will be excluded because radioisotopes may be excreted in milk. 
5.2.3 Exclusion of Participants who are HIV Positive 
Persons with HIV infection are excluded because HIV infection itself may cause 
neuroinflammation, and we wish to specifically study the effect of MS on neuroinflammation.
5.2.4
Exclusion of Participation of NIH Staff or family members of study team members
NIH staff and family members of study team members may not be enrolled in this study.
5.3
INCLUSION OF VULNERABLE PARTICIPANT
None
5.4
LIFESTYLE CONSIDERATIONS
None
5.5
SCREEN FAILURES
Screen failures are defined as participants who consent/assent to participate in the clinical 
trial but are not subsequently assigned to the study intervention or entered in the study. A 
minimal set of screen failure information is required to ensure transparent reporting of screen 
failure participants, to meet the Consolidated Standards of Reporting Trials (CONSORT) 
publishing requirements and to respond to queries from regulatory authorities. Minimal 
information includes demographic characteristics, screen failure details, eligibility criteria, and 
any serious adverse event (SAE).
Individuals who do not meet the criteria for participation in this trial (screen failure) 
because of an exclusion criterion that may resolve by time of treatment may be rescreened. 
Rescreened participants should be assigned the same participant number as for the initial 
screening.
5.6
STRATEGIES FOR RECRUITMENT AND RETENTION
Patients will be referred here after recruitment under protocol HP-00079860 (In vivo 
assessment of meningeal inflammation and its clinical impact in multiple sclerosis by 7 Tesla 
MRI), PI Daniel Harrison at University of Maryland, Baltimore. Potential participants will have 
signed a clause in that study’s consent document allowing contact for future research and will 

24
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
have given Dr. Harrison permission to provide the NIH study team with their contact 
information. These potential participants will then be contacted by the NIH study team, informed 
of the study, and a screening visit will be arranged with their permission. This process and 
subsequent study procedures will be governed by an IRB reliance agreement in which the UMB 
IRB will approve reliance upon the NIH IRB.
The protocol and the contact information to obtain further details will be listed on 
www.clinicaltrials.gov.
5.6.1
Costs
We expect that patients will incur no costs for participating in this study. 
5.6.2
Compensation
Subjects will be compensated for time- and research-related inconveniences. 
Reimbursement is based on NIH standards for time devoted to the research project. Volunteers 
will be paid for each portion of the study they complete whether or not they opt for early 
withdrawal from participation. Without any delay of study procedures or unanticipated 
inconvenience, the total possible compensation is $960. If the investigators need to delay study 
procedures or if additional time is need for completion, subjects may receive additional 
compensation in accordance with NIH guidelines.  
Visit 1 to NIH
Screening
$50
Pregnancy test 
$10
Escort fee
$20
Visit 2 to NIH
Pregnancy test
$10
PET scanning
$150
Antecubital venous catheter
$30
Movement restriction
$10
Escort fee
$20
Visit 3 to NIH
Pregnancy test
$10
PET scanning
$150
Antecubital venous catheters
$30
Movement restriction
$10
Escort fee
$20
Visit 4 to NIH
Pregnancy test
$10
PET scanning
$150
Antecubital venous catheter
$30
Movement restriction
$10
Escort fee
$20
Visit 5 to NIH
Pregnancy test
$10
PET scanning
$150
Antecubital venous catheter
$30

25
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
Movement restriction
$10
Escort fee
$20
Total
$960
6
STUDY INTERVENTION
6.1
STUDY INTERVENTIONS(S) ADMINISTRATION
6.1.1
Study Intervention Description
Each participant will receive an injection of [11C]PS13 and [11C]MC1 before and after 
blockade by ketoprofen and celecoxib, respectively.
6.1.2
Dosing and Administration
Each participant will be intravenously injected with up to 20 mCi of [11C]PS13 and 
[11C]MC1 for each PET scan. The yield of the radioligand synthesis varies such that the available 
dose may be < 20 mCi. By prior agreement with NIH’s Radiation Safety Committee, the 
clinician covering the scan can approve a dose as low as half of the prescribed dose (i.e., 10 - 20 
mCi). We expect that a dose of 10-20 mCi will likely be adequate for all participants. The 
maximal dose will provide the best accuracy to measure radioactivity in brain with PET. Please 
note that the half-life of 11C is only 20 minutes; thus, the scan will last several half-lives. 
6.1.2.1
Dose Escalation
None
6.1.2.2
Dose Limiting Toxicity
Toxicity from this radiolabeled drug comes from radioactive emissions and the mass dose 
of the nonradioactive carrier. Both the injected radioactivity and mass dose are many-fold lower 
than that required to cause toxicity. 
6.1.2.3
Drug Modifications
The dose will not be modified by toxicity. Instead, the dose may be less than that 
prescribed, based on the PI’s judgment of the magnitude of noise that will be acceptable in the 
brain and blood measurements.
6.1.2.4
Drug Administration
The radioligand will be injected intravenously and must be administered within one hour of its 
preparation.
6.2
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
The radioligands are prepared by the NIMH radiochemistry laboratory and handled by 
the PET Department radiopharmacy according to the associated INDs and SOPs. The 
radioligands have minimal storage because they must be injected within one hour of their 
preparation.

26
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
6.2.1
Acquisition and Accountability
The radioligand will be delivered by the NIMH radiochemistry laboratory to the PET 
Department’s radiopharmacy. Acquisition and accountability are the responsibility of the NIMH 
radiochemistry laboratory.
6.2.2
Formulation, Appearance, Packaging, and Labeling
Each product will be formulated in sterile, apyrogenic saline containing 10% dehydrated 
alcohol in a single-use vial and labeled according to requirements for PET drug products 
described in USP Chapter <823>.  The following label will be affixed directly to the vials prior 
to filling:
Two additional labels are placed on the outer lead shielding used to transport the vial to 
the radiopharmacy:
6.2.3
Product Storage and Stability
Products are stable at controlled room temperature for the one-hour expiration period and 
have no additional storage requirements. Product vials are expected to be single-use, but if the 
seal is broken and additional product must later be withdrawn, the same storage conditions and 
original expiration time would apply.
6.2.4
Preparation
Products are provided as sterile, directly injectable solution in a multi-dose vial. The PET 
radiopharmacist will aseptically remove from the multi-dose vial only the volume required for a 
patient dose. If necessary, this volume will be diluted with 0.9% normal saline, USP to 12 mL.
6.3
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING
This study is neither randomized nor blinded.

27
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
6.4
STUDY INTERVENTION COMPLIANCE
The injected dose is documented in CRIS.
6.5
CONCOMITANT THERAPY
This study has no concomitant therapies
7
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
7.1
DISCONTINUATION OF STUDY INTERVENTION
Discontinuation instituted by the investigator has been rare in our PET studies but would 
likely occur during PET scans. Examples include a subject experiencing such anxiety that the 
investigator recommends study discontinuation, even though the participant is willing to 
proceed, or a post-scan safety measurement that indicates a clinically significant abnormality that 
must be investigated and rectified before s/he can proceed. More specifically, the PI may 
discontinue or withdraw a participant from the study for the following reasons:

Disease progression that requires discontinuation of the study intervention, which is 
unlikely for this relatively short study.

A clinically significant adverse event (AE), laboratory abnormality, or other medical 
condition or situation suggesting that continued participation in the study would not be in 
the best interest of the participant.

Screen failure, including positive pregnancy test.

Investigator discretion – e.g., excessive anxiety of the participant.
Any new clinically relevant finding will be reported as an AE, and the cause of 
discontinuation will be recorded in CRIS.
In addition to discontinuation instituted by the PI, the subject may discontinue (i.e., 
withdraw) from the study at any point for any reason.
In the event of any discontinuation, we will seek to obtain the next safety measure – i.e., 
post-scan labs or EKG.
7.2
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY
Participants may withdraw from the study at any point for any reason upon request.
An investigator may discontinue or withdraw a participant from the study for the following 
reasons:

If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation

Screen failure
7.3
LOST TO FOLLOW-UP
A participant will be considered lost to follow-up if s/he fails to return for a scheduled 
visit and is unable to be contacted by the study site staff. The following actions must be taken if a 
participant fails to return to the clinic for a required study visit:

The site will attempt to contact the participant and reschedule the missed visit as soon as 
practicable and counsel the participant on the importance of maintaining the assigned 
visit schedule. Concomitantly, we will ascertain whether the participant wishes to and/or 
should continue in the study.

28
Abbreviated Title:  COXes in MS
Version Date:  04/20/23

Before a participant is deemed lost to follow-up, the PI or their designee will make every 
effort to regain contact with the participant (where possible, three telephone calls and, if 
necessary, a certified letter to the participant’s last known mailing address or local 
equivalent methods). These contact attempts will be documented in the participant’s 
medical record or study file. 

Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.
8
STUDY ASSESSMENTS AND PROCEDURES
8.1
SCREENING PROCEDURES
8.1.1
Screening activities performed prior to obtaining informed consent
The following activities may be performed before the subject has signed a consent include the 
following: 

Email, written, in person or telephone communications with prospective subjects. 

Review of existing medical records to include H&P, laboratory studies, etc.  

Review of existing MRI, x-ray, or CT images.

Review of existing photographs or videos.

Review of existing pathology specimens/reports from a specimen obtained for diagnostic 
purposes.

Obtain medical release form
Patients will be evaluated for their ability and willingness to tolerate study procedures such as 
lying still in the PET scanner; their caregivers will be also interviewed to provide information 
about tolerability. 
Some clinical data will be taken from protocol HP-00079860, including patient demographic 
characteristics, details on multiple sclerosis history and treatment history, disability scales which 
may include ((EDSS (Expanded Disability Status Scale), MSFC (multiple sclerosis functional 
composite), low contrast visual acuity, MFIS (modified fatigue impact scale), and the BICAMS 
(Brief international cognitive assessment for MS) cognitive battery.)
Clinical ratings will be obtained from UMB for the MS volunteers to describe the patient 
population in future publications. However, we will not correlate current rating scales with the 
PET findings, because current dysfunction represents the sum of prior plaques that are now 
quiescent and new plaques(s) with active neuroinflammation.
8.1.2
Screening activities performed after a consent for screening has been signed
The following activities will be performed only after the subject has signed the consent this 
study. Assessments performed at outside facilities or on another NIH protocol within the 
timeframes below may also be used to determine eligibility once a participant has signed the 
consent.
All screening tests and procedures must be performed within 28 days prior to enrollment unless a 
time period is specifically mentioned.
If the following screening tests have been performed up to 28 days before enrollment they won’t 
be repeated under this protocol:

29
Abbreviated Title:  COXes in MS
Version Date:  04/20/23

General medical history, 

physical examination, 

four vital signs, 

EKG, 
Screening labs (done within 28 days) Patients will be evaluated for their ability and 
willingness to tolerate study procedures such as lying still in the PET scanner; their caregivers 
will be also interviewed to provide information about tolerability.
8.2
EFFICACY ASSESSMENTS
In addition to the screening procedures described in Section 8.1, all participants will undergo:

Physical examination Subjects will undergo a comprehensive medical history and 
examination by a credentialed investigator. The purpose of the medical history and 
examination is to rule out a medical condition as the cause of the subject’s signs and 
symptoms, and to determine if subjects are eligible for enrollment in other protocols.

Electrocardiograms (EKGs): EKG is for screening purposes only. Screening EKGs are 
taken in the Heart Station Department and results are directly reported in CRIS.

Pregnancy Tests. For women of childbearing potential, urine pregnancy testing will be 
done within the 24 hours prior to any PET scan. If the pregnancy test is positive, the PET 
will not be done, and the participant will be removed from the protocol.

8.2.1
PET Procedures

Radioligand. [11C]PS13 and [11C]MC1 will be prepared according to the IND and 
administered via an indwelling intravenous catheter over approximately one to three 
minutes.

Insertion of the intravenous line. An intravenous line will be placed in the arm. The 
venous line will be used to inject the radioligand and will be removed at the end of 
the day. The IV line may be replaced if it fails to remain patent.

PET scans. The two baseline/blocked scans for COX-1 and COX-2 each may occur 
on the same or on different days. Brain PET imaging will be performed using a PET 
or PET/CT scanner for up to two hours. Participants will be placed on the scanner 
bed. The participant’s head may be secured with a head holder or a thermoplastic 
mask to prevent excessive motion, but the mask can be removed if the participant 
finds it uncomfortable. A CT transmission scan will be performed to measure and 
correct for attenuation. Tracer infusions will be performed when the participant is 
already on the scanner bed. The total amount of blood withdrawal is described in 
Section 8.2.5. When the scan is completed, the venous line will be removed, and the 
participant will be instructed to void frequently to minimize radiation exposure. 

Administration of celecoxib. In these scans, specific binding of [11C]MC1 to COX-2 
in the brain will be verified by a pre-blocking study using celecoxib (600 mg PO). 
Participants will be encouraged to have a light meal prior to PET studies with 
blockade by celecoxib. After oral administration, the plasma concentration peaks at 
about two hours [23]. Thus, we will administer celecoxib about two hours before the 
second PET scan. Participants will be monitored by study clinicians after drug 
administration to assess drug associated adverse events. To allow the drug’s effect to 

30
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
resolve, we will wait for at least two days to perform the second set of PET scans 
with ketoprofen.

Administration of ketoprofen. In these scans, specific binding of [11C]PS13 to COX-1 
in the brain will be verified by a pre-blocking study using ketoprofen (75 mg PO). 
Participants will be encouraged to have a light meal prior to PET studies with 
blockade by ketoprofen. Similar to protocol 17-M-0179, which showed peripheral 
organ blockade, we will administer ketoprofen about two hours before the second 
PET scan. Participants will be monitored by study clinicians after drug administration 
to assess drug associated adverse events. To allow the drug’s effect to resolve, we 
will wait for at least two days to perform the second set of PET scans with celecoxib.
8.2.2
Biospecimen Evaluations
Safety labs will include chemistry panel and complete blood count. Women age of child-
bearing potential (age 55 or younger without history of sterilization) will be tested for pregnancy. 
Women older than 55 years will also be tested for pregnancy unless they have not had menses 
for one year.
The amount of blood that will be drawn for research purposes, including screening, will 
not exceed 10.5 mL/kg or 550 mL, whichever is smaller, over any eight-week period.
8.2.3
Correlative Studies for Research/Pharmacokinetic Studies
Not applicable.
8.2.4
Samples for Genetic/Genomic Analysis
Not applicable.
8.3
SAFETY AND OTHER ASSESSMENTS

Safety Monitoring of PET Scans. Data for safety monitoring will be recorded at three 
timepoints: no more than three hours before injection, about the middle of the PET 
scan, and after the PET scan. Recorded data include: blood pressure, pulse, 
respiratory rate, and EKG (either 3- or 12-lead). The following laboratory tests will 
also be obtained, but only at two timepoints (before and after the PET scan): CBC, 
acute care panel (Na, K, Cl, CO2, creatinine, glucose, urea nitrogen).

Pregnancy Tests.  For women of childbearing potential, urine pregnancy testing will 
be done within the 24 hours prior to any PET scan. If the pregnancy test is positive, 
PET will not be done, and the subject will be taken off the protocol.

Follow-up Procedures. Subjects will be contacted one to three business days after 
each PET scan to determine whether they have had any untoward sequelae.
8.4
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS
8.4.1
Definition of Adverse Event
Adverse Events (AE) are defined as any untoward medical occurrence associated with the 
use of an intervention in humans, whether or not the AE is considered intervention-related (21 
CFR 312.32 (a)).

31
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
8.4.2
Definition of Serious Adverse Events (SAE)
An AE or suspected adverse reaction is considered "serious" if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes: death; a life-threatening AE; 
inpatient hospitalization or prolongation of existing hospitalization; a persistent or significant 
incapacity or substantial disruption of the ability to conduct normal life functions; or a congenital 
anomaly/birth defect. Important medical events that do not result in death, are not life-
threatening, or do not require hospitalization may be considered serious when, based upon 
appropriate medical judgment, they may jeopardize the participant and may require medical or 
surgical intervention to prevent one of the outcomes listed in this definition. Examples of such 
medical events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias or convulsions that do not result in inpatient hospitalization, 
or the development of drug dependency or drug abuse.
In consultation with the PI, a trained member of the study team will be responsible for 
conducting an evaluation of all adverse events and shall report the results of such evaluation to 
the NIH Institutional Review Board (IRB) as per Policy 801."
8.4.3
Classification of an Adverse Event
8.4.3.1
Severity of Event
The following guidelines will be used to describe severity. 
•
Mild – Events require minimal or no treatment and do not interfere with the 
participant’s daily activities. 
•
Moderate – Events result in a low level of inconvenience or concern with the 
therapeutic measures. Moderate events may cause some interference with 
functioning.
•
Severe – Events interrupt a participant’s usual daily activity and may require 
systemic drug therapy or other treatment. Severe events are usually potentially life-
threatening or incapacitating. Notably, the term “severe” does not necessarily equate 
to “serious”.
8.4.3.2
Relationship to Study Intervention
All adverse events (AEs) must have their relationship to study intervention assessed by 
the investigator who will examine and evaluate the participant based on temporal relationship 
and his/her clinical judgment. The degree of certainty about causality will be graded using the 
categories below. In a clinical trial, the study product must always be suspect. 
•
Definitely Related – There is clear evidence to suggest a causal relationship, and other 
possible contributing factors can be ruled out. The clinical event, including an abnormal 
laboratory test result, occurs within a plausible time relationship to study intervention 
administration and cannot be explained by concurrent disease or other drugs or 
chemicals. The response to withdrawal of the study intervention (dechallenge) should be 
clinically plausible. The event must be pharmacologically or phenomenologically 
definitive, with use of a satisfactory rechallenge procedure if necessary.
•
Probably Related – There is evidence to suggest a causal relationship, and the influence 
of other factors is unlikely. The clinical event, including an abnormal laboratory test 
result, occurs within a reasonable time after administration of the study intervention, is 
unlikely to be attributed to concurrent disease or other drugs or chemicals, and follows a 

32
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
clinically reasonable response on withdrawal (dechallenge). Rechallenge information is 
not required to fulfill this definition.
•
Potentially Related – There is some evidence to suggest a causal relationship (e.g., the 
event occurred within a reasonable time after administration of the trial medication). 
However, other factors may have contributed to the event (e.g., the participant’s clinical 
condition, other concomitant events). Although an AE may rate only as “possibly related” 
soon after discovery, it can be flagged as requiring more information and later be 
upgraded to “probably related” or “definitely related”, as appropriate.
•
Unlikely to be related – A clinical event, including an abnormal laboratory test result, 
whose temporal relationship to study intervention administration makes a causal 
relationship improbable (e.g., the event did not occur within a reasonable time after 
administration of the study intervention) and in which other drugs or chemicals or 
underlying disease provide plausible explanations (e.g., the participant’s clinical 
condition, other concomitant treatments).
•
Not Related – The AE is completely independent of study intervention administration, 
and/or evidence exists that the event is definitely related to another etiology. There must 
be an alternative, definitive etiology documented by the clinician.
8.4.3.3
Expectedness 
The PI will be responsible for determining whether an AE is expected or unexpected.  An 
AE will be considered unexpected if the nature, severity, or frequency of the event is not 
consistent with the risk information previously described for the study intervention.
8.4.4
Time Period and Frequency for Event Assessment and Follow-Up
The occurrence of an AE or serious adverse event (SAE) may come to the attention of 
study personnel during study visits and interviews of a study participant presenting for medical 
care, or upon review by a study monitor.
All AEs including local and systemic reactions not meeting the criteria for SAEs will be 
captured on the appropriate case report form (CRF). Information to be collected includes event 
description, time of onset, clinician’s assessment of severity, relationship to study product 
(assessed only by those with the training and authority to make a diagnosis), and time of 
resolution/stabilization of the event. All AEs occurring during the study must be documented 
appropriately regardless of relationship. All AEs will be followed to adequate resolution.
Any medical condition that is present at the time that the participant is screened will be 
considered as baseline and not reported as an AE. However, if the study participant’s condition 
deteriorates at any time during the study, it will be recorded as an AE. 
Changes in the severity of an AE will be documented to allow an assessment of the 
duration of the event at each level of severity to be performed. AEs characterized as intermittent 
require documentation of onset and duration of each episode.
Credentialed clinicians will record all reportable events with start dates occurring any 
time after informed consent is obtained until seven (for non-SAEs) or 30 days (for SAEs) after 
the last day of study participation. At each study visit, the investigator will inquire about the 
occurrence of AE/SAEs since the last visit. Events will be followed for outcome information 
until resolution or stabilization.

33
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
8.4.5
Adverse Event Reporting 
Non-SAEs will be reported to the ISM (annually), to the IRB at the time of Continuing 
Review and to the Sponsor at regular intervals per request.
8.4.6
Serious Adverse Event Reporting 
It is both the Principal Investigator’s (PI) and the Sponsor’s responsibility to ensure the 
safety of those on the clinical trial.  The PI is responsible for tracking adverse events during the 
study and providing adverse events lists to the Sponsor at regular intervals per request. These 
may be requested quarterly and will be requested no less than once a year at the time of IND 
annual report to the FDA. ALL AEs that are collected, as determined by the written protocol, 
should be tracked in the ORSC RSS’ template AE Tracker or similar document. If the sponsor 
determines that adverse events are occurring more frequently or more severely than the written 
protocol had expected and/or anticipated, this should be submitted in an IND Safety Report, as 
described below. In addition, the PI is responsible for updating the Sponsor about known risks 
from the drug, as discovered from literature searches or other means.  In addition, the PI is 
responsible for updating the Sponsor about known risks from the drug, as discovered from 
literature searches or other means.
In accordance with the requirements of 21 CFR 312.32, the PI or designee will report all 
SAEs, whether or not these are considered related to the investigational drug or study 
intervention, that occur throughout the study to the Sponsor, including those events listed in the 
protocol or Investigator’s Brochure as anticipated to occur, as follows: 
Deaths:  within 24 hours of the investigator’s* awareness
All other SAEs:  within 48 hours of the investigator’s awareness
All AEs will be sent to the Sponsor quarterly, unless requested more or less 
frequently, for submission to the FDA in the IND Annual Report.
*“Investigator’s awareness” includes awareness by anyone on the study team.
The PI will immediately report all deaths and SAEs to the Sponsor by disclosing all 
event-related information in a completed MedWatch Form 3500A. This form should include the 
IND number, protocol number, PI name, and an assessment on the reasonable possibility of a 
relationship between the event and the study drug or intervention. MRNs should NOT be 
included on this form. The completed MedWatch Form 3500A will be sent ENCRYPTED to 
the Clinical Director/CEO and/or designated medical monitor with a copy to the NIH Office of 
Research Support & Compliance (ORSC) Regulatory Support Section.
The Clinical Director/CEO and/or designated medical monitor will be responsible for 
determining whether the event is reportable to the FDA as an IND Safety Report if it is a serious, 
unexpected, and suspected adverse reaction (SUSAR). If the sponsor determines the SAE meets 
the criteria of a SUSAR, the ORSC will submit an Initial IND Safety Report to the FDA no later 
than 15 calendar days after the PI’s notification of the event to the Sponsor. Deaths or life-
threatening events will be reported to the FDA no later than 7 calendar days after the PI’s 
notification of the event to the Sponsor. The Sponsor will submit any relevant additional 
information in a Follow-up IND Safety Report no later than 15 calendar days after receiving the 
information. All SAEs will be monitored until satisfactory resolution. All AEs and SAEs will be 
documented on appropriate study records.

34
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
8.4.7
Events of Special Interest 
None.
8.4.8
Reporting of Pregnancy 
Subjects will be excluded if they are or may become pregnant.
8.5
UNANTICIPATED PROBLEMS
8.5.1
Definition of Unanticipated Problems (UP)
Any incident, experience, or outcome that meets all of the following criteria:
•
Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the Institutional Review 
Board (IRB)-approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; and
•
Related or possibly related to participation in the research (“possibly related” means there 
is a reasonable possibility that the incident, experience, or outcome may have been 
caused by the procedures involved in the research); and
•
Suggests that the research places participants or others (which many include research 
staff, family members, or other individuals not directly participating in the research) at a 
greater risk of harm (including physical, psychological, economic, or social harm) than 
was previously known or expected.
8.5.2
 Unanticipated Problem Reporting 
The investigator will report unanticipated problems (UPs) to the NIH Institutional 
Review Board (IRB) as per Policy 801.
8.5.3
NIH Intramural IRB Reporting of IND Safety Reports
Only IND Safety Reports that meet the definition of an unanticipated problem will need to 
be reported to the NIH Intramural IRB.
9
STATISTICAL CONSIDERATIONS
9.1
STATISTICAL HYPOTHESIS

Primary Endpoint: We hypothesize that administration of ketoprofen or celecoxib 
will reduce COX-1 or COX-2 levels (measured as SUVR between a lesion and a 
reference region such as the contralateral mirror image of the lesion) in MS 
lesions. Please note that detectable or specific binding is defined as that which can 
be displaced by a COX selective inhibitor. Thus, the primary objective 
“detectable binding” will be assessed with the primary endpoint “displaceable 
binding.”

Secondary Endpoint: 1) We hypothesize that more active MS lesions will have 
higher levels of COX-1 and COX-2 specific binding than less active ones, and 
that MS lesions will have higher binding than normal white matter. Active lesions 
will be identified as those that show contrast enhancement with administration of 
gadolinium. Chronic-active lesions will be identified as those who have a 
paramagnetic outer rim identified on ME-GRE images that have been processed 
for quantitative susceptibility maps (QSM). Inactive lesions will be white matter 

35
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
lesions that do not meet criteria for active or chronic-active. Normal appearing 
white matter will be all white matter minus lesioned white matter. 2) We 
hypothesize that the expressions of COX-1 and COX-2 are correlated within the 
same individuals.
9.2
SAMPLE SIZE DETERMINATION
Using novel radioligands, this pilot study will attempt to measure the density of COX-1 
and COX-2. When the standard deviation and the effect size are unknown, the resource equation 
method provides an alternative to the power analysis for calculating sample size [24-27]. This 
method is based on the law of diminishing returns and is normally used in animal experiments to 
minimize the number of animals committed to an exploratory study. The minimum and 
maximum sample sizes calculated using the equation are: 
minimum n = 10/k + 1 
maximum n = 20/k + 1
where k = number of groups and n = number of samples per group
For example, if there are two groups to compare (e.g., baseline vs blocked studies in the 
same participants), the minimum n = 10/2 + 1 = 6 and the maximum n = 20/2 + 1 = 11. 
Expressed in other terms, using fewer than six participants per group would have little value 
because of a high rate of false negatives. On the other hand, using more than 11 participants per 
group would have diminishing return of true positives.
Following this statistical approach, we request to scan 11 participants per group.  Because 
of the failure rate for completing all scans is 30-40%, we request permission to accrue 16 
participants per group. 
9.3
POPULATIONS FOR ANALYSES
Using a within-subject comparison, the baseline scan of each MS participant will be 
compared to that after blockade
9.3.1
Evaluable for toxicity 
No toxicity is expected from the radioligand; nevertheless, safety will be monitored as 
described in Section 8.3. Regarding the two blockers, participants will be asked if they have any 
discomfort or side effects after its administration and within one to three days after the PET scan 
via telephone.
9.3.2
Evaluable for objective response 
No therapeutic response is expected from the radioligand as we are testing a diagnostic 
agent at sub-pharmacological doses.
9.3.3
Evaluable Non-Target Disease Response
Not applicable.
9.4
STATISTICAL ANALYSES
9.4.1
General Approach
Two-tailed paired: t-tests will be used to assess whether there are statistically significant 
differences between PET scans at baseline and after blockade.

36
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
ANOVA will be used to assess whether COX-1 and COX-2 binding differs in active, 
chronic-active, and inactive lesions, and normal appearing white matter.
Correlation analyses will be used to correlate the uptake of COX-1 and COX-2 in the 
same lesions of the same subjects.
9.4.2
Analysis of the Primary Endpoints
The outcome measure for the primary endpoint will be SUVR between the lesion and a 
reference region such as the contralateral mirror image of the lesion.
9.4.3
Analysis of the Secondary Endpoint(s)
The outcome measure for the secondary endpoint will be SUVR between the lesion and a 
reference region such as the contralateral mirror image of the lesion, and between the SUVR in 
the same lesions imaged with both tracers.
9.4.4
Safety Analyses
The safety measurements will be recorded but not analyzed statistically.
9.4.5
Baseline Descriptive Statistics
None.
9.4.6
Planned Interim Analyses
None.
9.4.7
Sub-Group Analyses
None.
9.4.8
Tabulation of individual Participant Data
Individual participant data will be listed by measure and timepoint.
9.4.9
Exploratory Analyses
None.
10 REGULATORY AND OPERATIONAL CONSIDERATIONS
10.1
INFORMED CONSENT PROCESS
10.1.1 Consent/Assent Procedures and Documentation
Only the study investigators designated to obtain consent will be allowed to do so. All 
study investigators obtaining informed consent must have completed the NIMH HSPU training 
“Elements of Successful Informed Consent”.
The informed consent document will be provided as a physical or electronic document to 
the participant or consent designee as applicable for review prior to consenting. A designated 
study investigator will carefully explain the procedures and tests involved in this study, and the 
associated risks, discomfort and benefits. In order to minimize potential coercion, as much time 
as is needed to review the document will be given, including an opportunity to discuss it with 
friends, family members and/or other advisors, and to ask questions of any designated study 
investigator. A signed informed consent document will be obtained prior to any research 
activities taking place.

37
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
The initial consent process as well as re-consent, when required, may take place in person 
or remotely (e.g., via telephone or other NIH approved remote platforms used in compliance 
with policy, including HRPP Policy 303) per discretion of the designated study investigator and 
with the agreement of the participant/consent designee(s). Whether in person or remote, the 
privacy of the subject will be maintained. Consenting investigators (and participant when in 
person) will be located in a private area (e.g., clinic consult room). When consent is conducted 
remotely, the participant will be informed of the private nature of the discussion and will be 
encouraged to relocate to a more private setting if needed. If the consent process is occurring 
remotely, participants and investigators will view individual copies of the approved consent 
document on screens at their respective locations; the same screen may be used when both the 
investigator and the participant are co-located but this is not required.
Note: When required, the witness signature will be obtained similarly as described for the 
investigator and participant below.
When a hand signature on an electronic document is used for the documentation of 
consent, this study will use the following electronic platform to obtain the required signatures:
•
iMed Consent platform (which is 21 CFR Part 11 compliant)
Both the investigator and the participant will sign the electronic document using a finger, 
stylus or mouse. Electronic signatures (i.e., the “signature” and a timestamp are digitally 
generated) will not be used.
The consent process will be documented in CRIS. A copy of the consent form will be 
given to the participant and also uploaded in CRIS.
10.1.2 Consent for minors when they reach the age of majority 
Not applicable.
10.1.3 Considerations for Consent of NIH staff, or family members of study team members
NIH staff and family members of study team members may not be enrolled in this study.
10.1.4 Consent of Subjects who are, or become, decisionally impaired
Adults unable to give consent are excluded from enrolling in the protocol.  However, it is 
possible that subjects enrolled in the protocol may lose the capacity to consent for themselves.  
In the event this occurs, the subjects will be removed from the study.
10.2
STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. If the study is prematurely terminated or suspended, the PI will promptly 
inform study participants, the IRB, and the Sponsor. Study participants will be contacted, as 
applicable, and be informed of changes to the study visit schedule.
 
Circumstances that may warrant termination or suspension include, but are not limited to:

Determination of unexpected, significant, or unacceptable risk to participants.

Demonstration of efficacy that would warrant stopping.

Insufficient compliance with protocol requirements.

Data that are not sufficiently complete and/or evaluable.

38
Abbreviated Title:  COXes in MS
Version Date:  04/20/23

Determination that the primary endpoint has been met.

Determination of futility.
The study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the sponsor, the IRB, and/or the Food and Drug Administration (FDA).
10.3
CONFIDENTIALITY AND PRIVACY
Participant confidentiality and privacy are strictly held in trust by the participating 
investigators, their staff, and the sponsor(s). This confidentiality is extended to cover testing of 
biological samples in addition to the clinical information relating to participants. Therefore, the 
study protocol, documentation, data, and all other information generated will be held in strict 
confidence.
All research activities will be conducted in as private a setting as possible.
The study monitor, other authorized representatives of the sponsor, representatives of the 
IRB, and/or regulatory agencies may inspect all documents and records required to be 
maintained by the investigator, including but not limited to, medical records (office, clinic, or 
hospital) and pharmacy records for the participants in this study. The clinical study site will 
permit access to such records.
The study participant’s contact information will be securely stored at the NIH for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure 
location for as long a period as dictated by the reviewing IRB, institutional policies, or sponsor 
requirements.
To further protect the privacy of study participants, a Certificate of Confidentiality (COC) 
has been issued by the NIH. This certificate protects identifiable research information from 
forced disclosure. It allows the investigator and others who have access to research records to 
refuse to disclose identifying information on research participation in any civil, criminal, 
administrative, legislative, or other proceeding, whether at the federal, state, or local level. By 
protecting researchers and institutions from being compelled to disclose information that would 
identify research participants, COCs help achieve the research objectives and promote 
participation in studies by helping ensure confidentiality and privacy to participants.
See Section 10.4 for information regarding sharing of research data during or after 
completion of the study.
10.4
FUTURE USE OF STORED SPECIMENS AND DATA
Genetic testing will not be performed in this protocol. No samples will be stored or 
shared. 
In the consent form, we ask permission of the subject (yes/no response) to share 
imaging and other research during or after completion of the study with collaborating 
laboratories at the NIH or outside of the NIH and/or submitted to open-access repositories for 
secondary research that may or may not involve a collaboration with the NIMH.  Such open 
access repositories (e.g., OpenNeuro, sponsored by the NIMH) allow anyone to access the data 
for any purpose. Data will be stripped of all identifiers, including name, address, contact 
information, and medical record number prior to sharing. In addition, the face will be removed 
from MRI images. The data may be coded, but the key to the code will not be provided to any 
collaborator or party external to the NIH. After the study is completed, the de-identified data 

39
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
and the code may be indefinitely maintained at the NIH and used for secondary analysis. In 
contrast to data, no biological samples that you provide will be shared.
10.5
SAFETY OVERSIGHT
Monitoring for this study will be performed by the independent safety monitor (ISM) for 
this study, Michael Gregory, MD, who is with full clinical privileges at the NIH Clinical Center.  
The PI will prepare a report on data and safety parameters for the ISM approximately 
every 12 months. The ISM will provide a written monitoring report to be submitted to the IRB at 
the time of continuing review.
10.6
CLINICAL MONITORING
Clinical site monitoring is conducted to ensure that the rights and well-being of trial 
participants are protected, that the reported trial data are accurate, complete, and verifiable, and 
that the conduct of the trial complies with the currently approved protocol/amendment(s), with 
International Conference on Harmonization Good Clinical Practice (ICH GCP), and with 
applicable regulatory requirement(s). 
As per ICH-GCP 5.18 and FDA 21 CFR 312.50 clinical protocols are required to be 
adequately monitored. Monitoring for the NIH site will be conducted according to the "NIMH 
Intramural Program Guidelines for Monitoring of Clinical Trials". Monitors under contract to the 
NIMH OCD ORO will visit the NIH site to monitor aspects of the study in accordance with the 
appropriate regulations and the approved protocol. The objectives of a monitoring visit will be: 
1) to verify the existence of signed informed consent documents and documentation of the ICF 
process for each monitored subject; 2) to verify the prompt and accurate recording of all 
monitored data points, and prompt reporting of all SAEs; 3) to compare abstracted information 
from clinical databases (e.g. CTDB) with individual subjects' records and source documents 
(subjects' charts, laboratory analyses and test results, physicians' progress notes, nurses' notes, 
and any other relevant original subject information); and 4) to help ensure investigators are in 
compliance with the protocol. The monitors also will inspect the clinical site regulatory files to 
ensure that regulatory requirements (Office for Human Research Protections-OHRP), FDA, and 
applicable guidelines (ICH-GCP) are being followed. During the monitoring visits, the 
investigator (and/or designee) and other study personnel will be available to discuss the study 
progress and monitoring visit.
The investigator (and/or designee) will make study documents (e.g., consent forms, 
clinical database records and pertinent hospital/sources or clinical records readily available for 
inspection by the local IRB, FDA, the site monitors, and the NIMH staff for confirmation of the 
study data.
A specific protocol monitoring plan will be discussed with the Principal Investigator and 
study staff. The plan will outline the frequency of monitoring visits based on such factors as 
study enrollment, data collection status and regulatory obligations.
10.7
QUALITY ASSURANCE AND QUALITY CONTROL
Each clinical site will perform internal quality management of study conduct, data and 
biological specimen collection, documentation and completion.  
Following written Standard Operating Procedures (SOPs), the monitors will verify that 
the clinical trial is conducted and data are generated and biological specimens are collected, 

40
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
documented (recorded), and reported in compliance with the protocol, International Conference 
on Harmonization Good Clinical Practice (ICH GCP), and applicable regulatory requirements 
(e.g., Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). 
The investigational site will provide direct access to all trial related sites, source 
data/documents, and reports for the purpose of monitoring and auditing by the sponsor, and 
inspection by local and regulatory authorities.
10.8
DATA HANDLING AND RECORD KEEPING
10.8.1 Data Collection and Management Responsibilities
Data collection is the responsibility of the clinical trial staff at the site under the 
supervision of the PI. The PI is responsible for ensuring the accuracy, completeness, legibility, 
and timeliness of the data reported.
All source documents will be completed in a neat, legible manner to ensure accurate 
interpretation of data. Hardcopies of the study visit worksheets will be provided for use as source 
document worksheets for recording data for each participant enrolled in the study. Data recorded 
in the electronic case report form (eCRF) derived from source documents will be consistent with 
the data recorded on the source documents. 
Clinical data (including AEs, eligibility, and primary outcome data) will be entered into 
the Clinical Trials Database (CTDB) at NIH. CTDB complies with the Federal Information 
Security Management Act of 2002 and 21 CFR Part 11. The data system includes audit trail, 
password protection, and control staff access level to the application and data. Edit checks 
implemented at the eCRF include: data type validation and numeric range checks. Clinical data 
will be entered directly from the source documents.
10.8.2 Study Records Retention
Study documents will be retained for a minimum of two years after the last approval of a 
marketing application in an International Conference on Harmonisation (ICH) region and until 
there are no pending or contemplated marketing applications in an ICH region or until at least 
two years have elapsed since the formal discontinuation of clinical development of the study 
intervention, or as per the NIH Intramural Records Retention Schedule. No records will be 
destroyed without the written consent of the sponsor, if applicable. It is the responsibility of the 
sponsor to inform the investigator when these documents no longer need to be retained.
10.9
PROTOCOL DEVIATIONS AND NON-COMPLIANCE
The PI will use continuous vigilance to identify and report deviations to the NIH 
Institutional Review Board as per Policy 801. All deviations will be addressed in study source 
documents, reported to the NIMH Program Official and the IND sponsor; Dr. Maryland Pao, 
Clinical Director, holds both of these positions. The investigator will be responsible for knowing 
and adhering to the reviewing IRB requirements.
10.9.1 NIH Definition of Protocol Deviation
A protocol deviation is any changed, divergence, or departure from the IRB-approved 
research protocol. 

Major deviations: Deviations from the IRB approved protocol that have, or may have the 
potential to, negatively impact the rights, welfare or safety of the subject, or to 
substantially negatively impact the scientific integrity or validity of the study.

41
Abbreviated Title:  COXes in MS
Version Date:  04/20/23

Minor deviations: Deviations that do not have the potential to negatively impact the 
rights, safety or welfare of subjects or others, or the scientific integrity or validity of the 
study.
10.10 PUBLICATION AND DATA SHARING POLICY
10.10.1
Human Data Sharing Plan
This study will be conducted in accordance with the NIH Public Access Policy, which 
ensures that the public has access to the published results of NIH-funded research. It requires 
scientists to submit final peer-reviewed journal manuscripts that arise from NIH funds to the 
digital archive PubMed Central upon acceptance for publication. This study will also comply 
with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded Clinical Trial 
Information and the Clinical Trials Registration and Results Information Submission rule. The 
trial will be registered at ClinicalTrials.gov, and results information from this trial will be 
submitted to ClinicalTrials.gov. In addition, every attempt will be made to publish results in 
peer-reviewed journals.  
10.10.2
 Genomic Data Sharing Plan
No genomic data will be acquired during this study.
10.11 COLLABORATIVE AGREEMENTS 
10.11.1
 Agreement Type
Transfers that are associated with correlative studies conducted under an approved 
protocol: Investigators in the NIH intramural program may participate in multi-site clinical trials 
(either as a site or as the coordinating center) under which data will be transferred from the 
intramural program to another site for correlative studies that are part of the approved protocol. 
In such a situation, the protocol clearly documents the tests conducted under the correlative 
studies, and each institution participating in the clinical study is bound by the terms of their 
Protocol and their obligations are cleared by the IC Clinical Director. In such situations, use of 
an MTA is not necessary for these transfers.
This is a multisite study with NIH as the lead site. The other site is University of Maryland, 
Baltimore.
This protocol is a collaboration with investigators at UMB, and it will be performed under a 
Reliance Agreement in which NIH is the responsible IRB. Investigators at UMB will recruit and 
screen volunteers with MS and give NIMH’s contact information for potential PET study.  They 
may also ask the volunteers if their contact information with NIMH investigators to contact them 
directly. If the volunteer is interested to participate, we’ll ask him/her to sign UMB’s release of 
medical information for both clinical and research data to be sent to NIMH. If the volunteer is 
eligible based on this information, the volunteer will be asked to visit NIMH to review and sign 
the consent form. That is, only NIMH investigators will obtain consent. After the consent is 
obtained, we will order any additional data for inclusion and exclusion criteria as specified in this 
protocol. Investigators at NIMH and UMB will bilaterally share clinical and research data that 
may include PII.

42
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
10.12 CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed 
and managed. Furthermore, persons who have a perceived conflict of interest will be required to 
have such conflicts managed in a way that is appropriate to their participation in the design and 
conduct of this trial. The study leadership, in conjunction with the NIMH, has established 
policies and procedures for all study group members to disclose all conflicts of interest and will 
establish a mechanism for managing all reported dualities of interest.
11 ABBREVIATIONS
AE
Adverse Event
CFR
Code of Federal Regulations
COC
Certificate of Confidentiality
CONSORT
Consolidated Standards of Reporting Trials
COX
Cyclooxygenase
CRF
Case Report Form
DCC
Data Coordinating Center
DHHS
Department of Health and Human Services
DSMB
Data Safety Monitoring Board
eCRF
Electronic Case Report Forms
FDA
Food and Drug Administration
 fP
Free fraction in plasma
GCP
Good Clinical Practice
GLP
Good Laboratory Practices
GMP
Good Manufacturing Practices
ICH
International Conference on Harmonisation 
IND
Investigational New Drug Application
IRB
Institutional Review Board
ISM
Independent Safety Monitor
LPS
Lipopolysaccharide
MRI
Magnetic resonance imaging
MS
Multiple Sclerosis
NCT
National Clinical Trial
NIH 
National Institutes of Health
NIH IC
NIH Institute or Center
NIMH
National Institutes of Mental Health
NSAID
Non-steroidal anti-inflammatory drug
OHRP
Office for Human Research Protections
PBR
Peripheral benzodiazepine receptor
PET
Positron emission tomography
PI
Principal Investigator
SAE
Serious Adverse Event

43
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
SMC
Safety Monitoring Committee
SOA
Schedule of Activities
SOP
Standard Operating Procedure
UP
Unanticipated Problem
US
United States
VT
Total (specific plus nondisplaceable) distribution volume

44
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
12 REFERENCES 
1.
Shrestha S, Kim MJ, Eldridge M, Lehmann ML, Frankland M, Liow JS, Yu Z-X, Cortes-
Salva MY, Telu S, Henter ID et al: PET measurement of cyclooxygenase-2 using a 
novel radioligand: upregulation in primate neuroinflammation and first-in-human 
study. J Neuroinflammation 2020, 17:140.
2.
Compston A, Coles A: Multiple sclerosis. Lancet 2008, 372(9648):1502-1517.
3.
Lassmann H, van Horssen J, Mahad D: Progressive multiple sclerosis: pathology and 
pathogenesis. Nat Rev Neurol 2012, 8(11):647-656.
4.
Barkhof F: The clinico-radiological paradox in multiple sclerosis revisited. Current 
opinion in neurology 2002, 15(3):239-245.
5.
Kutzelnigg A, Lucchinetti CF, Stadelmann C, Bruck W, Rauschka H, Bergmann M, 
Schmidbauer M, Parisi JE, Lassmann H: Cortical demyelination and diffuse white 
matter injury in multiple sclerosis. Brain : a journal of neurology 2005, 128(Pt 
11):2705-2712.
6.
Cumming P, Burgher B, Patkar O, Breakspear M, Vasdev N, Thomas P, Liu GJ, Banati 
R: Sifting through the surfeit of neuroinflammation tracers. J Cereb Blood Flow 
Metab 2018, 38(2):204-224.
7.
Vowinckel E, Reutens D, Becher B, Verge G, Evans A, Owens T, Antel JP: PK11195 
binding to the peripheral benzodiazepine receptor as a marker of microglia 
activation in multiple sclerosis and experimental autoimmune encephalomyelitis. J 
Neurosci Res 1997, 50(2):345-353.
8.
Banati RB, Newcombe J, Gunn RN, Cagnin A, Turkheimer F, Heppner F, Price G, 
Wegner F, Giovannoni G, Miller DH et al: The peripheral benzodiazepine binding site 
in the brain in multiple sclerosis: quantitative in vivo imaging of microglia as a 
measure of disease activity. Brain 2000, 123 ( Pt 11):2321-2337.
9.
Briard E, Zoghbi SS, Imaizumi M, Gourley JP, Shetty HU, Hong J, Cropley V, Fujita M, 
Innis RB, Pike VW: Synthesis and evaluation in monkey of two sensitive 11C-labeled 
aryloxyanilide ligands for imaging brain peripheral benzodiazepine receptors in 
vivo. J Med Chem 2008, 51(1):17-30.
10.
Zanotti-Fregonara P, Zhang Y, Jenko KJ, Gladding RL, Zoghbi SS, Fujita M, Sbardella 
G, Castellano S, Taliani S, Martini C et al: Synthesis and evaluation of translocator 18 
kDa protein (TSPO) positron emission tomography (PET) radioligands with low 
binding sensitivity to human single nucleotide polymorphism rs6971. ACS chemical 
neuroscience 2014, 5(10):963-971.
11.
Ikawa M, Lohith TG, Shrestha S, Telu S, Zoghbi SS, Castellano S, Taliani S, Da Settimo 
F, Fujita M, Pike VW et al: 11C-ER176, a Radioligand for 18-kDa Translocator 
Protein, Has Adequate Sensitivity to Robustly Image All Three Affinity Genotypes 
in Human Brain. J Nucl Med 2017, 58(2):320-325.

45
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
12.
Masuch A, Shieh CH, van Rooijen N, van Calker D, Biber K: Mechanism of microglia 
neuroprotection: Involvement of P2X7, TNFα, and valproic acid. Glia 2016, 
64(1):76-89.
13.
Rissanen E, Virta JR, Paavilainen T, Tuisku J, Helin S, Luoto P, Parkkola R, Rinne JO, 
Airas L: Adenosine A2A receptors in secondary progressive multiple sclerosis: a 
[(11)C]TMSX brain PET study. J Cereb Blood Flow Metab 2013, 33(9):1394-1401.
14.
Hsieh HL, Yang CM: Role of redox signaling in neuroinflammation and 
neurodegenerative diseases. Biomed Res Int 2013, 2013:484613.
15.
Rose JW, Hill KE, Watt HE, Carlson NG: Inflammatory cell expression of 
cyclooxygenase-2 in the multiple sclerosis lesion. Journal of Neuroimmunology 2004, 
149(1):40-49.
16.
Kim MJ, Shrestha S, Cortes M, Singh P, Morse CL, Liow JS, Gladding RL, Brouwer C, 
Henry K, Gallagher E et al: Evaluation of two potent and selective PET radioligands 
to image COX-1 and COX-2 in rhesus monkeys. J Nucl Med 2018, 59:1907-1912.
17.
Kim MJ, Lee J-H, Juarez Anaya F, Hong J, Miller W, Telu S, Morse C, Singh P, Cortes-
Salva MY, Henry K et al: First-in-human evaluation of [11C]PS13, a novel PET 
radioligand, to quantify cyclooxygenase-1 in brain. Eur J Nucl Med Mol Imaging 
2020, May 12 [epub ahead of print].
18.
Silverstein FE, Faich G, Goldstein JL, Simon LS, Pincus T, Whelton A, Makuch R, Eisen 
G, Agrawal NM, Stenson WF et al: Gastrointestinal toxicity with celecoxib vs 
nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: 
the CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis 
Safety Study. JAMA 2000, 284:1247-1255.
19.
McKenna F, Borenstein D, Wendt H, Wallemark C, Lefkowith JB, Geis GS: Celecoxib 
versus diclofenac in the management of osteoarthritis of the knee. Scand J Rheumatol 
2001, 30:11-18.
20.
Geba GP, Weaver AL, Polis AB, Dixon ME, Schnitzer TJ: Efficacy of rofecoxib, 
celecoxib, and acetaminophen in osteoarthritis of the knee: a randomized trial. 
JAMA 2002, 287:64-71.
21.
Pelliccia F, Pasceri V, Granatelli A, Pristipino C, Speciale G, Roncella A, Cianfrocca C, 
Mercuro G, Richichi G: Safety and efficacy of short-term celecoxib before elective 
percutaneous coronary intervention for stable angina pectoris. Am J Cardiol 2006, 
98:1461-1463.
22.
Motsko SP, Rascati KL, Busti AJ, Wilson JP, Barner JC, Lawson KA, Worchel J: 
Temporal relationship between use of NSAIDs, including selective COX-2 
inhibitors, and cardiovascular risk. Drug Saf 2006, 29:621-632.
23.
Paulson SK, Vaughn MB, Jessen SM, Lawal Y, Gresk CJ, Yan B, Maziasz TJ, Cook CS, 
Karim A: Pharmacokinetics of celecoxib after oral administration in dogs and 
humans: effect of food and site of absorption. J Pharmacol Exp Ther 2001, 297:638-
645.

46
Abbreviated Title:  COXes in MS
Version Date:  04/20/23
24.
Arifin WN, Zahiruddin WM: Sample size calculation in animal studies using resource 
equation approach. Malays J Med Sci 2017, 24:101-105.
25.
Charan J, Kantharia ND: How to calculate sample size in animal studies? J Pharmacol 
Pharmacother 2013, 4:303-306.
26.
Festing MF, Altman DG: Guidelines for the design and statistical analysis of 
experiments using laboratory animals. ILAR J 2002, 43:244-258.
27.
Festing MF: Design and statistical methods in studies using animal models of 
development. ILAR J 2006, 47:5-14.