Patent Abstract:
this invention relates to methods for the treatment or prevention of central nervous system cell damage and functional damage in mammals due to demyelinating disease including multiple sclerosis . more specifically , the invention comprises a method of treating a demyelinating disease of the cns in a mammal , the method comprising co - administering to the mammal , either sequentially or simultaneously , gpe or analogues or peptidomimetics or a prodrug thereof , or a pharmaceutically acceptable salt thereof , and an ampa / kainate antagonist , or a pharmaceutically acceptable salt thereof , and an anti - inflammatory agent .

Detailed Description:
as defined above , the invention provides a method for treating demyelinating diseases of the cns , that has particular application in treating the diseases at an advanced stage . the present invention resides in the applicant &# 39 ; s surprising finding that the effectiveness of the synergistic combination of gpe and the ampa / kainate antagonist nbqx agents can be enhanced by administration of an anti - inflammatory agent , such that the effectiveness of the neuroprotective agents and the anti - inflammatory agent in combination exceeds that of either the two neuroprotective agents or the anti - inflammatory agent when administered alone . the therapeutic methods of the invention therefore comprise administering gpe and an ampa / kainate antagonist and an anti - inflammatory agent , preferably an anti - inflammatory agent which inhibits the activity of a cell adhesion molecule and most preferably the anti - inflammatory agent is an antibody directed against the cell adhesion molecule madcam - 1 and / or its integrin α4 receptors ( α4β1 and ( α4β7 ), to a patient suffering from a demyelinating disease of the cns . the methods of the invention may be used to treat inflammatory diseases including autoimmune diseases including multiple sclerosis , as well as viral and bacterial induced encephalitis , and have particular application in treating advanced forms of the diseases . the compound nbqx is preferred as the ampa / kainate antagonist for use in the methods of the present invention . other anti - inflammatory agents that may be used in the methods of the present invention include anti - integrin alpha 4 subunit reagents , anti - integrin beta 7 subunit reagents , anti - integrin beta 2 subunit reagents , anti - integrin alpha l subunit reagents , anti - vcam - 1 reagents and anti - icam - 1 reagents . gpe and nbqx are anti - apoptotic and anti - necrotic . their anti - apoptotic and anti - necrotic activity in vivo can be measured by cell counts , by methods such as those discussed in klempt et al ., 1992 . their activity can also be measured in vitro . the therapeutic ratio of a compound can be determined , for example , by comparing the dose that gives effective anti - apoptotic and anti - necrotic activity in a suitable in vivo model such as experimental immune encephalomyelitis [ mendel et al ., 1995 ] in a suitable animal species such as the mouse , with the dose that gives significant weight change ( or other observable side - effects ) in the test animal species . in general , compounds of this invention will be administered in therapeutically effective amounts by any of the usual modes known in the art , either singly or in combination with at least one other compound of this invention and / or at least one other conventional therapeutic agent for the disease being treated . a therapeutically effective amount may vary widely depending on the disease or injury , its severity , the age and relative health of the patient being treated , the potency of the compound ( s ), and other factors . as an anti - apoptotic and anti - necrotic agent , therapeutically effective amounts of gpe in this invention may range from 1 μg to 100 mg per kilogram ( mg / kg ) mass of the animal , for example , 0 . 1 to 10 mg / kg , with lower doses such as 0 . 001 to 0 . 1 mg / kg , eg . about 0 . 01 mg / kg , being appropriate for administration through the cerebrospinal fluid , such as by intracerebroventricular administration , and higher doses such as 1 to 100 mg / kg , e . g . about 10 mg / kg , being appropriate for administration by methods such as oral , systemic ( eg . transdermal ), or parenteral ( eg . intravenous ) administration . a person of ordinary skill in the art will be able without undue experimentation , having regard to that skill and this disclosure , to determine a therapeutically effective amount of a compound of this invention for a given disease or injury . as an anti - apoptotic and anti - necrotic agent , therapeutically effective amounts of nbqx in this invention may range from 60 μg to 600 mg per kilogram ( mg / kg ) mass of the animal , for example , 0 . 6 to 60 mg / kg , with lower doses such as 0 . 006 to 0 . 6 mg / kg , e . g . about 0 . 06 mg / kg , being appropriate for administration through the cerebrospinal fluid , such as by intracerebroventricular administration , and higher doses such as 6 to 600 mg / kg , e . g . about 60 mg / kg , being appropriate for administration by methods such as oral , systemic ( e . g . transdermal ), or parenteral ( e . g . intravenous ) administration . a person of ordinary skill in the art will be able without undue experimentation , having regard to that skill and this disclosure , to determine a therapeutically effective amount of a compound of this invention for a given disease or injury . as an anti - inflammatory agent , therapeutically effective amounts of anti - madcam - 1 antibody in this invention may range from 30 μg to 300 mg per kilogram ( mg / kg ) mass of the animal , for example , 0 . 3 to 30 mg / kg , with lower doses such as 0 . 003 to 0 . 3 mg / kg , e . g . about 0 . 03 mg / kg , being appropriate for administration through the cerebrospinal fluid , such as by intracerebroventricular administration , and higher doses such as 3 to 300 mg / kg , e . g . about 30 mg / kg , being appropriate for administration by methods such as oral , systemic ( eg . transdermal ), or parenteral ( e . g . intravenous ) administration . a person of ordinary skill in the art will be able without undue experimentation , having regard to that skill and this disclosure , to determine a therapeutically effective amount of a compound of this invention for a given disease or injury . in general , compounds of this invention will be administered as pharmaceutical compositions by one of the following routes : oral , topical , systemic ( eg . transdermal , intranasal , or by suppository ), parenteral ( eg . intramuscular , subcutaneous , or intravenous injection ), by administration to the cns ( eg . by intraspinal or intracisternal injection ); by implantation , and by infusion through such devices as osmotic pumps , transdermal patches , and the like . compositions may take the form of tablets , pills , capsules , semisolids , powders , sustained release formulation , solutions , suspensions , elixirs , aerosols , or any other appropriate compositions ; and comprise at least one compound of this invention in combination with at least one pharmaceutically acceptable excipient . suitable excipients are well known to persons of ordinary skill in the art , and they , and the methods of formulating the compositions , may be found in such standard references as gennaro ar : remington : the science and practice of pharmacy , 20 th ed ., lippincott , williams & amp ; wilkins , 2000 . suitable liquid carriers , especially for injectable solutions , include water , aqueous saline solution , aqueous dextrose solution , and the like , with isotonic solutions being preferred for intravenous , intraspinal , and intracisternal administration and vehicles such as artificial cerebrospinal fluid being also especially suitable for administration of the compound to the cns . compounds of this invention are also suitably administered by a sustained - release system . suitable examples of sustained - release compositions include semi - permeable polymer matrices in the form of shaped articles , e . g ., films , or microcapsules . sustained - release matrices include polylactides ( u . s . pat . no . 3 , 773 , 919 ; ep 58 , 481 ), copolymers of l - glutamic acid and gamma - ethyl - l - glutamate ( sidman et al ., 1983 ), poly ( 2 - hydroxyethyl methacrylate ) ( langer et al ., 1981 ), ethylene vinyl acetate ( langer et al ., supra ), or poly - d -(−)- 3 - hydroxybutyric acid ( ep 133 , 988 ). sustained - release compositions also include a liposomally entrapped compound . liposomes containing the compound are prepared by methods known per se : de 3 , 218 , 121 ; hwang et al ., 1980 ; ep 52 , 322 ; ep 36 , 676 ; ep 88 , 046 ; ep 143 , 949 ; ep 142 , 641 ; japanese pat . appln . 83 - 118008 ; u . s . pat . nos . 4 , 485 , 045 and 4 , 544 , 545 ; and ep 102 , 324 . ordinarily , the liposomes are of the small ( from or about 200 to 800 angstroms ) unilamellar type in which the lipid content is greater than about 30 mole percent cholesterol , the selected proportion being adjusted for the most efficacious therapy . compounds of this invention may also be pegylated to increase their lifetime in vivo , based on , e . g ., the conjugate technology described in wo 95 / 32003 . desirably , if possible , when administered as anti - apoptotic and anti - necrotic agents , gpe and nbqx and an anti - madcam antibody , as an anti - inflammatory agent , will be administered orally . the amount of a compound of this invention in the composition may vary widely depending on the type of composition , size of a unit dosage , kind of excipients , and other factors well known to those of ordinary skill in the art . in general , the final composition may comprise from 0 . 0001 percent by weight (% w ) to 10 % w of the compound of this invention , preferably 0 . 001 % w to 1 % w , with the remainder being the excipient or excipients . the invention will now be described in more detail with reference to the following non - limiting examples . the following experimental protocol followed guidelines approved by the university of auckland animal ethics committee . c57bl / 6 mice ( 8 – 10 week old ) were injected subcutaneously in one flank with 300 μg of mog35 - 55 peptide ( mevgwyrspfsrvvhlyrngk : seq id no : 1 ) synthesized by mimotapes pty ltd , clayton , australia and emulsified in cfa containing 500 μg of mycobacterium tuberculosis h37ra ( difco laboratories , detrit , usa ). they also received 500 ng of pertussis toxin ( list biological laboratories , ca , usa ) in 200 μl pbs intravenously via the tail vein , followed 48 hours later by a second dose . a second injection of mog peptide was given in the absence of pertussis toxin one week later in the opposite flank , as described previously ( kanwar et al ., 2000b ). two treatment protocols were employed , involving the treatment of early disease , versus advanced disease . for early disease , reagents were administered at day 35 ( following mog injection ). antibody was administered thrice on alternate days , whereas neuroprotectors were given daily for 6 days , where 50 % of reagent was given ip and 50 % iv . in the treatment of advanced disease , therapy as above was initiated at day 60 , with either three or eight anti - madcam - 1 mab injections , and neuroprotectors given daily for either 7 or 18 days . the mice were monitored daily and scored according to the following scale : 0 , no clinical signs of eae ; 1 , limp tail ; 2 , partial hind limb paralysis ; 3 , complete hind limb paralysis ; 4 , complete hind limb and partial fore limb paralysis ; 5 , paralysis extending to diaphragm ; 6 , hind and fore limb paralysis ; 7 , death due to eae . paralysis extending to the diaphragm was denoted as difficulty in remaining upright . they had to be maintained in a state of hind - limb paralysis , hence care was shown in the provision of drinking water , food , and comfort . the daily mean clinical score for each group is the mean disease score of at least five mice . the body weight of animals was measured regularly throughout the experiments . the expanded disability status scale for eae treated mice was scored using an earlier published scoring system ( villoslada et al . 2000 ). the rat hybridoma meca - 367 ( rat igg2a ), 5 which secretes a mab against mouse madcam - 1 was either provided by dr eugene butcher , stanford university , stanford , calif . ( fig1 a and b ), or obtained directly from the american type culture collection , rockville , md . ( fig1 c , and remainder of studies ). rat igg obtained from sigma co ., usa , served as a control . antibodies were administered into the tail vein ( 70 % of mab ) and intraperitoneally ( 30 % of mab ) at 10 mg / kg separately or in combination on alternate days at the time points indicated ( fig1 – 4 ). the rat igg control antibody was also administered at 10 mg / kg . backbones from sacrificed mice were frozen in isopentane at − 70 ° c . transverse 10 μm sections made through the spinal cord of control and diseased mice , in each case made at the same levels of the cord , were mounted on poly l - lysine - coated slides , and stained with haematoxylin and eosin . an antibody to exon - 2 of mbp was raised in a rabbit by coupling a mouse mbp exon 2 peptide ( h - dshtrtthygslpqksqhgrtqdenpvvhffkncg - oh : seq id no : 2 ) to the carrier protein thyroglobulin . rabbits were immunized four times with 0 . 5 to 1 mg of peptide at 2 to 4 week intervals . the antibody titre was determined at 1 : 8000 by elisa . the antibody was used to stain the spinal cord sections at 1 : 50 dilution . mice were perfused through the left cardiac ventricle with ice - cold pbs or glutaraldehyde , and the cns including brain and spinal cord were prepared for frozen or epoxy sections , respectively . thin slices were taken at all levels of the cns including spinal cord ( cervical , midthoracic , t11 , t12 / 13 , upper lumbar , l6 , l7 and sacral ) and sacral roots . one - μm thick epoxy sections taken from different levels of the spinal cord were stained with toluidine blue , and examined by light microscopy by an investigator blinded to the sample identity . multiple sections from the spinal cord were scored from 0 to 5 for inflammation , demyelination , remyelination , and axonal necrosis or damage , using a previously published scoring system ( moore et al ., 2000 ). frozen sections from lumbar spinal cord ( 10 μm ) were acetone - fixed and immunostained for oligodendrocyte content with an antibody against cnpase ( sigma ; diluted 1 : 100 ); for axonal damage with an antibody against non - phosphorylated neurofilament - h ( sm 1 - 32 ; stemberger monoclonals incorporated , lutherville , md ., usa ; diluted 1 : 1000 ), and for glur2 and nr1 content using mouse mabs obtained from zymed laboratories inc ., carlton , san francisco , calif . antibody staining was visualized with an avidin : biotinylated enzyme complex ( vector laboratories , burlingame , calif ., usa ). sections were viewed under a light microscope , and cells stained with the anti - cnpase and sm 1 - 32 antibodies were counted . pbs - perfused spinal cords were homogenized in lysis buffer ( 50 mm tris ph 7 . 4 , 100 μm edta , 0 . 25 m sucrose , 1 % sodium dodecyl sulfate [ sds ], 1 % nonidet p - 40 [ np40 ], 1 μg / ml leupeptin , 1 μg / ml pepstatin a , and 100 μm phenylmethylsulfonylfluoride ) at 4 ° c . using a motor - driven homogenizer ( virtus , gardiner , n . y .). spinal cord lysates from each group of mice were pooled and centrifuged at 10000 g for 10 minutes at 4 ° c . to remove tissue debris . protein concentrations of the supernatants were determined as described ( peterson , 1983 ), and 100 μg of protein resolved on 10 % polyacrylamide sds - gels under reducing conditions and then electrophoretically transferred to hybond c extra nitrocellulose membranes ( amersham life science , england ). the membranes were blocked with 3 % bovine serum albumin in tbs - t ( 20 mm tris , 137 mm nacl , ph 7 . 6 containing 0 . 1 % tween - 20 ) for 2 hours at room temperature . immunodetection was accomplished by incubation overnight at 4 ° c . with sm1 - 32 ( 1 : 500 dilution ), anti - cnpase ( 1 : 100 dilution ) antibody , or anti - glur2 and nr1 mabs ( 1 : 200 dilution ). the membranes were washed thrice with tbs - t and incubated with horseradish peroxidase - conjugated anti - mouse igg ( sigma ) diluted 1 : 5000 in tbs - t . immunoreactivity was detected by enhanced chemiluminescence ( amersham international plc . england ) and autoradiography . cells undergoing apoptosis were identified using the in situ tunel assay . five - μm thick serial sections of brain and spinal cord were prepared to detect apoptosis by tunel ( i . e ., terminal deoxynucleotidyl transferase - mediated deoxyuridine triphosphate - digoxigenin nick end labeling ) staining using the in situ apoptosis detection kit from boehringer mannheim ( germany ). briefly , frozen sections were fixed in 4 % paraformaldehyde , permeabilized in 0 . 1 % triton x - 100 , incubated with 20 μl tunel reagent for 60 minutes at 37 ° c ., and then examined by fluorescence microscopy . adjacent sections were counterstained with hematoxylin and mounted onto poly - l - lysine coated slides to allow the total number of nucleated cells to be counted . the percentage of apoptotic cells was assessed in ten randomly selected fields viewed at 40 × magnification . the apoptotic index ( ai ) was calculated as follows : ai = number of apoptotic ( tunel - positive ) cells × 100 / total number of nucleated cells . suppression of the development of eae by early blockade of inflammation , and excitotoxic damage , or addition of neuroprotector gpe the first signs of clinical eae ensued between days 28 to 35 , depending on the particular batch of mog 35 - 55 peptide autoantigen , leading to chronic sustained paralysis of the hind limbs eight days later ( fig1 ). the prolonged persistence of clinical symptoms at the same level for several months is characteristic of mog - induced eae in the c57bl / 6 strain of mice ( mendel et al ., 1995 ). three iv and ip injections of anti - madcam - 1 mab , given on days 35 , 36 , and 37 following injection of autoantigen completely prevented the induction of eae such that no overt clinical symptoms could be observed for 60 days after suspension of antibody treatment ( fig1 a ). gpe given daily from day 35 for 6 days suppressed eae , up to 27 days after suspension of treatment ( disease score 0 . 4 to 2 . 2 compared to 2 . 6 to 5 . 9 for controls ). however , thereafter disease severity gradually increased . nbqx given daily for 6 days also suppressed eae , but to a greater extent than achieved with gpe , however as with gpe the severity of disease gradually increased 27 days following suspension of treatment . in contrast , combined treatment with gpe and nbqx led to sustained suppression of disease symptoms , at least for the 55 days the animals were monitored following suspension of treatment . the triple combination of anti - madcam - 1 mab , nbqx and gpe , as with anti - madcam - 1 mab alone completely prevented the development of disease in all mice . as described previously , anti - cam therapy to block inflammation is only preventative when administered early , prior to establishment of significant nerve damage . thus , three injections of anti - madcam - 1 mab at high dose starting on day 51 caused initial remission of disease , but this was quickly followed by a gradual and complete relapse after suspension of treatment ( fig1 b ). nbqx and gpe administered for 7 days as monotherapies only caused temporary remission , and by day 105 the disease had almost returned to control levels of crippling paralysis . in contrast , the combination of nbqx with gpe appeared to be synergistic as the disease was suppressed ( disease score reduced from 4 . 5 to 1 ) for 40 days following suspension of treatment ( fig1 b ). this indicates that administering a combination of gpe and nbqx delays disease progression . it makes no sense to inhibit demyelinating inflammation without attempting repair of the cns ; or achieving repair without damage limitation . for the first time we have combined both approaches to successfully treat advanced disease . remarkably , simultaneous administration of anti - madcam - 1 mab , nbqx and gpe delivered sustained protection ( disease score reduced from 5 to & lt ; 1 ) against disease progression . long - term treatment is non - toxic , but has to be maintained to be protective . the various treatment regimes were administered for 16 days in order to determine whether prolonged treatment was non - toxic ( fig1 c ). in this experiment , similar results were obtained as in fig1 b . thus the effectiveness of the treatments was in the order nbqx + gpe + anti - madcam - 1 & gt ; nbqx + gpe & gt ; nbqx & gt ; gpe ; whereas anti - madcam - 1 monotherapy only weakly attenuated disease severity . however , the disease relapsed in all cases following suspension of treatment , suggesting that therapy must be maintained if it is to be consistently effective . two mice died for unknown reasons in the nbqx + gpe combination , but not in the nbqx + gpe + anti - madcam - 1 combination . since no mice from the triple combination , or the earlier experiment ( fig1 b ) had died , the combinational treatment protocols appear to be safe and effective at the doses employed . weight loss was found to correlate with disease severity . at disease onset the body weight of mice rapidly decreased , such that mice had lost 50 % of their average body weight within 2 weeks of disease progression ( fig2 ). mice experienced a weight gain following treatment that correlated with the efficacy of the particular treatment regime ( ie nbqx + gpe + anti - madcam - 1 & gt ; nbqx + gpe & gt ; nbqx , gpe , or madcam - 1 monotherapies ), where the weight of mice receiving the triple treatment returned almost to normal . the disability scores ( table 1 ) for the various treatment groups correlated well with the clinical scores of paralysis . diseased mice displayed discernible impairments in spontaneous mobility , tone , motor function ( grip ), sensory function , and shiny hair / skin firmness . the total clinical scores inversely correlated with the efficacy of the particular treatment regime ( ie nbqx + gpe + anti - madcam - 1 & gt ; nbqx + gpe & gt ; nbqx or gpe or anti - madcam - 1 mab ). for example the total scores at day 70 were 3 for nbqx + gpe + anti - madcam - 1 , 10 for nbqx + gpe , 10 for gpe , 30 for nbqx , 19 anti - madcam - 1 mab , compared to 35 for rat igg treated control mice ). neuropathological evaluation confirmed the observed clinical protection achieved with the various treatment regimes . spinal cord sections stained by tunel analysis revealed extensive apoptosis which peaked at the height of disease severity ( day 49 ), and then subsequently declined slightly to reach a plateau that was maintained for the duration of the experiment ( fig3 ). apoptotic cells were not identified but it is probable that infiltrating t cells , macrophages , and resident microglia and oligodendrocytes are all represented . infiltrating t cells in particular appear to undergo apoptosis , as the body tries to clear autoimmune inflammation . sections taken from nbqx + gpe + anti - madcam - 1 , and anti - madcam - 1 treated mice had substantial reductions ( 60 %) in the numbers of apoptotic cells compared to mice that had been mock treated with either pbs or rat igg . in contrast , sections taken from nbqx + gpe , nbqx , and gpe treated mice showed lesser reductions (˜ 30 %) in the number of apoptotic cells . axonal damage is a critical feature of multiple sclerosis lesions . dephosphorylated heavy chain neurofilament - h is a quantitative molecular marker of demyelinated and dystrophic axons , and is employed to assess axonal damage and disease severity . using both immunohistochemistry ( fig4 b ) and western blot analysis ( fig4 a and c ), it was revealed that the spinal cords of mock - treated eae mice ( disease score 4 . 5 ) displayed a large increase of abnormally dephosphorylated neurofilament - h , whereas normal undiseased mice had almost undetectable levels ( figs . a and b ). in accord these spinal cords also contained increased numbers of damaged axonal cells ( fig4 b ). once again , the levels of dephosphorylated neurofilament - h , and numbers of damaged axonal cells correlated with the efficacy of the particular treatment regime . for example the average relative densities of neurofilament - h in spinal cord homogenates resolved by western blot analysis were 1 . 2 for nbqx + gpe + anti - madcam - 1 , 2 . 2 for nbqx + gpe , 2 . 3 for anti - madcam - 1 , 3 . 2 for gpe , and 3 . 5 for nbqx , compared to 6 . 1 for either rat igg or pbs treated control mice ). this indicates that the triple combination was very effective in reducing axonal damage almost to background levels . gpe and nbqx administered individually almost halved the amount of axonal damage , and in combination further reduced damage by 30 %, indicating the involvement of glutamate excitotoxicity . surprisingly , anti - madcam - 1 mab treatment was almost as effective as the combination of gpe + nbqx , which correlated with its ability to reduce the apoptotic index ( fig3 ). these results clearly indicate that the anti - inflammatory reagents and neuroprotectors used act in concert to reduce the degree of axonal damage , as reflected in the attenuation of clinical symptoms of disease . to evaluate the effects of the different treatment regimes on the loss of oligodendrocytes , a key cellular target in demyelinating diseases of the cns , oligodendrocytes were enumerated by immunohistochemical staining of spinal cord sections and the number of oligodendrocytes within the dorsal columns of x transverse sections were counted ( fig5 b ), and reductions in oligodendrocyte numbers were calculated and expressed as % loss of oligodendrocytes per dorsal section ( fig5 c ). the % loss of oligodendrocytes correlated with the efficacy of the different treatment regimes , such that the % loss was 9 for nbqx + gpe + anti - madcam - 1 , 16 for nbqx + gpe , 13 for anti - madcam - 1 , 14 for gpe , and 13 for nbqx , compared to 31 for rat igg and 26 for pbs treated control mice . these results were confirmed by western blot analysis to quantitate the amount of cnpase in spinal cord homogenates ( fig5 d ). levels of the ampa receptor subunits glur1 and 2 have been shown to increase in the rat spinal cord after inflammation , suggesting their upregulation is an indicator of disease ( zhou et al ., 2001 ). thus levels of glur2 and the nmda receptor subunit nr1 were determined in the current investigation . as shown by both immunohistochemical staining of spinal cord sections ( fig6 a ), and western blot analysis of spinal cord homogenates ( fig6 b and c ) there were marked increases in glur2 and nr1 subunit expression in the spinal cords of mock - treated eae mice . treatments that included nbqx led to a marked down - regulation of glur2 expression , whereas gpe and anti - madcam - 1 mab reagents had negligible effect . thus , nbqx either directly or indirectly downregulates the ampa receptor following binding . surprisingly , nbqx also caused down - regulation of the nmda receptor , whereas anti - madcam - 1 mab and gpe were not effective . this is in accord with a study showing that drug regimes targeting one ionotropic glutamate receptor subtype may indirectly affect other subtypes ( healy et al ., 2000 ). sections were stained with a rabbit polyclonal antibody raised against a peptide containing exon 2 of mbp , to provide evidence of remyelination . distinct patches in the spinal cord stained with the anti - exon 2 mbp antibody , where the number of stained patches correlated with the efficacy of each treatment regime ( fig7 ). a score was given to each neuropathological parameter , based on the degree of cns involvement ( table 2 ). the cumulative scores for inflammation , demyelination , remyelination , apoptosis , oligodendrocyte loss , and axonal damage following treatment correlated with the efficacy of the different treatment regimes , such that the score was 24 for nbqx + gpe + anti - madcam - 1 , 40 for nbqx + gpe , 42 for anti - madcam - 1 , 55 for gpe , and 46 for nbqx , compared to 46 for rat igg and 58 for pbs treated control mice . these results show anti - madcam - 1 , gpe and nbqx monotherapies which either block inflammation , or glutamate excitotoxicity , or induce remyelination are preventative when administered early , prior to establishment of significant nerve damage . furthermore , the results indicate that blockade of madcam - 1 alone is able to prevent the early development of disease . the results also show that effects of gpe and nbqx are synergistic ( fig1 b ). the combination of gpe and nbqx reduced the average clinical score , led to increased weight gain , and reduced the neuropathology in particular axonal damage , and loss of oligodendrocytes , compared to the respective monotherapies . the results further show that the triple combination of nbqx + gpe + anti - madcam - 1 was the most efficacious approach , reducing the clinical , disability , and neuropathology scores almost to background levels . the weight of mice returned to normal , and there were few signs of axonal damage , paralysis , or disability . although the invention has been described with reference to particular embodiments , those persons skilled in the art will appreciate that variations and modifications may be made without departing from the scope of the invention . baron , j . l ., madri , j . a ., ruddle , n . h ., hashim , g ., janeway , c . a . jr ., 1993 . surface expression of □ 4 integrin by cd4 t cells is required for their entry into brain parenchyma . j . exp . med . 177 , 57 – 68 . berg , r . w ., yang , y ., lehnert , k ., and krissansen , g . w . mouse m290 is the functional homologue of the human mucosal lymphocyte integrin hml - 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