Oral FMT (Fecal Microbial Transplant) in Subjects With Multiple Sclerosis

Study Overview
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Brief Summary
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The goal of this pilot study is to determine whether fecal microbial transplant (FMT) has the potential to be an effective, safe and tolerable therapy for the treatment of multiple sclerosis (MS). The investigators plan to gather preliminary data in a small cohort of 10 to 15 adults with MS.

Detailed Description
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The specific aims are to: Determine the tolerability of a single dose of 30 capsules in a group of adults with MS Determine whether any unexpected outcomes arise in participants who successfully complete an FMT procedure consisting of a single dose of 30 capsules Determine whether successfully completed FMT leads to engraftment of donor microbiome in participants If the FMT leads to engraftment of donor microbiome in participants, determine whether participants revert back to previous microbiome profiles, and if so, at what time point Determine whether engrafted species following the FMT, if detected, result in any changes in immune or metabolomic parameters relative to baseline Determine whether the FMT has any adverse impact, relative to baseline, on study participants' self-reported levels of fatigue, mental well-being, and health-related qualify of life Determine whether the FMT has any adverse impact, relative to baseline, on study participants' neurological status, relative to baseline The study population will consist of adults with clinically definite MS who are currently untreated with any disease-modifying therapy or are being treated with glatiramer acetate or interferon beta. The research team will offer study participants a single FMT procedure in the form of 30 oral capsules which contain fecal material. Study participants will visit Griffin Hospital facilities 8 times. The first visit will involve a clinical screening. Of the 7 remaining visits, 6 will involve data collection and one will involve the FMT procedure.

Official Title
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A Pilot Study of Oral FMT (Fecal Microbial Transplant) in Subjects With Multiple Sclerosis

Conditions
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Multiple Sclerosis

Intervention / Treatment
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* Biological: Fecal microbial transplant (FMT)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diagnosis of clinically definite multiple sclerosis (CDMS) by 2017 McDonald Criteria Ages between 18 and 55 years, inclusive; Expanded Disability Status Score (EDSS) between 1.0 and 6.5. Currently untreated with any disease-modifying therapy (DMT) or currently being treated with glatiramer acetate or interferon beta. Ability to travel to Griffin Hospital for 8 visits over a 5-month period Exclusion Criteria: Inability to give consent; Non-fluency in English; Inability to adhere to the protocol; Inability (e.g., dysphagia) to or unwillingness to swallow capsules; Active gastrointestinal infection at the time of enrollment; Use of antibiotics or corticosteroids within three months of study entry; Requiring or anticipating antibiotic use during the four weeks after study entry; MS relapse within one month of study entry; Previous use of any of the following FDA-approved disease-modifying drugs within 12 months of study entry, including natalizumab, fingolimod, siponimod, ozanimod, teriflunomide, diroximel, ocrelizumab, ofatumumab, and/or dimethyl fumarate; or any of the following off-label therapies, including rituximab and cyclophosphamide; Any previous use of the following FDA-approved DMTs, including mitoxantrone, alemtuzumab, and cladribine; IV immunoglobulin or plasma exchange within six months prior to study entry; Known or suspected toxic megacolon and/or known small bowel ileus; Major gastrointestinal surgery (e.g., significant bowel resection) within 3 months prior to enrollment (this does not include appendectomy or cholecystectomy); History of total colectomy or bariatric surgery; Concurrent intensive induction chemotherapy, radiation therapy or biological treatment for active malignancy; Anticipated life expectancy of less than six months; Concomitant other known autoimmune diseases; Concomitant pulmonary, cardiac, gastrointestinal (except as noted above) (Crohns, Colitis, inflammatory bowel, intestinal blockage), hepatic, dermatological or genitourinary disease. Moderate to severe dysphagia; History of alcohol abuse, as defined by the following criteria: Men: 5 or more alcoholic beverages per session or day, or 15 or more per week; Women: 4 or more alcoholic beverages per session or day, or 8 or more per week; History of illicit drug abuse, e.g., of cocaine, heroin, PCP, and/or narcotic substances; Grade 1 or greater lymphopenia, as measured at baseline/clinical screening; Liver Function Tests (LFTs) greater than 1½ times upper limits of normal, as measured at baseline/clinical screening; History of use of FMT or microbiome-based products (excluding probiotics) at any time, excluding this study; History of severe anaphylactic or anaphylactoid food allergy; History of solid organ transplantation; Risk for Cytomegalovirus (CMV) or Epstein Barr virus (EBV) associated disease (at investigator's discretion, e.g., immunocompromised and negative (immunoglobulin gamma) IgG testing for CMV or EBV); Women who are pregnant, lactating, planning to become pregnant, and/or not using an effective method of contraception (women of childbearing potential will undergo a pregnancy test, and will be excluded from the study if results are positive); Any allergies to neomycin or similar antibiotics such as amikacin (Amikin), gentamicin (Garamycin), kanamycin (Kantrex), paromomycin (Humatin, Paromycin), streptomycin, or tobramycin (Nebcin, Tobi); Any condition that would jeopardize the safety or rights of the subject, would make it unlikely for the subject to complete the study, or would confound the study results. Household contacts, including children under the age of 5 years, pregnant women, any person with an immunocompromised condition or on medications causing immunosuppression or persons 70 years or older; Failure to document a COVID-19 vaccine series at least two weeks prior to study entry.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 55 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Interventional Model Description: Pre/post pilot investigational study
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention<br>Fecal microbial transplant capsules | Biological: Fecal microbial transplant (FMT)<br>* Oral fecal microbial transplant capsules<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in engraftment of donor microbiome in stool samples | Evidence of engraftment as measured by 16s rRNA microbiome sequencing | Pre-FMT and 4 time points post-FMT (3-7 days, 10-15 days, 40-45 days, 100-110 days) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in immune markers in blood samples assessed using assays of lymphocyte phenotyping and intracellular cytokines | Phenotyping will be performed: for T cells - TCRβ, TCRγ, CD4, CD8, CD25, CD44, CD62L, CD69, PD1, CTLA4; for B cells - B220, CD19, CD21, CD23, CD1d, CD5, IgA, IgG1, IgG2a(c), IgG2b; for DCs - CD11c, CD11b, BDCA1, CD8, CD103, CD205 and CD86. The intracellular cytokine (ICC) panel will be IL-6, IL-10, IL-12, IL-17, TNFα, and IFNγ. | Pre-FMT and 2 time points post-FMT (40-45 days, 100-110 days) | 
| Change in neurological status using Kurtzke Functional Systems Scale (FSS) | The FSS uses a set of single-item ordinal clinical rating scales to rate levels of function in seven domains (pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual, and cerebral/mental). Each single item scale ranges from 0 to 5 or 6 (0 = normal; 5 or 6 represents the worst level of function; and 9 = unknown). For each single item scale, scores representing the highest level of function are as follows: pyramidal: 6 = quadriplegia; cerebellar: 5 = unable to perform coordinated movements due to ataxia; brainstem: 5 = inability to swallow or speak; sensory: 6 = sensation essentially lost below the head; bowel and bladder: 6 = loss of bowel and bladder function; visual: 6 = grade 5 plus maximal visual acuity of better eye of 20/60 or less; cerebral/mental: 5 = dementia or chronic brain syndrome - severe or incompetent. The ratings are used in conjunction with observations and information concerning gait and use of assistive devices to rate the EDSS. | Pre-FMT and 4 time points post-FMT (3-7 days, 10-15 days, 40-45 days, 100-110 days) | 
| Change in neurological status using Kurtzke Expanded Disability Status Scale (EDSS) | The EDSS is an ordinal clinical rating scale ranging from 0 (normal neurological examination) to 10 (death due to MS) in half-point increments. | Pre-FMT and 4 time points post-FMT (3-7 days, 10-15 days, 40-45 days, 100-110 days) | 
| Change in self-reported health-related quality of life assessed using the Health Status Questionnaire Short-Form 36 (SF-36) | The SF-35 has 36 questions. It has a single item covering change in health status over the last year and 8 multi-item scales. The scoring system is relatively complex and generates 8 subscales and 2 summary scores. The 8 subscales are: physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role-limitations due to emotional problems, and mental health. Two summary scales (Physical and Mental) have been derived using factor analytic methods. Scales are set up so that a higher score indicates better health. To achieve this, responses on 10 items are recoded before being added to other items on the same scale. Raw scale scores are then transformed to a 0-100 scale. | Pre-FMT and 3 time points post-FMT (10-15 days, 40-45 days, 100-110 days) | 
| Change in self-reported mental health status assessed using Mental Health Inventory (MHI) | The MHI consists of 18 items and assesses several domains of mental health. The scoring system generates 4 subscale scores (Anxiety, Depression, Behavioral Control, and Positive Affect) and 1 total score. The subscale and total scores range from 0-100, with higher scores indicating better mental health. | Pre-FMT and 3 time points post-FMT (10-15 days, 40-45 days, 100-110 days) | 
| Change in self-reported levels of fatigue assessed using Modified Fatigue Impact Scale (MFIS) | The MFIS provides an assessment of the effects of fatigue on physical, cognitive, and psychosocial function. It consists of 21 items. The items be aggregated into 3 subscales (Physical, Cognitive, and Psychosocial), as well as into a total MFIS score. All items are scaled so that higher scores indicate a greater impact of fatigue on a patient's activities. The physical subscale can range from 0-36. The cognitive subscale can range from 0-40. The psychosocialsub scale can range from 0-8. The Total MFIS score can range from 0-84. | Pre-FMT and 3 time points post-FMT (10-15 days, 40-45 days, 100-110 days) | 
| Incidence of Treatment-Emergent Adverse Events [Safety and Tolerability] | Measured by subject's ability to consume capsules as directed without vomiting or adverse side effects (as opposed to mild side effects) | Day of FMT procedure and 5 time points post-FMT (1 day, 3-7 days, 10-15 days, 40-45 days, 100-110 days), or any time the study team is contacted by subjects who report adverse side effects | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Fecal microbial transplant, FMT, Pilot study