Dimethyl fumarate and vaccination regimens

Abstract

Provided herein is a method of treating or preventing a disease or disorder (e.g., MS) in a subject in need thereof, comprising (a) administering to the subject a first dose of a pharmaceutical composition comprising a fumarate agent (e.g., DMF) for a first dosing period; (b) administering a vaccine; and (c) administering to the subject a second dose of the pharmaceutical composition for a second dosing period.

Claims

1. A method of treating multiple sclerosis in a human subject in need thereof, said method comprising: (a) administering to the subject a first dose of a pharmaceutical composition for a first dosing period, wherein the pharmaceutical composition comprises a fumarate agent selected from the group consisting of monomethyl fumarate, a pharmaceutically acceptable salt of monomethyl fumarate, dimethyl fumarate, and a combination thereof; (b) administering a vaccine to the subject, wherein the subject receives the vaccine during the first dosing period; and (c) administering to the subject a second dose of the pharmaceutical composition for a second dosing period, wherein: (i) the second dosing period is after the first dosing period, and (ii) the second dosing period is initiated within one day of the end of the first dosing period; wherein the second dose is the same as the first dose, and the first dose and the second dose are administered daily; wherein the multiple sclerosis is a relapsing form of multiple sclerosis; wherein the first dose is a therapeutically effective amount of monomethyl fumarate, a pharmaceutically acceptable salt of monomethyl fumarate, dimethyl fumarate, or a combination thereof; and wherein the vaccine induces (a) a T cell-dependent anamnestic humoral immune response, (b) a T cell-dependent neoantigen immune response, or (c) a T cell-independent immune response.

2. The method of claim 1, wherein the fumarate agent is dimethyl fumarate.

3. The method of claim 2, wherein the first dose is a daily amount of about 480 mg dimethyl fumarate.

4. The method of claim 1, further comprising administering a titration dose of the fumarate agent prior to the first dosing period.

5. The method of claim 4, wherein the fumarate agent is dimethyl fumarate and the titration dose is a daily amount of about 240 mg dimethyl fumarate.

6. The method of claim 1, wherein the pharmaceutical composition is in the form of a capsule or tablet.

7. The method of claim 2, wherein the dimethyl fumarate is in the form of microtablets or micropellets, and wherein the microtablets or micropellets are enterically coated.

8. The method of claim 7 wherein the microtablets or micropellets are contained in a capsule.

9. The method of claim 1, wherein the vaccine induces a T cell-dependent anamnestic humoral immune response.

10. The method of claim 1, wherein the vaccine induces a T cell-dependent neoantigen immune response.

11. The method of claim 1, wherein the vaccine induces a T cell-independent immune response.

12. The method of claim 1, wherein the vaccine is a vaccine selected from the group consisting of tetanus diphtheria toxoids vaccine, keyhole limpet hemocyanin vaccine, pneumovax-23 vaccine, and any combination thereof.

13. The method of claim 12, wherein the vaccine is tetanus diphtheria toxoids vaccine.

14. The method of claim 12, wherein the vaccine is keyhole limpet hemocyanin vaccine.

15. The method of claim 12, wherein the vaccine is pneumovax-23 vaccine.

16. The method of claim 1, wherein the vaccine is meningococcal polysaccharide diphtheria conjugate vaccine quadrivalent.

17. The method of claim 1, wherein the multiple sclerosis is relapsing-remitting multiple sclerosis.

18. The method of claim 1, wherein the multiple sclerosis is secondary progressive multiple sclerosis.

19. The method of claim 3, further comprising administering a titration dose of the fumarate agent prior to the first dosing period.

20. The method of claim 19, wherein the titration dose is a daily amount of about 240 mg dimethyl fumarate.

21. The method of claim 1, wherein the fumarate agent is monomethyl fumarate.

22. The method of claim 1, wherein the fumarate agent is a pharmaceutically acceptable salt of monomethyl fumarate.

Description

5. EXAMPLES

5.1 Example 1: A Randomized, Open-Label Study to Assess the Effects of BG00012 on the Immune Response to Vaccination and on Lymphocyte Subsets in Subjects with Relapsing Forms of Multiple Sclerosis

5.1.1 Introduction

(1) The primary objective of the study is to evaluate the effects of DMF administered over approximately 6 months on immune responses to vaccination with tetanus diphtheria toxoids vaccine (Td) [T cell-dependent anamnestic humoral response] and keyhole limpet hemocyanin (KLH) [T cell-dependent neoantigen response] in subjects with relapsing forms of MS.

(2) Secondary objectives of this study in this study population are as follows: (1) to evaluate the effects of DMF administered over approximately 6 months on the immune response to vaccination with pneumovax-23 (PPSV23) [a mostly T cell-independent humoral response]; (2) to evaluate the pharmacodynamic effects of DMF on lymphocyte subtypes over 1 year of treatment; (3) to evaluate the pharmacodynamic effect of DMF on immunoglobulin levels over time; and (4) to evaluate the safety and tolerability of DMF.

5.1.2 DMF and Vaccines for the Study

(3) DMF is a drug product formulated as enteric-coated microtablets in gelatin capsules (blue and white) for oral administration. Each capsule contains 120 mg DMF. Excipients for the manufacturing of the enteric-coated microtablets include microcrystalline cellulose, croscarmellose sodium, talc, colloidal anhydrous silica (colloidal silicon dioxide), magnesium stearate, triethyl citrate, methacrylic acid-methyl methacrylate copolymer, methacrylic acid-ethyl acrylate copolymer, simethicone, sodium lauryl sulfate, and polysorbate 80. Excipients for the manufacturing of the capsule shell include gelatin, titanium dioxide, and indigotin.

(4) Tetanus diphtheria toxoids vaccine (Td [Tenivac]; Sanofi Pasteur, Swiftwater, Pa.) is indicated for active immunization for the prevention of tetanus and diphtheria. It is used in this study to assess the integrity of a T cell-dependent anamnestic humoral response, as tetanus toxoid is an immunogen commonly administered to the general population.

(5) Keyhole limpet hemocyanin (KLH) is used to test the integrity of a T cell-dependent primary response, as it is a novel immunogen for most individuals. KLH is administered as Immucothel (Biosyn Arzneimittel AG, Fellbach, Germany), a hemocyanin product derived from KLH, which is obtained from the sea snail giant keyhole limpet. Immucothel is approved for treatment of bladder cancer in several countries and is considered an investigational agent in the US, where it is used in clinical studies to produce an immune response.

(6) Pneumovax 23 (PPSV23; Merck & Co., Inc., Rahway, N.J., USA) is a 23-valent carbohydrate antigen vaccine approved for the prophylaxis of community-acquired pneumonia. Pneumococcal polysaccharide antigens are able to activate B cells without T cell help, and thus are considered type 2 T cell independent antigens. However, they are also able to induce an adaptive humoral immune response, due to a secondary signal of B cell activation provided by other immune cells and with some T cell involvement. PPSV23 is therefore be used in this study to assess a mostly T cell-independent humoral response.

5.1.3 Dosage Selection

(7) The DMF dosage selected for this study (120 mg twice daily [BID] for the first week, 240 mg BID thereafter) is the approved DMF dosing regimen in patients with relapsing forms of MS in the United States (US).

(8) Td (0.5 mL) and PPSV23 (0.5 mL) doses selected for this study are the current approved doses for these vaccines. KLH (1 mg) is the subcutaneous (SC) injection dose based on Immucothel Investigator's Brochure.

(9) Subjects with relapsing forms of MS between the ages of 18 and 55 years, with a known history of tetanus immunization.

5.1.4 Inclusion/Exclusion Criteria

(10) Exemplary eligibility criteria at randomization include: (1) Male and female subjects of childbearing potential will practice effective contraception during the study and be willing and able to continue contraception for 30 days after their last dose of study treatment; (2) Aged 18 to 55 years old, inclusive, at the time of informed consent; (3) a confirmed diagnosis of a relapsing form of MS; and (4) a known history of tetanus immunization.

(11) Exemplary exclusion criteria at randomization include: (1) Tetanus vaccination given less than 2 years or more than 15 years prior to Screening, or an anti-tetanus IgG titer at Screening that is greater than one-half the upper limit of detection for the assay; (2) Pneumococcal vaccination within the 5 years prior to Screening; (3) Previous exposure to KLH or vaccines containing KLH components (e.g., cancer vaccines); (4) Known hypersensitivity to KLH, PPSV23, or tetanus/diphtheria toxoids or any other administered vaccinations or their components (e.g., thimerosol); (5) Known allergy to shellfish; (6) History of, or positive test result at Screening for hepatitis C virus (HCV) antibody or hepatitis B virus (defined as positive for hepatitis B surface antigen [HBsAg] or hepatitis B core antibody [HBcAb]); (7) History of human immunodeficiency virus (HIV); (8) History of drug or alcohol abuse (as defined by the Investigator) within 2 years prior to Screening; (9) Current smoking or smoking within 6 months prior to Screening; (10) Any clinically significant (in the judgment of the Investigator) infectious illness (e.g., cellulitis, abscess, pneumonia, septicemia) within 30 days prior to Screening; (11) Any active bacterial or viral infection (as assessed by the Investigator) at randomization; (12) History of clinically significant (in the judgment of the Investigator) cardiovascular, dermatologic, endocrinologic, gastrointestinal, hematologic, hepatic, immunologic, metabolic, neurologic (other than MS), psychiatric, pulmonary, renal, urologic, and/or other major disease that would preclude participation in a clinical trial; (13) History of malignancy (subjects with basal cell carcinoma that has been completely excised prior to study entry remain eligible); (14) History of severe allergic or anaphylactic reactions or known drug hypersensitivity; (15) Any of the following abnormal blood tests at Screening that are confirmed on repeat testing 2 weeks later: (a) alanine transaminase/serum glutamate-pyruvate transaminase (ALT/SGPT), or aspartate transaminase/scrum glutamic-oxaloacctic transaminase (AST/SGOT), or gamma-glutamyl-transferase (GGT) times the upper limit of normal (ULN); (b) leukocytes<3500/mm.sup.3; and (c) eosinophils>0.710.sup.3/L or >0.7 GI/L; (16) Any of the following abnormal urine tests at Screening confirmed by a second urinalysis 2 weeks later: (a) proteinuria (1+ or greater); (b) hematuria, without known etiology; (c) glycosuria, without known etiology; (17) Any previous treatment with Fumaderm or DMF (FAG-201); (18) Any type of live vaccine within 4 weeks prior to randomization, including but not limited to measles/mumps/rubella vaccine, varicella zoster virus vaccine, oral polio vaccine, and nasal influenza vaccine; (19) Prior treatment with any of the following: cladribine, mitoxantrone, fingolimod, alemtuzumab, total lymphoid irradiation, T-cell or T-cell receptor vaccination, any therapeutic monoclonal antibody, with the exception of Tysabri (natalizumab) (see exclusion #20); (20) Treatment with Tysabri (natalizumub) within 1 year prior to randomization; (21) Treatment with any of the following medications or procedures within the 6 months prior to randomization: cyclosporine, azathioprine, teriflunomide, methotrexate, mycophenolate mofetil, intravenous immunoglobulin, plasmapheresis or cytapheresis; (22) Treatment with any of the following within 2 weeks prior to randomization: subcutaneous or oral glatiramer acetate, interferon-, interferon-; (23) Treatment with any of the following within 4 weeks prior to randomization: Steroids (intravenous [IV] or oral corticosteroid treatment, including agents that may act through the corticosteroid pathway [e.g., low dose naltrexone]), 4-aminopyridine or related products; and (24) Treatment with another investigational drug or approved therapy for investigational use within the 6 months prior to randomization.

5.1.5 Endpoints

(12) The primary end points of this study are (1) the proportion of subjects with a 2-fold rise in anti-tetanus serum immunoglobulin G (IgG) levels from pre-vaccination to 4 weeks after Td vaccination; and (2) The proportion of subjects with a 2-fold rise in anti-KLH serum IgG levels from pre-vaccination to 4 weeks after the final KLH vaccination.

(13) Secondary end points for this study are (1) the proportion of subjects with a 4-fold rise in anti-tetanus serum IgG levels from pre-vaccination to 4 weeks after Td vaccination; (2) the proportion of subjects with a 4-fold rise in anti-KLH serum IgG levels from pre-vaccination to 4 weeks after the final KLH vaccination; (3) the proportion of subjects with a 2- and a 4-fold rise in anti-pneumococcal IgG levels from pre-vaccination baseline to 4 weeks after PPSV23 vaccination; (4) Anti-tetanus, anti-KLH, and anti-pneumococcal immunoglobulin levels over time; (5) Change over time in lymphocyte subsets, including: T cells, B cells, NK cells (e.g., Total T cells: CD4+/CD8+; Total B cells; Total NK); (6) Additional analysis of lymphocyte subsets which can include: Treg Panel (total Treg, Resting/nave Treg; and/or active Treg); T-cell panel (Nave; Effector; Central/Effector Memory; and/or Activated (expressing HLA-DR/CD38)); (7) Myeloid NK panel (Monocytes: CD16+(non-classical)/CD16 (classical); Dendritic cells: myeloid/plasmacytoid; and/or NKs: CD56.sup.d1m/CD56.sup.br1g.sup.t); B cell panel (Translational; Nave; Memory: IgD+/IgD-; and/or Plasmablast); and (8) Safety parameters, including incidence of all AEs, including those leading to treatment discontinuation and study withdrawal, and all serious adverse events (SAEs); clinical laboratory shifts in reported values; and clinically significant changes in vital sign measurements.

(14) In addition, Ribonucleic acid (RNA) and peripheral blood mononuclear cells (PBMCs) are collected in certain subjects evaluate lymphocyte subsets. PBMCs are separated and frozen for testing at a later time at the Sponsor's discretion.

5.1.6 Treatment Schedule

(15) Approximately 68 subjects are enrolled in the study. Subjects are randomized in a 1:1 ratio to Group 1 (DMF treatment plus immunizations) or Group 2 (immunizations alone).

(16) Group 1 subjects are treated with DMF 120 mg BID for first 7 days and 240 mg BID thereafter up to 48 weeks. Table 1 shows a detailed schedule of events for Group 1 subjects.

(17) At Week 24, subjects in Group 1 receive Td, PPSV23, and KLH vaccinations. At 2 and 4 weeks after the Week 24 vaccination, subjects receive an additional KLH vaccination (Weeks 26 and 28). Anti-tetanus and anti-pneumococcal IgG titers are measured just prior to and at 4 and 8 weeks after the Week 24 vaccinations (i.e., Weeks 24, 28, and 32). Anti-KLH IgG titers are measured just prior to and at 4, 8, and 12 weeks after the Week 24 vaccination (i.e., Weeks 24, 28, 32, and 36). (Anti-tetanus titers are also measured at Screening, as part of the eligibility criteria). Blood samples for lymphocyte subset analysis, as well as blood samples for determination of each subject's complete blood count (CBC) with differential, are collected at Screening, Baseline (Day 1), and Weeks 12, 24, 36, and 48. Clinical samples for analysis of blood chemistries and urinalysis are collected at Screening and at Weeks 24 and 48. A serum pregnancy test is performed at Screening, as part of the eligibility criteria. Urine pregnancy tests are performed at Baseline (Day 1), and Weeks 12, 24, 26, 28, 32, 36, and 48. Vital signs, AEs, and concomitant therapies arc assessed at every clinic visit. A final follow-up clinic visit at which safety assessments are performed occurs 4 weeks after the final dose of DMF in subjects who do not continue treatment with commercial DMF. Subjects who plan to continue treatment with commercial DMF after Week 48 are contacted by telephone 2-4 weeks after their last study dose to ensure transition has taken place. If for any reason they have not started commercial DMF, they are required to have a final follow-up clinic visit 4 weeks after their last study dose.

(18) Group 2 subjects receive the same vaccinations and assessments over a 12-week period according to the schedule in Group 1, but with vaccinations starting on Day 1. That is, subjects receive Td, PPSV23, and KLH vaccinations at Baseline (Day 1) and an additional KLH vaccination at Weeks 2 and 4. Anti-tetanus and anti-pneumococcal IgG titers are measured just prior to and at 4 and 8 weeks after Baseline (Day 1). Anti-KLH IgG titers arc measured just prior to and at 4, 8, and 12 weeks after the Day 1 vaccination. (Anti-tetanus titers are also measured at Screening, as part of the eligibility criteria). Blood samples for lymphocyte subset analysis (as well as CBC with differential for laboratory safety analysis) are collected at Screening, Baseline (Day 1), and Week 12. Clinical samples for analysis of blood chemistries and urinalysis are collected at Screening and Week 12 and at Screening, Baseline (Day 1), and Week 12, respectively. A serum pregnancy test is performed at Screening, as part of the eligibility criteria. Urine pregnancy tests are performed at Baseline (Day 1), and Weeks 2, 4, and 12. Vital sign measurements, AEs, and concomitant therapies are performed at every clinic visit. After completing the study, Group 2 subjects may be eligible to begin treatment with commercial DMF if deemed appropriate. Table 2 shows a detailed schedule of events for Group 2 subjects.

(19) Subjects randomized to Group1 (DMF treatment plus immunizations) have 9 clinic visits: Screening, Baseline (Day 1), and Weeks 12, 24, 26, 28, 32, 36, and 48. Subjects who do not continue treatment with commercial DMF after Week 48 have a final follow-up clinic visit 4 weeks after the final dose. Subjects who plan to continue treatment with commercial DMF after Week 48 are contacted by telephone 2-4 weeks after their last study dose to ensure transition has taken place. If for any reason they have not started commercial DMF they are required to have a final follow-up clinic visit 4 weeks after their last study dose.

(20) Subjects randomized to Group 2 (immunizations alone) have 6 clinic visits: Screening, baseline (Day 1), and Weeks 2, 4, 8, and 12.

5.1.7 Efficacy Analysis

(21) Analysis of the primary endpoint for the Td and KLH vaccinations is based on evaluable subjects (i.e., subjects who are appropriately vaccinated per protocol; are 70% compliant with DMF [Group 1 only], and have non-missing IgG levels at pre-vaccination and 4 weeks after final vaccination).

(22) TABLE-US-00001 TABLE 1 Group 1 Schedule of Events Screening (w/in 28 Week Week Week Week Week Week Week 48 Follow-Up days 12 (Day 24 (Day 26 (Day 28 (Day 32 (Day 36 (Day (Day 336 (4 weeks 5 Tests and before Baseline 84 3 168 3 182 3 196 3 224 3 252 3 3 days)/ days after Assessments.sup.1 Baseline) (Day 1) days) days) days) days) days) days) W/D.sup.2 final dose).sup.2 Informed consent.sup.3 X Medical history X Physical X X examination Vital signs.sup.4 X X X X X X X X X X Hepatitis B and C X screen Hematology (CBC X X X X.sup.5 X X X with differential) Blood chemistry X X.sup.5 X X Urinalysis X X.sup.5 X X Serum pregnancy X test.sup.6 Urine pregnancy X X X X X X X X test.sup.6 Dispense DMF X X X X X X DMF DMF is to be taken as 120 mg BID for the first 7 days and thereafter as 240 mg BID. Subjects administration are to be instructed to take DMF orally, by swallowing the capsules whole without chewing, and with or without food. Tetanus toxoid X vaccine.sup.7 PPSV23 vaccine.sup.7 X Anti-tetanus and Anti- X.sup.5 X.sup.5 X anti-pneumococcal tetanus antibody assays only KLH vaccine.sup.7 X X X KLH antibody X.sup.5 X.sup.5 X X assay Lymphocyte X X X X.sup.5 X X X subset analysis Concomitant X X X X X X X X X X therapy and procedures SAE recording X X X X X X X X X X AE recording X X X X X X X X X RNA collection.sup.8 X X X.sup.5 X X X PBMC collection.sup.8 X X.sup.5 X X .sup.1All tests and assessments will be performed before dispensing study treatment. .sup.2Subjects who discontinue treatment prematurely are withdrawn from the study and have a Withdrawal visit within 4 weeks after taking their final study dose. Subjects who do not continue treatment with commercial DMF after Week 48/early withdrawal have a final follow-up clinic visit 4 weeks after their final study dose. Subjects who plan to continue treatment with commercial DMF after Week 48 are contacted by telephone 2-4 weeks after their last study dose to ensure transition has taken place. If for any reason they have not started commercial DMF they are required to have a final follow-up clinic visit 4 weeks after their last study dose. .sup.3Written informed consent will be obtained prior to performing any study-related procedures, and may be obtained prior to Screening if a washout period is required for prior therapy. .sup.4Vital signs include height (measured at Screening only), weight, diastolic and systolic blood pressure, heart rate, and temperature. Subjects will be seated for 5 minutes prior to having their pulse and blood pressure measured. .sup.5Blood as well as urine samples will be collected prior to immunization. .sup.6Females of childbearing potential only. Results will be known to be negative prior to dispensing DMF and immunization. .sup.7Subjects are observed for any severe local or systemic reactions for 45 minutes following immunization. .sup.8RNA and PBMC are collected in subjects who have signed a separate Future Scientific Research informed consent form.

(23) TABLE-US-00002 TABLE 2 Group 2 Schedule of Events Screening Week 2 Week 4 Week 8 Week 12 (Day Tests and (within 28 days (Day 14 3 (Day 28 3 (Day 56 3 84 3 Assessments.sup.1 before Baseline) Baseline (Day 1) days) days) days) days)/W/D.sup.2 Informed X consent.sup.3 Medical history X Physical X examination Vital signs.sup.4 X X X X X X Hepatitis B and X C screen Hematology X X.sup.5 X (CBC with differential) Blood chemistry X X Urinalysis X X.sup.5 X Serum X pregnancy test.sup.6 Urine pregnancy X X X X test.sup.6 Tetanus toxoid X vaccine.sup.7 PPV23 vaccine.sup.7 X Anti-tetanus and Anti-tetanus only X.sup.5 X.sup.5 X anti- pneumococcal antibody assays KLH vaccine.sup.7 X X X KLH antibody X.sup.5 X.sup.5 X X assay Lymphocyte X X.sup.5 X subset analysis Concomitant X X X X X X therapy and procedures SAE recording X X X X X X AE recording X X X X X RNA collection.sup.8 X.sup.5 PBMC X.sup.5 X collection.sup.8 .sup.1All tests and assessments will be performed prior to immunization. .sup.2In subjects who are withdrawn from the study, a Withdrawal Visit is performed within 4 weeks after their last immunization. .sup.3Written informed consent will be obtained prior to performing any study-related procedures, and may be obtained prior to Screening if a washout period is required for prior therapy. .sup.4Vital signs include height (measured at Screening only), weight, diastolic and systolic blood pressure, heart rate, and temperature. Subjects will be seated for 5 minutes prior to having their pulse and blood pressure measured. .sup.5Blood as well as urine samples will be collected prior to immunization. .sup.6Females of childbearing potential only. Results will be known to be negative prior to immunization. .sup.7Subjects are observed for any severe local or systemic reactions for 45 minutes following immunization. .sup.8RNA and PBMC are collected in subjects who have signed a separate Future Scientific Research informed consent form.

5.2 Example 2: An Open-Label Study to Assess the Immune Response to Vaccination in Tecfidera (BG00012)-Treated Versus Interferon-Treated Subjects with Relapsing Forms of Multiple Sclerosis

5.2.1 List of Abbreviations

(24) The following abbreviations and definitions are used in this study protocol:

(25) TABLE-US-00003 AE adverse event BID twice daily CI confidence interval CRF case report form EDC electronic data capture GCP Good Clinical Practice ICF informed consent form ICH International Conference on Harmonisation IFN interferon IgG immunoglobulin G MCV4 meningococcal polysaccharide diphtheria conjugate vaccine (quadrivalent) MS multiple sclerosis PHI protected health information PPSV23 23-valent pneumococcal polysaccharide vaccine RRMS relapsing-remitting multiple sclerosis SAE serious adverse event SUSAR suspected unexpected serious adverse reaction Td tetanus diphtheria toxoids vaccine US United States

5.2.2 Synopsis

(26) This is a brief summary of the study protocol.

(27) Existing Multiple Sclerosis Treatment (Not Supplied by the Sponsor) include Tecfidera (dimethyl fumarate) and non-pegylated interferon (IFN; e.g., Avonex, Betaseron, Rebif, Extavia).

(28) 5.2.2.1. Study Objectives

(29) Primary

(30) The primary objective of the study is to evaluate the immune response to vaccination with Td in subjects with relapsing forms of MS who have been treated with Tecfidera versus those treated with non-pegylated IFN.

(31) Secondary

(32) The secondary objective of the study is to evaluate the immune response to vaccination with PPSV23 and MCV4.

(33) 5.2.2.2. Study Endpoints

(34) Primary

(35) The primary endpoint of the study is: The proportion of subjects with a 2-fold rise in anti-tetanus serum immunoglobulin G (IgG) levels from pre-vaccination to 4 weeks after Td vaccination.

(36) Secondary

(37) The secondary endpoints of the study are: The proportion of subjects with a 4-fold rise in anti-tetanus serum IgG levels from pre-vaccination to 4 weeks after Td vaccination. The proportion of subjects with a 2-fold and a 4-fold rise in anti-pneumococcal serum IgG levels against serotypes 3 and 8 from pre-vaccination to 4 weeks after PPSV23 vaccination. The proportion of subjects with a 2-fold and a 4-fold rise in anti-meningococcal serum IgG levels against serotype C from pre-vaccination to 4 weeks after MCV4 vaccination. The geometric mean titer ratios from pre-vaccination to 4 weeks after Td, PPSV23, and MCV4 vaccinations. Incidence of adverse events (AEs) and serious adverse events (SAEs). Clinical laboratory shifts in reported values. Clinically significant changes in vital sign measurements.

(38) Exploratory

(39) The exploratory endpoints of the study are: The proportion of subjects with a 2-fold and a 4-fold rise in anti-diphtheria toxoid serum IgG levels from pre-vaccination to 4 weeks after MCV4 vaccination. The anti-diphtheria geometric mean titer ratio from pre-vaccination to 4 weeks after MCV4 vaccination. The proportion of subjects with anti-tetanus and anti-meningococcal seroprotective levels at 4 weeks after Td and MCV4 vaccinations.

(40) 5.2.2.3. Study Design

(41) This is an open-label, multicenter study to evaluate the immune response to vaccination in subjects with relapsing forms of MS who have been treated for at least 6 months with the approved dose of Tecfidera (240 mg twice daily [BID]) or who have been treated for at least 3 months with the approved dose of a non pegylated IFN (e.g., Avonex, Betaseron, Rebif, Extavia).

(42) After a 28-day Screening Period, eligible subjects will be enrolled and assigned as appropriate into either Group 1 (currently treated with Tecfidera) or Group 2 (currently treated with non-pegylated IFN). Throughout the study, subjects will remain on their existing, stable dosing regimen of Tecfidera or non pegylated IFN.

(43) Subjects will come to the clinic on Day 1 and have blood samples drawn for pre vaccination anti-tetanus, anti pneumococcal, anti meningococcal, and anti-diphtheria TgG titers. All subjects will receive 3 vaccinations: Td, PPSV23, and MCV4. They will return to the clinic at Week 4 for their final study visit, at which time blood samples will be drawn for post-vaccination IgG titers.

(44) Subjects who receive at least 1 dose of a vaccine should remain in the study and attend the Week 4 Visit. Subjects who receive at least 1 dose of a vaccine but would like to withdraw from the study prematurely will be asked to return to the clinic for an Early Withdrawal Visit, at which time blood samples will be drawn for IgG titers.

(45) Safety evaluations in this study will include blood samples for complete blood count with differential and blood chemistry, urine pregnancy tests, and vital signs at Day 1 and Week 4, as well as ongoing collection of AEs, SAES, and concomitant medications.

(46) The subjects' neurologist or primary healthcare provider will manage their MS care before, during, and after study participation.

(47) This study will be conducted at approximately 10 to 15 sites in the United States, and the number of planned subjects will be 70 (approximately 35 in each group)

(48) 5.2.2.4. Study Population

(49) Subjects with relapsing forms of MS between the ages of 18 and 55 years, inclusive, with a known history of tetanus immunization and on a stable approved dose of either Tecfidera (240 mg BID) for 6 months or a non pegylated IFN for 3 months.

(50) 5.2.2.5. Treatment Groups

(51) Subjects treated with Tecfidera will be assigned to Group 1. Subjects treated with non pegylated IFN will be assigned to Group 2.

(52) All subjects will receive the same 3 vaccinations on Day 1 intramuscularly in the specified order: 1. Td 0.5 mL 2. PPSV23 0.5 mL 3. MCV4 0.5 mL

(53) 5.2.2.6. Study Duration

(54) Subjects will have 3 clinic visits: Screening, Day 1, and Week 4. The duration of study participation will be approximately 8 weeks.

(55) 5.2.2.7. Criteria for Evaluation

(56) Efficacy

(57) Anti-tetanus, anti pneumococcal, anti meningococcal, and anti-diphtheria IgG levels at pre vaccination (Day 1) and at Week 4

(58) Safety

(59) The following safety assessments will be performed: Vital sign measurements Physical examination Hematology and blood chemistry Serum and urine pregnancy testing Monitoring and recording of AEs Monitoring and recording of concomitant therapy and procedures

(60) 5.2.2.8. Statistical Methods

(61) No formal statistical testing is planned. The proportion of responders to each vaccine antigen will be estimated with 95% confidence intervals (CIs) using the exact method. Differences in the proportion of subjects with an antibody response between Group 1 and Group 2 will also be estimated with 95% CIs using the exact method. The IgG level to each antigen will also be summarized by geometric mean concentration for each group with 95% CI as well as the ratio between the 2 groups.

(62) All safety data will be summarized using descriptive statistics. Incidence of AEs will be summarized using frequency distribution tables by group, overall, by severity, and by relationship to vaccines. Change from baseline in laboratory values and vital signs will also be descriptively summarized by group.

(63) No interim analysis will be performed.

(64) 5.2.2.9. Sample Size Determination

(65) The sample size for this study is not based on formal hypothesis testing, but on the precision of estimated response rates. The 95% CIs for the difference between Groups 1 and 2 in the proportion of vaccination responders will be provided to quantify the variability in the differences of response rates.

(66) Assuming a response rate of 95% to Td in Group 2 (the reference group) and a range of hypothetical response rates in Group 1 (the test group), an evaluable size of 32 subjects per group would provide the following 95% CIs for the difference between groups (Group 1-Group 2) in the proportion of vaccination responders:

(67) TABLE-US-00004 Group 1 Difference 95% CI for the Response Rate (Group 1 Group 2) Difference 95% 0 [13.8%, 13.8%] 75% 20% [39.9%, 0.1%] 70% 25% [45.7%, 4.3%] 65% 30% [51.3%, 8.7%] 55% 40% [61.9%, 18.1%]

(68) The analysis population for the primary endpoint of 2-fold rise in anti-tetanus serum IgG levels comprises subjects who are appropriately vaccinated per protocol, have not taken any concomitant medication that could impact immune responses, and who have nonmissing pre-vaccination and post vaccination IgG levels with a pre-vaccination level less than or equal to one half the upper limit of detection for the assay. It is anticipated that a total sample size of approximately 70 subjects (35 subjects per group) will need to be enrolled in order to obtain a total of 64 evaluable subjects (32 subjects per group). The sample size determination takes into account an approximate 10% loss of evaluable subjects.

5.2.3 Schedule of Events

(69) TABLE-US-00005 TABLE 3 Schedule of Events Screening (Within 28 days Week 4 (Day 28 3 Before days) or Early Tests and Assessments Day 1) Day 1 Withdrawal Informed Consent.sup.1 X Inclusion/Exclusion Criteria X X Medical History X Vital Signs.sup.2 X X X Physical Examination X Hematology (CBC With X .sup.X.sup.3 X Differential) Blood Chemistry X .sup.X.sup.3 X Pregnancy Tests.sup.4 Serum Urine Urine Blood Collection for Anti- .sup.X.sup.3 X Anti-Tetanus, Tetanus Anti-Pneumococcal Only Anti-Meningococcal, and Anti-Diphtheria IgG Titers Vaccines Td.sup.5 X PPSV23.sup.5 X MCV4.sup.5 X SAE and Concomitant X--------------------------------------------------X Therapy and Procedures Recording AEs Recording X-----------------------------X AEs = adverse events; CBC = complete blood count; IgG = immunoglobulin G; MCV4 = meningococcal polysaccharide diphtheria conjugate vaccine (quadrivalent); PPSV23 = 23-valent pneumococcal polysaccharide vaccine; SAEs = serious adverse events; Td = tetanus diphtheria toxoids vaccine. .sup.1Written informed consent will be obtained prior to performing any study-related procedures. .sup.2Vital signs will include height (measured at Screening only), weight, diastolic and systolic blood pressure, heart rate, and temperature. Subjects will be seated for 5 minutes prior to having their pulse and blood pressure measured. .sup.3Blood samples will be collected prior to vaccine administration. .sup.4Females of childbearing potential only. Results will be known to be negative prior to vaccine administration. .sup.5Subjects will be observed in the clinic for at least 30 minutes following their final vaccine administration.

5.2.4 Study Objectives and Endpoints

(70) 5.2.4.1. Objectives

(71) Primary Objective

(72) The primary objective of the study is to evaluate the immune response to vaccination with Td in subjects with relapsing forms of MS who have been treated with Tecfidera versus those treated with non pegylated IFN.

(73) Secondary Objective

(74) The secondary objective of the study is to evaluate the immune response to vaccination with PPSV23 and MCV4.

(75) 5.2.4.2. Endpoints

(76) Primary Endpoint

(77) The proportion of subjects with a 2-fold rise in anti tetanus serum immunoglobulin G (IgG) levels from pre-vaccination to 4 weeks after Td vaccination.

(78) Secondary Endpoints The proportion of subjects with a 4 fold rise in anti tetanus serum IgG levels from pre vaccination to 4 weeks after Td vaccination. The proportion of subjects with a 2-fold and a 4-fold rise in anti pneumococcal serum IgG levels against serotypes 3 and 8 from pre vaccination to 4 weeks after PPSV23 vaccination. The proportion of subjects with a 2-fold and a 4-fold rise in anti meningococcal serum IgG levels against serotype C from pre-vaccination to 4 weeks after MCV4 vaccination. The geometric mean titer ratios from pre-vaccination to 4 weeks after Td, PPSV23, and MCV4 vaccinations. Incidence of adverse events (AEs) and serious adverse events (SAEs). Clinical laboratory shifts in reported values. Clinically significant changes in vital sign measurements.

(79) Exploratory Endpoints The proportion of subjects with a 2-fold and a 4-fold rise in anti-diphtheria toxoid serum IgG levels from pre-vaccination to 4 weeks after MCV4 vaccination. The anti-diphtheria geometric mean titer ratio from pre-vaccination to 4 weeks after MCV4 vaccination. The proportion of subjects with anti-tetanus and anti-meningococcal seroprotective levels at 4 weeks after Td and MCV4 vaccinations.

5.2.5 Study Design

(80) 5.2.5.1. Study Overview

(81) This is an open-label, multicenter study to evaluate the immune response to vaccination in subjects with relapsing forms of MS who have been treated for at least 6 months with the approved dose of Tecfidera (240 mg BID) or who have been treated for at least 3 months with an approved dose of a non pegylated IFN (e.g., Avonex, Betaseron, Rebif, Extavia). This study will be conducted at approximately 10 to 15 sites in the US.

(82) After a 28-day Screening Period, approximately 70 eligible subjects will be enrolled and assigned as appropriate into either Group 1 (currently treated with Tecfidera) or Group 2 (currently treated with non-pegylated IFN), with approximately 35 subjects in each group.

(83) Throughout the study, subjects will remain on their existing, stable dosing regimen of Tecfidera or non pegylated IFN.

(84) Subjects will come to the clinic on Day 1 and have blood samples drawn for pre-vaccination anti-tetanus, anti pneumococcal, anti meningococcal, and anti diphtheria IgG titers. All subjects will receive 3 vaccinations: Td, PPSV23, and MCV4. They will return to the clinic at Week 4 for their final study visit, at which time blood samples will be drawn for post-vaccination IgG titers.

(85) Subjects who receive at least 1 dose of a vaccine should remain in the study and attend the Week 4 Visit. Subjects who receive at least 1 dose of a vaccine but would like to withdraw from the study prematurely will be asked to return to the clinic for an Early Withdrawal Visit, at which time blood samples will be drawn for IgG titers.

(86) Safety evaluations in this study will include blood samples for complete blood count with differential and blood chemistry, urine pregnancy tests, and vital signs at Day 1 and Week 4, as well as ongoing collection of AEs, SAEs, and concomitant medications as detailed in Table 3: Schedule of Events.

(87) The subjects' neurologist or primary healthcare provider will manage their MS care before, during, and after study participation.

(88) 5.2.5.2. Overall Study Duration and Order of Study Procedures

(89) In both groups, subjects will have 3 clinic visits: Screening, Day 1, and Week 4. The duration of study participation will be approximately 8 weeks. The following sections outline the timing and order of procedures conducted at each study visit. The procedures are listed in the order of preferred collection by the Sponsor to enhance data clarity. Altering the order is not considered a protocol deviation with the exception of the timing of blood collection in relation to vaccination (i.e., blood samples for pre-vaccination titers will be collected before vaccinations are given) and the order of vaccine administration.

(90) 5.2.5.3. Screening Visit

(91) Subjects will be screened and meet eligibility criteria for the study within 28 days prior to study entry.

(92) At the Screening Visit, informed consent will be given before any screening activities are conducted. Other procedures to be conducted during the Screening Visit, in preferred order, are listed below: Concomitant therapy and procedure recording Medical history Vital signs Physical examination Review of inclusion/exclusion criteria (except laboratory results) Collection of blood samples for anti-tetanus IgG titer, hematology, blood chemistry, and serum pregnancy test AE assessment and reporting

(93) 5.2.5.4. Day 1 Visit

(94) Subjects who pass screening will return to the clinic for the Day 1 Visit.

(95) At the Day 1 Visit, the following procedures will be completed before study vaccines arc administered and arc listed in preferred order: AE and SAE assessment and recording Concomitant therapy and procedure recording Review of inclusion/exclusion criteria Urine pregnancy test (females only)do not vaccinate subject unless pregnancy has been excluded with a negative pregnancy test Vital signs Collection of blood samples for anti-tetanus, anti-pneumococcal, anti meningococcal, and anti-diphtheria IgG titers; hematology; and blood chemistry

(96) After completing these assessments, study vaccines will be administered in the following order: 1. Td 2. PPSV23 3. MCV4

(97) Subjects will remain at the clinic for at least 30 minutes after their final vaccination for observation.

(98) 5.2.5.5. Week 4/Early Withdrawal Visit

(99) Subjects in both groups will have a clinic visit 4 weeks after vaccination. Subjects who have received at least 1 vaccination but withdraw prematurely from the study will be asked to return to the clinic for an Early Withdrawal Visit.

(100) Procedures to be conducted during the Week 4/Early Withdrawal Visit, in preferred order, are listed below: AE and SAE assessment and recording Concomitant therapy and procedure recording Urine pregnancy test (females only) Vital signs Collection of blood samples for anti-tetanus, anti-pneumococcal, anti meningococcal, and anti-diphtheria IgG titers; hematology; and blood chemistry

(101) 5.2.5.6. End of Study

(102) The end of study is last subject, last visit for final collection of data.

5.2.6 Selection of Subjects

(103) 5.2.6.1. Inclusion Criteria

(104) Unless otherwise specified, to be eligible to participate in this study, candidates will meet the following eligibility criteria at Screening and on Day 1 or at the timepoint specified in the individual eligibility criterion: 1. Ability to understand the purpose and risks of the study and provide signed and dated informed consent and authorization to use protected health information (PHI) in accordance with national and local subject privacy regulations. 2. Aged 18 to 55 years old, inclusive, at the time of informed consent. 3. Women of childbearing potential will practice appropriate contraception (per the local Tecfidera or non-pegylated IFN prescribing information) as determined by the Investigator. 4. Will have a confirmed diagnosis of RRMS per the 2010 McDonald criteria [Polman 2011]. 5. Will have a known tetanus immunization history with most recent tetanus vaccination given 2 to 15 years prior to Screening and an anti-tetanus IgG titer at Screening that is less than or equal to one-half the upper limit of detection for the assay. 6. Will have been on a stable approved dose of Tecfidera (240 mg BID) [Group 1] for 6 months or on a stable approved dose of a non-pegylated IFN (e.g., Avonex, Betaseron, Rebif, Extavia) [Group 2] for 3 months prior to Day 1.

(105) Note: Subjects will have received their MS treatment as monotherapy for the required duration, except during treatment of relapses.

(106) 5.2.6.2. Exclusion Criteria

(107) Unless otherwise specified, candidates will be excluded from study entry if any of the following exclusion criteria exist at Screening and on Day 1 or at the timepoint specified in the individual eligibility criterion:

(108) Medical History 1. Clinical relapse requiring treatment within 30 days prior to Day 1. 2. Pneumococcal vaccination within 5 years prior to Screening. 3. Previous exposure to meningococcal vaccines. 4. Known hypersensitivity to Td, PPSV23, or MCV4 or their components. 5. History of hepatitis C or hepatitis B virus. 6. History of human immunodeficiency virus. 7. History of drug or alcohol abuse (as defined by the Investigator) within 2 years prior to Screening. 8. Current smoker or smoking within 6 months prior to Screening. 9. Any clinically significant infectious illness (e.g., cellulitis, abscess, pneumonia, septicemia) within 30 days prior to Screening. 10. Any active bacterial or viral infection or an oral temperature38.0 C./100.4 F. on Day 1 or within 3 days prior to Day 1. Subjects with a clinically significant active infection or measured oral (sublingual) temperature38.0 C./100.4 F. should have vaccinations postponed until the subject's temperature remains below 38.0 C./100.4 F. for at least 3 days and the subject's acute illness has resolved. 11. History of clinically significant cardiovascular, dermatologic, endocrinologic, gastrointestinal, hematologic, hepatic, immunologic, metabolic, neurologic (other than MS), psychiatric, pulmonary, renal, urologic, and/or other major disease that may confound safety or efficacy assessments. 12. History of malignancy (subjects with basal cell carcinoma that has been completely excised prior to study entry remain eligible). 13. History of severe allergic reactions, anaphylactic reactions, or known drug hypersensitivity to Tecfidera or fumaric acid esters. 14. Any abnormal laboratory assessment judged to be clinically significant by the Investigator at Screening.

(109) Note: The following analytes are strictly exclusionary: leukocytes<2500/mm.sup.3 lymphocytes<500/mm.sup.3 alanine transaminase or aspartate transaminase>2 times the upper limit of normal

(110) Treatment History 15. Any type of vaccine, with the exception of inactivated influenza vaccination (the flu shot), within 4 weeks prior to Day 1 (the inactivated flu shot is allowed; the intranasal live vaccine is not allowed). 16. Prior treatment with any of the following: cladribine mitoxantrone fingolimod total lymphoid irradiation T-cell or T-cell-receptor vaccination any therapeutic monoclonal antibody, with the exception of Tysabri (natalizumab) (see exclusion #17). 17. Prior treatment with Tysabri (natalizumab) within 1 year prior to Screening. 18. Prior treatment with any of the following medications or procedures within 6 months prior to Screening: cyclosporinc azathioprine methotrexate mycophenolate mofetil intravenous immunoglobulin plasmapheresis or cytapheresis subcutaneous or oral glatiramer acetate 19. Treatment with any immunosuppressive drug or regimen within 3 months prior to Day 1, including but not limited to chronic steroid use (defined as continuous [>14 days] use of intravenous or oral corticosteroid treatment, with a dosage equivalence of >20 mg/day of oral prednisone) or agents that may act through the corticosteroid pathway (e.g., low dose naltrexone). 20. Treatment with any investigational drug or approved therapy for investigational use within the 6 months prior to Day 1 or during the study.

(111) Miscellaneous 21. Female subjects who are currently pregnant or breast-feeding or planning to become pregnant while in the study. 22. Current enrollment in any other investigational study within 6 months prior to Day 1. Note: Current enrollment in an observational study that does not involve drugs, vaccines, or medical devices is allowed. 23. Unwillingness or inability to comply with the requirements of the protocol including the presence of any condition (physical, mental, or social) that is likely to affect the subject's ability to comply with the protocol. 24. Any other reasons that, in the opinion of the Investigator and/or the Sponsor, the subject is determined to be unsuitable for enrollment in this study.

5.2.7 Treatment of Subjects

(112) 5.2.7.1. Vaccinations

(113) On Day 1, following all other assessments, subjects in both groups will receive the following vaccinations intramuscularly in the specified order: 1. Td (Tenivac, 0.5 mL) 2. PPSV23 (Pneumovax 23, 0.5 mL) 3. MCV4 (Menveo, 0.5 mL)

(114) 5.2.7.2. Concomitant Therapy

(115) A concomitant therapy is any drug or substance administered from the time the subject is enrolled in the study until the subject's final study visit.

(116) 5.2.7.3. Disallowed Concomitant Therapy

(117) Concomitant therapy with any of the following is not allowed, unless approved by the Medical Monitor, or as otherwise described in this protocol: Any treatment for MS, such as chronic immunosuppressant therapy or other immunomodulatory treatments (including, but not limited to: glatiramer acetate, natalizumab, cyclophosphamide, methotrexate, azathioprine, fingolimod, alemtuzumab, teriflunomide, or related products, etc.), with the exception of treatments required as a condition for study eligibility and treatments for acute management of relapses. Any investigational product, including investigational symptomatic therapies for MS and investigational therapies or vaccines for non-MS indications. Any systemic steroid therapy including, but not limited to, oral corticosteroids (e.g., prednisone) or periodic (e.g., monthly) treatment with intravenous methylprednisolone, except for treatment of a relapse. Steroids that are administered by nonsystemic routes (e.g., topical, inhaled) are allowed. Total lymphoid irradiation, cladribine, T-cell or T-cell-receptor vaccination, any therapeutic monoclonal antibody, mitoxantrone, cyclosporine, intravenous immunoglobulin, plasmapheresis, or cytapheresis. Live or live-attenuated vaccines.

(118) Subjects should be instructed not to start taking any new medications, including nonprescribed drugs, unless they have received permission from the Investigator.

(119) 5.2.7.4. Concomitant Procedures

(120) A concomitant procedure is any therapeutic intervention (e.g., surgery/biopsy, physical therapy) or diagnostic assessment (e.g., blood gas measurement, bacterial cultures) performed between the time the subject is enrolled in the study until the subject's final study visit.

(121) The use of concomitant therapies or procedures defined above will be recorded on the subject's case report form (CRF), according to instructions for CRF completion. AEs related to administration of these therapies or procedures will be documented on the appropriate CRF.

(122) 5.2.8 Efficacy Assessments

(123) Blood samples will be collected for anti-tetanus, anti pneumococcal, anti meningococcal, and anti-diphtheria IgG titers before vaccination on Day 1 and after vaccination at Week 4 or the Early Withdrawal Visit.

(124) Refer to Table 3: Schedule of Events, for the timing of assessments.

5.2.9 Safety Assessments

(125) 5.2.9.1. Clinical Safety Assessments

(126) The following clinical assessments will be performed during the study: Vital sign measurements Physical examination Monitoring/recording of AEs Monitoring/recording of concomitant therapy and procedures

(127) Refer to Table 3: Schedule of Events, for the timing of assessments.

(128) 5.2.9.2. Laboratory Safety Assessments

(129) The following laboratory tests will be performed during the study: Hematology: hemoglobin, hematocrit, red blood cell count, white blood cell count (with differential), and platelet count Blood chemistry: sodium, potassium, chloride, total bilirubin, alanine transaminase, aspartate transaminase, gamma glutamyl transferase, blood urea nitrogen, and creatinine Urine and serum pregnancy tests

(130) Refer to Table 3: Schedule of Events, for the timing of assessments.

5.2.10 References for Example 2

(131) Olberg H K, Cox R J, Nostbakken J K, et al. Immunotherapies influence the influenza vaccination response in multiple sclerosis patients: an explorative study. Mult Scler. 2014; 20(8):1074-1080. Polman C H, Reingold S C, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 Revisions to the McDonald criteria. Ann Neurol. 2011; 69(2):292-302. Schwid S R, Thorpe J, Sharief M, et al. Enhanced benefit of increasing interferon beta-1a dose and frequency in relapsing multiple sclerosis: the EVIDENCE Study. Arch Neurol. 2005; 62(5):785-92.

6. INCORPORATION BY REFERENCE

(132) Various references such as patents, patent applications, and publications are cited herein, the disclosures of which are hereby incorporated by reference herein in their entireties.