About this trial

Multiple sclerosis (MS) witnessed relevant therapeutic progress in the last decade. Following the extraordinary progress in the treatment of relapsing-remitting (RR) multiple sclerosis (MS), two major unmet needs remain to be addressed by translational research in this field: progressive MS and the "dream" of a world free of MS. As far as the latter is concerned, the investigators can hope to make the dream come true by understanding the etiology of the disease and hence design definitive cures. A more realistic and pragmatic perspective may be the prevention of the clinical onset of the disease, a research field that promises to become increasingly important as the integration of genetic data with endophenotypes, magnetic resonance imaging and other biomarkers ameliorates the ability to predict the development of the disease under clinical circumstance. Bacille Calmette-Guerin (BCG) vaccine has been tested with encouraging results in early MS and clinically isolated syndrome (CIS). The knowledge that disease-modifying therapies work best when used early in the demyelinating process raises the question about whether to try this approach - which is safe, cheap and handy - in individuals with radiologically isolated syndrome (RIS).

Radiologically isolated syndrome is a new entity, diagnosed when the unanticipated magnetic resonance imaging (MRI) finding of brain spatial dissemination of focal white matter (WM) lesions highly suggestive of MS occurs in subjects without symptoms of MS, and with normal neurological examinations. Conversion to clinically isolated syndromes (CIS) were described in 84% of RIS individuals with spinal cord lesions over a median time of 1.6 years from the date of the first MRI. Whether or not to treat this condition remains currently a clinical conundrum. Bacille Calmette-Guérin (BCG) vaccine may have these characteristics since it resulted beneficial in early MS and first demyelinating episodes. Being safe, cheap and handy, the investigators propose to investigate its use to prevent progression of the demyelinating process in radiologically isolated syndrome. An approach such as BCG vaccine seems appropriate as a front-line immunomodulatory approach for RIS people. In a pilot study BCG vaccine was safe and effective in reducing disease activity at MRI, and the risk of developing persistent T1-hypointense lesions ('black holes' -BH- expression of tissue damage) in subjects with MS.

Eligibility criteria

This trial does not accept healthy volunteers

Qualifiers

Male and female of any race and > 18 years old.

Diagnosis of RIS (4) within the last five years.

Signed Informed Consent.

Disqualifiers

Pregnancy or lactation.

Concomitant or previous use of immunosuppressive or immunomodulating treatment (except sporadic use of corticosteroids) within the last five years.

Subjects with a clinically significant or unstable medical or surgical condition that would preclude safe and complete study participation. Such conditions may include cardiovascular, pulmonary, hepatic, renal, severe systemic mycotic infections, metabolic diseases or malignancies, primary or secondary immunodeficiencies as determined by medical history, physical exam, laboratory tests, chest X-ray, electrocardiogram (ECG), and Mantoux reaction.

Any medical or psychiatric condition that may affect the subjects ability to give informed consent, or to complete the study, or if the subject is considered by the treating neurologist to be, for any other reason, an unsuitable candidate for this study.

Trial design

Design model

Parallel

Treatments tested in this trial

Bacille Calmette-Guerin vaccine
Drug
One dose (0.1 mL) contains 50 μg of the semi-dry mass of BCG bacilli, i.e. from 150,000 to 600,000 of live BCG bacilli (Bacillus Calmette-Guerin), the Brazilian Moreau substrain. One ampoule or vial with the powder contains: 0.5 mg (from 1.5 mln to 6 mln) of live BCG bacilli (Bacillus Calmette-Guerin), the Brazilian Moreau substrain. Powder: monosodium glutamate. Solvent: isotonic solution of sodium chloride.
Placebo
Drug
isotonic solution of sodium chloride (2mL vials).

Treatment groups

100 Participants

are divided into 2 treatment groups

Group A: BCG treated patientsExperimental treatment 1 intervention

Group B: Placebo treated patientsPlacebo comparator 1 intervention

Trial outcomes

Primary outcomes

1

cumulative number of CUAL (new gadolinium T1-weighted lesions and non-enhancing new and newly enlarging T2-weighted lesions) on MRI scans over 1 year.

To evaluate the cumulative number of new combined unique active lesions (CUAL; defined as new gadolinium T1-weighted lesions and non-enhancing new and newly enlarging T2-weighted lesions) on magnetic resonance imaging (MRI) scans over 1 year. Brain MRI will be acquired in all subjects at each centre using a magnet at 1.5T or 3T. * A sagittal survey image will be used to identify the anterior and posterior commissure (AC and PC). * A dual-echo, turbo spin-echo sequence (slice thickness: 3mm). * A high-resolution (3D, MPRAGE) T1- weighted image (slice thickness: 1mm). * A Magnetization Transfer (MT) sequence will be performed acquiring two 2-dimensional gradient-echo sequences, one without and one with MT saturation pulse (slice thickness: 3 mm). * A double inversion recovery (DIR) sequence * A T1-weighted scan, post-gadolinium injection, after 10-minute wait period. * A FLAIR sequence to be acquired between the DIR and the T1-weighted scans, after the gadolinium injection.

Time frame

12 months

Secondary outcomes

1

Time to the first clinical event.

The secondary endpoint will be the time to the first clinical event over the 3 years period. Five visits (including physical and neurological examinations) per subject are planned: * Visit 1 - from day -3 to day +1 * Visit 2 - 6 months (±7 days) * Visit 3 - 12 months (±7 days) * Visit 4 - 24 months (±7 days) * Visit 5 - 36 months (±7 days)

Time frame

36 months

Other outcomes

1

number of cortical lesions

To evaluate the number of cortical lesions on magnetic resonance imaging (MRI) scans at 6 months, as well as at 1, 2 and 3 years: Cortical lesions will be assessed on the DIR sequence and defined as those focal hyperintensities entirely or partly located in the cortical GM.

Time frame

6, 12, 24, 36 months

2

Percentage of Brain Volume Changes (PBVC)

Brain atrophy (global and regional) will be assessed on the 3D T1-weighted images using the software SIENA/SIENAX (Structural Image Evaluation, using Normalization, of Atrophy) method.

Time frame

6, 12, 24, 36 months

3

Cortical and white matter Volume Changes

Brain atrophy (global and regional) will be assessed on the 3D T1-weighted images using the software SIENA/SIENAX (Structural Image Evaluation, using Normalization, of Atrophy) method. To avoid GM misclassification due to WM lesions, the latter will be masked out and refilled with intensities matching the surrounding normal-appearing WM before segmentation analysis. Volume in the subcortical grey matter will be assessed with FMRIB's Integrated Registration and Segmentation Tool (FIRST).

Time frame

6, 12, 24, 36 months

4

Magnetization Transfer ratio (MTr) in lesions

Magnetization Transfer (MT) sequence will be performed acquiring two 2-dimensional gradient-echo sequences, one without and one with MT saturation pulse, which allows to obtain MT ratio in lesions, and normal-appearing brain.

Time frame

6, 12, 24, 36 months

Bacille Calmette-Guérin (BCG) Vaccine In Radiologically Isolated Syndrome (RIS)

About this trial

Eligibility criteria

Qualifiers

Disqualifiers

Trial design

Treatments tested in this trial

Treatment groups

Trial outcomes

Primary outcomes

Secondary outcomes

Other outcomes

Sponsors and contacts