The gut-brain-axis one year after treatment with cladribine tablets in patients with relapsing remitting multiple sclerosis: a pilot study

Jeske van Pamelen ^1,2* Carla Rodriguez-Mogeda ³ Lynn van Olst ³ Susanne MA van der Pol ³ Maarten L Boon ⁴ Janet De Beukelaar ⁵ Oliver HH Gerlach ^6,7 Andries E Budding ⁴ Joep Killestein ² Helga E De Vries ³ Leo H Visser ¹

• ¹ Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
• ² MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
• ³ Department of Molecular Cell Biology and Immunology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC LOcation Vrije Universiteit Amsterdam, Amsterdam, Netherlands
• ⁴ inBiome, Amsterdam, Netherlands
• ⁵ Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
• ⁶ Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, Netherlands
• ⁷ School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands

Introduction: Cladribine tablets are an effective treatment for relapsing remitting multiple sclerosis (RRMS). However, almost half of the treated patients are not free of disease activity after two years. The aim of this study was to describe the changes that cladribine tablets effectuate in the gut and oral microbiota and the peripheral immunological profile between responders and non-responders. Methods: In this pilot study of the multicenter, prospective, observational BIA (Brain-Immune-Intestine Axis) study, we included patients aged 18 to 55 years with RRMS who were scheduled to start treatment with cladribine tablets. We assessed the clinical status and the immunological and microbiological profile prior to the start of the treatment and after three and twelve months. At twelve months, we assessed the response status, based on clinical relapses, radiological activity and disability progression on the Expanded Disability Status Scale. Results: The first twenty-five patients of the BIA study were included in this analysis. Ten patients (40%) were responders twelve months after treatment. Three months after treatment we found a significant decline of naïve and transitional B cells and memory B cells, and of CD57 + CD56 dim NK cells. After twelve months the values recovered to baseline levels, except for the memory B cells. We did not find significant changes of the microbiological profile over time, except for a decline of the phylum Bacteroidetes in the oral samples twelve months after treatment. Baseline values and changes over time did not significantly differ between responders and non-responders. However, several phyla, genera or species (Bacteroidetes, Prevotella, Faecalibacterium prausnitzii) showed a higher relative abundance, and several phyla, genera or species (Proteobacteria, Escherichia coli) had a lower relative abundance in responders compared to non-responders.Discussion: After treatment with cladribine tablets, we found significant changes in the immunological landscape. Also, the microbiological profile showed several differences in microbes with known anti-or pro-inflammatory properties between responders and non-responders. Overall, we showed that we can measure a treatment effect from cladribine tablets with our analyses. Future research on data from the BIA study, with a larger sample size and extended follow-up, can possibly confirm the reliability of our findings.