1) The document discusses the hypothesis that viral infections, such as Epstein-Barr virus (EBV) and human endogenous retroviruses (HERVs), may play a role in the etiology of multiple sclerosis (MS). 2) Interferon-beta (IFN-β) was the first disease-modifying therapy approved for relapsing-remitting MS based on its ability to reduce clinical relapses and magnetic resonance imaging (MRI) lesions in clinical trials. 3) IFN-β formulations target the proposed viral triggers of MS through the drug's antiviral properties, providing a potential link between the etiology and treatment of the disease.

1. IFN-b and multiple sclerosis: From etiology to therapy and back
V. Annibali a,1
, R. Mechelli a,1
, S. Romano a
, M.C. Buscarinu a
, A. Fornasiero a
,
R. Umeton a
, V.A.G. Ricigliano a,b
, F. Orzi c
, E.M. Coccia d
, M. Salvetti a,
*, G. Ristori a
a
Centre for Experimental Neurological Therapies (CENTERS), Neurology and Department of Neurosciences, Mental Health and Sensory Organs, Sapienza
University of Rome, Italy
b
Neuroimmunology Unit, Fondazione Santa Lucia-I.R.C.C.S., Rome, Italy
c
Neurology and Department of Neurosciences, Mental Health and Sensory Organs, Sapienza University of Rome, Italy
d
Department of Infectious, Parasitic and Immune-mediated Diseases, Istituto Superiore di Sanita`, Rome, Italy
1. Introduction
Multiple sclerosis (MS) is an inflammatory demyelinating
disease of the central nervous system (CNS) characterized, in its
most common clinical presentation, by an unpredictable occur-
rence of relapse and remission phases [1–3]. The disease generally
affects young adults [4], with a preference for female gender, as
observed in many other immune-mediated conditions. Being a
multifactorial disorder, its etiology involves both genetic and
environmental risk factors. So far, genome-wide association
studies (GWAS) have shown that genetic predisposition to MS is
determined by more than 100 disease-associated susceptibility
polymorphisms, located in coding and non-coding DNA [5]. Path-
way analyses on MS-related genes demonstrated a relation with
cellular networks specifically involved in immune cell functioning,
antiviral response and interferon (IFN) signaling [6].
Major environmental risk factors for MS include Epstein–Barr
virus (EBV) infection, the reactivation of human endogenous
retroviruses (HERV) in specific conditions, vitamin D deficit and
cigarette smoking, as supported by epidemiological surveys,
serological evidences and other experimental laboratory based
studies [7–13]. Nonetheless, a comprehensive overview of the
events leading to MS development is still lacking.
There is no cure for MS and treatments focus on treating
relapses, slowing the progression of the disease and managing
symptoms. Several immunomodulatory and immunosuppressive
therapeutic agents are currently available for relapsing-remitting
forms (RR) of MS, being interferon beta (IFN-b) the first
therapeutic intervention able to interfere with the course of the
disease and still the most used first-line treatment in RR MS.
Cytokine & Growth Factor Reviews 26 (2015) 221–228
A R T I C L E I N F O
Article history:
Available online 31 October 2014
Keywords:
Multiple sclerosis
Interferon beta
Epstein–Barr virus
Human endogenous retroviruses
Genome-wide Association Studies
A B S T R A C T
Several immunomodulatory treatments are currently available for relapsing-remitting forms of multiple
sclerosis (RRMS). Interferon beta (IFN) was the first therapeutic intervention able to modify the course of
the disease and it is still the most used first-line treatment in RRMS.
Though two decades have passed since IFN-b was introduced in the management of MS, it remains a
valid approach because of its good benefit/risk profile. This is witnessed by new efforts of pharmaceutical
industry to improve this line: a PEGylated form of subcutaneous IFN-b 1a, (Plegridy1
) with a longer half-
life, has been recently approved in RRMS.
This review will survey the various stages of the use of type I IFN in MS, with special attention to the
effect of the treatment on the supposed viral etiologic factors associated to the disease. The antiviral
activities of IFN (that initially prompted its use as immunomodulatory agent in MS), and the mounting
evidences in favor of a viral etiology in MS, allowed us to outline a re-appraisal from etiology to therapy
and back.
ß 2014 Elsevier Ltd. All rights reserved.
Abbreviations: ARR, annualized relapse rate; CIS, clinically isolated syndrome; CNS,
central nervous system; EBNA, Epstein–Barr nuclear antigen; EBV, Epstein–Barr
virus; EDSS, expanded disability status scale; ELISA, enzyme-linked immunosor-
bent assay; GWAS, genome-wide association studies; HERV, human endogenous
retroviruses; HIV, human immunodeficiency virus; IFN, Interferon; IFNAR, IFN–a
receptor; IPA, ingenuity pathway analysis; IRF, interferon regulatory factor; ISGF,
IFN-stimulated gene factor; JAK, Janus-family tyrosine kinases; LMP1, latent
membrane protein-1; MRI, magnetic resonance imaging; MS, multiple sclerosis;
MSRV, MS-associated retroviruses; MxA, myxovirus-induced protein A; NAbs,
neutralizing antibodies; 20
,50
-OAS, 20
,50
-oligoadenylate synthetase; PEG, polyeth-
ylene glycol; RAL, raltegravir; RR, relapsing–remitting forms; STAT, signal
transducers and activators of transcription; SNPs, single nucleotide polymor-
phisms; TLR, toll-like receptors; TYK, tyrosine kinase.
* Corresponding author at: Neurologia, Ospedale S. Andrea, Via di Grottarossa
1035, 00189 Rome, Italy. Tel.: +39 06 33775994; fax: +39 06 33775900.
E-mail address: marco.salvetti@uniroma1.it (M. Salvetti).
1
These authors contributed equally to this work.
Contents lists available at ScienceDirect
Cytokine & Growth Factor Reviews
journal homepage: www.elsevier.com/locate/cytogfr
http://dx.doi.org/10.1016/j.cytogfr.2014.10.010
1359-6101/ß 2014 Elsevier Ltd. All rights reserved.

2. 2. From etiology. . .
The hypothesis of a viral etiology in MS led to several
investigations on a large number of microbes, that, after an initial
enthusiastic attention, failed to be demonstrably associated to MS.
At the moment two agents seem consistently linked to diseases
development: EBV and HERV.
Converging epidemiological, clinical and laboratory studies
support an etiologic role for EBV in MS [14]. EBV is a g-herpesvirus
that infect quite all the adult population and that persists in
infected B cells in a latent or lytic phase [15]. Humans are the
exclusive natural host for EBV which may explain why MS is
unique to humans [16]. Prospective studies have shown that
elevation in serum antibody titers to EBV precedes the occurrence
of MS [17,18]. Epstein–Barr viral load in the peripheral blood of
healthy adults may predict the risk of MS [19], while in children
who develop MS immunoreactivity to EBV, but not to other viruses,
is higher than in controls [20,21]. A history of late EBV infection
and of infectious mononucleosis (IM is often the clinical
manifestation of a late primary EBV infection) is strongly
associated to MS [22]. EBV may be a target of oligoclonal
cerebrospinal fluid IgG [23], CD8+ T cells [24–26] and CD4
response [27], and a vast literature on the cross-reactivity between
EBV and myelin epitopes was produced over the past two decades
[28–30].
Recent works provided further evidences aimed at clarifying
how EBV contributes to disease development. An inadequate
control of EBV at primary infection or at a later stage can lead to
low grade, persistently active EBV infection in CNS infiltrating B
cells [26,31–33]. A ‘‘candidate-interactome’’ aggregate analysis of
genome-wide association data in multiple sclerosis demonstrated
a significant enrichment of potential interactions between the
virus and MS-related genomic regions [34]. The EBV infection of
the MS brain as cause of CNS damage that remains controversial
[35–37], is supported by several recent studies demonstrating a
selective enrichment of EBV-specific CD8+ T cells in the
cerebrospinal fluid of MS patients [38,39] and the presence of
EBV DNA in brain (Mechelli et al., manuscript submitted).
Besides to role of herpesviruses many studies support a
potential contribution for HERV to MS development. Retroviruses
are RNA viruses that may cause a spectrum of diseases of the
nervous system. Their genome contains three genetic domains: env
is responsible for the surface glycoproteins and trans-membrane;
gag encodes the proteins necessary for viral assembly, including
matrix proteins and core shell; pol encodes the enzymes needed for
viral replication, such as reverse transcriptase, protease, ribonu-
clease and integrase [40].
Specific sequences within retroviral genes can lead to the
development of neurovirulence, in particular, the proteins env-
associated, which mediates the binding of the virus to the cell
membrane surface. Neurovirulent retroviruses are able to activate
the host immune response that, through pro-inflammatory
molecules and neurotoxic molecules, ultimately leads to neuronal
death [40].
In 1997, Perron described the isolation and identification of new
retrovirus particles from cell cultures of leptomeninges, choroid
plexus and peripheral B lymphocytes in MS patients. This study
provided molecular evidence that the production of extracellular
virions containing MS-associated retroviruses (MSRV) pol se-
quence was associated with MS. This virus, previously called LM7,
was a new retrovirus which was present in the cerebrospinal fluid
of patients with MS [41]. The same group showed the production of
a specific envelope protein with gliotoxic and pro-inflammatory
actions that may be crucial in MS pathogenesis [42]. Further
studies have tried to explain and confirm the association between
MS and the expression of MSRV envelope (Env), providing
evidences that the retrovirus appears to be related to MS clinical
progression [43,44]. Recently, env antigen was detected in the
serum of 73% of MS patients with similar prevalence in all clinical
forms, and not in subjects affected by other inflammatory diseases.
The different forms of the disease (primary-progressive, RR and
clinically isolated syndrome-CIS) show different ELISA (enzyme-
linked immunosorbent assay) and/or PCR profiles indicative of an
increase with the evolution of the disease [45].
3. To therapy. . .
Interferons were discovered by Isaacs and Lindenmann [46];
they use this term to describe a soluble substance with biological
activity able to interfere with viral replication. Due to their
antiviral activities and considering the plausible viral etiology of
MS, IFNs, regardless of their type, were proposed as immunomod-
ulatory therapeutic agents in MS patients.
The first trials using IFN-g (a type II IFN) were conducted in the
late 1980s and were interrupted because the treated patients
showed an increase of severity and frequency of relapses
[47,48]. These negative results led to study another type of IFNs
(type I), IFN-a and IFN-b, that may act as inhibitors of IFN-g.
Different preparations of IFN-a resulted in reduction of clinical
relapses and activity at magnetic resonance imaging (MRI) in MS
patients, but unacceptable side effects precluded its use in clinical
practice [49–53]. IFN-b was similarly effective in decreasing
disease activity and showed an acceptable risk profile, thus
becoming the first disease-modifying therapy for MS (Table 1).
Subcutaneous IFN-b 1b (Betaseron1
) was the first immuno-
modulatory therapy to receive approval for the treatment of RRMS
in 1993. It is produced by recombinant DNA technology in the
bacterial cell (Escherichia coli) and currently is the only IFN-b
licensed for RR and secondary progressive (SP) MS [54]. In the
registration trial 372 patients were randomized to receive placebo
or IFN-b 1b (50 or 250 mcg subcutaneously every other day) for
2 years. The annualized relapse rate (ARR) was significantly lower
in the IFN-b1b treated groups compared to the placebo group with
a dosage effect. Moreover a significative reduction of activity at
MRI activity was showed. No difference in disease progression
between treatment and placebo groups was demonstrated [55,56].
IFN-b1a IM (Avonex1
) is produced in Chinese hamster ovary
cells and was approved for treatment in RRMS in 1996. In the
Table 1
INF-b formulations approved for RRMS. For detailed description, see text.
Rebif 22/44 Avonex Betaferon/Betaseron/Extavia
IFN subtype Beta 1a Beta 1a Beta 1b
Production CHO CHO E. coli
Aminoacid 166 aa 166 aa 165 aa
Glycosylation 1 N-linked complex 1 N-linked complex None
Administration SC, 3 times/week IM, 1 time/week SC, every other day
Weekly dose 66/132 mcg 30 mcg 875 mcg
CHO = Chinese hamster ovary cells; SC = subcutaneous; IM = intramuscular.
V. Annibali et al. / Cytokine & Growth Factor Reviews 26 (2015) 221–228222

3. pivotal study 301 patients with expanded disability status scale
(EDSS) score of 1.0–3.5 and at least two relapses in the preceding
3 years were randomized to receive placebo or IFN-b 1a (30 mg
intramuscularly once weekly) for 2 years [57,58]. The IFN-b 1a
group showed a significant decrease in the disease activity
compared with placebo.
IFN-b 1a SC (Rebif1
) is also produced in mammalian Chinese
hamster ovary cells using DNA technology. It was approved for
treatment of RRMS in 1998 in Europe and Canada and in 2002 in
the USA. In the PRISM study [59] 560 patients with an EDSS score
between 1.0 and 5.0 and at least two relapses in the preceding
2 years were randomized to receive placebo or IFN-b 1a (22 or
44 mg subcutaneously three times weekly). After 2 years of
treatment, IFN-b 1a showed significant results compared with
placebo in relapse rate and MRI activity with a statistically
significant dose-effect.
While the pivotal clinical trials consistently demonstrated that
both forms of IFN-b reduce ARR by about 1/3 and new brain MRI
lesions over periods of 1–3 years in RRMS, four randomized,
placebo-controlled trials demonstrated poor or no effects on
established progressive MS [54,60–63]. IFN-b has a significant
effect in the earlier inflammatory stages of the disease: three large
clinical trials (CHAMPS, ETOMS and BENEFIT) in CIS patients,
demonstrated an effect on clinical and MRI measures of disease
activity delaying the development to clinically definite (CD) MS
[64–66]. Although these studies had limited comparability because
of different patient populations recruited (BENEFIT and ETOMS
enrolled patients with multifocal manifestations at onset, while
CHAMPS enrolled patients with monofocal forms), the risk of
progression to CDMS was comparably reduced by 40–50%.
Considering the different formulations of IFN-b, head-to-head
trials were conducted to compare the different licensed IFNs
(EVIDENCE and INCOMIN). These studies demonstrated that
increasing the dose of IFN-b (more frequent dosing schedule or
higher dose) gave greater benefit than lower doses, supporting a
dose–response relationship [67,68].
The IFNs-b are generally well tolerated, being the most
frequent side effects injection-site reaction, and a flu-like
syndrome that tends to wanes over time in most patients.
Lymphopenia, hepatic failure, hepatitis, and elevated liver
enzymes have also been reported especially during IFN-b-1b
treatment [69]. Though IFN-b therapy represents a significant
advance in the management of MS, the treatment response is not
uniform and clinical experience shows that about 40% of the MS
patients do not or only poorly respond to IFN-b treatment (‘‘non-
responders’’) [70]. So far there are no established biological
markers able to predict the response. The development of
neutralizing antibodies (NAbs), which at high titers may block
the biological response of the drug with a reduced efficacy, can
contribute to treatment failure [71,72]. Persistent high-titers of
NAbs depend on the formulation and dosing regimen, and occur
more commonly with subcutaneous preparations [73].
IFN was tried in MS as a ‘general’ antiviral approach and gave
positive results as disease modifying therapy. This was not the case
with more ‘specific’ antiviral treatment such as those active on
herpes viruses. Over the last twenty years several clinical trials
have been carried out especially with acyclovir and valacyclovir
[74–76]. Overall, these studies did not obtain significant results in
favor of the drug compared to placebo, though positive trends were
noted. An analysis that also took into account the pharmacokinetic
of acyclovir and valacyclovir suggested an inhibitory effect on
some viruses (Herpes viruses 1, 2, 6 and varicella zoster virus) but
not on others that seem to have a greater correlation with MS (EBV,
Herpes virus 6, and MSRV), thus explaining, at least in part, the
failure of this approach [77]. Further studies with new antiviral
drugs having improved pharmacological characteristics and
antiretroviral activity may result in better outcome and are
currently actively investigated (see Raltegravir in next section).
4. And back. . .
4.1. MS genome-wide association studies and IFN-b pathway
The exact mode of action of IFN-b in MS is likely to be complex
and is not yet fully understood. This topic will be not treated in the
present review, being object of other contributions in this issue. At
the molecular level IFN-b is recognized by the IFN-a receptor
(IFNAR), which is found on many different cell types. The receptor
is a heterodimer formed by IFNAR1 and IFNAR2, which assemble
into a functional receptor complex and initiates the signal
transduction pathway that involves the phosphorylation of several
intracellular mediators. Upon assembly of the IFN receptor
complex, the intracellular domains of IFNAR1 and IFNAR2 active
Janus kinases 1 (JAK1) and tyrosine kinase 2 (TYK2). The JAK1/TYK2
along with IFNAR, phosphorylate signal transducers and activators
of transcription (STAT) 1, and 2, which dimerize and form a
complex with interferon regulatory factor 9 (IRF9). The STA-
T1:2:IRF9 complex is a transcription factor (IFN-stimulated gene
factor, ISGF3), which translocates to the nucleus and binds to the
IFN-stimulated response element (ISRE) of multiple genes
[78]. Different kinds of genes are targeted by ISGF3 complex,
including early genes such as IFN regulatory factor-1 (IRF-1), the
primary positive regulator of IFN production, and IRF-2, an
inhibitor of IFN production. The later genes include the IFN-b
itself and antiviral proteins such as 20
,50
-oligoadenylate synthetase
(20
,50
-OAS) and myxovirus-induced protein A (MxA), which are
specifically induced by type I IFNs. MxA is the established marker
of IFN-b biological activity in IFN-b-treated MS patients [79].
Some genes related to the IFN-b signaling pathway showed
single nucleotide polymorphisms (SNPs) that resulted to be MS-
associated in GWAS [5]. To review this, we highlighted the network
that leads to the connectivity between the IFN-b signaling
pathway and genes exceeding the genome-wide significance
threshold in GWAS published from 2007 in MS (http://www.ge-
nome.gov/gwastudies/). To perform this analysis it was used
Quigen Ingenuity Pathway Analysis (IPA), which was set to run a
‘‘core analysis’’ correlating all MS-associated genes (retrieved on 8/
26/2014) with the known interactors of IFN-b (314 molecules
present in IPA version 21249400); the analysis included only
experimental evidence observed in human samples. Among all
known interactors of IFN-b, 18 genes were also MS-associated
(Table 2 and Fig. 1, that shows most of these connections and how
they relate to IFN-b). The list includes several genes that control
the immune responses (including major histocompatibility
complex alleles, cytokines and co-stimulator molecules), as well
as direct interactors with IFN signaling such as IRF8, NFKB1 and
TYK2 [80,81]. This IPA analysis showed a significant (p-
value < 1.18 Â 10À7
) relationship between the MS-associated
genes and the IFN-b signaling and confirmed previous results
obtained by our group with another approach [6]. Overall, these
data suggest that single unfavorable SNPs (or a combination of
them) affecting components of IFN-b signaling may determine
some deregulation in MS. Further investigation are needed to
clarify the role of these components in MS pathogenesis and
possible corrective effects of exogenous IFN-b on deregulated
pathways (see next section).
4.2. EBV and IFN-b
EBV is a kind of ‘‘one man band’’ in its ability to control the
antiviral immune response of infected cells both in lytic and latent
phase. IFN pathway is no exception, being sabotaged by multiple
V. Annibali et al. / Cytokine & Growth Factor Reviews 26 (2015) 221–228 223

4. mechanisms of immune evasion. In an in vitro setting was
demonstrated that the expression of BRLF1 and BZLF1 (two
immediate-early transcription factors that controls the initiation
of viral lytic gene expression and lytic reactivation from latency)
reduce the IFN-b production down modulating the expression of
IRF3 and IRF7 [82,83]. During the latent phase the up-regulation of
latent membrane protein-1 (LMP1), possibly due to a toll-like
receptors 7 (TLR7) aberrant activation, may blocks TYK2 and the
consequent STATs phosphorylation, inhibiting the expression of
IFN-b stimulated genes [84,85]. Moreover EBV infection of primary
B cells may reduce the cellular antiviral activity inhibiting the TLR9
activation through the expression of LMP1 [86], that in turn may be
Table 2
The MS-associated genes of the IFN-b signaling pathway. For detailed description, see text.
Gene symbol Description Location Type
CD40 CD40 molecule, TNF receptor super family member 5 Plasma membrane Transmembranereceptor
CD86 CD86 molecule Plasma membrane Transmembranereceptor
HLA-B Major histocompatibility complex, class I, B Plasma membrane Transmembranereceptor
HLA-DQA1 Major histocompatibility complex, class II, DQ alpha 1 Plasma membrane Transmembranereceptor
HLA-DQB1 Major histocompatibility complex, class II, DQ beta 1 Plasma membrane Other
HLA-DRA Major histocompatibility complex, class II, DR alpha Plasma membrane Transmembranereceptor
HLA-DRB1 Major histocompatibility complex, class II, DR beta 1 Plasma membrane Transmembranereceptor
IL12A Interleukin 12A Extracellular space Cytokine
IL12B Interleukin 12B Extracellular space Cytokine
IRF8 Interferon regulatory factor 8 Nucleus Transmembranereceptor
MAPK1 Mitogen-activated protein kinase 1 Cytoplasm Kinase
MERTK MER proto-oncogene, tyrosine kinase Plasma membrane Kinase
MMP10 Matrix metallopeptidase 10 (stromelysin 2) Extracellular space Peptidase
MYC V-myc avian myelocytomatosis viral oncogene homolog Nucleus Transmembranereceptor
NFKB1 Nuclear factor of kappa light polypeptide gene enhancer in B-cells 1 Nucleus Transmembranereceptor
PRKRA Protein kinase, interferon-inducible double stranded RNA dependent activator Cytoplasm Other
STAT3 Signal transducer and activator of transcription 3 Nucleus Transmembranereceptor
TYK2 Tyrosinekinase 2 Plasma membrane Kinase
Fig. 1. Representation of the interactions between proteins coded by MS-associated and IFN beta-related genes (see Table 2 for the list of the interaction points strictly shared
by the MS-associated gene list and the IFN interactors).
V. Annibali et al. / Cytokine & Growth Factor Reviews 26 (2015) 221–228224

5. up-regulated by Epstein–Barr nuclear antigen 2 (EBNA2). This
protein is able to control gene expression of viral and cellular
genes, mainly during the first phase of the infection [87]. Some
evidences suggest its potential implication in MS pathology:
EBNA2 expressing cells have been observed in affected brains [31]
and specific EBNA2 genotypes associate with disease status [88].
It seems plausible that IFN-b therapy may compensate for
some of the EBV-induced dysfunctions in the antiviral immune
responses: CD8+ T cells specific for lytic-phase antigens are
detected with high frequency in the peripheral blood of patients
with active disease and are reduced by IFN-b treatment [26], as
well as CD4+ T cell response to EBNA1 peptides pool [89]; in
dendritic cells obtained from MS patients under IFN-b treatment a
reduced TLR9 activation (that promote pro-inflammatory
responses) was observed [90]; a recent work demonstrated an
impaired activation of TLR7 in MS subjects, that decrease the
ability of B cells to mature in plasma cells and that is restored by
IFN-b treatment [91].
4.3. MSRV and IFN-b
IFN-b appears to be capable of interfering with MSRV biology.
An in vitro study showed that IFN-b inhibits the release of MSRV
from peripheral blood mononuclear cells derived from MS patients
[92]. These data were confirmed through a longitudinal evaluation
of patients with MS, during one year of therapy with IFN-b: the
MSRV load in the blood was directly related to the duration of MS
and underwent a considerable reduction to below the limits of
detection within 3 months of IFN therapy; this work suggested to
consider the evaluation of MSRV in plasma as a prognostic marker
to monitor the progression of the disease and the outcome of
therapy [43].
At variance with several trials conducted with anti-herpes
drugs, and notwithstanding evidences of retroviral contribution to
disease pathogenesis, no major attempt has been performed with
anti-retroviral therapy in MS, except for a humanized monoclonal
antibody against the envelope of MSRV, that was tried in a phase I
study [93]. A pilot study, that is ongoing, may herald such an
approach, investigating raltegravir (RAL) in relapsing remitting MS
(ClinicalTrials.gov Identifier: NCT01767701).
RAL is an inhibitor of human immunodeficiency virus (HIV)
integrase, approved in 2007 for clinical use as antiretroviral agent
in HIV infected adults. Clinical studies and subsequent clinical
experience have shown durable virologic suppression, low rates of
adverse effects and long-term safety. Not interacting with the
cytochrome P450 system, RAL may be a good option for
polytherapy. As an inhibitor of retroviral integrase, RAL can be
active against the MSRV that is transactivated by several viruses,
EBV being one of these. RAL is also able to inhibit recombinase and
terminase, two key proteins for EBV [94]. Altogether, RAL seems to
be a good candidate to tackle plausible etiologic agents for MS and
might also add to the effects of IFN.
5. Conclusions
Though two decades have passed since IFN-b was introduced in
the management of MS, it remains a valid approach because of its
good benefit/risk profile. The persisting interest is witnessed by
new efforts that pharmaceutical industry has produced to improve
this line.
Recently, a PEGylated form of subcutaneous IFN-b 1a (Ple-
gridy1
) with a longer half-life (injection frequency every 2 weeks)
has been approved in RRMS. Conjugation of IFN-b 1a with a
molecule of polyethylene glycol (PEG; PEGylation) increases the
size of the product resulting in more solubility, half-life and
efficacy the drug. Compared to placebo, PEG INF has reduced ARR
by about one-third (0.397 in the placebo group versus 0.256 in the
every 2 weeks group). A slight reduction in sustained disability
progression and in several MRI activity measures has also been
demonstrated. The drug was generally well tolerated: the most
common adverse events were influenza-like illness, injection-site
reactions and headache [95]. Due to its frequency of administra-
tion (every 2 weeks), PEG IFN-b1a may have a better safety profile
than other IFNs-b formulations. Moreover, results from the
extension of the phase III study showed that the therapeutic
effects of PLEGRIDY may reach a size that was not attained by
increasing doses of non-pegylated IFN-b and may become even
more relevant over time, suggesting that prolonged treatment with
PLEGRIDY may induce therapeutic effects that go beyond the
immunomodulatory action of IFN-b.
Given the potent antiviral effects of type-1 IFN, the added value
of PLEGRIDY treatment might be related to its ability to target more
efficiently the non-heritable (i.e. viral) cause(s) of MS. This hints at
future therapeutic approaches based on type 1 interferon alone or
in association with specific antiviral drugs that might act as an
etiologic treatment for MS.
The main fields of investigation regard:
(a) etiopathogenesis of multiple sclerosis;
(b) the identification of the world’s largest twin registry in Italian
population; the registry is currently exploited for concordance
studies and for laboratory investigations (studies on twin pairs
discordant for disease); and
(c) clinical trials (especially phase II independent studies) in
patients with multiple sclerosis, Huntington disease and
cerebellar ataxia.
Conflict of interest
MS receives research support and has received fees as speaker
from Sanofi-Aventis, Biogen, Bayer Schering, and Merck Serono.
Acknowledgements
MS is supported from: Italian Multiple Sclerosis Foundation
(Fondazione Italiana Sclerosi Multipla grant number: 2011/R/31)
and Italian Ministry of Health (Ministero della Salute, grant
number: RF-2010-2321254).
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Viviana Annibali graduated in biological sciences from
Roma Tre University of Rome (Italy) in 2001. In 2006 she
obtained her PhD in cell sciences and technologies and
after a postgraduate master degree in methodologies for
research and development of new therapies from
Sapienza University of Rome, where she recently earned
a clinical pathology specialty. From 2002 she is a re-
search scientist at the CENTERS, S. Andrea Hospital,
Department of Neuroscience, Mental Health and Senso-
ry Organs (NESMOS), Sapienza University of Rome. Dur-
ing her research activities on neurodegenerative
diseases she gained experience in gene expression anal-
ysis at the RNA and protein level in peripheral T cell
subsets. Dr. Annibali has also gained relevant experience in studying molecular
pathways and gene function via genetic and pharmacological approaches. Most
recently, she is investigating the involvement of B cells transcriptome dysfunctions
in multiple sclerosis disease, with particular attention to the role of the cellular and
extracellular microRNAs. She is a member of Italian Association of Neuroimmunol-
ogy (AINI).
Rosella Mechelli received her master degree in Biologi-
cal Sciences in 2000, PhD in genetic and molecular
biology in 2003 from Sapienza University of Rome
where she also earned a postgraduate master degree
in methodologies for the research and development of
new therapies in 2007. During her PhD training she
studied the structure of telomeric chromatin and its
epigenetic modifications. From 2004 she is a research
scientist at the CENTERS, S. Andrea Hospital, Depart-
ment of Neuroscience, Mental Health and Sensory
Organs (NESMOS), Sapienza University of Rome. Her
research interests lie in etiopathogenesis of multiple
sclerosis in monozygotic twins discordant for the dis-
ease. Currently most of her studies are focused on the interaction between heritable
and environmental risk factors, in particular on Epstein–Barr virus genetic variants
and virus–host interactions. She is a member of Italian Association of Neuroim-
munology (AINI).
Silvia Romano obtained a doctor of medicine degree
from Sapienza University of Rome in 2000 and a spe-
cialization degree in Neurology at Sapienza University
of Rome in 2006. She was also a Research Fellow at
Clinical and Behavioral Neurology Laboratory, S. Lucia
Foundation, Rome (2008–2009, project on neurocogni-
tive pattern of multiple sclerosis patients). She obtained
a PhD in Experimental Neurological Sciences in
2010 and then undertook post-doctoral work at the
Center of Experimental Neurological Therapies (CEN-
TERS), a Department Unit of S. Andrea Hospital,
Sapienza University of Rome (2012–2013) working on
demyelinating and hereditary neurodegenerative dis-
ease. Her current position is Researcher of Neurology at Department of Neuros-
ciences, Mental Health and Sensory Organs (NESMOS), at S. Andrea Hospital,
Sapienza University of Rome. Her research activity is focused on (1) etiopathogen-
esis, cognitive impairment and treatment of multiple sclerosis; (2) clinical features
and treatment of patients with hereditary cerebellar ataxias and Huntington
diseases.
Maria Chiara Buscarinu graduated in medicine and
surgery in 2006 and specialized in neurology in
2012 at the University of Sassari. From 2005 to
2011 she worked at the Neurological Clinic of Sassari.
She moved to Rome and she began her PhD in experi-
mental neurology at Sapienza University of Rome. She
carries out ambulatory activity and research at the S.
Andrea Hospital in Rome, with increased interest in
multiple sclerosis and etiopathogenetic factors related
to the disease. She is a member of the Italian Society of
Neuroimmunology (AINI) and the Italian Society of
Neurology (SIN).
Arianna Fornasiero obtained a doctor of medicine de-
gree from Sapienza University of Rome in 2004 and a
Specialization degree in Neurology at Sapienza Univer-
sity of Rome in 2009. From 2010 to 2014 she was
research fellow in experimental neurology at Sapienza
University of Rome. From 2009 to today she work at the
Center of Experimental Neurological Therapies (CEN-
TERS) a Department Unit of S. Andrea Hospital, Sapienza
University of Rome working on demyelinating disease.
Her research activity is focused on etiopathogenesis and
treatment of multiple sclerosis.
V. Annibali et al. / Cytokine & Growth Factor Reviews 26 (2015) 221–228 227

8. Renato Umeton obtained his bachelor’s and master’s
degrees in computer science from University of Calabria.
He earned his PhD in mathematics and informatics
focusing his research on optimization and ontology
studies that found their application in solving problems
in the area of medicine and biology. His experience
included working at Microsoft and at Massachusetts
Institute of Technology, as well as collaborating with
other major institutions such as the Harvard Medical
School and the University of Cambridge in the UK. He
carried out his most recent Postdoc at Sapienza Univer-
sity of Rome – S. Andrea Teaching Hospital, where he
applied his informatics and bioinformatics skills to un-
ravel the genetic and environmental components of the
pathogenesis of multiple sclerosis and other neurology-
related diseases.
Vito AG Ricigliano obtained his medical degree at
‘‘Sapienza’’ University of Rome, Italy, in 2013. He is
currently a MD at Center for Experimental Neurological
Therapies (CENTERS), S. Andrea hospital, Rome, and in
the present year he has been Academic visitor at the
University of Oxford, UK, Nuffield Department of Clini-
cal Neurosciences (NDCN). His research investigates the
role of gene–environment interactions in the etiology of
multiple sclerosis, especially focusing on the character-
ization of the interplay between EBV and the host net-
works, functional interpretation of GWAS data and use
of next-generation techniques (e.g. RNA-sequencing,
exome sequencing).
Francesco Orzi has spent several years dedicated to lab
research, in animal models of neurological diseases, and
in exploiting methods for assessment of brain functional
parameters. Following a 3 years stage (1979–1982) in
the Lab of Dr. L. Sokoloff at NIH, in Bethesda, he became
specifically interested in mapping local cerebral func-
tional changes in animal models. A few studies have
contributed to define the functional circuitry of the
Basal Ganglia in relation to their role in movement
disorders and in motivated behavior. Other studies,
since the early experiences in the laboratory of Dr Klatzo
at NIH, have been carried out in the field of the brain
damage maturation following temporary brain ische-
mia, and in the field of neuroprotection in animal models of brain ischemia. In the
last 15 years he has been fully involved in clinical neurology. Fields of interest are
cerebrovascular diseases and dementias. The focus is on mechanisms that underlie
neuronal degeneration associated with energy defects, dysfunction of the neuro-
muscular unit, and implications for neuroprotection.
Eliana Marina Coccia is head of the Anti-Infectious
Immunity Unit at the Department of Infectious, Parasitic
and Immunomediated Diseases, Istituto Superiore di
Sanita`, Rome-Italy. She received her Ph.D. in biological
sciences in 1984 from University of Rome, working on the
effect of type I IFN on the growth and differentiation of
Friend erythroleukemia cells. From 1984 to 1985, she was
a post-doctoral fellow at the Weizmann Institute of Sci-
ence (Rehovot, Isreal) in Dr. Michel Revel’s group where
she cloned the mouse 2-5A synthetase. In 1991–1992 she
moved at the Pasteur Institute (Paris, France) in the
laboratory of Dr. Ara Hovanessian to investigate the role
of type I IFN on HIV replication. The group lead by E.
Coccia is interested in understanding how type I IFN contribute to the induction of the
immune response against several pathogens, such as HIV, Mycobacterium tuberculosis,
Aspergillus fumigatus and Epstein–Barr virus. In particular the long-term objectives of
her projects is to investigate IFN-driven immune-regulation and aberrant activation
of IFN pathways in microbial infection and autoimmunity, with specific regard to B
lymphocytes and primary dendritic cells.
Marco Salvetti obtained his primary medical qualifica-
tion in 1986 from the Sapienza University of Rome
where he also trained as a clinical neurologist. He
was a postdoctoral fellow at the Max Planck Society
for Multiple Sclerosis in Prof. Hartmut Wekerle’s lab.
Following studies on the fine specificity of the T cell
response to putative autoantigens in multiple sclerosis,
he instituted the world largest twin registry in
1997. From then on, epidemiological, gene expression
and virological studies in twins with multiple sclerosis
begun. At present much of the studies are focused on the
interaction between heritable and environmental fac-
tors in the etiology of multiple sclerosis. This informa-
tion, combined with data from the in vitro screening of off-label activities of
registered drugs (on oligodendrocyte precursors), is exploited for the design of
exploratory clinical trials. These studies are carried out in the context of the clinical
research activity of CENTERS, an institution devoted to nonprofit, phase II trials in
multiple sclerosis and orphan neurological diseases.
Giovanni Ristori obtained in 1985 the degree in medi-
cine, at ‘Universita` Cattolica del Sacro Cuore’, Rome,
Italy and in 1989 the specialization in neurology at
the same University. In 1995 he obtained a PhD in
Neuroscience at Sapienza University of Rome, Italy.
The present position is at Neuroimmunology laboratory
and Neurogenetic Unit, Faculty of Medicine and Psy-
chology, Sapienza University of Rome, Italy.
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