Out-of-balance bacteria is linked to multiple sclerosis − the ratio can predict severity of disease
Multiple sclerosis is a disease that results when the immune system mistakenly attacks the brain and spinal cord. It affects nearly one million people in the U.S. and over 2.8 million worldwide. While genetics play a role in the risk of developing multiple sclerosis, environmental factors such as diet, infectious disease and gut health are major contributors.
The environment plays a key role in determining who develops multiple sclerosis, and this is evident from twin studies. Among identical twins who share 100% of their genes, one twin has a roughly 25% chance of developing MS if the other twin has the disease. For fraternal twins who share 50% of their genes, this rate drops to around 2%.
Scientists have long suspected that gut bacteria may influence a person's risk of developing multiple sclerosis. But studies so far have had inconsistent findings.
To address these inconsistencies, my colleagues and I used what researchers call a bedside-to-bench-to-bedside approach: starting with samples from patients with multiple sclerosis, conducting lab experiments on these samples, then confirming our findings in patients.
In our newly published research, we found that the ratio of two bacteria in the gut can predict multiple sclerosis severity in patients, highlighting the importance of the microbiome and gut health in this disease.
First, we analyzed the chemical and bacterial gut composition of patients with multiple sclerosis, confirming that they had gut inflammation and different types of gut bacteria compared with people without multiple sclerosis.
Specifically, we showed that a group of bacteria called Blautia was more common in multiple sclerosis patients, while Prevotella, a bacterial species consistently linked to a healthy gut, was found in lower amounts.
In a separate experiment in mice, we observed that the balance between two gut bacteria, Bifidobacterium and Akkermansia, was critical in distinguishing mice with or without multiple sclerosis-like disease. Mice with multiple sclerosis-like symptoms had increased levels of Akkermansia and decreased levels of Bifidobacterium in their stool or gut lining.
To explore this further, we treated mice with antibiotics to remove all their gut bacteria. Then, we gave either Blautia, which was higher in multiple sclerosis patients; Prevotella, which was more common in healthy patients; or a control bacteria, Phocaeicola, which is found in patients with and without multiple sclerosis. We found that mice with Blautia developed more gut inflammation and worse multiple sclerosis-like symptoms.
Even before symptoms appeared, these mice had low levels of Bifidobacterium and high levels of Akkermansia. This suggested that an imbalance between these two bacteria might not just be a sign of disease, but could actually predict how severe it will be.
We then examined whether this same imbalance appeared in people. We measured the ratio of Bifidobacterium adolescentis and Akkermansia muciniphila in samples from multiple sclerosis patients in Iowa and participants in a study spanning the U.S., Latin America and Europe.
Our findings were consistent: Patients with multiple sclerosis had a lower ratio of Bifidobacterium to Akkermansia. This imbalance was not only linked to having multiple sclerosis but also with worse disability, making it a stronger predictor of disease severity than any single type of bacteria alone.
One of the most interesting findings from our study was that normally beneficial bacteria can turn harmful in multiple sclerosis. Akkermansia is usually considered a helpful bacterium, but it became problematic in patients with multiple sclerosis.
A previous study in mice showed a similar pattern: Mice with severe disease had a lower Bifidobacterium-to-Akkermansia ratio. In that study, mice fed a diet rich in phytoestrogens – chemicals structurally similar to human estrogen that need to be broken down by bacteria for beneficial health effects – developed milder disease than those on a diet without phytoestrogens. Previously we have shown that people with multiple sclerosis lack gut bacteria that can metabolize phytoestrogen.
Although the precise mechanisms behind the link between the Bifidobacterium-to- Akkermansia ratio and multiple sclerosis is unknown, researchers have a theory. Both types of bacteria consume mucin, a substance that protects the gut lining. However, Bifidobacterium both eats and produces mucin, while Akkermansia only consumes it. When Bifidobacterium levels drop, such as during inflammation, Akkermansia overconsumes mucin and weakens the gut lining. This process can trigger more inflammation and potentially contribute to the progression of multiple sclerosis.
Our finding that the Bifidobacterium-to-Akkermansia ratio may be a key marker for multiple sclerosis severity could help improve diagnosis and treatment. It also highlights how losing beneficial gut bacteria can allow other gut bacteria to become harmful, though it is unclear whether changing levels of certain microbes can affect multiple sclerosis.
While more research can help clarify the link between the gut microbiome and multiple sclerosis, these findings offer a promising new direction for understanding and treating this disease.
This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world. It was written by: Ashutosh Mangalam, University of Iowa
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Ashutosh Mangalam received funding from the NIH/NIAID, VA, and the University of Iowa. He holds a patent licensed to Evelo Biosciences by Mayo Clinic on a technology using Prevotella histicola to treat autoimmune diseases. No funds or products from this patent were used in this study.

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The Phase III program includes FENhance 1 and 2 studies in relapsing multiple sclerosis (vs. teriflunomide) and the FENtrepid trial in primary progressive multiple sclerosis (vs. ocrelizumab), marking the first head-to-head comparison of a BTK inhibitor with an approved PPMS therapy. Regulatory submissions for both RMS and PPMS are planned for 2026. In September 2024, Roche presented 48-week results from the FENopta Phase II open-label extension at the 40th ECTRIMS Congress. Remibrutinib is an oral covalent BTK inhibitor under investigation for multiple sclerosis and chronic spontaneous urticaria (CSU), where it blocks BTK signaling to prevent histamine release. While no Phase I or II trials have yet been conducted for multiple sclerosis, remibrutinib is in Phase III development for CSU through the REMODEL-1 and REMODEL-2 trials. Primary completion is expected in 2026, with regulatory submission anticipated in 2027. Earlier Phase IIb CSU data showed favorable safety and tolerability. CNM-Au8 is an oral gold nanocrystal therapy designed to address mitochondrial dysfunction in multiple sclerosis by boosting NAD+ production, enhancing antioxidant capacity, and activating the heat shock factor-1 pathway to support protein homeostasis. Although the VISIONARY-MS Phase II trial was halted early due to COVID-19, CNM-Au8 is being evaluated in the ongoing Phase II REPAIR-MS trial. Results from REPAIR-MS, along with a planned FDA End-of-Phase II meeting in 2025, will inform the design of a global Phase III trial. In April 2025, Clene Nanomedicine presented promising new data at the AAN Annual Meeting, showing meaningful improvements in cognition and visual function from the VISIONARY-MS open-label extension. Masitinib is being developed for progressive multiple sclerosis with a focus on inhibiting mast cells and microglia, key players in chronic neuroinflammation. This approach aims to slow progression in patients with primary progressive multiple sclerosis (PPMS) and non-active secondary progressive multiple sclerosis (SPMS). Following positive results from a Phase IIb/III study, a confirmatory Phase III trial is ongoing. In September 2024, AB Science provided an update on masitinib's development at the ECTRIMS 2024 conference. Discover more about the multiple sclerosis pipeline @ Multiple Sclerosis Clinical Trials The anticipated launch of these emerging therapies for multiple sclerosis are poised to transform the market landscape in the coming years. As these cutting-edge therapies continue to mature and gain regulatory approval, they are expected to reshape the multiple sclerosis market landscape, offering new standards of care and unlocking opportunities for medical innovation and economic growth. DelveInsight estimates that the market size for Multiple Sclerosis is expected to grow from USD 20 billion in the 7MM in 2024 at a 3.8% CAGR by 2034. This expansion across the 7MM will be driven by the introduction of innovative therapies, remibrutinib, tolebrutinib, fenebrutinib, frexalimab, vidofludimus calcium, CNM-Au8, and masitinib, among others. Furthermore, multiple sclerosis prevalence is rising due to modifiable environmental and lifestyle factors like Epstein-Barr virus, low vitamin D, smoking, obesity, and night shifts, with genetics and geography also contributing. DelveInsight's latest published market report, titled Multiple Sclerosis – Market Insight, Epidemiology, and Market Forecast – 2034, will help you to discover which market leader is going to capture the largest market share. The report provides comprehensive insights into the multiple sclerosis country-specific treatment guidelines, patient pool analysis, and epidemiology forecast to help understand the key opportunities and assess the market's underlying potential. The multiple sclerosis market report proffers epidemiological analysis for the study period 2020–2034 in the 7MM, segmented into: Total Diagnosed Prevalent Cases of Multiple Sclerosis Gender-specific Diagnosed Prevalent Cases of Multiple Sclerosis Phenotype-specific Diagnosed Prevalent Cases of Multiple Sclerosis EDSS-specific Diagnosed Prevalent Cases of Multiple Sclerosis The report provides an edge while developing business strategies by understanding trends shaping and driving the 7MM multiple sclerosis market. Highlights include: 10-year Forecast 7MM Analysis Epidemiology-based Market Forecasting Historical and Forecasted Market Analysis upto 2034 Emerging Drug Market Uptake Peak Sales Analysis Key Cross Competition Analysis Industry Expert's Opinion Access and Reimbursement Download this multiple sclerosis market report to assess the epidemiology forecasts, understand the patient journeys, know KOLs' opinions about the upcoming treatment paradigms, and determine the factors contributing to the shift in the multiple sclerosis market. Also, stay abreast of the mitigating factors to improve your market position in the multiple sclerosis therapeutic space. Related Reports Multiple Sclerosis Epidemiology Forecast Multiple Sclerosis Epidemiology Forecast – 2034 report delivers an in-depth understanding of the disease, historical and forecasted multiple sclerosis epidemiology in the 7MM, i.e., the United States, EU4 (Germany, France, Italy, Spain), the United Kingdom, and Japan. Multiple Sclerosis Pipeline Multiple Sclerosis Pipeline Insight – 2025 report provides comprehensive insights about the pipeline landscape, pipeline drug profiles, including clinical and non-clinical stage products, and the key multiple sclerosis companies, including Sanofi, Immunic, InnoCare Pharma, Tiziana Life Sciences, Biogen, Bristol-Myers Squibb, ImStem Biotechnology, Idorsia Pharmaceuticals, among others. Relapsing-Remitting Multiple Sclerosis Market Relapsing-Remitting Multiple Sclerosis Market Insights, Epidemiology, and Market Forecast – 2034 report deliver an in-depth understanding of the disease, historical and forecasted epidemiology, market share of the individual therapies, and key RRMS companies including Mapi Pharma, Apimeds, Genentech (Roche), Merck, Clene Nanomedicine, InnoCare Pharma, Oryzon Genomics, among others Relapsing-Remitting Multiple Sclerosis Pipeline Relapsing-Remitting Multiple Sclerosis Pipeline Insight – 2025 report provides comprehensive insights about the pipeline landscape, pipeline drug profiles, including clinical and non-clinical stage products, and the key RRMS companies, including TG Therapeutics, Novartis, Sanofi, CinnaGen, Immunic, Mapi Pharma, Apimeds, Genentech (Roche), Merck, Clene Nanomedicine, InnoCare Pharma, Oryzon Genomics, GeNeuro SA, GlaxoSmithKline, among others. About DelveInsight DelveInsight is a leading Business Consultant and Market Research firm focused exclusively on life sciences. It supports pharma companies by providing comprehensive end-to-end solutions to improve their performance. Get hassle-free access to all the healthcare and pharma market research reports through our subscription-based platform PharmDelve. Contact UsShruti Thakur info@ +14699457679 Logo: View original content: SOURCE DelveInsight Business Research, LLP