ClinicSpeak: aspirin for DMF flushing

Does aspirin work for your DMF-related flushing? #ClinicSpeak #MSBlog #MSResearch

"The following study shows that pretreatment (30 minutes before) with aspirin (325mg) reduces the flushing some MSers have when they start DMF (dimethyl fumarate or tecfidera). The response seems to be relatively small, but does provide a pragmatic option in managing this transient side effect. In my experience warning MSers about the flushing and educating them about the transient nature of flushing (usually disappears within 8-12 weeks of starting treatment) seems to help. We have not had many patients stop DMF because of flushing. I think GI symptoms are more problematic than the flushing, in particular the diarrhoea. Any of you want to share your personal experiences?"

Epub: O'Gorman et al. Effect of Aspirin Pretreatment or Slow Dose Titration on Flushing and Gastrointestinal Events in Healthy Volunteers Receiving Delayed-Release Dimethyl Fumarate. Clin Ther. 2015. pii: S0149-2918(15)00188-5. doi: 10.1016/j.clinthera.2015.03.028.

PURPOSE: In Phase III trials, delayed-release dimethyl fumarate (DMF; also known as gastro-resistant DMF) demonstrated significant efficacy and an acceptable safety profile in RRMSers. The purpose of the present study was to examine 2 potential mitigation strategies for flushing and gastrointestinal (GI) events associated with DMF treatment: aspirin (ASA) 325 mg pretreatment for flushing, and slow dose titration of DMF for flushing and GI events.

METHODS: The 8-week study included 173 healthy volunteers randomized to 4 groups; 172 underwent dosing. The placebo group (n = 44) received placebo ASA 30 minutes before placebo DMF (weeks 1-4), then placebo DMF alone (weeks 5-8). The DMF without ASA group (n = 43) and the DMF with ASA group (n = 43) received placebo ASA or ASA, respectively, 30 minutes before DMF (weeks 1-4), then DMF alone (weeks 5-8); in both groups, DMF was dosed at 120 mg BID (week 1) and 240 mg BID (weeks 2-8). The slow dose titration DMF group (n = 42) received DMF 120 mg once daily (week 1), 120 mg BID (week 2), 240 mg in the morning/120 mg in the evening (week 3), and 240 mg BID (weeks 4-8). Subjects recorded information about flushing and GI-related events by using an eDiary and numerical rating scales.

FINDINGS: Flushing and GI-related events were reported in all groups and were mostly rated as mild or moderate in severity. Flushing events were generally ~1 hour in duration and, for most subjects with flushing, initially occurred the first day of study treatment. The duration of GI-related events and time to first GI-related event varied by event type. ASA reduced the incidence, severity, and number of flushing events without affecting duration or time to first flushing event, and had no adverse effect on GI-related events. Dose titration of DMF had no significant effect on flushing or GI events. No subjects discontinued the study due to flushing events. One subject (2%) in the placebo group, 3 subjects (7%) in the DMF without ASA group, 6 subjects (14%) in the DMF with ASA group, and 2 subjects (5%) in the slow dose titration DMF group discontinued treatment because of GI events.

IMPLICATIONS: ASA pretreatment may mitigate flushing associated with DMF, with no adverse effect on GI events. Dose titration of DMF did not have a significant effect on flushing or GI events and is being evaluated further in ongoing clinical trials.

CoI: multiple

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