title: Effect of Aspirin Pretreatment or Slow Dose Titration on Flushing and Gastrointestinal Events in Healthy Volunteers Receiving Delayed-release Dimethyl Fumarate.
abstract: OBJECTIVE
  In Phase III trials, delayed-release dimethyl fumarate (DMF; also known as gastro-resistant DMF) demonstrated significant efficacy and an acceptable safety profile in patients with relapsing-remitting multiple sclerosis. 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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. ClinicalTrials.gov identifier: NCT01568112.
authors.affiliation: Biogen, Inc, Cambridge, Massachusetts.
authors.forename: John
authors.initials: J
authors.lastname: O'Gorman
authors.affiliation: PROMETRIKA, LLC, Cambridge, Massachusetts.
authors.forename: Heidy K
authors.initials: HK
authors.lastname: Russell
authors.affiliation: Biogen, Inc, Cambridge, Massachusetts.
authors.forename: Jie
authors.initials: J
authors.lastname: Li
authors.affiliation: Biogen, Inc, Cambridge, Massachusetts.
authors.forename: Glenn
authors.initials: G
authors.lastname: Phillips
authors.affiliation: Biogen, Inc, Cambridge, Massachusetts.
authors.forename: Nuwan C
authors.initials: NC
authors.lastname: Kurukulasuriya
authors.affiliation: Biogen, Inc, Cambridge, Massachusetts. Electronic address: vissia.viglietta@biogen.com.
authors.forename: Vissia
authors.initials: V
authors.lastname: Viglietta
mesh_terms: D015746:Abdominal Pain / Q000139:chemically induced / Q000517:prevention & control; D000328:Adult; D001241:Aspirin / Q000008:administration & dosage* / Q000627:therapeutic use; D003248:Constipation / Q000139:chemically induced / Q000517:prevention & control; D003692:Delayed-Action Preparations / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D003967:Diarrhea / Q000139:chemically induced / Q000517:prevention & control; D000069462:Dimethyl Fumarate / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D005260:Female; D005483:Flushing / Q000139:chemically induced / Q000517:prevention & control; D064368:Healthy Volunteers; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D020529:Multiple Sclerosis, Relapsing-Remitting / Q000188:drug therapy; D011897:Random Allocation
chemical_list: D003692:Delayed-Action Preparations; D007166:Immunosuppressive Agents; D000069462:Dimethyl Fumarate; D001241:Aspirin
keywords: aspirin; delayed-release dimethyl fumarate; flushing; gastrointestinal; multiple sclerosis; prostaglandin