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Material Safety Data Sheet(MSDS)

Questions And Answer

• Overview

  Dimethyl fumarate[DMF] is the methyl ester of fumaric acid^{[1, 2]}. DMF, marketed in Germany under the trade name of Fumaderm, is used for oral therapy of psoriasis in combination with other drugs^[2]. Later it has been used to treat adults with relapsing multiple sclerosis[a chronic inflammatory, demyelinating and neurodegenerative disease of the CNS resulting in neurological disability] since 2013(trade name Tecfidera)^[3]. DMF is thought to have immunomodulatory properties without significant immunosuppression. In preclinical studies, dimethyl fumarate exhibited anti-inflammatory and cytoprotective properties that are generally thought to be mediated via activation of the nuclear factor [erythroid-derived 2]-like 2 transcriptional pathway, which is involved in the cellular response to oxidative stress.
  In a non-medical use, DMF has been used as a biocide in furniture or shoes to prevent growths of mold during storage or transport in a humid climate. However, due to incidences of allergic reactions after skin contact the European Union has banned DMF in consumer products since 1998, and since January 2009 the import of products containing DMF has also been banned^[4]. ;

• Indication

  Dimethyl fumarate[DMF] is mainly indicated for the treatment of the relapsing-remitting Multiple sclerosis(MS), which is a chronic inflammatory, demyelinating and neurodegenerative disease of the CNS, resulting in neurological disability^{[5, 6]}. The disease typically begins in young adults(average age of onset &29 years) and affects twice as many women as men^{[7, 8]}. Initially, most(80–85 %) individuals with MS have a relapsing-remitting[RRMS] disease course with defined clinical exacerbations of neurological symptoms, followed by complete or incomplete remission^{[7, 8]}. Around 50 % of patients develop a secondary progressive MS within 10–15 years of RRMS onset and &89 % of patients develop secondary progressive MS after 25 years[9]. Globally, the estimated median incidence of MS is 2.5 per 100,000 persons and it has a median estimated prevalence of 30 per 100,000 persons^[8].
  The pathogenic process of the relapsing-remitting multiple sclerosis involves the migration of auto-reactive T cells across the blood–brain-barrier into the central nervous system where they damage myelin, oligodendrocyte and nerve fibers and lead to further immune cell recruitment^[10]. This inflammatory process causes lesions[predominantly in the cerebellum, brain stem, spinal cord, optic nerves and white matter of brain ventricles] that result in the symptoms typical of MS, including weak/stiff muscles, limb numbness/tingling, balance problems, visual disturbances and cognitive dysfunction^[11]. The lesional inflammatory environment also contributes to MS pathogenesis through the generation of proinflammatory cytokines and oxygen and nitrogen free radicals, establishing a cycle of inflammation and oxidative stress^[12]. ;

• Mode of action

  In MS, neuronal tissue damage is thought to be caused by aberrant activation and subsequent infiltration of immune cells into the CNS12. Infiltrating cells propagate inflammatory processes within the CNS13, ultimately leading to oligodendrocyte damage that results in demyelination and subsequent axonal transection and neurodegeneration^{[13, 14]}. In addition to pathogenic adaptive autoimmunity processes, the release of free radicals[oxygen and nitrogen] by infiltrating monocytes leads to mounting oxidative stress^[15-17]. As cells of the CNS are highly sensitive to excessive oxidative stress, this further promotes neurodegenerative processes.
  Dimethyl fumarate has demonstrated beneficial effects in preclinical models of neuro-inflammation, neuro-degeneration, and toxic oxidative stress but its precise mechanism of action remains unclear^{[18, 19]}. As a second-generation fumarate ester, dimethyl fumarate appears to exert its effects predominantly through activation of the nuclear factor[erythroid-derived 2]-like 2[Nrf2] antioxidant response pathway^[19], which modulates the expression of biomolecules involved in the phase 2 detoxification pathway, and is an important cellular defense mechanism involved in the response to oxidative and xenobiotic stress, and immune homeostasis. The activation of the Nrf2 pathway has a clear role in maintaining immune homeostasis and also appears to have a role in promoting modulation of functional immune responses^[20]. ;

• Adverse reactions

  Common side effects may include flushing/warmth, itching, redness, and burning feeling of the skin. Taking this drug with food may reduce flushing. Some other side effects may also include stomach/abdominal pain, heartburn, indigestion, diarrhea, nausea, and vomiting may also occur. These effects usually improve or go away as your body adjusts to the medication. If any of these effects persist or worsen, tell your doctor or pharmacist promptly^{[22, 23]}.;

• Warning and Risk

  Patients who are allergic to dimethyl fumarate should be disabled.
  To make sure dimethyl fumarate is safe for administration, the patients should tell your doctor if he/she have: an active infection; or low white blood cell[WBC] counts.
  It is not known whether dimethyl fumarate will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using dimethyl fumarate.
  If you are pregnant, your name may be listed on a pregnancy registry. This is to track the outcome of the pregnancy and to evaluate any effects of dimethyl fumarate on the baby. It is not known whether dimethyl fumarate passes into breast milk or if it could harm a nursing baby. Tell your doctor if you are breast-feeding a baby^[23]. ;

• References

  1. https://www.drugbank.ca/drugs/DB08908
  2. Mrowietz U, Altmeyer P, Bieber T, et al. Treatment of psoriasis with fumaric acid esters(Fumaderm®). JDDG. 2007;5(8):716‑717.
  3. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/204063s020lbl.pdf
  4. https://chemicalwatch.com/1719/eu‑agrees‑to‑ban‑dimethyl‑fumarate‑dmf‑in‑consumer‑products
  5. Compston A, Coles A. Multiple sclerosis. Lancet. 2008;372(9648):1502‑1517.
  6. Nylander A, Hafler DA. Multiple sclerosis. J Clin Invest. 2012;122(4):1180‑1188.
  7. Menge T, Weber MS, Hemmer B, et al. Disease‑modifying agents for multiple sclerosis: recent advances and future prospects. Drugs. 2008;68(17):2445‑2468.
  8. World Health Organization. Atlas: multiple sclerosis resources in the world; 2008. Available at: http://www.who.int/mental_health/neurology/Atlas_MS_WEB.pdf. Accessed Feb 14, 2014.
  9. Weinshenker BG, Bass B, Rice GP, et al. The natural history of multiple sclerosis: a geographically based study. I. Clinical course and disability. Brain. 1989;112(Pt 1):133‑146.
  10. National Multiple Sclerosis Society. What is MS?; 2015. Available at: http://www.nationalmssociety.org. Accessed Dec 3, 2015.
  11. National Institute of Neurological Disorders and Stroke. Multiple sclerosis: hope through research; 2015. Available at: http://www.ninds.nih.gov/disorders/multiple_sclerosis/detail_multiple_sclerosis.htm. Accessed Dec 3, 2015.
  12. Ortiz GG, Pacheco‑Moises FP, Bitzer‑Quintero OK, et al. Immunology and oxidative stress in multiple sclerosis: clinical and basic approach. Clin Dev Immunol. 2013;2013:708659.
  13. De Stefano N, Narayanan S, Matthews PM, et al. In vivo evidence for axonal dysfunction remote from focal cerebral demyelination of the type seen in multiple sclerosis. Brain. 1999;122:1933‑1939.
  14. Ferguson B, Matyszak MK, Esiri MM, et al. Axonal damage in acute multiple sclerosis lesions. Brain. 1997;120:393‑399.
  15. Silber E, Sharief MK. Axonal degeneration in the pathogenesis of multiple sclerosis. J Neurol Sci. 1999;170:11‑18.
  16. Trapp BD, Peterson J, Ransohoff RM, et al. Axonal transection in the lesions of multiple sclerosis. N Engl J Med. 1998;338:278‑285.
  17. Witherick J, Wilkins A, Scolding N, et al. Mechanisms of oxidative damage in multiple sclerosis and a cell therapy approach to treatment. Autoimmune Dis. 2011;2011:164608.
  18. Linker RA, Lee DH, Ryan S, et al. Fumaric acid esters exert neuroprotective effects in neuro‑inflammation via activation of the Nrf2 antioxidant pathway. Brain. 2011;134:678‑692.
  19. Scannevin RH, Chollate S, Jung MY, et al. Fumarates promote cytoprotection of central nervous system cells against oxidative stress via the Nrf2 pathway. J Pharmacol Exp Ther. 2012;341:274‑284.
  20. Nguyen T, Sherratt PJ, Pickett CB. Regulatory mechanisms controlling gene expression mediated by the antioxidant response element. Annu Rev Pharmacol Toxicol. 2003;43:233‑260.
  21. https://www.rxlist.com/tecfidera‑drug.htm#side_effects_interactions
  22. https://www.webmd.com/drugs/2/drug‑163864/dimethyl‑fumarate‑oral/details
  23. https://www.drugs.com/sfx/dimethyl‑fumarate‑side‑effects.html;

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