VUMERITY Offers the Well-Understood Safety of dimethyl fumarate With Additional Data on GI Tolerability From Patient-Reported Outcomes1,2

Pivotal trial study design1

The efficacy and safety of dimethyl fumarate were demonstrated in 2 studies (Study 1 and Study 2), both of which enrolled patients with RRMS who had experienced at least 1 relapse over the year preceding the trial or had an MRI scan demonstrating at least 1 gadolinium-enhancing lesion within 6 weeks prior to randomization.

Study 1: a 2-year, randomized, double-blind, placebo-controlled study in which 1234 patients with RRMS were randomized to receive dimethyl fumarate 240 mg BID (n=410), dimethyl fumarate 240 mg TID (n=416), or placebo (n=408).

Study 2: a 2-year, randomized, double-blind, placebo-controlled study in which 1417 patients with RRMS were randomized to receive dimethyl fumarate 240 mg BID (n=359), dimethyl fumarate 240 mg TID (n=345), an open-label comparator (n=350), or placebo (n=363).

The only approved dose of dimethyl fumarate is the 240 mg BID dose.

The adverse reactions presented in the table below are based on safety information from 769 patients treated with dimethyl fumarate 240 mg twice a day and 771 placebo-treated patients.

Adverse reactions in Study 1 and Study 2 reported for dimethyl fumarate
240 mg BID at ≥2% higher incidence than placebo

DMF
n=769
 Placebo
n=771
Flushing 40% 6%
Abdominal pain 18% 10%
Diarrhea 14% 11%
Nausea 12% 9%
Vomiting 9% 5%
Pruritus 8% 4%
Rash 8% 3%
Albumin urine present 6% 4%
Erythema 5% 1%
Dyspepsia 5% 3%
Aspartate aminotransferase increased 4% 2%
Lymphopenia 2% <1%

GI Events

  • Dimethyl fumarate caused GI events (eg, nausea, vomiting, diarrhea, abdominal pain, and dyspepsia)
  • 4% of patients treated with dimethyl fumarate and less than 1% of placebo patients discontinued due to GI events
  • The incidence of serious GI events was 1% in patients treated with dimethyl fumarate
  • The incidence of GI events was higher early in the course of treatment (primarily in month 1) and usually decreased over time in patients treated with dimethyl fumarate compared with placebo

Study was funded by Biogen

EVOLVE-MS-2 study design2

  • EVOLVE-MS-2 was a phase 3, randomized, head-to-head, active-controlled, 5-week study to evaluate patient-assessed GI tolerability of VUMERITY versus dimethyl fumarate in patients with RRMS
  • The EVOLVE-MS-2 study used an adaptive trial design in which data from Part A were used to evaluate the utility of GI symptom scales and to inform the GI tolerability endpoints and sample size for Part B
  • Parts A and B were identical in study assessments. Following the completion of Part A, a planned, unblinded analysis of GI tolerability was performed to refine the primary endpoint to reflect the most sensitive measure for detecting a difference between VUMERITY and dimethyl fumarate and re-estimate sample size

5-week treatment period

Patients who completed EVOLVE-MS-2 could roll over into EVOLVE-MS-1, a 96-week open-label study

*In study week 1, the titrated dose for VUMERITY was one 231 mg delayed-release capsule taken orally, twice daily. The titrated dose for dimethyl fumarate was one 120 mg delayed-release capsule taken orally, twice daily. From study weeks 2–5, the full dose for VUMERITY was two 231 mg delayed-release capsules taken orally, twice daily, and the full dose for dimethyl fumarate was one 240 mg delayed-release capsule taken orally, twice daily.

Limitations and disclosures

  • The GI symptom intensity scales are not validated
  • Results should be interpreted with caution due to the 5-week duration
  • Patients were excluded if they had a history of GI surgery, clinically significant recurring or active GI symptoms within 3 months of screening, or chronic use of medical therapy to treat GI symptoms within 1 month of screening
  • The results from this study are not included in the full Prescribing Information for VUMERITY. The US Food and Drug Administration did not consider the results of this study when approving VUMERITY

Key eligibility criteria

  • Patients aged 18–65 years with a confirmed RRMS diagnosis
  • Patients had no history of GI surgery, clinically significant recurring or active GI symptoms within 3 months of screening, or chronic use of medical therapy to treat GI symptoms within 1 month of screening

GI tolerability assessments

  • Patients used 2 GI tolerability scales to self-assess the duration and severity of their GI symptoms (nausea, vomiting, upper abdominal pain, lower abdominal pain, and diarrhea) on an 11-point patient-reported numerical rating scale using eDiaries
    • Individual Gastrointestinal Symptom and Impact Scale (IGISIS): patients self-assessed the intensity of each of the 5 GI symptoms twice daily, within 9 hours of taking each dose
    • Global Gastrointestinal Symptom and Impact Scale (GGISIS): patients self-assessed the intensity of any GI symptoms over the last 24 hours

Primary endpoint

  • Number of days (relative to exposure) with any individual GI symptom intensity score ≥2 in the overall population

Secondary endpoints

Secondary endpoints were assessed in this study, but results are not presented here.

 

  • Number of days (relative to exposure) with individual GI symptom intensity scores of ≥1 or ≥3 in the overall population
  • Number of days (relative to exposure) with an individual GI symptom intensity score of ≥2 in patients from Part B only
  • Number of days (relative to exposure) with global GI symptom intensity scores of ≥1, ≥2, or ≥3 in the overall population
  • Worst individual GI symptom score by study week

Patients self-reported 46% fewer days (relative to exposure) with GI symptoms on VUMERITY vs dimethyl fumarate

Over a 5-week treatment period, VUMERITY showed a 46% reduction (P=0.0003) in the number of days (adjusted rate ratio, 0.54 [95% CI, 0.39–0.75]) patients experienced a GI symptom rated ≥2 on on a 0- to 10-point individual GI symptom and impact scale

Overall, 19.3% of patients (17 out of 88) in the VUMERITY group and 30.6% of patients (37 out of 121) in the DMF group used concomitant medications to treat GI-related AEs during the treatment period

  • These days were not consecutive

†Intensity of nausea, vomiting, upper abdominal pain, lower abdominal pain, and diarrhea reported twice per day. ‡Patients completed ≥1 postbaseline tolerability eDiary assessment and were included in the analysis of patient-assessed GI tolerability.

<1% of patients discontinued VUMERITY due to GI AEs

Disposition of Patients With RRMS in EVOLVE-MS-2

Patients, n (%) VUMERITY§
n=254
 DMF§
n=252
Received ≥1 dose of study drug 253 (99.6) 251 (99.6)
Completed the treatment period 245 (96.8) 233 (92.8)
Mean (SD) days of treatment exposure, IGISISII 35.2 (4.2) 34.2 (5.9)
Mean (SD) days of treatment exposure, GGISISII 33.3 (4.8) 32.6 (5.6)
Rolled over to EVOLVE-MS-1 239 (94.5) 225 (89.6)
Discontinued the study 8 (3.2) 18 (7.2)
AE leading to discontinuation during the treatment period 4 (1.6) 14 (5.6)
GI AE leading to discontinuation 2 (0.8) 12 (4.8)
Upper abdominal pain 0 5 (2.0)
Diarrhea 1 (0.4) 3 (1.2)
Abdominal pain 0 3 (1.2)
Vomiting 1 (0.4) 2 (0.8)
Abdominal distension 0 1 (0.4)
GI pain 0 1 (0.4)
Nausea 0 1 (0.4)

§Patients were randomized.

‖VUMERITY, n=253; DMF, n=249.

6x

fewer discontinuations due to GI adverse events compared to dimethyl fumarate (0.8% of patients taking VUMERITY vs 4.8% of patients taking DMF)

brush stroke brush stroke

GI AEs Experienced in ≥5% of Patients in Either Group

System organ class preferred term, n (%) VUMERITY
n=253
 DMF
n=251
Any AE 198 (78.3) 210 (83.7)
GI disorders 88 (34.8) 123 (49.0)
Diarrhea 39 (15.4) 56 (22.3)
Nausea 37 (14.6) 52 (20.7)
Upper abdominal pain 17 (6.7) 39 (15.5)
Abdominal pain 16 (6.3) 24 (9.6)
Lower abdominal pain 15 (5.9) 17 (6.8)
Vomiting 9 (3.6) 22 (8.8)

Study was funded by Biogen

Indication

VUMERITY® (diroximel fumarate) is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

Important Safety Information

CONTRAINDICATIONS

VUMERITY is contraindicated in patients

  • With known hypersensitivity to diroximel fumarate, dimethyl fumarate, or to any of the excipients of VUMERITY. Reactions may include anaphylaxis and angioedema
  • Taking dimethyl fumarate

WARNINGS AND PRECAUTIONS

Anaphylaxis and Angioedema

  • VUMERITY can cause anaphylaxis and angioedema after the first dose or at any time during treatment. Signs and symptoms in patients taking dimethyl fumarate (which has the same active metabolite as VUMERITY) have included difficulty breathing, urticaria, and swelling of the throat and tongue. Patients should be instructed to discontinue VUMERITY and seek immediate medical care should they experience signs and symptoms of anaphylaxis or angioedema

Progressive Multifocal Leukoencephalopathy

  • Progressive multifocal leukoencephalopathy (PML) has occurred in patients with MS treated with dimethyl fumarate (which has the same active metabolite as VUMERITY). PML is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically only occurs in patients who are immunocompromised, and that usually leads to death or severe disability. A fatal case of PML occurred in a patient who received dimethyl fumarate for 4 years while enrolled in a clinical trial
  • PML has occurred in patients taking dimethyl fumarate in the postmarketing setting in the presence of lymphopenia (<0.9 x 109/L). While the role of lymphopenia in these cases is uncertain, the PML cases have occurred predominantly in patients with lymphocyte counts <0.8×109/L persisting for more than 6 months
  • At the first sign or symptom suggestive of PML, withhold VUMERITY and perform an appropriate diagnostic evaluation. Typical symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes
  • Magnetic resonance imaging (MRI) findings may be apparent before clinical signs or symptoms. Monitoring with MRI for signs consistent with PML may be useful, and any suspicious findings should lead to further investigation to allow for an early diagnosis of PML, if present

Herpes Zoster and Other Serious Opportunistic Infections

  • Serious cases of herpes zoster have occurred in patients treated with dimethyl fumarate (which has the same active metabolite as VUMERITY), including disseminated herpes zoster, herpes zoster ophthalmicus, herpes zoster meningoencephalitis, and herpes zoster meningomyelitis. These events may occur at any time during treatment. Monitor patients on VUMERITY for signs and symptoms of herpes zoster. If herpes zoster occurs, appropriate treatment for herpes zoster should be administered
  • Other serious opportunistic infections have occurred with dimethyl fumarate, including cases of serious viral (herpes simplex virus, West Nile virus, cytomegalovirus), fungal (Candida and Aspergillus), and bacterial (Nocardia, Listeria monocytogenes, Mycobacterium tuberculosis) infections. These infections have been reported in patients with reduced absolute lymphocyte counts (ALC) as well as in patients with normal ALC. These infections have affected the brain, meninges, spinal cord, gastrointestinal tract, lungs, skin, eye, and ear. Patients with symptoms and signs consistent with any of these infections should undergo prompt diagnostic evaluation and receive appropriate treatment
  • Consider withholding VUMERITY treatment in patients with herpes zoster or other serious infections until the infection has resolved

Lymphopenia

  • VUMERITY may decrease lymphocyte counts. In the MS placebo-controlled trials with dimethyl fumarate (which has the same active metabolite as VUMERITY), mean lymphocyte counts decreased by approximately 30% during the first year of treatment with dimethyl fumarate and then remained stable. Four weeks after stopping dimethyl fumarate, mean lymphocyte counts increased but did not return to baseline. The incidence of infections and serious infections was similar in patients treated with dimethyl fumarate or placebo. There was no increased incidence of serious infections observed in patients with lymphocyte counts <0.8 x 109/L or ≤0.5 x 109/L in controlled trials, although one patient in an extension study developed PML in the setting of prolonged lymphopenia (lymphocyte counts predominantly <0.5 x 109/L for 3.5 years)
  • In controlled and uncontrolled clinical trials with dimethyl fumarate, 2% of patients experienced prolonged, severe lymphopenia (defined as lymphocyte counts <0.5 x 109/L for at least six months); in this group of patients, the majority of lymphocyte counts remained <0.5 x 109/L with continued therapy. In these patients with prolonged, severe lymphopenia, the median time for lymphocyte counts to return to normal after discontinuing dimethyl fumarate was 96.0 weeks
  • In these controlled and uncontrolled clinical studies, among patients who did not experience prolonged, severe lymphopenia during treatment, the median times for lymphocyte counts to return to normal after discontinuing dimethyl fumarate were as follows:
    • 4.3 weeks in patients with mild lymphopenia (lymphocyte count ≥0.8 x 109/L) at discontinuation,
    • 10.0 weeks in patients with moderate lymphopenia (lymphocyte count 0.5 to <0.8 x 109/L) at discontinuation, and
    • 16.7 weeks in patients with severe lymphopenia (lymphocyte count <0.5 x 109/L) at discontinuation.
  • Neither VUMERITY nor dimethyl fumarate have been studied in patients with preexisting low lymphocyte counts
  • Obtain a complete blood count (CBC), including lymphocyte count, before initiating treatment with VUMERITY, 6 months after starting treatment, and then every 6 to 12 months thereafter, and as clinically indicated. Consider interruption of VUMERITY in patients with lymphocyte counts less than 0.5 x 109/L persisting for more than six months. Given the potential for delayed recovery of lymphocyte counts, continue to obtain lymphocyte counts until their recovery if VUMERITY is discontinued or interrupted because of lymphopenia. Consider withholding treatment from patients with serious infections until resolution

Liver Injury

  • Clinically significant cases of liver injury have been reported in patients treated with dimethyl fumarate (which has the same active metabolite as VUMERITY) in the postmarketing setting. The onset has ranged from a few days to several months after initiation of treatment with dimethyl fumarate. Signs and symptoms of liver injury, including elevation of serum aminotransferases to greater than 5-fold the upper limit of normal and elevation of total bilirubin to greater than 2-fold the upper limit of normal have been observed. These abnormalities resolved upon treatment discontinuation. Some cases required hospitalization. None of the reported cases resulted in liver failure, liver transplant, or death. However, the combination of new serum aminotransferase elevations with increased levels of bilirubin caused by drug-induced hepatocellular injury is an important predictor of serious liver injury that may lead to acute liver failure, liver transplant, or death in some patients
  • Elevations of hepatic transaminases (most no greater than 3 times the upper limit of normal) were observed during controlled trials with dimethyl fumarate
  • Obtain serum aminotransferase, alkaline phosphatase (ALP), and total bilirubin levels prior to treatment with VUMERITY and during treatment as clinically indicated. Discontinue VUMERITY if clinically significant liver injury induced by VUMERITY is suspected

Flushing

  • VUMERITY may cause flushing (e.g., warmth, redness, itching, and/or burning sensation). In clinical trials of dimethyl fumarate (which has the same active metabolite as VUMERITY), 40% of dimethyl fumarate-treated patients experienced flushing. Flushing symptoms generally began soon after initiating dimethyl fumarate and usually improved or resolved over time. In the majority of patients who experienced flushing, it was mild or moderate in severity. Three percent (3%) of patients discontinued dimethyl fumarate for flushing and <1% had serious flushing symptoms that were not life-threatening but led to hospitalization

Serious Gastrointestinal Reactions

  • Serious gastrointestinal (GI) reactions, including perforation, ulceration, hemorrhage, and obstruction, some with fatal outcomes, have been reported in the postmarketing setting with the use of fumaric acid esters, including VUMERITY, with or without concomitant aspirin use. The majority of these events have occurred within 6 months of fumaric acid ester treatment initiation. In controlled clinical trials, the incidence of serious gastrointestinal adverse reactions was 1% in patients treated with dimethyl fumarate; these events, none of which were fatal, included vomiting (0.3%) and abdominal pain (0.3%)
  • Monitor patients, promptly evaluate, and discontinue VUMERITY for new or worsening severe gastrointestinal signs and symptoms

ADVERSE REACTIONS

  • The most common adverse reactions (incidence ≥10% and ≥2% more than placebo) for dimethyl fumarate (which has the same active metabolite as VUMERITY) were flushing, abdominal pain, diarrhea, and nausea
  • Gastrointestinal adverse reactions: Dimethyl fumarate caused GI events (e.g., nausea, vomiting, diarrhea, abdominal pain, and dyspepsia). The incidence of GI events was higher early in the course of treatment (primarily in month 1) and usually decreased over time in patients treated with dimethyl fumarate compared with placebo. Four percent (4%) of patients treated with dimethyl fumarate and less than 1% of placebo patients discontinued due to gastrointestinal events. The incidence of serious GI events was 1% in patients treated with dimethyl fumarate
  • Hepatic transaminases: An increased incidence of elevations of hepatic transaminases in patients treated with dimethyl fumarate was seen primarily during the first six months of treatment and most patients with elevations had levels <3 times the upper limit of normal (ULN) during controlled trials. There were no elevations in transaminases ≥3 times the ULN with concomitant elevations in total bilirubin >2 times the ULN. Discontinuations due to elevated hepatic transaminases were <1% and were similar in patients treated with dimethyl fumarate or placebo
  • Eosinophilia adverse reactions: A transient increase in mean eosinophil counts was seen during the first 2 months of therapy

USE IN SPECIFIC POPULATIONS

Pregnancy

  • There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to VUMERITY during pregnancy. Encourage patients to enroll by calling
    1-833-569-2635 or visiting www.blossomspregnancyregistry.com

Renal Impairment

  • No dosage adjustment is necessary in patients with mild renal impairment. Because of an increase in the exposure of a major metabolite, use of VUMERITY is not recommended in patients with moderate or severe renal impairment

Please see full Prescribing Information.

GI=gastrointestinal; DMF=dimethyl fumarate; RRMS=relapsing-remitting multiple sclerosis; BID=twice per day; TID=three times per day; CI=confidence interval; AEs=adverse events; SD=standard deviation.
References: 1. VUMERITY Prescribing Information, Biogen, Cambridge, MA. 2. Naismith RT, et al. CNS Drugs. 2020;34(2):185-196.

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