毒理性
在大规模随机对照试验中,对银屑病和多发性硬化症患者使用二甲基富马酸盐,血清ALT升高是常见的,发生在多达25%的患者中。然而,这些升高通常是轻到中度的,即使没有调整剂量也能迅速解决。与安慰剂接受者相比,二甲基富马酸盐的升高超过3倍ULN的发生率为6%,而安慰剂为3%至6%。酶升高通常是短暂的,不伴有症状或黄疸,需要停药的患者不到1%。在甲基富马酸盐的预注册试验中没有报告急性肝炎或临床上明显的肝损伤的病例。尽管如此,在其批准后2到3年内,随着更广泛的使用,报告了几例临床上明显的肝损伤伴黄疸的病例。大多数病例在开始使用二甲基富马酸盐后的2到3个月内发生,但也报告了一些潜伏期较长的病例。典型病例表现为急性肝炎样特征,血清转氨酶水平显著升高,碱性磷酸酶升高仅适度。免疫过敏特征和自身抗体并不常见,所有患者在停药后都恢复,没有报告慢性损伤或肝衰竭的实例。
临床上明显的肝损伤在使用二噁烷或单甲基富马酸盐时并未报告,但这些药物的临床经验有限。由于这三种单甲基富马酸盐的前药的副作用概况相似,因此怀疑这三种药物都是临床上明显肝损伤的罕见原因。
二甲基富马酸盐的可能性评分:C(可能是临床上明显肝损伤的罕见原因)。
二噁烷富马酸盐的可能性评分:E*(未证实但怀疑是临床上明显肝损伤的罕见原因)。
单甲基富马酸盐的可能性评分:E*(未证实但怀疑是临床上明显肝损伤的罕见原因)。
In large randomized controlled trials of dimethyl fumarate in patients with psoriasis and multiple sclerosis, serum ALT elevations were frequent, occurring in up to 25% of patients. The elevations, however, were generally mild-to-moderate and resolved rapidly even without dose modification. Elevations above 3 times ULN were reported in 6% of dimethyl fumarate compared to 3% to 6% of placebo recipients. The enzyme elevations were usually transient and not associated with symptoms or jaundice, requiring drug discontinuation in less than 1% of patients. No cases of acute hepatitis or clinically apparent liver injury were reported in the preregistration trials of methyl fumarate. Despite this, several cases of clinically apparent liver injury with jaundice were reported within 2 to 3 years of its approval and more widescale use. Most cases occurred within 2 to 3 months of starting dimethyl fumarate but some instances with more prolonged latency were reported. The typical case presented with acute hepatitis like features, marked increases in serum aminotransferase levels, and only modest alkaline phosphatase elevations. Immunoallergic features and autoantibodies were not frequent and all patients recovered upon stopping the medication with no reported instances of chronic injury or hepatic failure.
Cases of clinically apparent liver injury have not been reported with diroximel or monomethyl fumarate but the clinical experience with these agents has been limited. Because the side effect profiles of these three pro-drugs of monomethyl fumarate are similar, it is suspected that all three are rare causes of clinically apparent liver injury.
Likelihood score for dimethyl fumarate: C (probable rare cause of clinically apparent liver injury).
Likelihood score for diroximel fumarate: E* (unproven but suspected rare cause of clinically apparent liver injury).
Likelihood score for monomethyl fumarate: E* (unproven but suspected rare cause of clinically apparent liver injury).
来源:LiverTox