Successful treatment of recalcitrant cutaneous sarcoidosis with fumaric acid esters

BACKGROUND

Sarcoidosis is a multisystem disease of unknown origin characterized by the formation of noncaseating granulomas, in particular in the lungs, lymph nodes, eyes, and skin. Systemic treatment for cutaneous sarcoidosis can be used for large disfiguring lesions, generalized involvement, or recalcitrant lesions that did not respond to topical therapy.

CASE PRESENTATIONS

We report three patients with recalcitrant cutaneous sarcoidosis who were treated with oral fumaric acid esters (FAE). Three female patients presented with cutaneous sarcoidosis that have proved to be refractory to various therapies, including corticosteroids and chloroquine. We treated the patients with FAE in tablet form using two formulations differing in strength (Fumaderm initial, Fumaderm). Dosage of FAE was performed according to the standard therapy regimen for psoriasis patients. After treatment with FAE (4-12 months), a complete clearance of skin lesions was achieved in the three patients. The side effects observed in this trial correspond to the well-known spectrum of adverse effects of FAE (flush, minor gastrointestinal complaints, lymphopenia).

CONCLUSIONS

On the basis of our findings FAE therapy seems to be a safe and effective regimen for patients with recalcitrant cutaneous sarcoidosis. Nevertheless further investigations are necessary to confirm our preliminary results.

Topical calcipotriol plus oral fumaric acid is more effective and faster acting than oral fumaric acid monotherapy in the treatment of severe chronic plaque psoriasis vulgaris

BACKGROUND

Calcipotriol is an established topical therapy for psoriasis vulgaris.

OBJECTIVE

This study aimed to investigate whether the addition of calcipotriol to fumaric acid ester (FAE) monotherapy had an additive efficacy and an FAE-sparing effect in patients with severe plaque psoriasis.

METHODS

This multicentre, randomised, double-blind, vehicle-controlled study included 143 patients for up to 13 weeks treatment. Group A received FAE tablets (Fumaderm) with an increasing daily dosage from 105 to 1,075 mg + ointment vehicle. Group B received FAE tablets + calcipotriol ointment (50 microg/g). Ointments were applied twice daily. Clinical response was assessed using percentage changes in the Psoriasis Area and Severity Index (PASI), from baseline to treatment end.

RESULTS

The mean percentage change in the PASI was -76.1% in group B and -51.9% in group A, the difference between treatments was -24.2% (95% CI from -34.2 to -14.2%; p < 0.001). Group B responded more rapidly to treatment. Investigators' and patients' overall efficacy assessments were significantly more favourable for group B (p < or = 0.001). Group B was prescribed less FAE than group A. This difference was greatest at the last visit (mean daily dose 529 and 685 mg, respectively; p = 0.006). Overall adverse events in the two groups were similar.

CONCLUSION

This study shows that the combination of calcipotriol and FAEs is significantly more effective and faster acting than FAE monotherapy in the treatment of severe plaque psoriasis. The combination has a slight FEA-sparing effect and therefore a superior benefit/risk ratio.

Prevention of scours in neonatal kids after oral administration of an organic acid solution

The purpose of this study was to evaluate under field conditions, the efficacy of mild organic acid solutions in the prevention of neonatal kid diarrhoea. At a goat farm, two experimental groups of approximately 120 kids each were formed. The kids of the first group were not submitted to any treatment and served as negative controls, whereas the kids of the second group received a solution of organic acids (Euroacid 50-L; Eurotec, Waterloo, Belgium) which was administered orally on the first and second day of life. Groups were compared with regard to the incidence of diarrhoea, its duration, and the mortality of the kids. The results showed that, in comparison with the control group, the morbidity, the mortality and the case fatality of the treated kids was significantly reduced (P < 0.05). Furthermore, the duration of diarrhoea per sick kid was markedly reduced in the acidifier-treated group in comparison with the control animals (P < 0.05). Cultures of the diarrhoeic faeces from kids indicated that enterotoxigenic strains of Escherichia coli, and more specifically strains that were positive for K88 and K99 antigens, were present in the particular farm. It was concluded that the administration of organic acids can be a helpful means in controlling scours in neonatal kids.

Influence of dietary phosphorus deficiency with or without addition of fumaric acid to a diet in pigs on bone parameters

The purpose of this study was to examine if substantial bone loss occurs in weaned pigs by feeding a phosphorus-deficient diet with or without fumaric acid. Eighteen weaned pigs were used. The animals were assigned to three groups: group C (control; 0.65% P on DM basis), group LP (low phosphorus; 0.37% P on DM basis) and group LPF (low phosphorus plus fumaric acid; 0.35% P on DM basis plus 2% fumaric acid). These three diets were fed to the groups for a period of four weeks after a two-week adaptation period. Blood samples were collected once a week. Carboxyterminal telopeptide of type I collagen (ICTP) in serum was used as a bone resorption marker. Osteocalcin (OC) and bone-specific alkaline phosphatase (bAP) were used as bone formation markers. Bone mineral density (BMD) and content (BMC) were determined by peripheral quantitative computer tomography. BAP activities significantly increased (24%) in group LPF, and at the last sampling day group LPF had significantly increased activities in comparison to group C. In contrast, ICTP concentrations significantly increased with time in group LP and LPF, and at the last sampling day group LPF had significantly increased activities in comparison to group C. BMD and BMC in femur and tibia significantly decreased in group LP and LPF. The results show that P-deficient diets induce a bone loss. Fumaric acid did not influence the degree of bone loss. With a better understanding of its effect on bone, dietary phosphorus requirements in pigs could be more precisely defined.

Therapeutic strategies: rotational therapy and combinations

Long-term management of psoriasis requires an individualized approach. Some treatments such as calcipotriol, methotrexate and acitretin may be used as maintenance treatment for many months. However, most anti-psoriasis treatments should be prescribed for restricted periods of time. Rotational treatment is a practical approach to reduce the cumulative toxicity of anti-psoriasis treatments. The selection of a treatment is based on the clinical presentation of psoriasis and whether contraindications might exist. Combination treatment is another approach, which is used by the majority of patients. Useful combinations are calcipotriol-acitretin, calcipotriol-cyclosporin, calcipotriol-PUVA, calcipotriol-topical corticosteroids, dithranol-UVB, dithranol-tar, coaltar-UVB, acitretin-UVB and acitretin-PUVA. Combinations which are contraindicated are coaltar-PUVA, UVB-cyclosporin, PUVA-cyclosporin and methotrexate-acitretin. Combined use of UVB-methotrexate, UVB-PUVA; PUVA-methotrexate; methotrexate-cyclosporin and cyclosporin-acitretin require careful monitoring and might be helpful in patients with severe and recalcitrant psoriasis. Depending on the individual presentation of psoriasis, previous anti-psoriatic treatments and side-effects, treatment adjustments are made.

[Granuloma annulare disseminatum: successful therapy with fumaric acid ester]

A 64-year old female patient was treated for a therapy-resistant generalized granuloma annulare with fumaric acid esters (Fumaderm initial). One week following begin of therapy with an initial dose of 30 mg per day, the papules had regressed significantly. A 6-week therapy with a final dose of 90 mg Fumaderm initial per day led to a nearly complete healing of the illness.

Fumaric acid esters suppress peripheral CD4- and CD8-positive lymphocytes in psoriasis

BACKGROUND

For severe forms of psoriasis vulgaris, the antipsoriatic fumaric acid esters (FAE) therapy has recently gained increasing acceptance and importance. Until today, there is little knowledge about the mode of action of FAE. However, some evidence exists indicating immunosuppressive effects.

OBJECTIVE

The aim of this study was to examine the systemic, particularly the immunological changes in patients suffering from psoriasis treated with FAE over a long period of time, since we expect to see pharmacological effects of FAE at this point.

METHODS

This study is based on continuously recorded clinical data and laboratory parameters of 10 patients, who were treated over a period of 12 months with FAE. A quantitative analysis of lymphocytes and their subtypes was carried out by means of flowcytometric methods.

RESULTS

3 months after starting treatment with FAE, a clinical effect with a remission index > 95% was achieved in all 10 patients examined. This remained constant until the end of this study. Focusing on leukopenia, and particularly on lymphopenia as important parameters, these effects were found in all patients. The lymphocyte subpopulations data demonstrated extensive proportionate reductions. Within the T cell fraction a stronger suppression of CD8+ lymphocytes was observed.

CONCLUSION

Our investigations of systemic effects of fumaric acid esters demonstrate the suppressive character of this medication. Effects of cell count reduction in leukocyte and lymphocyte numbers over the entire period of 12 months could be observed. The lymphocytic cell count number is obviously linked to the clinical effect.

[Immunomodulating therapy of psoriasis vulgaris]

BACKGROUND

Newest studies have shown that psoriasis is not primarily a skin disorder but an immunological disturbance under the skin. The skin manifestations are a result of overstimulation of superficial skin cells (Langerhans cells) due to increased production of interleukin 2, 6 and 8 as well as transforming growth-factor-alpha. Interleucin-10 production is diminished. In a recent study (11 German University Skin Clinics) fumaric acid was shown to improve the skin leasons in 80% of treated patients.

OWN EXPERIENCES

Our own studies on 54 patients which where treated in addition with intravenous thymus extract (Thymoject) and selenium (Selenase) showed a faster healing rate with fumaric acid alone. From these results one can postulate that the above treatments (fumaric acid, thymus and selenium) have a synergystic effect.

CONCLUSIONS

Internal immunmodulating treatments should therefore have preference over external symptomatic treatments like UV-light, ointments, salt water bath, etc.

Effect of the addition of fumarate on methane production by ruminal microorganisms in vitro

The effect of fumarate used as a feed additive on the reduction of methanogenesis in the rumen was evaluated by in vitro experiments. The addition of fumarate to the culture of mixed ruminal microorganisms that were fermenting hay powder and concentrate reduced methane production. Most fumarate was metabolized to propionate, and a slight increase was noted in other volatile fatty acids. Fumarate was utilized by mixed bacteria but not by mixed protozoa. Fibrobacter succinogenes, Selenomonas ruminantium ssp. ruminantium, Selenomonas ruminantium ssp. lactilytica, Veillonella parvula, and Wollinella succinogenes oxidized H2 by using fumarate as a final electron acceptor, suggesting that these bacteria compete with methanogens for H2, which is the main substrate for methanogenesis in the rumen. However, the affinity of these bacteria to H2 was lower than their affinity to methanogens. These fumarate-utilizing bacteria metabolized malate to products that were similar to those from fumarate, suggesting the possession of fumarate dehydratase. Fibrobacter succinogenes, V. parvula, and W. succinogenes utilized formate, another substrate for methanogenesis, as an electron donor for fumarate reduction. The affinity of these bacteria to formate was higher than the affinity methanogenes have for formate. When methanogens were cocultured with an equal cellular amount of each of the fumarate-utilizing bacteria, methane production was markedly decreased, not only from formate, but also from H2. These results suggest that the addition of fumarate to ruminant feed reduces methanogenesis and enhances propionate production in the rumen.

Influence of sodium fumarate addition on rumen fermentation in vitro

The influence of sodium fumarate on rumen fermentation was investigated in vitro using batch and semi-continuous cultures of mixed rumen micro-organisms taken from three sheep receiving a basal diet of hay, barley, molasses, fish meal and a mineral-vitamin supplement (500, 299.5, 100, 91 and 9.5 g/kg DM respectively). Batch cultures consisted of 10 ml strained rumen fluid in 40 ml anaerobic buffer containing 200 mg of the same feed given to the sheep. Sodium fumarate was added to achieve a final concentration of 0, 5 or 10 mmol/l, as a result of the addition of 0, 250 or 500 mumol, equivalent to 0, 200 and 400 g/kg feed. CH4 production at 24 h (360 mumol in the control cultures) fell (P < 0.05) by 18 and 22 mumol respectively (SED 7.5). Total gas production was increased by the addition of fumarate without significant accumulation of H2. Substantial increases in acetate production (92 and 194 mumol; SED 26.7, P < 0.01) were accompanied by increases in propionate formation (212 and 396 mumol; SED 13.0, P < 0.001). Longer-term effects of fumarate supplementation on ruminal fermentation and CH4 production were investigated using the rumen simulation technique (Rusitec). Eight vessels were given 20 g basal diet/d, and half of them received a supplement of fumarate (disodium salt) over a period of 19 d. The response to the daily addition of 6.25 mmol sodium fumarate was a decrease in CH4 production of 1.2 mmol (SED 0.39, P < 0.05), equivalent to the consumption of 4.8 mmol H2, and an increase in propionate production of 4.9 mmol (from 10.4 to 15.3 (SED 1.05) mmol/d, P < 0.01). The inhibition of CH4 production did not decline during the period of time that fumarate was added to the vessels. Thus, the decrease in CH4 corresponded well to the fraction of the fumarate that was converted to propionate. Fumarate had no significant (P > 0.05) effect on total bacterial numbers or on the number of methanogenic archaea, but numbers of cellulolytic bacteria were increased (8.8 v. 23.9 (SED 2.49) x 10(5) per ml, P < 0.01). Fumarate also increased DM digestibility of the basal diet after 48 h incubation (0.476 v. 0.508 (SED 0.0123), P < 0.05). Thus, it was concluded that sodium fumarate may be a useful dietary additive for ruminants, because it diverts some H2 from CH4 production and because it is able to stimulate proliferation of cellulolytic bacteria and digestion of fibre.

Antihepatotoxic activity of monomethyl fumarate isolated from Fumaria indica

Monomethyl fumarate, isolated for the first time from the methanolic extract of the whole plant of Fumaria indica, was characterised and screened for its antihepatotoxic activity in albino rats. The compound showed significant (P < 0.01) antihepatotoxic activity against thioacetamide in vitro, and against hepatotoxicities induced by carbon tetrachloride, paracetamol and rifampicin in vivo to an extent almost similar to that of silymarin, a known antihepatotoxic agent.

Bioavailability and pharmacokinetics of magnesium after magnesium fumarate administration in humans

Bioavibility and pharmacokinetics of magnesium after magnesium fumarate administration in humans. The volunteers were given a single oral dose of 530 mg of magnesium on an empty stomach. The preparation was a magnesium fumarate tablet. The simplest formule to describe the course of blood magnesium concentration changes was a two exponential equation for an open monocompartmental model.

Retention and utilization of amino acids in piglets fed ad libitum or restrictively diets supplemented with organic acids

In a metabolic trial 4 groups of 8 piglets of 5 kg weight each were kept individually for 45 days (final weight 23 kg) and fed a practical diet. At the beginning of the experiment the body amino acid contents of an additional group of 8 piglets were determined by carcass analysis, and at the end of the experiment the body amino acid contents of the 4 test group piglets (A = control fed ad libitum, B and C = supplement of 1.5% fumaric acid fed ad libitum or restrictively, D = supplement of 1.5% citric acid fed ad libitum) were also analysed. The amino acid retention during the experimental period was determined by difference. The supplements of fumaric or citric acid did not influence the amount of the amino acid retention. The quotient of amino acid retention to amino acid consumed or the "productive amino acid value" was calculated and the maintenance requirements of essential amino acids for piglets were used to estimate the productive amino acid value for both retention and maintenance. The mean amino acid retention amounted to about 56 g/d, i.e. 3.49 g/kg W0.75.d of essential amino acids. The essential amino acid requirements for maintenance was 2.0 g, i.e. 0.29 g/kg W0.75.d, showing a variation of 4% (Leu) to 20% (Met+Cys) when related to the amount of the corresponding amino acid retention. With regard to the amino acid pattern for retention of the nutritionally most important amino acids, the following ratios were found: Lys, 100 (6.27 g/16 g N): Met+Cys, 48 (3.03 g): Thr, 56 (3.49 g): Trp, 13 (0.80 g). The productive amino acid values ranged from 40% (Trp), 55% (Thr), 66% (Met) to 80% (Lys). Under the conditions investigated, neither the supplements of organic acids nor the feed restriction influenced the amino acid utilization.

Antipsoriatic effect of fumaric acid derivatives. Results of a multicenter double-blind study in 100 patients

BACKGROUND

Psoriasis vulgaris may benefit from treatment with fumaric acid and/or its derivatives; however, because different preparations have been used, results have been contradictory and difficult to interpret.

OBJECTIVE

The purpose of this clinical trial was to evaluate the therapeutic value of fumaric acid derivatives.

METHODS

A randomized double-blind study was carried out in patients with psoriasis, comparing a well-characterized formulation of fumaric acid derivatives with placebo.

RESULTS

The results indicated statistically significant superiority of the fumaric acid derivatives over placebo. Adverse events (flush, gastrointestinal disturbances) were initially relatively frequent, but decreased thereafter.

CONCLUSION

Fumaric acid derivatives were found to be effective and safe in the treatment of psoriasis.

Characterization of the nutritional interactions between organic acids and inorganic bases in the pig and chick

Four experiments were conducted to characterize the interactions between fumaric (FA), malic (MA), or citric acid (CA) and NaHCO3. In two experiments, seven diets were formulated containing 2.5% FA, MA, and CA, with or without 2.3, 1.9, or 1.4% NaHCO3, respectively, as well as a control diet (no addition of organic acids or NaHCO3) for 28-d-old pigs (Exp. 1, corn-soy protein concentrate-based diet) and 1-wk-old chicks (Exp. 4, corn-soy-based diet). In Exp. 1, at 2 and 4 wk, the FA+NaHCO3 treatment resulted in greater average daily gain (ADG) and feed intake (ADFI) compared with the control (P < .05). In Exp. 2, 28-d-old pigs were fed corn-soy diets with .9, 1.6, and 2.3% NaHCO3 in addition to 2.5% FA. After wk 2, there was a quadratic response in ADG (P < .08) and ADFI (P < .05) when increasing levels of NaHCO3 were added to the diet. This was true at wk 4 for both ADG and ADFI (P < .05). In Exp. 3, finishing pigs were fed corn-soy diets containing 2.5% FA or 2.5% FA + 2.3% NaHCO3 added to a control diet. No effect (P < .05) of FA or NaHCO3 was observed. In Exp. 4, the combination of CA+NaHCO3 or MA+NaHCO3 was superior to FA+NaHCO3 for ADG (P < .08) and ADFI (P < .05) when fed to young chicks.

The risk of sensibilization and contact urticaria upon topical application of fumaric acid derivatives

Systemic and sometimes topical therapy with fumaric acid (FA) and its derivatives is used in the treatment of psoriasis. Scattered data show that the topical application of these derivatives elicits side effects. Application of FA and some derivatives on the skin was accompanied by perilesional skin irritation, macular papular rashes and urticarial reactions. In order to determine the irritating and sensitizing properties of FA derivatives we used a cytotoxicity, flank irritation, ear swelling and guinea pig maximization test. The results of the cytotoxicity test demonstrated that dimethylfumarate (DMF) was the most toxic derivative. DMF induced also contact-urticarial reactions in contrast to mono-ethylfumarate (MEF). Challenge experiments with FA, MEF and DMF in MEF- and DMF-sensitized guinea pigs demonstrated that both MEF and DMF are moderate contact sensitizers. In DMF-sensitized animals cross-reactions with MEF were found. As DMF and MEF have cytotoxic, contact-urticarial and/or sensitizing properties, topical application should be avoided.

Effect of feeding organic acids on selected intestinal content measurements at varying times postweaning in pigs

Pigs weaned at 21 d of age (n = 72) were fed a 20% CP corn-soybean meal-based diet (control) with 1.5% fumaric or 1.5% citric acid added to observe the effect of these acids on the pH, chloride ion concentration (Cl-), VFA profile, and microflora population in the stomach, jejunum, cecum, and lower colon contents at -2, 0, 3, 7, 14, and 21 d postweaning. Feeding organic acids had no appreciable effect (P greater than .10) on stomach jejunum, cecum, or lower colon pH, Cl-, VFA profile, or microflora populations, except for increasing the concentration of fumaric acid in the stomachs of pigs fed fumaric acid. The pH of the gastrointestinal tract generally decreased from -2 to 21 d postweaning with no corresponding change in Cl- over time. No age effects on total anaerobic culture counts were observed except in the stomach, where counts decreased from -2 to 3 d postweaning. Clostridia counts generally decreased after weaning in all intestinal sections. Lactobacillus counts were usually lower at d 0 and 3 and greatest at d 7 postweaning in the stomach, jejunum, and lower colon, but no age effect was observed for concentration of cecum lactobacilli. Escherichia coli counts generally increased after weaning to 3 and 7 d postweaning. Intestinal content measurements were affected by postweaning age but were not affected by feeding organic acids.

Postirradiation sensitization of mammalian cells by the thiol-depleting agent dimethyl fumarate

Dimethyl fumarate (DMF) depletes intracellular glutathione (GSH) by covalent bond formation in a reaction mediated by GSH-S-transferase. Treatment of hypoxic Chinese hamster V79 cells with 5 mM DMF before irradiation radiosensitizes the cells, resulting in an enhancement ratio (ER) of about 2.7 with minimal toxicity, when the end point is clonogenic cell survival. Under the same conditions aerobic cells are sensitized, and ER of about 1.3 is found, and GSH is reduced to about 3% of control. Very similar results were obtained previously with Chinese hamster ovary (CHO) cells. In addition, new data presented here show that DMF treatment of V79 or CHO cells immediately after irradiation under hypoxic conditions sensitizes the cells, resulting in an ER of about 1.5, DMF treatment after irradiation under aerobic conditions results in an ER of 1.3, and this DMF treatment reduces protein thiols (PSH) to about 70% of control. When induction of DNA damage is measured using the neutral elution assay, treatment of V79 or CHO cells with DMF prior to irradiation under hypoxic conditions results in an ER of 1.9-2.0, but there is no enhancement of DNA damage when DMF is added after irradiation under hypoxic conditions or when cells are treated with DMF before or after irradiation under aerobic conditions. Based on these data we postulate that DMF radiosensitizes killing of hypoxic cells by two actions: depletion of GSH interferes with the chemical competition between damage fixation and repair, and depletion of PSH causes an inhibition of enzymatic repair processes. We also suggest that DMF sensitizes aerobic cells only by inhibition of enzymatic repair processes.