dimethyl fumarate + diroximel fumarate

This is a combination of two oral small molecule drugs, dimethyl fumarate and diroximel fumarate, both used as disease-modifying therapies for relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS. Both agents are prodrugs that are rapidly converted in the body to the same active metabolite, monomethyl fumarate (MMF). MMF is believed to exert its therapeutic effect by activating the nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway, which enhances cellular antioxidant responses and reduces oxidative stress. This mechanism provides neuroprotective and anti-inflammatory effects in MS. MMF also activates hydroxycarboxylic acid receptor 2 (HCAR2), contributing further anti-inflammatory activity. Diroximel fumarate was developed as an alternative to dimethyl fumarate with improved gastrointestinal tolerability but similar efficacy due to their shared active metabolite[1][2][8].