# Effect of Diflunisal in Patients with Transthyretin Cardiomyopathy: A Pilot Study

## TL;DR

This pilot study explores the effects of diflunisal on patients with transthyretin cardiomyopathy, finding it generally well-tolerated and possibly slowing disease progression.

## Contribution

The study is the first to assess diflunisal's impact on morphological changes in ATTR-CM using CMR and real-world patient data.

## Key findings

- Diflunisal showed a non-significant trend towards stabilizing CMR parameters like LVEF, ECV, and T2.
- Patients who completed treatment had a significant decrease in 6MWT distance compared to those who did not.
- Diflunisal was well-tolerated with only minor, clinically irrelevant renal function changes observed.

## Abstract

Background: ATTR-CM is becoming more prevalent, and disease-modifying therapy has been investigated in recent years with promising results. Diflunisal has shown TTR-stabilizing properties assessed by biomarkers and echocardiography, but there are no trials addressing the evolution of morphological changes with CMR. Methods and Results: AMILCA-DIFLU is an exploratory pilot study prospective, single-center, non-randomized, open-label clinical trial. Patients diagnosed with ATTR-CM underwent clinical, functional, biochemical and imaging assessment before and one year after diflunisal therapy initiation. Of the twelve ATTR-CM patients included, only nine patients completed treatment and study protocol in 12 months. To increase the sample size, we included seven real-world patients with one year of diflunisal treatment. Among the group of patients who completed treatment, diflunisal therapy did not show improvement in cardiac disease status as assessed by many cardiac and inflammatory biomarkers, 6MWT and CMR parameters after one year of treatment. However, a non-significant trend towards stabilization of CMR parameters such as LVEF, ECV and T2 at one year was found. When comparing the group of patients who completed diflunisal therapy and those who did not, a significant decrease in the distance performed in the 6MWT was found in the group of patients who completed treatment at one year (−14 ± 81.8 vs. −173 ± 122.2; p = 0.032). Diflunisal was overall well tolerated, showing only a statistically significant worsening in renal function in the group of diflunisal-treatment patients with no clinical relevance or need for treatment discontinuation. Conclusions: In patients with ATTR-CM, treatment with diflunisal was overall well tolerated and tended to stabilize or slow down amyloid cardiac disease progression assessed by CMR parameters, cardiac and inflammatory biomarkers and functional capacity.