Patozone

Definitions

 

Biologic

Biological products are defined as “a virus, therapeutic serum, toxin,

antitoxin, vaccine, blood, blood component or derivative, allergenic

product, protein, or analogous product, or arsphenamine or derivative of

arsphenamine (or any other trivalent organic arsenic compound),

applicable to the prevention, treatment, or cure of a disease or condition

of human beings”.

• Biological product definition revised in BPCIA of 2009 to include

“protein”

• 2020 – added that chemically synthesized material is included in

definition

• FDA defined a Protein as any alpha amino acid polymer with a

defined sequence greater than a total number of 40 amino acids

(even if comprised of several shorter polypeptide chains).

 

• March 23, 2020 – FDA Biologic definition updated

– > 40 amino acids: Protein – Must have Biologics License Applications (BLA)

– ≤ 40 amino acids: Peptide

– Synthetic material inclusion in biologic definition

• Removal of human chorionic gonadotropin,

hyaluronidase, follicle stimulating hormone (FSH or

urofollitropin), tesamorelin acetate, and menotropins

 

“Metaflammation”

• Also know as “Inflammaging” and metabolism induced inflammation

• Chronic low‐grade inflammatory sequela induced by alterations in metabolic signaling

• Increases aging processes and metabolic signaling issues

• Endoplasmic reticulum stress reported key to excessive inflammatory response

Caused by AND leads to “diabesity”:

– Insulin resistance; type 2 diabetes

– Obesity

– Stress

– Diet

– LPS induced GUT issues and inflammation

– Liver / kidney issues

 

Stress causes cravings, sleepdisturbance and weight gain

• Cortisol – DHEA ratio

• Insulin resistance follows

• Weight gain leads to adiponectin

alterations and loss of AMPK in

the cell

. . . the inflammatory cycle begins

 

Peptides

• Short chains of amino acids linked By amide bonds

• < 50 amino acids

• Less likely to evoke immune response when administration

• Peptide from Greek word meaning “to digest”

• Played a role in therapeutics since the 1920s – insulin

 

• High specificity and affinity for target

• Highly efficacious, good tissue penetration

• Low allergenicity

• Natural compounds

• Safe, well tolerated

• Fast clearance

• Low Toxicity

• Over 7,000 naturally occurring peptides identified

• Crucial roles in human physiology – improves

metabolic signaling

 

• Over 100 peptide‐based drugs approved by US FDA in past 30 years

• Market = 14.4 billion in 2011 to almost 28 billion in 2018

• US market 40% of global peptide sales

 

Examples of FDA Approved Peptides Already on the Market:

• Erythropoietin – RBC production

• Sermorelin acetate – diagnostic for pituitary function;

increases growth in children

• Tissue plasminogen activator (TPA)‐ heart attack/stroke

• Oxytocin – maintain labor pain ; “cuddle” hormone ‐

improve sexual libido; also may help with decreasing opiate

withdrawal

• Bradykinin – improve peripheral circulation

• Somatostatin – decrease bleeding ulcer

• Gonadotropin – induce ovulation

• Insulin – maintain blood glucose level

• Bremelanotide (Vyleesi) – Female or Male Sexual

Dysfunction

• Zadaxin – Thymosin Alpha1 for Hepatitis B and C

• Semaglutide GLP‐1

• Tirzepatide mixed GLP‐1

 

Potential General Side Effects from Peptide Injections

• Itchy at the injection site

• Redness at the injection site

• Water retention ‐ most likely need to reduce dose

• Increased hunger

• Dry mouth

• Nausea

• Tingling or numbness in the extremities (toes,

fingers – reduce dose)

• Increased hair and nail growth

 

Current Regulatory Environment

• FDA clamping down on Compounding Pharmacies ability to

manufacture and sell high quality, highly therapeutic and SAFE

peptides

• FDA issued at 503‐A compounded products now have many

peptides added to “category 2”

• FDA considers category 2 peptides to be banned from bulk

drug compounding

• “raise significant safety risks”

• Several law‐suits on this issue are currently in the system

 

• According to FDA, the term “protein” is distinct from and excludes

the term “peptide” (i.e., amino acid chains that are generally

shorter and simpler than a protein).

• FDA uses “bright-line rule” based on number of amino acids in an

amino acid polymer regardless of method of manufacture.

• But FDA uses fact-specific, case-by-case analysis for amino acid

chains not found in naturally occurring proteins.

• Between 2015–2019, the U.S. Food Drug Administration (FDA)

authorized a total of 208 new drugs (150 new chemical entities and

58 biologics), 15 of which were peptides or peptide-containing

molecules.

 

A (compounded) peptide is regulated as a drug under the

FD&C Act unless the peptide otherwise meets the statutory

definition of a “biological product” (>40 amino acids) and is

therefore regulated under the Public Health Service Act.

 

History of Commonly Used Peptides

• Before April 2020

• FDA and State Boards of Pharmacy did not specifically indicate that certain

peptide bulk drug substances were an issue and provided little to no objection

to the practice.

• After April 2020

• The tides changed after an FDA warning letter issue sometime in April 2020

identifying multiple peptides used in practice today.

• FDA indicated these products were not in conformance with 503A and not eligible for compounding.

• Indicated that nomination with sufficient data and lack of FDA safety concerns may have cured deficiency.

• State Boards of Pharmacy became emboldened after an October 2020 DOJ guilty

plea by a pharmacy to a single count of manufacturing an unapproved drug.

• Confusion exists on how a single count of unapproved drug manufacturing can encompass numerous bulk

substances primarily compounded separately.

 

Physician Marketing 101

• Do not make claims!

• The use of may and has been shown

• Provide supporting evidence

• Websites are being monitored!

• Drug pricing

• Don’t put yourself under FDA regulation

 

USP 2020–2025 Biologics

USP Monographs

• Expert Committee Established!!

• Mission

• The Biologics Monographs 1 – Peptides & Oligonucleotides Expert Committee is responsible for

the development and revision of USP-NF monographs and their associated USP Reference

Standards in peptides and oligonucleotides

• Focus

• Monographs and reference standards (RS) for synthetic, recombinant, naturally-derived

therapeutic peptides under 40 amino acids in length

• Quality control of raw materials used in manufacturing of synthetic peptides

• Selected general chapters that pertain to peptides and oligonucleotides

• Modernization of outdated monographs

• Identification and development of new monographs and RS

• Key Issues

• Work with other Biologics Expert Committees, FDA and stakeholders to improve existing peptide

monographs and develop new peptide monographs

• Conduct workshops relevant to areas of interest to the Expert Committee

• Transition from recombinant to synthetic drug and regulatory considerations and reference

standards needed to support both forms

 

Beyond Compounding…

• Online Peptide Sales

– Legal Statements:

• “By placing orders with this company it we understood by the buyer that under no

circumstances should use any of these chemicals/materials in an inappropriate manner.

No products here are to be used for recreational purposes or human consumption. All

customers are assumed and expected to be qualified researchers.”

• “Products on this website are sold for laboratory research purposes only. The

information provided on this website and the products offered on this website are for invitro

lab research use only. The products are not medicines or drugs and they have not

been approved by the fda to prevent, treat, diagnose, mitigate, or cure any disease,

ailment or medical condition. ALL ARTICLES AND PRODUCT INFORMATION PROVIDED

ON THIS WEBSITE ARE FOR INFORMATIONAL AND EDUCATIONAL PURPOSES ONLY. The

products offered on this website are not for human or animal consumption of any

kind.”

– Quality:

• The purchaser agrees that the products have not been sterilized or tested for safety and efficacy in food, drug, medical device, cosmetic, commercial or any other use.

 

Unique Class of Pharmaceutical Compounds

 Molecularly poised between small molecules &

proteins

 As signaling molecules, therapeutic intervention

closely resembling natural pathways

 Natural sources  Synthetic  Exotic sources 

Ligands  Analogs  Conjugation

 Native – Analogs – Heterologous

 60+ Peptides approved in U.S., E.U., Japan

 150+ in active clinical development/trials

 ~260 tested in human clinical trials

 500+ in preclinical development

 More than 3,200 antimicrobial peptides (AMPs) have

been discovered, nine of which have been

approved by the U.S. Food and Drug Administration

(FDA).

 

PEPTIDE CONJUGATES

 Represent an important class of

therapeutic agents that combine

one or more drug molecules with a

short peptide through a

biodegradable “linker”.

 This prodrug strategy uniquely and

specifically exploits the:

 (a) biological activities and

 (b) self-assembling potential of

small-molecule peptides

to improve the treatment efficacy

of medicinal compounds.

 

RESEARCH USE = UNREGULATED

 RUOs are defined very briefly by FDA regulations:

 Commercial RUO products are described as products “in the laboratory research phase of

development and not represented as an effective in vitro diagnostic (therapeutic) product.”

 RUO products must bear the following labeling statement:

 “For Research Use Only—Not for Use in Diagnostic Procedures.” (Although not authorized by

the regulation, many companies have shortened the statement to just the first-half of the clause).

 FDA regulations do not define any other restrictions/limitations on RUO products beyond this

labeling statement.

 FDA regulations define the category and labeling . . . and nothing more.

 Not clear that they are even subject to FDA’s jurisdiction.

 Aside from bearing the mandated statement, the manufacturing of RUO products:

 Do NOT need to be listed with FDA or comply with ANY Quality System Regulation (QSR).

 Can be sold (for research) without any FDA clearance or approval.

 Unregulated by FDA.

 

RESEARCH USE ≠ CGMP

Products labeled RUO are not required to be manufactured in accordance with cGMP and FDA Quality System Regulation. “. . . the lack of manufacturing controls may be detrimental to the quality of the control material. As such, clinical laboratories using RUO quality control materials to ensure the quality of testing may be placing patients at unnecessary risk.”

 https://microbiologics.com/

Are RUO and IUO products required to be manufactured in compliance with the Quality

System regulation?

 FDA does not require RUO products or IUO products . . . to be manufactured in

compliance with the Quality System (QS) regulation (21 CFR 820).

In addition to overt expressions by the manufacturer (such as those present in labeling and advertising), intended use may be “shown by the circumstances surrounding the distribution of the product and the manufacturer's knowledge that its product is offered and used for a purpose for which it is neither labeled nor advertised.”

 

RESEARCH USE ≠ FDA APPROVAL

 RUO products are essentially unregulated in the U.S. but must be branded with

the statement: “For Research Use Only. Not for use in diagnostic procedures”.

 Labeling a product as such permits it to be used by researchers, who can

evaluate usefulness for a specific diagnostic purpose.

 “RUO manufacturers do not have to register or list their RUO products with FDA or

comply with manufacturing standards.”

https://regulatoryandmore.com/

 RUO products can be legally offered for sale without any FDA knowledge,

clearance, oversight, or approval.

 

FDA & RUO/IUO PRODUCTS

DOCKET NUMBER: 2011-D-0305 (LINK TO FDA FINAL GUIDANCE DOCUMENT)

 “FDA is concerned that distribution . . . has led to . . . the use of products

with manufacturing controls that are inadequate . . .”

 Intended Use:

 Refers to the “objective intent” of those responsible for labeling the product.

 Intent may be shown by the circumstances surrounding the distribution of product.

 Merely placing RUO/IUO on the label does not render it exempt

 Determined by other evidence, including how the product is marketed

 Product design; statements; claims; clinical info; workshops; presentations

 Misbranded; 502(a) & 502(o) of 21 U.S.C. 352(a), 352(o)

 Adulterated; 501(f) of 21 U.S.C. 351(f)

Peptide Synthesis

 

SIDE-CHAIN PROTECTING

GROUPS FOR FMOC AMINO

ACIDS

 “Linkers” provide point of attachment for

the C-terminal amino acid.

 Most cleavage/deprotection methods are

TFA-based, and they differ primarily in:

 the final concentration of TFA

 types of scavengers used

 reaction times

 Mainly dictated by the amino acid composition of the peptide.

 

BUILDING A PEPTIDE

• Made of amino acids linked together in a chain-like structure

• Fluorenyl methoxycarbonyl (Fmoc) protecting group

• Prevention of unwanted reactions

• Must be removed from NH2 side, but left on the COOH

• R-group requires protection as well

• SPPS developed by chemist Bruce Merrifield in 1963

• AA preloaded to resin; successive Fmoc removal/coupling

 

Cleave peptide from resin;

Trifluoroacetic acid (TFA)

• Must perform salt exchange with Acetic or HCl Acid

 

TFA CLEAVAGE COCKTAIL

FORMULATIONS – HIGH % TFA

 Structure of the linker:

 determines method of cleavage

 peptide functionality

 Low %TFA: XAL (“Seiber”) or HAL

 High %TFA: PAC (“Wang”), PAL, AM, or BAL

Source: Thermofisher

TFA: trifluoroacetic acid

TIPS: triisopropylsilane

EDT: 1,2-ethanedithiol

DTT: dithiothreitol

TES: triethylsilane

DCM: dichloromethane

 

TRIFLUOROACETIC ACID/ACETATE EXCHANGE

 Prepare a small column of strong anion exchange resin

 Elute the column with a 1M solution of Sodium Acetate

 Wash column with distilled water removing excess

Sodium Acetate

 Dissolve peptide in distilled water and apply to column

 Elute the column with distilled water and collect fractions

containing the peptide

 Lyophilize peptide containing fractions to obtain the

peptide acetate salt

• (reconstitute/repeat lyophilization step 2-3x)

 

TRIFLUOROACETIC ACID (TFA)

 The dose level of 160mcg/mL of sodium trifluoroacetate is considered

to be the NOAEL in both sexes; approximately equal to:

 8mg - 10mg TFA/kg body weight/day in males and females, respectively.

 organ weights and organ+body weight ratios; Hgb, Hct, Bilirubin, Glucose,

ALT/AST

https://echa.europa.eu/registration-dossier/-/registered-dossier/5203/7/6/2

 Cornish J, et al. Am J Physiol. 1999 Nov;277(5):E779-83. doi: 10.1152/ajpendo.1999.277.5.E779.

 inhibits proliferation of osteoblasts and chondrocytes

 Cousins M, et al. Anaesth. Intens. Care (1979), 7, 9

 Hepatotoxic, Neurotoxic

 Binds to hepatic proteins forming neoantigens, responsible for

production of autoantibodies against liver tissue

 

SOURCING PEPTIDES

Chemicals Must Minimally Be:

• From FDA registered Manufacturer

• https://www.accessdata.fda.gov/scripts/cder/

drls/default.cfm

• Accompanied by a valid C of A

 Contain Identifiers:

• MF, CAS, A.A. Sequence, MW

 Include Tests:

• Appearance

• H2O (and CH3COOH) content

• Assay/Purity

• Impurities

 Lot, Storage, Expiration, etc

 

CALCULATIONS FOR PEPTIDE PRODUCTS

Summary of Calculations

I. Determine correct chemical & observe assay or potency.

II. Remove and/or account for impurities, assay, and water content

(actual peptide content) . . .

III. Solve for the API that is left in the remaining chemical based on the

assay/purity.

IV. Decide if there is need make further corrections for the salt-form in

the chemical.

V. Any other considerations that may apply to the chemical being

used.

 

CALCULATIONS FOR PEPTIDE PRODUCTS

Summary of Calculations

I. Purity . . . . . . 99.5%

II. H2O . . . . . . . . 5.1%

III. CH3COOH . . . 10.8%

• (0.995) x (0.949) x (0.892) = 84.2%

If making 5L @ 2mg/mL: requires 10gm … however, 11.9gm needed

to obtain required concentration.

 

STERILE FILTERING OF SOLUTIONS - 21 CFR 211.113 (B)

1. Appropriate to Use

• Material/Size

2. Sterilization of the Filter

• Irradiation, Autoclave

3. Stability of the Filter Used

• Filter construct material

interaction with product/pH

4. Binding on the Filter

• Contact surfaces do not bind

any formulation component

5. Compatibility of the Filter

• Chemical/Bio-compatibility

6. Extractables/Leachable

• Distressed/Normal conditions

7. Bacterial Retention

• B. diminuta (ATCC 19146)

• 1 x 107

• ASTM F838-05

8. Integrity Testing

• Bubble point

• Forward flow/Pressure hold

 

Stability of Peptides

• The shelf-life of peptides in solution is very limited.

• Especially true for peptides whose sequences contain:

• Cys, Met, Trp (oxidation) . . . or

• Asp, Gln, Arg, Lys, His, and N-terminal Glu

• Minimize exposure to air

• Avoid freeze-thaw cycling (degradation, pH shifts, etc.)

• Keep Refrigerated (what if . . . )

 

QUALITY CONTROL IN THE PHARMACEUTICAL

COMPOUNDING OF STERILE PRODUCTS

503A – USP <795> and <797>

 Compounding by a licensed pharmacist/pharmacy or physician

 “For an identified patient based on unsolicited receipt of a valid prescription . . . Or

notation that compound is necessary for patient”

 Copies of marketed products should not be in “inordinate amounts” (i.e. > 4 units/month)

 Chemicals must comply with USP monographs, if exists

 If monograph does not exist, must be components of approved drugs

 If neither available, bulk drug substance must:

• Be from FDA registered MFG under 510 of FD&C Act [207.3(a)(4) of Title 21 CFR]

• Be accompanied by a valid C of A

 

CFR21: § 216.23 Bulk drug substances that can be used to compound drug

products in accordance with section 503A of the Federal Food, Drug, and

Cosmetic Act:

(1) Brilliant Blue G

(2) Cantharidin (topical use only).

(3) Diphenylcyclopropenone (topical use only).

(4) N-acetyl-D-glucosamine (topical use only).

(5) Squaric acid dibutyl ester (topical use only).

(6) Thymol iodide (topical use only).

 

Personnel Garbing and Gloving

 Prior to and during aseptic compounding

 Particles generated ≥ 0.3μ/minute; slow walk (smock: 5,000,000 vs coverall: 500)

 > 10 million particles >0.3μ per 1 ft2 of the cleanest hands

 Personnel training and evaluation in aseptic manipulations and sterilization skills semi-annually***

 PPE Gowning, Didactic Training, Written Competence, Skill Assessment, Cleaning, Media Fills

 Environmental quality specifications & monitoring

 Air and surface sampling (required every 6 months***; but often performed more frequently)

 Temperature: ≤ 20°C (68°F) or cooler

 Humidity: 35% to 60%

 Routine and Scheduled Disinfection of gloves/surfaces within ISO-5 sources NLT every 30 minutes

 

503A – FACILITY DESIGN

 1° Engineering Controls (LAFW, BSC, CAI, CACI, etc.) – (ISO-5)

 Unidirectional @ ~90fpm; smoke studies

 2° Engineering Controls – (Buffer area, Ante; Prep) – (ISO-7/8)

 Differential Pressure

 > 0.02 (to 0.05) inch water column between adjacent areas (5-12 Pascals)

 NLT 30 ACPH: [CFM x 60 / (Area x Height)]

 

503A – ADOPTION OF USP <797>

 03/2021: 39 State Boards of Pharmacy require full

compliance

 An additional 11 states have strong requirements on

sterile compounding practice—which 10 states

characterize as “equivalent to or stricter than”

Chapter <797>

 2015: Only 26 states required <797> or equivalent

quality standards for sterile compounding.

 39 states prohibit traditional pharmacies from

compounding sterile office stock for humans.

 11 states have office stock policies (many predating

the federal law) that are not aligned with federal

statute

 

503B –

 Can compound large batches of medication to be dispensed to clinics, doctors’ offices

and other healthcare facilities for general office use.

 Must comply with cGMP & submit documentation of processes and testing results.

 May not compound a drug product from bulk drug substance unless:

1. the bulk drug substance appears on a list identifying bulk drug substances for which there

is a clinical need (the 503B bulks list), or

2. the drug product compounded from bulk drug substance appears on FDA’s drug

shortage list at the time of compounding, distribution, and dispensing.

 Chemicals must comply with USP monographs if exists

 If monograph does not exist, must be components of approved drugs

 If neither is available, bulk drug substance must:

• Be from FDA registered MFG under 510 of FD&C Act

• Be accompanied by a valid C of A

 

Added 4/6/23 – Federal Register

Quinacrine HCl (for oral use only)

NOT Included on list for 503B

 Hydroxyzine HCl Mannitol

 Methacholine Chloride Metoclopramide HCl

 Nalbuphine HCl Potassium Acetate

 Procainamide HCl Sodium Bicarbonate

 Sodium Nitroprusside Verapamil HCl

 

503B – USP <795>, <797>, 21 CFR Part 210 and 211 (cGMP)

 Part 210: Minimum practices in manufacturing, processing, packing, or

holding of all compounded drugs

 Part 211: Refers specifically to the requirements of finished pharmaceuticals

 Requirements of <797> found in 503A, PLUS:

 Increased Environmental/Personnel Monitoring Frequency

 Required product validation testing

 components/container closure/method suitability/sterility/stability

 maximum batch size & time parameters

 Documentation requirements

 

503B – cGMP

1. Facilities/Equipment

a) HEPA-filtered air @ ISO-5 quality

i. Leak tests and velocity uniformity biannually

ii. Smoke Studies; Under dynamic conditions

b) Supporting Clean Areas = ISO-6,7,8

c) ACPH (e.g., ISO-8 = 20 ACPH)

d) Pressure Differentials: 10-15 Pascals (0.04-0.06 inches water column)

e) Construction Materials (e.g., FRP walls; sealed ceiling tiles, easily cleanable)

f) Airlocks & Passthroughs

 

503B – cGMP

2. Personnel

• Technique, behavior, microbiology, hygiene, gowning, SOPs, etc.

3. Components/Containers/Closures

• API, SWI, Excipients (bioburden)

• Use of SWI for final rinse prior to sterilization/depyrogenation via dry heat

4. Endotoxin

• Not removed via sterile filtration - - chemicals must but be of pure quality

 

503B – cGMP

5. Time limitations to be established for each phase of production in compounding process

6. Validations of Aseptic Processing/Sterilization

• Media fills/Frequency, Duration, Size of batches

7. Laboratory Controls

• Active & Passive Air Monitoring (settling plates)

8. Sterility Testing

• USP<71>, Investigations, RCA

9. Documentation

 

503B - VENDOR EVALUATION

1. Ensure licensure is in place

2. Familiarize yourself with their regulatory history

• (FDA inspections with OAI (Official Action Indicated)

3. Review the number of SKUs they report in a 6-month period (503B only)

4. Examine any recall information and purpose thereof

5. Verify the annual drug review for the FDA (cGMP requirement for 503B)

6. Check references from customers with similar operations …

• *(beware of bad review trolls on internet)* - - (Reservations analogy)

7. On-site visit - - know what to look for ahead of time - - review <797> (or cGMP for 503B)

• evaluation based on the quality system in place and compliance with quality guidelines

8. ** know how to interpret the findings of a 483 ** request responses to 483 observations

(transparency)

Pathophysiology

 

HYPOTHALAMUS

 Connects the nervous system to the endocrine system

 GONADOTROPIN- RELEASING HORMONE

(GnRH)

 CORTICOTROPIN RELEASING HORMONE (CRH)

 THYROTROPIN RELEASING HORMONE (PROLACTIN RELEASING HORMONE) (TRH)

 GROWTH HORMONE RELEASING HORMONE (GHRH)

 SOMATOSTATIN (GH INHIBITING HORMONE)

 PROLACTIN INHIBITING HORMONE

 

HPA IS ACTIVATED BY PEPTIDES

The main activator of the HPA axis is the neuropeptide corticotropin-releasing hormone

(CRH) synthetized in the hypothalamic paraventricular nucleus (PVN)

CRH is released into the portal vessels of the median eminence to the pituitary

CRH release leads to synthesis and release of adenocorticotropic hormone (ACTH)

 

HYPOTHALAMUS TO ANTERIOR PITUITARY

Hypothalamic hormones travel through hypothalamo-pituitary portal circulation to anterior

pituitary and bind to receptors on surface of pituitary.

As a consequence the pituitary will start or stop secreting hormones into the systemic

circulation.

 

ANTERIOR PITUITARY

TSH

ACTH

GH

FSH

PROLACTIN

LH

 

POSTERIOR PITUITARY

Sometimes considered extension of hypothalamus

OXYTOCIN

VASOPRESSIN

 

ADRENAL GLANDS

ADRENAL CORTEX

Steroid

• mineralocorticoids (aldosterone)

• glucocorticoids ( cortisol and corticosterone)

• androgens

ADRENAL MEDULLA

Catecholamines

• epinephrine

• norepinephrine

 

CLASSIFICATION OF HORMONES

 PEPTIDE/PROTEIN

 (<50 aa) and polypeptide (protein) > 50 aa- insulin, ADH, FSH, ACTH, prolactin,

ghrelin, glucagon, GH, FSH, renin, TSH, glucagon-like peptide (GLP-1), oxytocin,

calcitonin, parathormone, thymulin, anti-Mullerian hormone, T3,Gastric inhibitory peptide,

somatostatin, Insulin-like growth factor, brain natriuretic peptide, endothelin,

thrombopoietin, adiponectin, lepsin, galanin, cortistatin, vasoactive intestinal peptide

 STEROID made from cholesterol- estrogen, progesterone, testosterone,

androstenedione, dehydroepiandrosterone (DHEA)

 TYROSINE (AMINE)- thyroxine, dopamine and catecholamines (epinephrine and

norepinephrine)

 EICOSANOID- thromboxanes, leukotriens, prostaglandins, prostacyclin

 

PEPTIDE/POLYPEPTIDE PROTEIN/HORMONES

Made up of amino acids +/- other molecules (eg. CHO )

Large or small hydrophilic molecules

Synthetized in the rough ER transferred to Golgi, repackaged into vesicles to be excreted

Stored until the signals are received for secretion

Freely transported through blood stream

Receptors inside nucleus

Bind to DNA to modify transcription

Rapid/temporary action

 

STEROID HORMONES

Secretions of ductless glands

Made from cholesterol

Small hydrophobic molecules

Synthesized in the smooth ER

Synthesized as needed

Attach to protein carrier for transport in blood stream (eg. SHBG- testosterone)

Receptors on cell surface- their signaling affects change in the cell

Serve as second messengers

Slow/permanent action

Eg. Estrogen, Testosterone, Cortisol, Aldosterone, Progesterone

 

TYROSINE DERIVATIVE HORMONES

 Derived from L- tyrosine

 One amino acid is manipulated to make hormones

 Act either way steroid or protein

 Thyroid T4- steroid like

 Catecholamines- Epinephrine and Nor-epinephrine- protein and polypeptide

 

PEPTIDE INFLUENCE ON HORMONE FUNCTION

Protection of cellular efficiency (improves metabolism, reduce oxidative stress)

Monitor and influence timing of cellular senescence (longevity)

Modulate inflammatory response (decrease oxidative stress)

Repair & Restore (cellular repair)

Adjuncts to hormone therapy and improve hormone balance and metabolic function at

cellular and nuclear levels

Every cell in our body has hormone receptors and peptides message these receptors

Glycolysis

 In the cytoplasm

 Does not require oxygen

 “Investment phase” uses 2 ATP

 C6H12O6

 C-C-C-C-C-C (glucose) +2 ATP ->2 P-C-C-C + 2 ADP

 “Payoff phase” uses 2 NAD+ and Mg++ -> 2 pyruvate +4

ATP and 2 NADH for electron transport chain

 Net gain 2 ATP

 

Acetyl CoA

 Can come from glycolysis producing 2 pyruvate

 Each pyruvate (3C) to Acetyl CoA(2C) reduces NAD+ to

NADH and yields Co2

 Can come from protein or fat

 Net 2 NADH for electron transport chain

 Ketones bypass need for this

 

Kreb/Citric Acid/TCA cycle

 Occurs in matrix of mitochondria

 Acetyl CoA(2C) merges with oxaloacetic acid(4C) to form citric

acid (6C)

 Reduces 3 NAD+, FAD+, one ADP (heart) or GDP (liver)

 Each pyruvate produces two CO2, 3 NADH, and 1 FADH2, ATP

for the electron transport chain

 Process occurs twice because one glucose(6C) produces two

pyruvate (3C)

 Inhibited by ATP and NADH

 

Oxidative phosphorylation

 In the mitochondrial matrix, too

 NADH oxidized to NAD+, losing electrons “reduced”

 Intermediary acceptors are CoQ and cytochromes I-IV in

phospholipid bilayer of inner mitochondrial membrane

 Release of energy pumps hydrogen ions into intermembrane

space, creating a gradient

 This gradient is used in transmembrane protein ATP Synthase

to create ATP

 Eventual acceptor of these electrons is oxygen (O2), which

splits to form water (H2O)

 

Energy Yield

 30-38 ATP

 In a real cell, some ATP is used to transport ADP into the Matrix

 Some ATP is used to transport ATP out of the mitochondrion

 Some ATP is used to transport other molecules

 2 net ATP in glycolysis

 2 net ATP in citric acid cycle

 All depends on the metabolic state of the cell

 

Glycogen

 Polysaccharide of glucose

 An energy reserve that can be quickly mobilized

 Stored in cells without disrupting osmotic pressure (vs glucose)

 Stored in liver and muscle, small amount in glial cells of brain

 Fasting causes release of glycogen for use in Glycolysis

 Glycogen in muscle is solely available for muscle use b/c muscle lacks G6P to move

glucose out of the cell

 Glycogen breakdown impedes muscle uptake of glucose from blood, increasing

blood glucose for other tissues like brain

 

Fermentation/Glycolysis

 Glycolysis in the absence of oxygen as an electron acceptor

 In yeast, makes alcohol

 In muscle tissue, makes lactic acid

 In RBC’s without mitochondria, only lactic acid fermentation occurs

 Pyruvate takes 2 NADH from glycolysis and produces 2 lactate plus 2 NAD+

 Lactic acid from muscle cells transported via blood to liver where it’s converted

back to pyruvate for normal cellular respiration

 

Beta oxidation

 Also occurs in mitochondrial matrix

 Triacylglycerol (TAG) in adipocytes and striated muscle

 Stimulated by epinephrine, ACTH

 CD36 transport protein

 Adipose tissue hormone sensitive lipase (HSL).

 Fatty acid tails broken into 2 carbon units that combine with CoA

forming acetyl CoA for the Kreb cycle

 Beta oxidation releases FADH2 and NADH for ETC inside IMM

 Intracellular fatty acid intermediates can be toxic

 All depends on the metabolic state of the cell

 

Osteoarthritis

◦ Chondrocytes in OA joints develop terminal differentiation and hypertrophy

(like adipocytes) near sites of trauma

◦ Secrete type X collagen (matrix mineralization),

◦ Secrete transglutaminases (creating modified immunogenic peptides),

and

◦ Release vesicles containing calcium phosphate crystals

◦ 120 70-ish, mostly male patients with end stage OA undergoing TKA

◦ 100% showed articular cartilage mineralization primarily BCP

◦ Degree of mineralization correlated with histologic cartilage destruction

◦ Basic calcium phosphate (BCP) crystals

◦ activate synovial macrophages to drive inflammation

◦ Leads to an imbalance in anabolic/catabolic mediators

◦ Upregulation of metalomatrix proteinases, NFKb, TNFa, IL6, IL1b,

inflammasome

◦ Fuerst, M. Calcification of articular cartilage in human osteoarthritis. Arthritis & Rheumatology. 2009;60(9):2694-703.

◦ Aeschlimann, D. P2X7 receptor-mediated TG2 externalization: a link to inflammatory arthritis? Amino Acids. 2017;49:453-60.

◦ Cunningham, C. Osteoarthritis-associated basic calcium phosphate crystals induce proinflammatory cytokines and damage-associated molecules via activation of Syk and PI3 kinase. Clinical Immunology.

2012;144(3):228-36.

◦ Millerand, M. Danger signals nd inflammaging in osteoarthritis. Clin and Exp Rheumatol. 2019;37(s120):s48-s56.

Macrophage

 Innate immune cell

 Activates in response to injury/illness

 Pathogens- fungal, bacterial, protozoal, viral

 Toxins- environmental, food, protein byproducts of disease

 Chronic stress, sleep disruption

 Trauma

 Autoimmune conditions

 Abundance of misfolded proteins

 Generates ROS for coping with these

 

Macrophage activation with canonical microbial compounds

such as lipopolysaccharide (LPS), a specific Toll-like receptor 4

(TLR4) ligand, leading to classically activated (M1)

proinflammatory macrophage generation. This activation

induces an increased glycolysis and a disrupted Krebs cycle, in

order to supply cell metabolic adaptations and cytokine

production. On the other hand, macrophage stimulation with

interleukin 4 (IL-4) generates alternatively activated (M2) antiinflammatory

macrophages. In this case, cells rely on fatty acid

oxidation (FAO) and oxidative phosphorylation to support the

metabolic program initiated by IL-4.

 

The Cell has a Choice

 The Efficient cell has Metabolic Flexibility:

 lots of NAD+ and ATP

 not too many ROS, plenty of antioxidants

 Excess glucose/lipid, dysbiosis are stressors

 The intelligent cell has a choice: autophagy, apoptosis, senescence

 The cell takes on a hyperglycemic phenotype:

 Upregulates citrate, glycolysis, cholesterol synthesis

 Downregulates fatty acid oxidation, BCAA metabolism, ox phos in general

 Creates an increased state of ROS- another stressor

 Burns through ATP and NAD+

 Increases NADPH to deal with increased ROS

 

Hyperglycemic phenotype

 Slows down, upregulates mTOR, upregulates fatty acid synthetase

 ER stress with misfolded proteins

 Nucleus turns on p53 to stop the cell cycle and handle the stress

 Can pull in the immune system for autophagy/mitophagy, apoptosis or

senescence

 BUT the T cells are also affected by hyperglycemia

 Inefficient

 Competing for increasingly limited NAD+ and ATP

 Spewing inflammatory cytokines

 

ER Stress and the UPR

 In resting “conditions’’, ER receptors are kept inactive by binding to the ER molecular chaperone GRP78

 In ER stress, normal protein processing is hindered, which results in an accumulation of unfolded or misfolded

proteins in the ER lumen.

 This accumulation triggers a cascade of signal transduction called unfolded protein response (UPR). UPR is

controlled by three transmembrane sensors : PKR-like ER kinase (PERK), inositol-requiring enzyme 1α (IRE1α),

and activating transcription factor 6 (ATF6).

 When the ER homeostasis is disrupted, GRP78 detaches from these three receptors, initiating further downstream

signaling cascades leading to decreasing protein synthesis in attempt to reduce the burden of misfolded proteins,

enhancing synthesis of molecular chaperones, and activating a proteasomal degradation process called the ERassociated

degradation (ERAD) pathway.

 The UPR is primarily adaptive, however, when the stress is severe, UPR may activate apoptosis.

 In humans, defective protein folding is believed to be one of the key molecular hallmarks of disorders such as

diabetes, obesity, neurodegeneration, or cancer.

 

The Inflammasome

 In peripheral monocytes, smooth muscle cells, endothelial cells

 Stimulation of TLR4 by PAMPS and DAMPS from ischemia, radiation, infection

 NFKB transloction to the nucleus

 Posttranslational modification of NLRP3: ubiquination, nitrosylation and

phosphorylation

 Plus K+ efflux, lysosomal dysfunction leads to Pyroptosis and propagation of

inflammation

 Higher levels of NLRP3, IL-1B, Il-18 in patients with AMI/UA

 

Continued decline in cellular efficiency

 Brain and intestinal cells unable to make

neurotransmitters because all need NAD+

 limits hypoglycemic effect of serotonin on

the pancreas

 Histone acetylation by oxidative stress,

regulating gene transcription

 mRNA expression of all SIRT genes reduced

 apoptosis no longer an option

 Senesence takes over

 Senesent cells affect tissue-specific stem cells (repair)

 

Senescence

 Permanent cell cycle arrest

 Large cell size

 Excessive lysosomal activity producing beta

galactosidase

 Senescence associated secretory phenotype

(SASP) of inflammatory cytokines Il6, IL1B, TNFa

 Paracrine effects on tissue-specific (PBC,

cardiac endothelial…) stem cells

 

Tissue non-specific alkaline phosphatase (TNAP) causes degradation of extracellular ATP and ADP to AMP and adenine causes cessation of inflammatory signaling, and induction through adenine receptors of an anti-inflammation response. TNAP has been implicated in protection against inflammation in multiple diseases and promotion of intestinal microbial populations through hydrolysis of extracellular ATP/ADP to AMP and adenosine.

◦ Intestinal AP has been shown to dephosphorylate (detoxify) the lipid A moiety of lipopolysaccharide (LPS), the outer lipid layer of the outer membrane of Gram-negative bacteria. In vertebrates, these phosphates are important for binding of LPS to the toll-like

receptor 4/MD-2 innate immune receptor complex, initiation of NF-kB signaling, and immune

response induction.

◦ Intestinal AP deficiency has been associated with inflammation in the human intestine.

Supplementation of IAP to animals where intestinal inflammation is induced directly or

indirectly (with antibiotic use for example) reduces inflammation. Use of AP as

treatment showed short-term improvement of severity of UC in patients with moderate-tosevere

UC.

◦ Rader, B. Alkaline Phosphatase, an Unconventional Immune Protein. Frontiers in Immunology. 2017;8:897.

 

◦ Inflammatory bowel disease (IBD), comprising Crohn's disease (CD) and ulcerative

colitis (UC), is characterized by chronic and relapsing inflammation in the

gastrointestinal tract, and some hypotheses propose that damage to the intestinal

mucosa occurs as a result of dysregulated innate immune response.

◦ The innate immune system is the first line defense, which can sense microbes or

endogenous danger signals via recognition of damage-associated molecular

patterns (DAMPs) or pathogen-associated molecular patterns (PAMPs) by host

pattern recognition receptors (PRRs), such as Toll-like receptors (TLRs) and NLRs.

 

◦ Under normal conditions, a basal level of reactive oxygen

species (ROS) has bactericidal effects, participating in the

intestinal defensive function. However, in the process of chronic

inflammation (such as IBD or PUD), excessive ROS produced by

the infiltrated neutrophil can trigger oxidative stress (OS) and

proteolytic enzymes, which act on endothelial cells and cause

cell injury and subsequent intestinal mucosal barrier damage

and luminal pathogen invasion, and further in turn exaggerate

inflammatory cell infiltration and inflammatory damage,

eventually leading to intestinal mucosal necrosis and ulceration.

◦ ROS could also act as secondary chemical messengers for the

activation of intracellular signal pathways to influence cell

proliferation, differentiation and apoptosis

◦ Omega-3 fatty acids can repress this inflammation

 

◦ In healthy adults, the distal part of the gastrointestinal tract is characterized

by a low level of oxygen tension as oxygen is used in epithelial cells for

oxidative phosphorylation in the mitochondria. The colon usually harbors large

communities of obligate anaerobes.

◦ In patients with Inflammatory Bowel Disease (IBD), fewer species of the

obligate anaerobes, phylum Firmicutes were present in IBD patients.

◦ The changing oxygen conditions may be due to the inflammatory reaction

itself, causing an oxidative burst in the intestinal tissue, for example, by the

release of reactive oxygen species by neutrophils.

◦

◦ Rigottier-Gois L. Dysbiosis in inflammatory bowel diseases: the oxygen hypothesis. ISME J. 2013;7(7):1256–1261

◦ Recent work suggests that anaerobiosis in the colon is maintained by

colonic epithelial cells (colonocytes), which consume oxygen through

oxidative phosphorylation in their mitochondria, thereby maintaining the

epithelial surface in a state of physiological hypoxia.

◦ By increasing epithelial oxygenation, colitis drives an aerobic expansion of

colibactin-producing E. coli, and Proteobacteria in the colon, also observed for other conditions that are associated with an increased risk for colorectal cancer formation, including a high-fat diet, antibiotic treatment, and alcohol dependence.

 

◦ Bacteria-derived butyrate affects colon epithelial O2 consumption

and results in stabilization of hypoxia-inducible factor (HIF), a

transcription factor coordinating barrier protection that requires SIRTNAD+

for activation.

◦ 3 days of Abx administered by oral gavage resulted in a nearly

complete loss of bacterial groups. Despite outgrowth of several

resistant organisms, cecal contents from abx-treated mice lost the

ability to produce SCFAs from inulin and lost HIF expression, both of

which are restored by butyrate administration.

◦ Metabolism of butyrate by epithelial cell lines depletes local

O2 (being used in oxidative phosphorylation in epithelial cell

mitochondria) to the extent that HIF is stabilized.

◦ Interestingly, mice with mitochondrial polymorphisms that maintain

increased oxidative phosphorylation activity are resistant to colitis.

◦ The primary energy source for cancerous colonocytes is glucose

(Warburg effect)

◦ Activated AMPK is an endogenous inhibitor of the Warburg effect

◦ Butyrate is a potent activator of AMPK in colonic cell lines

 

The Microbiome and the Circadian Rhythm

◦ Intestinal microbiota generates diurnal rhythms in innate immunity that synchronize with feeding rhythms to anticipate microbial exposure.

◦ Rhythmic expression of antimicrobial proteins was driven by daily rhythms in epithelial attachment by segmented filamentous bacteria (SFB), members of the mouse intestinal microbiota.

◦ Mechanistically, rhythmic SFB attachment activated an immunological circuit involving group 3 innate lymphoid cells. This circuit triggered oscillations in epithelial STAT3 expression and activation that produced rhythmic antimicrobial protein expression and caused resistance to Salmonella Typhimurium infection to vary across the day-night cycle.

◦ Host feeding rhythms synchronize with the microbiota to promote rhythms in intestinal innate immunity that anticipate exogenous microbial exposure.

 

Bile acids

 Bile acids are detergents derived from cholesterol that aid in digestion and nutrient absorption

 Hormone-like signaling agents between gut-liver-brain involved in glucose, lipid, and energy metabolism/homeostasis

 Bactericidal modulation of the microbiome

 Regulate mucosal homeostasis and inflammation

 Promote hematopoietic stem cell expansion in the fetal liver

 Gut microbes influence the composition of the circulating bile acid pool to prevent bactericidal activity and digestion of self

 Conjugated to taurine/glycine to retain structure critical for lipid emulsifying activities in the acidic duodenum

 

Secondary BAs, inflammation and cancer

 Derivatives of primary bile acids generated by microbial metabolism in the intestine. (Chen, 2019)

 DCA and LCA promote cell cycle arrest and apoptosis primarily through the generation of intracellular reactive oxygen species (ROS), genomic DNA breakage, activation of inflammasome.

 DCA suppresses p53 in response to DNA damage (senescence), activates resistance to apoptosis, angiogenesis (prostaglandin E2 through vascular endothelial growth factor), activates proliferation

and oxidative stress.

 In response to repeated DNA damage due to the exposure of secondary BAs, the large number of cell generations in the colonic (and other gastrointestinal) epithelia may allow time for induction and

selection of mutations leading to cancer in humans

 

Bile acids and the brain

 Activate bile acid receptors in the blood brain barrier (BBB) and brain to regulate neuroinflammation and neurodegeneration (Ferrell, 2021, Chen, 2019)

 Increased secondary BAs (DCA, LCA) in serum of Alzheimer’s Disease (AD) patients, worsening from MCI to AD and worsening ratio of DCA:CA indicating bacterial dihydroxylation

 Multiple bile acid receptors (CAR, PXR, FXR, S1pr2, TGR5) present on neurons, microglia, astrocytes

 Suggests protective effects via TGR5 and potentially detrimental effects via FXR and S1pr2

 

Tryptophan metabolism

 Most ingested protein is digested and

absorbed in the small intestine

 Significant amounts of proteins and

amino acids (6–18 g/day) may reach

the colon

 Endogenous tryptophan conversion to

metabolites: kynurenine, kynurenic

acid, xanthurenic acid, and

cinnabarinic acid, NAD+

 

Kynurenine pathway

 Goal of making NAD+ for energy for astrocytes and microglia

 Indoleamine 2,3-dioxygenase (IDO) enzyme triggered by pathogens and cytokines like TNFa

 Quinolinic acid (QA), an intermediary in the kynurenine pathway, is activating and toxic to the

CNS.

 stimulates astrocytosis

 is excitotoxic to neurons via the NMDAR

 can induce apoptosis in astrocytes, neurons, and oligodendrocytes.

 Kynurenine also has vasoactive effects

 exacerbate CNS infection and inflammation

 through pericytes kynurenine production disrupts the integrity of the BBB

 

Tryptophan metabolism

 Also in the colon, bacterial protein catabolism increases with increased protein intake,

carbohydrate depletion in the colon, increased colonic pH and prolonged colonic transit

time

 In 1897, tryptophan was found to be converted into indole by Bacillus coli (now Escherichia

coli)

 Tryptophan is one of the nine essential amino acids, which the human organism cannot

synthesize, and which therefore must be supplied in the diet.

 Indole is well-described as an intercellular signal molecule that appears to be important in

microbial communities by affecting spore formation, drug resistance, biofilm formation, and

virulence

 Indole strengthens the gut mucosal barrier and mucin generation; increases IL-10 expression

and reduces inflammatory indicators

 

 Tryptamine, a tryptophan catabolite produced by C. sporogenes and Ruminococcus gnavus induces the release of the neurotransmitter serotonin by enterochromaffin cells. Serotonin

stimulates gastrointestinal motility by acting on enteric nervous system neurons

 3-indoxyl sulfate (IS) is a tryptophan metabolite, uremic toxin which correlates with the development of CKD and cardiovascular disease; urinary IS level is a common marker of intestinal dysbiosis

 

Fiber

 Plant-derived nonstarch polysaccharides, resistant oligosaccharides, lignin, and resistant starch

 Water solubility within the gastrointestinal tract is related to the degree of fermentation by gut microbes. Soluble dietary fibers can increase digesta viscosity, which in turn delays gastric

emptying and nutrient release, thus reducing glycemic response.

 Fermented in the colon by the microbiome to SCFAs

 Production of SCFAs differs by microbial composition of the gut microbiome

 Improvements in inflammatory conditions such as cardiovascular disease, type 2 diabetes, metabolic syndrome, and depression have been linked to high intakes of dietary fiber.

 High dietary fiber intake has been associated with lower levels of CRP, leptin, and higher adiponectin

 

Dietary fiber and allergy

 Dietary fiber intake significantly suppressed the allergic responses, attenuated allergic symptoms of nasal rubbing and sneezing

 Decreased the pathology of eosinophil infiltration and goblet cell metaplasia in the nasal mucosa and lung, inhibited serum OVA-specific IgE levels, and lowered the levels of Th2 cytokines in NALF and BALF, but increased Th1 (IFN-γ) cytokines.

 Also increased the proportion of Bacteroidetes and Actinobacteria, and decreased Firmicutes and Proteobacteria. Levels of probiotic bacteria, such as Lactobacillus and Bifidobacterium, were upgraded significantly.

 

Fasting; its all about the ketones

 Energy restriction for 10 to 14 hours or more results in depletion of liver, brain glycogen stores

and hydrolysis of triglycerides (TGs) to free fatty acids (FFAs) in adipocytes. FFAs released into

the circulation are transported into hepatocytes, where they produce the ketone bodies

acetoacetate and β-hydroxybutyrate (β-HB).

 The metabolic switch from the use of glucose as a fuel source to the use of fatty acids and

ketone bodies results in a reduced respiratory-exchange ratio (the ratio of carbon dioxide

produced to oxygen consumed), indicating the greater metabolic flexibility and efficiency of

energy production

 Cells respond to intermittent fasting by engaging in a coordinated adaptive stress response

that leads to increased expression of antioxidant defenses, DNA repair, protein quality control,

mitochondrial biogenesis and autophagy, and down-regulation of inflammation

 

Fasting/ketogenesis

 Ketone bodies are potent signaling molecules that regulate the expression and activity of

many proteins and molecules known to influence health and aging.

 Ketone bodies stimulate expression of the gene for brain-derived neurotrophic factor (BDNF),

with implications for brain health and psychiatric and neurodegenerative disorders.

 Reduced levels of glucose and amino acids during fasting result in reduced activity of the

mTOR pathway and up-regulation of autophagy.

Inflammation as a Cause of IR

• Excessive production of inflammatory compounds

in the body can cause IR

• Inflammatory substances damage and/or

inactivate insulin receptors.

• Contributes to breakdown of one or more factors

needed to complete the process of glucose

transport

 

• IR leads to ↑ inflammatory markers

• Including ferritin, uric acid, white cell counts, fibrinogen, CRP and

IL-6

• insulin resistance in adipocytes results in production of the

chemokine monocyte chemoattractant protein 1 (MCP1)

• This recruits monocytes and activates proinflammatory

macrophage

• Insulin resistance is correlated with reduced insulin/mTORC2

signaling and elevated MCP1 production in visceral adipose tissue

 

T2D Inflammation

• T2D is an inflammatory disease

• T2DM promotes increased levels of pro-inflammatory cytokines including

TNFα and IL-6

• Involved in the development of insulin resistance in skeletal muscle

• Studies report inflammatory pathways in muscle - in particular, NF-κB -

contributes to T2DM-mediated muscle atrophy

• 2016 cohort of obese patients with T2DM compared to age-matched

controls

• Demonstrated patients with T2DM have 60% higher skeletal muscle

expression of the atrophy transcription factor FoxO1

 

Adiponectin and Mitochondria

• Adiponectin is an anti-diabetic adipokine

• Mitochondrial function linked to adiponectin synthesis

in adipocytes

• Mitochondrial dysfunction increased with excess

adipose tissue

• Decreases plasma adiponectin levels

 

• Adiponectin induces Ca++ influx via receptor

• AdipoR1 = adiponectin receptor

• Suppression of AdipoR1 results in decreased PGC-1α

• Leads to decreased mitochondrial content

• Decreased blood glucose control

 

GLUT 4 Glucose Transporter

• Glucose transporter type 4 - Hexose transporter system

• Uses ATP-independent, facilitative diffusion mechanism

• Mediates insulin-stimulated glucose transport in fat and muscle

• Predominantly expressed in skeletal muscle and adipocytes

• Failure of GLUT4 to translocate to the plasma membrane in response to insulin

• An early step in the development of insulin resistance and type 2 diabetes

 

Glut 1 Dominated Transport

• Leads to Increase RNA, DNA, NAD + FAD

• Increases the Pentose Pathway

• Regenerates its own glutathione (NADPH)

• GLUCOSE THROUGHPUT

• LACTATE PRODUCTION

• Intracellular pH reduced H+ ions pumped into intracellular space

creating necrotic space

ECM: Governs Cellular Functions

● Cocktail of proteins, signalling

molecules, and chemicals that

cells exude as they grow

● Cells use matrix to impart

strength & shape to tissues like

bone & brain

● ECM used to be dismissed as

an inert garden trellis, now

proven that ECM is critical for

cell behavior

● Muscle stem cells self renew only

on soft gels (not hard plastic

plates)

 

● ECM guides stem cells to

repair damaged tissues, reform

blood vessels damaged

by stroke & alter cellular

responses to chemotherapy

● ECM serves as a reservoir of

signaling molecules that

serves as a highway between

cells

● (25 yrs ago, ECM was just

thought to be structural)

● Regen med is trying to

improve engineered ECMs but

can be tricky

● Each synthetic or naturally

derived biomaterial has pros

and cons

 

Aromatase Inhibitors Musculoskeletal Syndrome (AIMSS)

● AIMSS is characterized by joint stiffness, decreased grip strength,

arthralgia, and myalgia likely caused by tenosynovial changes and intraarticular

fluid retention (25).

● Postmenopausal women taking AIs experience vaginal dryness and

sexual dysfunction compared to postmenopausal women without

breast cancer (26).

● Post-menopausal women have fewer relaxin and estrogen receptors on

fascial fibroblasts implying that postmenopausal women have fascia

that will not respond to usual hormonal cues (4).

● These hormonal cues prompt elastin synthesis; without elastin, these

women experience body stiffness.

Pharmacy types

 

503-A

Traditional compounding pharmacy

• USP <795> and <797> guidelines

• Patient specific prescriptions

– No office use

• Smaller batches

– Limited to anticipatory compounding (30

days)

• Largely regulated by state boards of

pharmacy

– FDA Influence

• May be compounded from FDA approved

finished product or bulk drug substance if

certain provisions are followed

comply with an applicable United States

Pharmacopeia (USP) or National Formulary

(NF) monograph if one exists, and the USP

chapter on pharmacy compounding;

• are components of FDA-approved drug

products if an applicable USP or NF

monograph does not exist; or

• appear on FDA’s list of bulk drug

substances that can be used in

compounding (the 503A bulks list) if such a

monograph does not exist and the

substance is not a component of an FDAapproved

drug product.

 

Category 1 – These substances may be eligible for inclusion on the list of bulk

drug substances that can be used in compounding under section 503A, were

nominated with sufficient information for FDA to evaluate them, and do not

appear on any other list. FDA does not intend to take action against a

compounder for compounding drugs using bulk drug substances listed in

Category 1, provided that the conditions described in the guidance document

are met.

• Category 2 – These are bulk drug substances that were nominated with

sufficient supporting information for FDA to evaluate them and they may be

eligible for inclusion on the 503A bulks list. However, FDA has identified

significant safety risks relating to the use of these substances in compounding,

and therefore, pending further evaluation, drug products compounded using

these substances are not eligible for the policy described for the substances in

Category 1. FDA would consider taking action against a compounder for

compounding drug products with this bulk drug substance under its general

enforcement policies. See Safety Risks Associated with Certain Bulk Drug

Substances Nominated for Use in Compounding for the substances and a

summary of the identified safety risks.

• Category 3 – These substances may be eligible for inclusion on the 503A bulks

list, but were nominated without sufficient supporting information for FDA to

evaluate them. These substances are not eligible for the policy that applies to

substances in Category 1. FDA would consider taking action against a

compounder for compounding drug products with this bulk drug substance

under its general enforcement policies. These substances can be re-nominated

with sufficient supporting information through Bulk Drug Substances That Can

Be Used To Compound Drug Products in Accordance With Section 503A of the

Federal Food, Drug, and Cosmetic Act; Establishment of a Public Docket.

 

503-B

Current good manufacturing practices (CGMP)

• 21 CFR Part 210 and 211

• Regulated by FDA

– States are beginning to enact their own

503B laws

• May compound for office use

• May compound in larger batches

• All processes, equipment, and facilities

must be validated

• Stability indicating studies required for

products

• May be compounded from FDA approved

finished product or bulk drug substance if

certain provisions are followed

 

the bulk drug substance appears on a

list identifying bulk drug substances

for which there is a clinical need

(the 503B bulks list), or

• the drug product compounded from

such bulk drug substance appears

on FDA’s drug shortage list at the

time of compounding, distribution

and dispensing.

 

Category 1 – These substances may be eligible for inclusion on the 503B bulks

list, were nominated with sufficient information for FDA to evaluate them, and

do not appear on any other list. FDA does not intend to take action against an

outsourcing facility for compounding drugs using bulk drug substances

identified in Category 1 provided that the conditions described in the guidance

document are met.

• Category 2 – These are bulk drug substances that were nominated with

sufficient supporting information for FDA to evaluate them, but FDA has

identified significant safety risks relating to the use of these substances in

compounding pending further evaluation. Drug products compounded using

these substances are not eligible for the policy described for the substances in

Category 1. FDA would consider taking action against an outsourcing facility

for compounding drug products with this bulk drug substance under its

general enforcement policies. See Safety Risks Associated with Certain Bulk

Drug Substances Nominated for Use in Compounding for the substances and a

summary of the identified safety risks.

• Category 3 – These substances may be eligible for inclusion on the 503B bulks

list, but were nominated with insufficient supporting information for FDA to

evaluate them. The substances are not eligible for the policy that applies to

substances in Category 1. FDA would consider taking action against an

outsourcing facility for compounding drug products with this bulk drug

substance under its general enforcement policies. These bulk drug substances

can be re-nominated with sufficient supporting information through Bulk Drug

Substances That Can Be Used To Compound Drug Products in Accordance With

Section 503B of the Federal Food, Drug, and Cosmetic Act; Establishment of a

Public Docket.

 

Peptides

 

ACE‐031

• Fusion peptide of activin receptor type IIB and IgG1‐Fc

• Binds myostatin and related ligands

• Myostatin inhibitor

• Used in humans for Duchenne Muscular dystrophy

– Reported to disrupt the inhibitory effect on muscle

development

– No adverse events in 2017 randomized, double‐blind placebocontrolled

ascending dose trial

 

• Also noticed in these study patients:

– Improved maintenance of the 6‐minute walk test (6MWT)

distance

– Trend for increased lean body mass and bone mineral density

(BMD)

– Reduced fat mass

– Dosage = 0.5 – 2.0 mg/kg Q2 weeks x 3 months

 

• Safety in human studies:

– Most common issue = injection site erythema (20.8%)

– Telangiectasia (20.8%)

– Epistaxis (16.7%)

– Erythema (12.5%)

– Headache (12.5%)

• No subjects discontinued treatment

 

Aged Garlic Extract

• Special garlic extract – higher levels of S-allyl cysteine vs.

regular garlic

• Proprietary Aging Process 20 months

• Removes volatile compounds and produces NEW watersoluble

compounds

• Not BLACK GARLIC

• Over 900 clinical studies supporting uses – human and lab

• Decreases LDL(and OxLDL) cholesterol while improving HDL

• Decreases metaflammation(IL6, TNF alpha)

• Effects against atherosclerosis development

• Inhibits coronary artery calcification (incl vulnerable plaque)

• Lowers homocysteine – improves methylation

• Microbiome supportive

• Neuroprotective

 

Aged Garlic Extract and IL-6, TNF-alpha

• Supports cardiovascular health, blood pressure, nitric oxide

• Reduces low attenuation plaque in coronary arteries

• Supports immunity - enhances immune cell function –

• NK cells, decreases Il-6 and TNF-alpha

• Antiviral activity

• Excellent antioxidant

• Improves blood pressure – approx. 16%

 

Aged Garlic Extract Immunity

• AGE reported to modulate inflammation and immunity - especially

those with obesity

• Clinical study n=51 adults with obesity, age 45.6 + 1.6yr

• Randomized, parallel, double-blind, placebo-controlled study for 6

weeks

• AGE 3.6gm daily or placebo

• Il-6 and TNF-alpha significantly lower in AGE

• LDL lower also in AGE individuals

 

New Research - AGE and Reducing Chronic

Inflammation

• 2019 double-blind, placebo controlled randomized clinical study

• n= 51 healthy but obese adults

• 3.6gm AGE daily in divided doses x 6wk

• IL-6 and TNF-alpha significantly lower in AGE vs. placebo

• Increased gamma-delta T cells – modulated immunity

• Significant reduction in LDL cholesterol

 

AGE Reduces Plaque in Coronary Arteries

• Single-center, randomized, placebo-controlled, double-blind trial at Harbor UCLA Medical

Center

• Published in Feb. 2020 Experimental and Therapeutic Medicine

• n= 66 final patients with diabetes mellitus

• 30-75 years, HbA1c>6.5%, Fasting blood glucose>125mg/dl)

• 2,400mg AGE or placebo x 12 months

• RESULTS:

• AGE suppresses adverse cardiovascular events by reducing low-attenuation plaque,

decreasing left ventricular mass and improving endothelial function

 

New Research - Aged Garlic Extract Improves

Microcirculation

• 2019 double-blind, placebo-controlled study

• N= 93 patients aged 40-75 w/ Framingham Risk Score > 10, CAC score > 10

completed test

• 2,400mg AGE daily for 12 months

• RESULTS:

• ★ AGE suppresses adverse cardiovascular events by reducing CAC progression in

not only non-Europeans but also European population

• ★ AGE facilitates wound healing by increasing the level of microvascular blood

flow

 

General dosage - 1-2 caps 2 times daily (600-1,200mg)

• New caplet = 2,400mg AGE daily ( a cap TID)

• Adds Grape seed extract 95% 300mg/ day for added vascular and BP support

• Immune and inflammation support; MetS support = 3.6 gm daily in divided

doses

• Does NOT interact with anticoagulants unlike other garlic preparations

 

Alpha GPC

• L-Alpha glycerylphosphorylcholine

• Natural choline compound

• Crosses BBB readily

• Improves mitochondrial function

• Supports growth hormone levels

• 300-600mg BID

 

ALA

• Affects beta cell function

• ↑cAMP-activated protein kinase (AMPK)

• ↑ PGC-1 alpha, ↑ PPAR alpha

• Improves glucose utilization and mitochondrial biogenesis

• Studies report exercise and ALA therapy improves IRS-1 dependent insulin

signaling

• DOSE = 600mg BID

• Nephroprotective

• Detoxifies heavy metals

 

ALRN‐5281 Peptide

• GHRH agonist – long‐acting growth hormone releasing

hormone

• Clinical studies on this peptide by Alieron

Therapeutics

• Used for treating:

– Orphan endocrine disorders

– Adult growth hormone deficiency

– HIV lipodystrophy

– Broader patient populations – metabolic/endocrine disorders

– Performance enhancement

 

• Initial Phase 1 trial evaluated the safety and tolerability of

single ascending doses of SubQ ALRN‐5281 in 32 healthy

adult subjects

• No serious adverse events, dose‐limiting safety findings, or

tolerability issues leading to withdrawal during the study

• Dosing

– 0.05 – 0.15 mg/kg subQ once weekly

 

ARA-290

• Non-erythropoietic/hematopoietic 11 amino acid peptide

• Also called helix B surface peptide (HBSP)

• Designed from structure of erythropoietin - preserves health effects

of EPO w/out creating RBCs

• Improves metabolic control

• Anti-inflammatory, anti-apoptic, anti-permeability effects

• Improves neuropathic symptoms in T2D patients

• Inhibits vascular leakage

• Protects against neuroglial degeneration

 

• Analgesic effect of ARA-290 is mediated by its anti-inflammatory and

immunomodulatory functions

• Inhibits TNF-alpha, NF-kB

• Targets the innate repair receptor (IRR) to down-regulate

inflammation to alleviate neuropathic pain

• Lab studies report ARA 290 inhibits TRPV1 channel activity

• Relieved the mechanical hypersensitivity induced by capsaicin

• Leads to decreased neuropathic pain

 

• Cibinetide is trade name – Araim Pharmaceuticals

• Granted US and EU Orphan Drug Designation for the treatment of

sarcoidosis

• US Orphan Drug Designation for treatment to increase survival and

improve functioning of pancreatic islets following transplantation.

• Improves Engraftment in Pancreatic Islet Transplantation by:

• Protecting Islets

• Reducing Inflammatory Reactions

 

Suggested Dosage :

• 6mg/ml 4ml vial

• 4mg (0.67ml) SubQ three times per WEEK x 4-5 weeks

 

AT-1001

larazotide

 Larazotide is a novel, locally acting, non-systemic, synthetic 8-

amino acid oral peptide, discovered during functional

screening of synthetic Vibrio cholera related peptides.

 Larazotide acetate is a first-in-class tight junction (TJ) regulator

 Larazotide prevents opening of intestinal TJs by promoting TJ

assembly and actin filament rearrangement, which prevents

gluten/gliaden and pathogens from reaching the intestinal

submucosa and triggering an inflammatory response,

macrophage recruitment and increases in intestinal

permeability (Hoilat 2021)

 

 type 1 diabetes, other autoimmune diseases, inflammatory

bowel disease, Kawasaki disease, respiratory (infective and/or

non-infective) diseases.

 Jacopo, T. “The Therapeutic Use of the Zonulin Inhibitor AT-1001 (Larazotide) for a

Variety of Acute and Chronic Inflammatory Diseases.” Current Medicinal Chemistry 28

(December 31, 1969): 1–20.

 Larazotide prevented gluten-induced symptoms and

blunted increases in anti-tTG antibodies, INF-gamma, and

intestinal permeability

 Safety profile comparable to placebo

 

BAM-15

• On horizon

• Mitochondrially targeted small molecule - mitochondrial uncoupler

• Enhances mitochondrial respiratory kinetics

• Improves insulin action

• Stimulates nutrient uptake by sustained activation of AMPK

• Therapeutic potential for treating obesity and associated

comorbidities

 

Benfotiamine

• Lipid soluble form of vitamin B1 (thiamin)

• Improves carbohydrate and amino acid metabolism to produce

cellular energy.

• Helps improve glucose regulation and insulin sensitivity

• Dose 100-150mg/day

 

• Clinical studies in diabetics report benfotiamine:

• Helps prevent endothelial dysfunction

• Decreases advanced glycation end-products (AGE)

• Decreases markers of inflammation

• Improves diabetic retinopathy symptoms

 

Beta 1,3 – 1,6 glucan Oromucosal Nanospray

• “SMART” Formulation of low molecular weight beta-glucans

• Extracted from the Almond Mushroom (Agaricus blazei)

• High levels of beta-1,3-1,6 glucan and zinc

• Sustainable cultivation in Brazil

• Oromucosal spray = most bioavailable oral beta-glucan supplement on market

 

• Beta-1,3-1,6 glucans reported in human trials to:

• Decrease metainflammation – improve inflammatory biomarkers

• Immune modulators

• Improve innate immune response

• Decreased infections

• Reduction of colds/flu symptoms + days sick

• Fewer URTI symptoms

• “TRAINS” T cells for more effective immune response – memory improved

• Bind to Dectin-1 domains on immune cells

• Increases dectin-1 CR3 signaling (complement receptor)

• Enhances oxidative bursts from primed innate immune cells

 

GENERAL IMMUNE SUPPORT

• A puff in the left and right inner cheek (buccally) and

under the tongue (sublingually) – 3 sprays

• Wait for 10 seconds and then swallow

• This sequence should be performed 3 times – 9 puffs total

• Repeat the whole procedure 3x daily - in the morning, noon and evening - before

meals and after brushing teeth

• Total of 27 puffs per day = 132mg highly absorbable nanotized beta 1,3-1,6

glucans

• In acute needs, dosage frequency may be increased

• May be used topically

 

BPC-157

(0ral) (Cellular repair)- overall inflammation, improves immune strength and gut

health, improves energy and optimizes growth hormone receptors, anti-inflammatory,

immune strengthening

(cellular repair)- decreases inflammation, increases collagen synthesis, quicker

recovery times post-injury, wound and bone healing

 

 15aa active fragment of naturally-occurring BPC

 A crucial organoprotective mediator of the stomach stress coping response

disovered in 1990 in Croatia

 Sikirić, P. “A New Gastric Juice Peptide, BPC. An Overview of the Stomach-Stress-Organoprotection Hypothesis and Beneficial Effects of BPC.” Journal of Physiology-Paris 87, no. 5 (January 1993): 313–27.

 A free radical scavenger to counteract reperfusion-induced oxidative injury

 A membrane stabilizer, counteracting leaky gut syndrome by modulating ischemiainduced increased capillary permeability

 

 Dosage range of BPC most employed in animals has been between 10

mcg and 10 ng/kg ip, ig, iv or topical. In some studies, however, even lower

dosages were effectively used

 No LD

 

Bovine Colostrum

• Supplies protein, immune factors, growth factors vitamins,

minerals

• Rich in iron-binding proteins (lactoferrin and lactoglobin)

• Natural source of IgA, IgD, IgE, IgG, IgM

• Supports immunity and cytokine system

• Supports GUT health to prevent dysbiosis

• DOSE 10,000 mg daily

 

 

 

 

CB4211 Peptide

• Mitochondrial peptide

• Derivative of MOTS‐c

• Useful in obesity/ fatty liver

• Reported to enhanced insulin mediated phosphorylation of IR,

IRS‐1, and Akt, without affecting IGF mediated

phosphorylation of IGF‐1R

• Consistent with activity through IR, CB4211 potentiated

insulin induced reduction in glucose production in H4‐IIE cells

 

• Animal Studies

– Reported to reduce NAFLD activity score, markers of

livery injury, body weight, and fat mass in animal

models of NASH or obesity

– lab mice with insulin enhanced insulin sensitivity,

prolonging the reduction in blood glucose levels

compared to insulin alone

• Human Study

– Phase 1b randomized, double‐blind placebo‐controlled

study using CB4211 25mg once daily x 4 weeks in

obese subjects w/ NAFLD

Loomba R, et al. AASLD Poster LB5. CB4211, a Novel Analog of MOTS‐c, Improves Markers of Liver Injury and

Metabolism in Obese Subjects with Nonalcoholic Fatty Liver Disease: a Multicenter, Double‐Blind, Randomized,

Placebo‐Controlled Study.

 

• Results:

– CB4211 well tolerated and safe

– No serious adverse events

– Robust reduction of:

ALT (‐21%)

AST (‐28%)

Glucose (‐6%)

– Lowered body weight

– Lowered liver fat content

• Human Dosage:

– 25mg SubQ x 4 weeks

 

Chondroitin Sulfate

• Dosage: 600mg, 3 times a day, with meals. For maintenance 300mg, 2-3 times per

day, with meals

• Synergistic effect with glucosamine

• Active Forms: Chondroitin sulfate (CS), as chondroitin-4-sulphate and

chondroitin-6-sulphate, found naturally combined with Type II collagen

• Stimulate proteoglycan production

• Inhibits breakdown or destruction of connective tissue matrix

 

Chromium

• Important in insulin regulation and blood sugar control

• Metabolism of carbs and fats

• Improves satiety

• ↓Carbohydrate cravings

• Helps convert T4 to T3

• Chromium depleted in high sugar diets

• Dosing 800mcg-1600mcg/day GTF chromium

 

Cistanche sp.

• “Desert ginseng”

• Used in Traditional Chinese Medicine

• Neuroprotective; decreases microglial activation

• Immune supportive

• Activates caspase-3 and caspase-8

• Helps improve mitochondrial function

• Improves cognitive function

• Dosage = 200-300mg daily

• Standardized to 22% echinacosides

 

CoQ10

CoQ10 Drug-Induced Nutrient Depletion

DIND

• HMG-CoA reductase inhibitors

“statins”

• Bile acid sequestrants

• Fibrates

• Phenothiazines

• Tricyclics

• Beta blockers

• Oral contraceptives

• Alpha blockers

(clonidine/methyldopa)

• Butyrophenones (haldol)

• Sulfonylureas (glipizide,

glyburide, tolazemide)

• Biguanides (metformin)

• Bisphosphonates

• Thiazide duiretics

 

 

 

Curcumin

• From turmeric (Curcuma longa) root/rhizome

• One of top selling botanicals globally

• Curcuminoids reported:

• Antiinflammatory

• Decreases inflammasome signaling

• Supports musculoskeletal system

• Joints/connective tissue support

• Helps improve flexibility and mobility

• Antiviral/antibacterial – COVID potential

 

Curcumin - Metaflammation

• Decreases oxidative stress via Nrf2-keap1 pathway

• Inhibits nuclear factor-kappaB

• Inhibits Toll-like receptor 4-dependent signaling pathways

• Inhibits activation of a peroxisome proliferator-activated receptorgamma

pathway

 

• Modulates multiple cell signaling molecules

• TNF-alpha

• IL 1, IL-6

• COX-2 and 5-lipoxygenase

• NF-kappaB

• CRP

• PgE2

• TGF-beta

• AST/ALT

• Malondialdehyde MDA

• Lab study reports curcumin ameliorates pancreatic beta cell destruction in

autoimmune diabetes

 

Issues with Curcumin Bioavailability

• Studies report curcumin (curcuminoids) have poor oral bioavailability

• Poor oral and/or GUT absorption

• Hepatic First pass effect

• Manufacturers have tried to compensate

• Bioperine – Piper sp. (pepper)

• Liposomes

• Now nanotized

 

• SMART turmeric oromucosal spray

• Superior formulation characteristics:

• SMART COATING – hydro layer

• Particles have positive charge

• 45-50 mV

• cross oromucosal membrane readily

• Particle size to cross membranes effectively

• < 400 nm (0.4 microns)

• STABILITY

• Fformulation tested to be stable for 24 months at room temp

 

SMART Oromucosal Curcumin Spray Dosage

• 9-18 sprays daily (3-6 sprays TID) = 25mg/ml

• Intensive therapy use higher dosages

• 30ml BPA free plastic

• Nanocurcumin effective at 9% of general oral dose

• Physical stability studies x 24mo – microbial x 16 mo

• Pharmaceutically manufactured - sterile

 

C3 Reduct Curcumin

• Tetrahydrocurcuminoids (THC) – hydrogenated curcuminoids

• More bioavailable than regular curcuminoids

• Improved anti-inflammatory activity

• Made as LPT oral liposomal tablet

• 25mg THC per LPT in a 350mg proprietary anti-inflammatory base

• Chew/swallow 1 BID

 

D-Ribose

• Simple sugar

• Replenishes ATP and Recycles Lactic Acid

• Helps normalize heart rate

• Reduces oxidative damage

 

• Improve Lactate disposal – helps w/ pH

• Improves stamina and endurance

• Rate limiting step for resynthesis of ATP

• Improves ATP production and recovery – improved energy

• Improves glutathione – reduces oxidative stress

• Helps with management of heart rate under hypoxic (anaerobic) load

• Dose = 5-20gm daily

 

Dihexa

20mg/ml(topical)

(HGF activity enhancer)- reverses the effects of

neurodegenerative diseases, neurocognitive/antidementia properties

 

Epigallocatechin-3-gallate (EGCG)

EGCG Mechanisms

• Epigallocatechin-3-gallate from Green tea leaves (Camellia sinensis)

• Antioxidant

• Neuroprotective

• Decreases microglial inflammation

• Improves adult neurogenesis in the hippocampus

• Immune supportive

• Decreases proinflammatory cytokine release

• Decreases inflammation

• Antiviral

• EGCG binds to viral cell membrane

• Represses the replication and transcription of virus

 

• Intake of EGCG is reported inversely associated with the risk of

cardiovascular diseases

• Anxiolytic

• Interaction with γ-aminobutyric acid (GABAA) receptors

• EGCG may inhibit spontaneous excitatory synaptic transmission

independently of GABA receptor activation

• Protects body from heavy metal-induced oxidative stress

 

• 50-200mg BID

• 21mg LPT – oral liposomal tab, 95% EGCG – chew/swallow 1 LPT BID

• Addition of theanine (200mg w/ each dose of EGCG) can decrease any

negative effects of high dose EGCG

 

Fermented Wheat Germ Extract (FWGE)

• Source of 2-methoxy-p-benzoquinone (2-MBQ) and 2,6- dimethoxy-p-benzoquinone

(2,6-DMBQ)

• Supports healthy cell metabolism

• Supports aging process

• Enhances Quality of Life

• Cancer therapy – antimetastatic, helps in cachexia

• Immune support

• Promotes NK cells and response of macrophages, B-cells and T-cells

• Improve Th1/Th2 balance

 

• Dosage

• 2 capsules daily ( 2 caps = 41 mg FWG)

• If over 90 kg (or 199 lbs), use 4 capsules daily

• Take 1 hour before or after meals or other supplements

• Do not use if on immunosuppressive meds

 

FGL (Fibroblast Growth Loop Peptide)

• Neural Cell Adhesion Molecule (NCAM) mimetic

• Binds to the Fibroblast Growth Factor Receptor 1 (FGFR‐

1)

• Antiinflammatory/antioxidant/neuroinflammation

• Neurological supportive/ Enhanced cognition

• Nasal Spray – 100‐200 mg daily

 

Fisetin

• 3,3′,4′,7-tetrahydroxyflavone

• first record of fisetin as an isolate from Venetian sumac (Rhus cotinus L.) dates back to 1833

• Flavonoid found in fruits/veggies, i.e. strawberry (highest content), apple, persimmon,

grape, onion, and cucumber

• Senolytic

• Reported to induce apoptosis in aged human umbilical-vein endothelial cells

• Mechanism of senescent-cell apoptosis related to its blocking on the PI3K/AKT

pathway

• mTOR blocked, autophagy activated

• Anti-inflammatory/antioxidant

• Increases glutathione synthesis

• Reported to decrease risk of CHD and CVDs

• 100 mg daily

• Poorly orally absorbed – take w/ fat (ie fish oil) to increase absorption or use

liposomal

 

GLP-1 agonists

 GLP-1 agonist not rapidly degraded by Dipeptidyl peptidase-4 (DPP-4)

 Alleviate endoplasmic reticulum stress, regulate autophagy, promote

metabolic reprogramming, stimulate anti-inflammatory signaling, alter gene

expression, and influence neuroprotective pathways

 Reduce gastric emptying, increase in satiety and inhibition of food motivated

behavior, replenishment of insulin stores, as well as cytoprotective and antiinflammatory

actions on β-cells

 Alleviate glucotoxicity, lipotoxicity, excess nitric oxide (NO), Ca2+ depletion,

oxidative stress, and cytokine-induced ER stress

 Facilitate autophagy under chronic exposure to excess nutrients, whereby it

prevents autophagosomal-lysosomal fusion impairment

 

 Improve cardiac function, restore lung function and reduce mortality in patients

with obstructive lung disease, influence blood pressure and lipid storage, and even

prevent synaptic loss and neurodegeneration

 GLP-1 based therapies are beneficial to kidney function through increases in renal

blood flow (RBF), urinary flow rate, prevention of rises in plasma creatinine, reduced

tubular necrosis, an increase in renal interstitial fluids and glomerular filtration rate

(GFR), as well as cytoprotective and anti-inflammatory actions through interactions

with the nervous system and the renin angiotensin system (RAS) (Rowlands, 2018)

 Re: weight loss, administration of GLP-1R agonists induced BAT thermogenesis

through increased uncoupling protein 1 (UCP1), mitochondrial respiratory chain

element and PGC1α, independent of nutrient intake. Also activate Adiposeresident

invariant natural killer T (iNK) critical to weight loss

 

 START LOW GO SLOW

 Liraglutide start 0.6mg SC daily, increase every 3-4 days as tolerated to max 3mg

 Semaglutide start 0.25mg SC weekly, increase every 1-2 weeks as tolerated to max

3.4mg

 Dulaglutide start 0.75mg SC weekly, increase every 1-2 weeks as tolerated to max 4.5mg

 Contraindication: personal history thyroid cancer

 SE: NAUSEA, constipation, fatigue, insomnia, weight loss, rare pancreatitis

 Dose away from GHS as it enhances somatostatin

 

• GLP-1 receptor agonists appear to have a favorable safety profile

• NOT FOR USE IN PREGNANCY – discontinue med at least 2 months

before a planned pregnancy

• Most common SE = GI symptoms, mainly nausea; headache

• Injection site reactions – redness, swelling, pruritus

• Severe SE’s include – pancreatitis, allergic reactions, thyroid C-cell

carcinoma

• Several cases report acute kidney injury, primarily through

hemodynamic derangement due to nausea, vomiting, and diarrhea

 

Glucosamine

• Commonly combined with chondroitin sulfate

• Active Forms: Glucosamine SO4 & HCl

•  flexibility;  inflammation

• “Trials of glucosamine and chondroitin preparations for OA symptoms demonstrate

moderate to large effects…”

 

• Chondrocytes use glucosamine as raw material to synthesize proteins that bind water in cartilage: proteoglycans and glycosaminoglycans (GAGs)

• Glucosamine  production of hyaluronic acid, which provides shock absorbing &

lubricating properties of synovial fluid

• Dosage: 1500mg/day over 200 lb, = 2000mg/day

• Combine w/ chondroitin for synergistic effects

 

 

Green Tea polyphenols

• From Camellia sinensis leaf

• Antioxidant polyphenol

Epigalocatechin gallate (EGCG)

• Antiinflammatory

• Inhibits lipid peroxidation

• Suppresses COX-2, MMPs, TNFalpha, IL-6, 8, 12

• Enhances DNA and cellular repair

 

• Green tea extract: 500mg daily in divided doses ; std 50% EGCG

• EGCG Lipotab = 21mg 95% EGCG – chew/swallow 1 QD

• High doses of standardized green tea extracts have been reported to cause

hepatotoxicity

• From EGCG > 800mg daily

• Taking EGCG w/ theanine reported to decrease the negative effects

 

GWO742

• PPAR β/δ agonist

• GW0742 uses:

– Promote muscle regeneration

– Increases exercise endurance

– Supports weight management

– Decreases risk of heart disease – improves BP,

endothelial function

– Accelerates wound healing

– Neurological supportive ‐ cognition

– Supports IR and T2D issues

– Pulmonary issues

– Supports improved eye health

 

• Lab animal studies report GW0742 improves

metabolic abnormalities

– Including IR in skeletal muscle in mice fed high‐fructose corn syrup

– Insulinotropic activity

• Study results: GW0742 improves glucose

homeostasis in diabetic rats through

activation of PPAR‐δ

 

 

 

Honokiol

• From Magnolia (Magnolia officinalis) bark extract

• Std. to 98% honokiol - pleiotropic lignan

• Honokiol - GABAA binding

• Decreases sleep latency to NREM sleep

• Increases N-REM sleep

• NMDA antagonist

• Anti-inflammatory – decreases NFkB expression; decreases microglial activation

 

• Readily crosses BBB

• Decreases LPS induced memory deficit

• GABAA binding

• Reduces anxiousness

• Pain modulation

• Endocannabinoid binding

 

KCF‐18

– Antioxidant/anti‐inflammatory

– Derived from cytokine receptors

– Binds to TNF‐alpha, IL‐1beta and IL‐6 receptors

– Cell experiments demonstrated that KCF18:;;;

• Significantly reduces the binding of proinflammatory cytokines to their cognate receptors

• Inhibited the mRNA and protein expressions of TNF‐α, IL‐1β, and IL‐6

• Reduce the expression of reactive oxygen species induced by

cytokines in human monocytes

• Decreases p65 nucleus translocation induced by cytokines

• Reduces expression of IL‐6 and increased white blood cells

stimulated by lipopolysaccharides

 

KPV

● A naturally occurring tripeptide: Lysine-proline-valine

● A C-terminal peptide fragment of α-melanocyte stimulating hormone (α-

MSH)

● A small molecule with broad anti-inflammatory effect & antimicrobial action

● In the absence of pro-inflammatory stimuli, LPS/IL-1, there is little to no

immunosuppressive potential of alpha MSH

● Contributes to innate defense; stabilizes mast cells

● No stimulation of melanocytes

 

L-arginine

○ Amino Acid

○ Improves nitric oxide levels

○ Precursor to creatine

○ Stimulate hGH by suppressing endogenous somatostatin secretion

 

• Cardiovascular benefits

• Erectile dysfunction

• Safe at moderate doses up to 10 gm

• Normal dose = 2-10gm sustained release daily

• Arginine reported to improve growth hormone AT REST by 100%

 

L-Glutamine

Glutamine as an anti-fatigue amino acid in sports nutrition. Nutrients. 2019;11(4):863.

Most abundant amino acid (AA) for protein synthesis

Makes up 50% of all AAs in blood and 60% AA’s in tissue

Supports GH levels

Helps maintain muscle mass

Dose = 5-10 gm daily

 

L-glutamine and GUT

• Protects GI mucosal barrier

• Skeletal muscle contains 60% of body glutamine

• FUEL

• Involved in glutathione synthesis

• Protects against endotoxemia

• Substrate for Growth hormone release

 

• Supports microfloral health

• Helps maintain secretory IgA

• Prevents attachment of bacteria (i.e. H pylori) to mucosal cells

• Inhibits gram-negative translocation of bacteria from colon

• Major fuel for enterocytes and colonocytes

• Maintain integrity and function of mucosal barrier

• Improves height of villi

• Reduces villi permeability

• Reduces leaky gut syndrome symptoms

• Defends against food allergies and intolerances

• Protects against injury and inflammation including drug induced (NSAID

damage)

• Helps in chemotherapy induced GUT damage

• Supports IBD - Crohn’s and UC

• Helps in ulcers – decreases mucosal apoptosis

 

L-Theanine

• Amino acid found in green tea (Camellia sinensis)

• Acts antagonistically against the stimulatory effects of caffeine in the tea on the

nervous system

• Glutamate antagonist

• Indirectly increases GABA (gamma-amino-butyric acid)

• balances the excitability that can sometimes lead to restlessness, insomnia,

and other disruptive conditions

 

• Antianxiety

• Cognitive and mood support

• Increases levels of dopamine

• Dampens Phenylethylamine (PEA)

• Increases alpha waves

 

• Good for sleep if daytime drowsiness a problem

• 200-400mg up to 4 times a day

 

Larazotide (oral)

- restores intestinal barrier, tight junction regulator, enterocyte

proliferation, suppresses pro inflammatory signaling pathways, protection against

apoptosis and cellular stress ( FDA fast track designation for celiac disease )

 

Macimorelin

• Growth hormone secretagogue (GHSR) agonist

• Stimulates GH release

• Binding potency to the GHS‐receptor in animal and human

tissues similar to that of ghrelin and peptidyl GHS

• Used for:

– Growth hormone support

– Performance support

– Improved body composition – weight management

support

Garcia JM, et al. J Clin Endocrinol Metab. 2013;98(6):2422‐29

 

• GHRYVELIN (Aeterna Zentaris, EU)

• MACRILEN (US)

• Both indicated for GH insufficiency

• Dosage of MACRILEN and GHRYVELIN to Dx GH

deficiency

– Oral granules

– 0.5mg/kg x 1

 

• Transient Side effects include:

– Metallic taste

– Fatigue

– Headache

– Nausea

– Dizziness

– Diarrhea

– Acute Hyperthermia – feeling “hot”

 

• Potential Drug Intx

– Avoid drugs that prolong QT interval

Antipsychotics – chlorpromazine, haloperidol, thioridazine,

ziprasidone

Class 1A antiarrhythmics – quinidine, procainamide

Antibiotics – moxifloxacin

Class III antiarrhytmic meds – amiodarone, sotalol

– Discontinue CYP34A inducers

St. John’s wort

Modafinil

Others Garcia JM, et al. J Clin Endocrinol Metab. 2013;98(6):2422‐29

 

Magnesium

Magnesium bisglycinate chelate

• Co-factor in over 300 biochemical reactions

• Over 75% of Americans are Magnesium deficient

• Help support sleep quality and quantity

• Helps improve restless leg syndrome, cramps and muscle spasms

• Mg in Sleep – improves GABA levels

 

• Magnesium critical in over 400 biological reactions

• 70% Americans deficient in magnesium

• Many drugs deplete magnesium – diuretics, PPIs, HRT/OCs, others

• Obesity depletes

• Magnesium supplementation:

• Improves GLUT4 in skeletal muscle

• Improves glycogen synthesis

• Improves pancreatic beta-cell proliferation and regeneration

• 400-800mg elemental magnesium per day, as chelate .

 

• Magnesium supplementation 500mg elemental form for 4 wk in overweight

individuals: distinct changes in gene expression

•  C-peptide .4ng/ml

•  Insulin -2.2uU/ml

• 24 gene up regulation and 36 down regulation

• All related to metabolic and inflammatory pathways

 

Magnolia/ Phellodendron

• Proprietary blend of Traditional Chinese Herbs Magnolia officinalis and Phellodendron

amurense barks

• Marketed for stress-related appetite control and reduction of stress-related fat

deposition

• Contained in multiple company formulations

 

• Anti-anxiety and anti-stress properties rival benzodiazepines, yet non-sedating

• Helps normalize cortisol and DHEA levels, including exercise induced

• Helps decrease food cravings associated with increased stress

• Low side-effect profile

• 250mg 2-3 times a day

 

Melatonin

• Natural sleep hormone

• The circadian counter-hormone to Cortisol

• Decreases with stress, hormonal imbalances

• Improves circadian insulin production

• Used for sleep problems

• Antioxidant

 

• Convincing evidence for exogenous melatonin in:

• Reducing sleep onset latency in primary insomnia

• Delayed sleep phase syndrome

• Regulating the sleep-wake patterns

• Authors conclude melatonin is of great value in treating certain first-degree sleep

disorders

Auld F, et al. Evidence for the efficacy. Of melatonin in the treatment of primary adult sleep disorders. Sleep

Med Rev. 2017;34:10-22.

 

Melatonin DIND – Drug-Induced Nutrient

Depletion

Melatonin is reported to be depleted by:

• Beta-blockers

• Calcium channel blockers

• Benzodiazepines

• Estrogen-containing medications

• Hydralazine

• Loop diuretics

• Theophylline

• Antidepressants, including SSRI (Selective serotonin reuptake

inhibitors)

• NSAIDs (Non-steroidal anti-inflammatory drugs)

 

Met‐Enkephalin

• Methionine Enkephalin AKA opioid growth factor, FK

33‐824

• Opioid neuropentapeptide

• Potent delta‐opioid receptor agonist

– Much less for μ‐opioid; None Kappa

• Produces anticonvulsant, anxiolytic, analgesic and

antidepressant like effects

Jankovic BD. Enkephalins and immune inflammatory reactions. Acta Neurol

(Napoli). 1991;13(5):433‐41.

 

• Involved in humoral and cell‐mediated immune reactions

• Immunomodulatory – increases IL‐2, T cells, NK cells

• Lower doses stimulate PMNs, higher depress immunity

• Anti‐inflammatory

• Human studies have used:

– IM dose 0.2‐0.5mg

– SQ –10‐80mcg/kg 3 x weekly

– IV infusion 250mcg/kg over 30 min

 

MK-677 (oral)

orally active GH secretagogue, reverses diet induced catabolism, post

injury and surgery tendon, ligament, muscle injuries

 

Nicotinamide Riboside (NR)

• Supports neuronal NAD+ synthesis

without inhibiting sirtuins

• Sirtulins - important regulators of metabolism and longevity

• NAD+ is a rate-limiting co-substrate for sirtuins enzymes

• NR regulates sirtuins function and subsequent regulation of oxidative metabolism

 

• Activation of NAD+ expression linked with a decrease in beta-amyloid (Aβ) toxicity in

Alzheimer's

• PGC-1α - a crucial regulator of Aβ generation

• Affects β-secretase (BACE1) degradation

• Helps promote peroxisome proliferator-activated receptor-γ coactivator 1 (PGC-1α)-

mediated BACE1 ubiquitination and degradation

 

• Orally available commercial product containing nicotinamide riboside is patented

• Oral Dose 250-500mg daily

• May also be used intranasally and/or sublingually in combination with Rg3 and

methylcobalamin

 

 

Phosphotidic Acid (PA)

Why Supplement With Phosphotidic Acid

(PA)

• Normally, small amount of PA present in muscle matrix

• PA is biosynthesized from phospholipids to small degree on an ongoing basis

• Mainly for cell membrane use

• Intrinsic amount of PA is just sufficient to impact mTOR signaling

• at a base level, even during exercise,

• Thus MPS and muscle accretion are continually compromised.

• Orally ingested PA provides an optimal amount of PA

• Critical requirement for sig. driving mTOR signaling

• Hence driving MPS and muscular hypertrophy

 

PA’s Effects On mTOR & MPB

• After an oral dose of PA and during mTOR signaling, MPB is reduced, thus

preserving existing muscle mass.

• PA is considered effective “anti-catabolic” nutrient.

• PA plays a role in “Anabolic Resistance”: Impaired rate of cellular anabolism in

response to various anabolic stimuli.

• Anabolic Resistance is the impaired ability to build muscle caused by an excess

calorie consumption over time.

• PA supports minimizing age related muscle loss (sarcopenia*)

• Dose 750mg-1500mg per day

• * Age-related loss of muscle protein is attributed to imbalance between MPS and

MPB rates, resulting in a negative muscle protein balance and, over time, a decline

in skeletal muscle mass.

 

Phosphatidylcholine

• Promotes cognitive function

• Improves neurological health

• Increases SIRT-1 expression

 

• Helps decrease vascular cognitive impairment

• A 2005 Cochrane Database Systematic Review reported evidence supporting use

of proprietary phos-choline in vascular dementia

• 250-500mg BID

 

Phosphatidylserine

• Phospholipid found in cell membranes

• Antioxidant

• Associated with improving brain and neurological function

• Also reported to help balance testosterone to cortisol ratio in response to

stressors

 

Plant Sterols/ Sterolins

• Improved cortisol/DHEA ratio

• Improved Th1/Th2 balance

• Supportive in Autoimmune Thyroiditis

 

• Adults: 1-2 capsules three times daily on an empty stomach – can

bind to cholesterol/lipids

• > 200 lb = 2 caps TID

• Children: one capsule twice daily (5-12yrs)

• 12 yrs and older can take adult dosage

• New Extra strength version – 30mg sterols/0.3mg sterolins per cap;

1 cap BID

 

Probiotics

• Probiotic flora consists of over 400

species of bacteria

• Enhanced immunity

• Interact with mucosal cells of GUT to provide a barrier against pathogens

• Microfloral imbalances

• Overtraining; intense physical exercise

• Poor food choices – high sugar, pesticides, additives, preservatives, antibiotics,

hormones, red meats

• Chronic stress

• Impure water

• Drugs

• 15-20 billion CFU QD

• Special 12 species probiotic – 60 billion CFU 1 cap daily

 

• Synthesize short chain fatty acids (SCFA)

• SCFA a primary source of fuel for intestinal epithelial cells, keeps them from flattening out.

• Butyrate - helps remove lipid soluble toxins

• Butyrate protects intestinal cells from abnormal growth, and may protect against colon cancer

• SCFA’s improve acidic environment in the intestines

• Acidic environment decreases pathogenic overgrowth

 

• Meta- analysis 1970-2011

• 79 randomized, controlled trials in 10,351 patients comparing probiotic to placebo

• 11 probiotic strains

• The Question - Are probiotics beneficial in treating gastrointestinal diseases, including

• Infectious diarrhea

• IBS

• H. pylori infections

• C. Difficile

• Antibiotic Associated Diarrhea

• Traveler’s Diarrhea

• Necrotizing entereocolitis

• Pouchitis

• The results: YES for all (statistically significant positive outcomes over placebo)

 

Pyrroloquinoline quinone (PQQ)

• Antioxidant

• Influences energy-related metabolism and neurologic function

• Reported to stimulate biogenesis of mitochondria

• Helps decrease inflammatory pathways (IL-6, CRP)

• Dose = 15-45mg daily

 

Rg3 Ginsenoside

• Ginsenosides are bio-active saponins found in ginseng (Panax ginseng,C.A.

Meyer) root

• About 150 ginseng saponins are known

• > 90% are classified as Rb1, Rb2, Rc, Rd, Re, Rg1, and Rg3

• Rg3 ginsenoside is formed after steaming the roots of Panax ginseng

• Rg3 makes up approx. 0.1% of total ginsenoside

 

Rg3 Physiological Properties (lab and human studies):

• Antioxidant

• Antiinflammatory

• Neuroprotective

• Antiaging

• Anticancer

• Metabolic syndrome support

• Vascular protective

 

Rg3 Neuro-Pharmacology

• Neuroprotective

• Decreases oxidative stress-induced inflammation

• Improves neuroinflammatory outcomes

 

• Helps attenuate microglial activation

• Decreases neuroinflammation

• COX-2 inhibition

• Inhibition of matrix metalloproteinase-9 (MMP-9)

• Improves NO and ROS (reactive oxygen species) levels

• Decreased inflammatory mediators - TNF-alpha, IL-1Beta

• Antinociceptive in lab animals – decreases pain

 

• Decreases excitotoxicity

• Attenuates NMDA (glutamate) receptor-mediated currents

• Decreases NMDA-induced neurotoxicity

• Inhibits L-type Ca(2+) channels

• Counters increased levels seen in microglial activation

 

• Dosage Intranasal:

• Intranasally added to Methylcobalamin + Nicotinamide riboside

• 2 sprays in each nostril 2 times daily

• Standardized to 90% (R) Rg3

• Used to support improved mitochondrial health and cognitive function

 

• LPT = proprietary oral liposomal tablets

• Rg3 LPT uses purified 85-90% Rg3 "R" ginsenoside

• LPT designed for average particle distribution of 100 nm

• Patent-pending liposome platform

• Improved absorption, improved bioavailability

• Rg3 LPT is highly advanced technology in a convenient, solid, chewable dosage

form

• 15mg LPT, ½ - 1 QD chewable

 

Selank

6mg (intranasal)

(Cell signaling- anxiolytic)- antidepressant, decreases anxiety,

positively influences memory and learning process, enhances GABA

 

Semaglutide sq- (GLP-1 agonist)

decreases appetite, slows gastric emptying, reduces

percent body fat, cardioprotective, improves cognitive function, antiinflammatory, lowers

HgA1c levels

 

Sermorelin (GHRH)

 GHRH analog derived from the first 29 amino acids of the GHRH protein

 Sermorelin also produced small acute rises in prolactin, FSH, and LH like endogenous GHRH and increased testosterone

 10 elderly men treated either 0.5 mg or 1 mg bid for 14 days on and 14 days off

 Sermorelin treatment resulted in elevations in IGF-1 in a dose-response fashion to levels approaching those of the younger men

 Elevations in IGF-1 remained above baseline levels in the elderly men even 2 weeks after stopping sermorelin

 

-improved sleep quality, increase in cognitive function, quicker

recovery times post-injury, increase in muscle mass, increase in strength

 

increase in IGF-1 levels, improved sleep quality, increase in

cognitive function, quicker recovery times post-injury, increased muscle mass, increase in

strength

 

SS‐31

• Aka elamipretide, Bendavia

• Mitochondrial peptide

• Uses:

 Antioxidant/antiinflammatory

 Mitochondrial protection/ stabilizes cardiolipin

 Anti‐aging

 Neurological protection / cognitive/memory support

 Alzheimer’s Disease support

 Brain injury support

 Musculoskeletal injury support

 Cardiomyopathy support

 Kidney support

 Ophthalmic – atrophy in dry Aged‐related macular

degeneration support (AMD)

 

• Preclinical studies suggest benefits in muscle aging, atherosclerosis,

ischemia, osteoarthritis, diabetes, and glaucoma.

Types of evidence:

 1 phase 3 double‐blind randomized controlled trial in primary mitochondrial

myopathy

 1 phase 2/3 randomized controlled trial in Barth syndrome patients

 1 double‐blind phase 2 RCT in patients with heart failure

 1 double‐blind phase 2 RCT in patients with primary mitochondrial myopathy

 1 double‐blind phase 1/2 RCT in patients with primary mitochondrial

myopathy

 1 double‐blind phase 2a RCT in patients with myocardial infarction

 2 double‐blind randomized controlled trials, 1 in patients with

atherosclerotic renal artery stenosis and 1 in heart failure

 1 pilot clinical study in renovascular hypertensive patients undergoing renal

revascularization

 Numerous preclinical studies

Birk AV, et al. J Am Soc Nephrol. 2013;24(8):1250‐61.

 

Dosage:

 SubQ

• 40 mg SubQ daily x 12‐24 weeks

 Oral

• 10‐50 mg daily

 

TB4 frag (oral)

–(multi- functional regenerative peptide). – thymus extract

 

Tesamorelin

 Stabilized analog of human GHRH

 FDA approved for HIV lipodystrophy

 Wang, Y. “Tesamorelin, a Human Growth Hormone Releasing Factor Analogue.” Expert

Opinion on Investigational Drugs 18, no. 3 (March 1, 2009): 303–10.

 2 strong studies in mild cognitive impairment demonstrating appropriate

increases in IGF-1 and improved neurotransmitter formation and cognition

 

Thai Ginseng (Kaempferia parviflora) root

• Aka Black ginger – used in SE Asia as a food and medicine

• Contains high level of antioxidant polymethoxyflavones

• Specifically 5,7 dimethoxyflavone

• Improves mitochondrial biogenesis – increased energy

• SIRT-1 upregulation - 3-4x that of resveratrol

• Sirtuins involved in metaflammation

• Sirtuins are also evolutionarily viral restriction factors - antiviral

 

• 100-200mg AM daily std. to 4-5% 5,7 dimethoxyflavone

• Although Thai ginseng is a WEAK PDE5 inhibitor, use with caution if patient taking

prescribed PDE5 inhibitors

 

Thymagen

• AKA Thymogen, Vilon®

• Dipeptide bioregulator

• Glu‐Trp (L‐glutamine/L‐tryptophan)

• Primary effects on thymus – immune support

• Originally isolated from calf thymus (natural thymic factors ‐ larger peptide called Thymalin)

– Now bioregulators are produced synthetically

thru DNA recombinant technology (Thymagen, Thymogen)

• As a bioregulator, supports Th1/Th2 balance

• Induces differentiation of T cells

• Enhances T cell function

• Prevents overproduction of inflammatory cytokines – cytokine storm

 

• Anti‐inflammatory/analgesic activity

– Acts directly on afferent nerve terminals through

prostaglandin‐E2 (PGE2)‐dependent mechanisms

• Activates neutrophil chemotaxis and phagocytosis

• Applications for Thymagen include:

– Chronic inflammatory conditions

– Tissue repair disorders

– Stress‐induced immuno‐depression

– Optimization of cancer immuno‐therapy,

chemotherapy and radiotherapy

– Age‐related immune dysfunction

 

Dose:

• General dosage = 100‐200mcg SubQ every 3 days x

15 days

• Therapeutic or preventative

• Repeat at least twice annually for prevention

• Synergistic w/ conventional Rx therapy ‐ no interactions

 

Thymosins: TA1/Tβ4

● Thymosins: discovered in the mid 1960’s

when Dr. Goldstein from Albert Einstein

College of Medicine (NY) studied the role of

the thymus in the immune system

● 2017: TA1 & TB4 → Topics include:

○ Immunomodulation, ID, Sepsis, Liver

dx, Eye dx,

○ Neuro --- CVA, Alz Dx, severe TBI,

○ Cardiac---vascular and stem cell effects

 

Thymosins: TA1

Thymosin is a “hormone” (smart small molecule) secreted from the thymus. Its

primary function is to stimulate the production of T cells, which are an important

part of the immune system. Thymosin also assists in the development of B cells

to plasma cells to produce antibodies.

Thymosin α1 (Tα1) is an immunostimulatory peptide that is commonly used as

an immune enhancer in viral infectious diseases such as hepatitis B, hepatitis C,

and acquired immune deficiency syndrome (AIDS).

Thymosin alpha 1 is usually administered twice a week via a subcutaneous

route. The standard single dosage ranges from 0.8 to 6.4 mg, while multiple

doses range from 1.6 to 16 mg for five to seven days.

When prescribed by a licensed healthcare provider for a legitimate medical purpose,

using FDA-approved peptides is generally considered legal. However, off-label use or

self-administration of peptides without proper medical supervision can result in legal

consequences and potential health risks

 

Thymosin Beta 4

● Regulates the cell/muscle building protein

actin

● Displays potent anti-inflammatory effects

● Promotes wound healing and angiogenesis

● Clinical trials have demonstrated its ability

to reactivate progenitor cells to repair

damaged tissue

 

● Due to its LMW, TB4 is able to

‘hone’; it has the ability ‘to

travel’ to the site of injury.

● Prevents adhesion and fibrous

band formation in injured

tissue– i.e. muscles, tendons,

and ligaments

● Protects and restores neurons

post TBI

 

● Promotes rapid wound healing with little-to-no

scarring

● Supports tissue stem cell vitality and

proliferation to regenerate and heal injured

tissue

● Promotes angiogenesis and actively combats

sarcopenia

● Anti-inflammatory properties help reduce

chronic and acute pain

 

Dosing:

● TB4-frag 150 mcg po per capsule

● TB4-frag plus 150 mcg po per capsule + Natural thymic

extract 350 mcg

 

TP508

• Non‐proteolytic thrombin peptide

• AKA rusalatide acetate, Chrysalin®

• Used for:

– Vascular damage including myocardial ischemiac

– Musculoskeletal injuries

– Wound healing®

– Chronic inflammatory issues including:

oSARS‐Cov2 infection

oAcute lung injury ‐ Acute Respiratory Distress

Syndrome (ARDS)

oChronic smoke inhalation

oMusculoskeletal injuries

oRadiation damage – radioprotective, including GUT

crypt cells

Ryaby JT, et al. J Bone Joint Surg Am. 2006;88(suppl 3):132‐139

 

• TP508 reported to initiate tissue repair and

regeneration by:

– Reversing endothelial dysfunction

– Stimulating revascularization

– Attenuating inflammation

– Stimulating NO production

– Reducing apoptosis

• Protects crypt cells in the GUT exposed to radiation

• Significantly increases expression of both LGR5 and

DCLK1 stem cell markers in intestinal crypts

• Also increases number of DCLK1‐positive cells per

crypt

Kantara C, et al. Lab Invest. 2015;95:1222‐33.

 

oSubQ – Locally for injury/wound

 For injury healing – 10 ‐ 30 mcg SubQ at site of injury x1 single dose

 Must be given w/in 24 hrs of injury

•

oSubQ – for aesthetics

 15 units to site

 Give 4 times, 1 month apart then repeat annually

•

oTopically

 10 mcg TP508 in small amount saline, apply to area then cover wound

with foam bandage

 Use this twice weekly along with routine wound care.

Ryaby JT, et al. J Bone Joint Surg Am. 2006;88(suppl 3):132‐139

 

Type II Collagen

• Novel, undenatured type II collagen

• Derived from chicken sternum cartilage

• Basis of articular and hyaline cartilage

• Increases synovial fluid production from the synovicites

• Small doses of collagen inhibit T-cell attack

 

• Collagen accumulation reduced after major surgery

• Pre-surgery radiation cancer patients significantly inhibits collagen

accumulation

• Corticosteroids/NSAIDs reduce collagen synthesis also

• Clinical studies report benefits from collagen use in RA and OA and in wound

healing post surgery

• 40 mg daily (20mg BID)

 

Vasoactive Intestinal Peptide (VIP)

• The twenty-eight amino acid peptide is structurally related to the

secretin/glucagon family of peptide hormones, sharing 70% sequence

identity with the neuropeptide pituitary adenylate cyclase-activating

polypeptide

• VIP is produced by neurons, endocrine and immune cells, and is

present in most organs including the CNS, heart, lung, thyroid, kidney,

urinary and gastrointestinal tracts, genital organs and the immune

system.

 

• Regulates Circadian rhythms

• Noncholinergic relaxation of vascular and nonvascular smooth muscle

• Increases neuronal survival and regulates glycogen metabolism in the

cerebral cortex

• Promotion of embryonic growth and brain development

• has neurotrophic effects and regulates bone metabolism

• Increases insulin and glucagon secretion

• Increases blood flow in thyroid but has no effect on hormone levels

• Promotes the release of prolactin, luteinizing hormone, and growth

hormone from the pituitary gland, and regulates insulin and glucagon

release

 

Regulates cardiac contractility

• Coronary and systemic vasodilatation

• Increases glycogenolysis and lowers arterial blood pressure

• Increases cardiac output

 

• Relaxes airway and pulmonary vascular smooth muscle

• Inhibits airway and pulmonary vascular smooth muscle proliferation

• Bronchodilatation

 

• Macrophage- deactivating factor

• Regulates the differentiation of CD4+ t cells

• Anti-Inflammatory

• Defense mechanism against septic shock

 

• Increases the secretion and inhibits the absorption of intestinal

luminal fluid

• Relaxes smooth muscle and mediates distension-induced reflexes

• Decreases intestinal paracellular permeability

• Increases epithelial cell proliferation

• Releases pancreatic enzymes

 

• Nasal Spray

• Lipotabs 100mg

 

Patients with autoimmune diseases such as lupus, autoimmune thyroiditis, MS and RA have low levels of VIP in serum, associated in some cases with high levels of VIPase autoantibodies

 

 VIP reduces the clinical and histopathological severity of mouse model crohn’s disease (CD) and reduces weight loss, diarrhea, and macroscopic and microscopic intestinal inflammation

 reduced the levels of various chemokines and pro-inflammatory cytokines, such as tumor necrosis factor-α (TNF-α), IL-6, IL-12, and IL-10

 In patients with food allergy, VIP stabilizes the expression of IL-10, Bregs, and restores immune regulation function, thereby reducing the food allergy response

 VIP-/- mice demonstrate reduced proliferation and migration of intestinal epithelial cells (IEC) and their increased apoptosis, resulted in increased intestinal permeability

 regulates the Th1/Th2 balance by directly acting on T cell differentiation and indirectly

regulating the antigen presenting cell function

 VIP also inhibits the transcription factors AP-1, nuclear factor-κB (NFκB), CREB, and IRF-1, and impairs the acquisition of the macrophage proinflammatory polarization profile

 

 Systemic administration of VIP causes cardiovascular and gastrointestinal side

effects including a marked decrease in blood pressure, tachycardia,

cutaneous flushing, and watery-diarrhea syndrome

 Nebulized VIP in a single 100-microg dose in 20 patients with idiopathic

pulmonary arterial hypertension produced small and temporary but significant

selective pulmonary vasodilation, an improved stroke volume and mixed

venous oxygen saturation. Overall, six patients experienced a pulmonary

vascular resistance reduction of >20%

 

 Check lipase prior to administration

 

Zinc Carnosine

• Zinc ions bound to L-carnosine

in a 4:1 ratio

• Advanced gastric cytoprotection

• Helps improve integrity of GI mucosa

• Protects against sensitizing proteins, i.e. gluten or casein

• Helps establish lower pH environment in hospitable to H. pylori

• L-carnosine helps transport zinc to heal tissue

 

• Improves cell migration to wound

• Increases cell proliferation and tissue repair

• Reported to protect against indomethacin-induced gut permeability changes in humans

• 1 cap BID

• Contains/cap:

• Zinc (as zinc carnosine) 17 mg

• Zinc-carnosine (chelated) 75 mg

 

Zizyphus

• Jujube (Ziziphus jujuba or Ziziphus spinosa) fruit extract 4:1

• Reported to improve sleep quality

• Anxiolytic, sedative and hypnotic effects in laboratory studies

• Neuroprotection

• Increases hippocampal neurogenesis

• Decreases neuro-oxidative stress

• Improves memory and learning

• Synergistic addition to Honokiol for sleep regulation

Selective androgen receptor

modulators (SARMs)

 

IF I am So Fit,

Why is My Testosterone Low?

• Free Testosterone/Cortisol Ratio Important Indicator

• Higher the ratio the better the training gains

• As Cortisol raises and Free and Total Testosterone lowers shifts occur

- More cortisol made from DHEA – less DHEA makes testosterone

- Immune changes tendency toward more allergies (food 7

environment)

-Anabolic drive reduces, gains from training disappear

-Inflammation signaling increases

-Gut breaks down becomes more “Leaky”

- Mood Alters

 

Cortisol and Sex Hormone Imbalances

• Increased cortisol blocks T4 conversion to T3

• TRH is up-regulated to create more T4

• Increasing TRH will increase prolactin which in turn

• Down regulates LH and FSH production which

• Down regulates testosterone

• As testosterone goes down, so does growth

hormone

 

Testosterone and the Heart

• In men, T levels begin to decrease after age 40

• Associated with an increase in all-cause mortality and cardiovascular (CV) risk

• Increases risk of developing coronary artery disease (CAD), metabolic syndrome,

and type 2 diabetes

• Reduced T levels in men with congestive heart failure (CHF) results in a poor

prognosis and associated with increased mortality.

• Studies have reported:

• Reduced CV risk with higher endogenous T concentration

• Improvement of known CV risk factors with T therapy

• Reduced mortality in T-deficient men who underwent T replacement therapy

versus untreated men

 

• Testosterone replacement therapy (TRT) reported to:

• Improve myocardial ischemia in men with CAD

• Improve exercise capacity in patients with CHF

• Improve serum glucose levels, HbA1c, and insulin resistance in men with

diabetes and prediabetes

 

CONSEQUENCES of Low T in Men

• Frailty

• Reduced lean body mass

• Reduced muscle strength

• Increased total body and

central obesity

• Reduced cognitive function

• Decreased/Low libido

• ED

• Loss of body hair

• Weight gain

• Mood changes

• Increased cardiometabolic

issues – IR, dyslipidemia,

atherosclerosis

• Poor athletic performance

• Increased mortality

 

Consequences of Low T in Women

• Fatigue

• Muscle weakness

• Increased CV events

• Sleep disturbances

• Reduced libido

• Decreased sexual satisfaction

• Weight gain

• Fertility issues

• Irregular menstrual cycles

• PCOS

• Vaginal dryness

• Loss of bone density

• Poor athletic performance

• Increased mortality

 

Low Testosterone and Sleep

• Testosterone levels display circadian variationPeak during sleep

• Superimposed on this are burst-like increases in testosterone production

• Occur every 90 min or so

• due to pulsatile LH secretion

• Increase in T during sleep requires at least 3hr sleep

• Sleep disorders can reduce T levels1

• Low total testosterone may affect overall sleep quality

• Especially older men

• Improved by T replacement

• Low T doesn’t seem to affect OSA (sleep apnea)

 

What are SARMs?

• Steroidal SARM vs. Nonsteroidal SARM

• Nonsteroidal SARMs pioneered by scientists at Ligand Pharmaceuticals and the

University of Tennessee, Knoxville

• Synthetic drugs w/ effects similar to testosterone

• Lignans that bind to cellular androgen receptors - modulate

• Found in some body building and performance enhancing supplements

• Still FDA unapproved for human use

 

• Used to increase muscle mass, decrease fat, improve bone density, performance

• Non-steroidal anabolic

– More non-specific binding

– Produce undesired effects or pharmacokinetic profiles

• Selective receptor stimulation more desirable than ”conventional” testosterone

support

 

Uses of SARMs

• Sold as research chemicals – similar to peptides

• Performance enhancing - for “bulking” and “cutting”

• Stacking – combinations of SARMs used

• Studied as potential treatments for

• Male contraception

• Cancer – breast, prostate CA

• Osteoporosis, improved BMD

• BPA – prostate issues

• Sexual dysfunction

• Multiple sclerosis, muscular dystrophy

• Alzheimer’s disease

• Cancer related Cachexia

• Sarcopenia

• Frailty; anti-aging

 

Why SARMs?

• As men and women age, GONADAL axis becomes imbalanced

• Lose skeletal mass, strength, power

• Mostly due to preferential loss of type 2 muscle fibers

• Increases risk of:

• Falls

• Fractures

• Mobility limitations

• Physical disability

• Poor QOL

• Functional decline and dependence in older individuals place a large burden on

health care services and costs

• Potential to improve skeletal muscle remodeling and gains in skeletal muscle

strength and muscle mass are based on circulating testosterone levels

• Administering anabolic steroids full of adverse effects

• Erythrocytosis

• Leg edema

• Prostate events

 

Potential SARMs Benefits

• High oral bioavailability

• Similar effects to testosterone (libido, strength gains, fat loss etc.…)

• No conversion to dihydrotestosterone (DHT) by 5 alpha-reductase

• No aromatase conversion to Estrogens

• Improved bioavailability vs. oral steroids/prohormones

• No significant liver toxicity from methylated compounds

• Does not inhibit your HPTA – hypothalamus-pituitary-testicular-adrenal

axis - to the large extent of steroids (no large reduction in LH or FSH)

 

Available SARMs

• Acadibol (ACP-105, AC-262536)

• Andarine (GTX-007, S4, S-4)

• Ostarine/Enobosarm (MK-2866, GTX-024)

• LGD-3033

• Ligandrol (LGD-4033)

• Stenabolic (SR-9099)

• Testolone (RAD-140)

• S-22

• S-23

• YK-11 (TK-11-OA)

• YK-500

• Cardarine, Endurobol (GW-501516) –

PPAR-omega agonist

• GSK2881078

• Ibutamoren (MK-677) – not for

compounding

 

Most Popular SARMs*

• Ostarine (MK-2866) - developed in 1990s

• Ligandrol (LGD-4033)

• Testolone (RAD-140)

• Andarine (GTx-007, S-4)

 

SARM Potential Side Effects

• Phase I and II trials, the first generation ORAL SARMs

have reported:

• Significant reductions in HDL cholesterol

• Significant reduction in SHBG concentrations

• Mild transient elevations of AST and ALT

• Insulin resistance, blood glucose dysregulation

• Headache, nausea, fatigue, back pain

• Altered parameters return to normal after cessation of tx – even at

doses 10x clinical

• Systemic administration may reduce these finding

 

Other potential SE’s

• Decreased endogenous testosterone

• Reduced sex drive

• Erectile dysfunction

• Infertility issues

• Muscle weakness

• Loss of bone density

• Weight gain accompanied by increased body fat

• Insomnia

• Depression

 

THE IMPORTANCE OF A PATHWAY TEST

• If the patient is takin estrogen, or birth control

pills, that estrogen can go down CIP1A1

pathway, it’s a very protective pathway and can

help protect from cancer

• If it goes down 16HIDROXY STRONE pathway, is

not that safe it’s a stronger estrogen

• And if it goes down 4HIDROXI STRONE this one

damages DNA its carcinogenic

 

Drug Interactions studied:

• Ostarine (and its major metabolite) and itraconazole, probenecid,

celecoxib, and rosuvastatin

• No clinically relevant or significant results

• Whether “stacking” SARMs increases side effects or drug interactions

is not known

 

• 2017 – FDA issues public advisory statement

• “SARMs were being included in bodybuilding products and that these

compounds posed an increased risk for heart attack, stroke, and liver

damage”

• FDA issues warning letters to several distributors for products containing

SARMs

• Products labeled as “dietary supplements” but deemed NOT by FDA

• Potential for life threatening reactions, including liver toxicity

• SARMs also have potential to increase the risk of heart attack and stroke

• Long-term effects on the body are unknown

 

SARMs - Safety

• Most important point - DO NOT PURCHASE from the INTERNET – Purchase from

Compounding Pharmacies

• 2017 study – compared chemical identity/amounts of ingredients of SARM

dietary supplements and products marketed and sold through the Internet

• Compared the analyzed contents to their product labels

• Study - 44 products marketed and sold as SARMs were tested

• Only 52% contained one or more actual SARMs as labeled

• No actives were detected in 9%

• FINAL RESULTS: Only 41% of internet products were labeled appropriately

 

SARMS - Cautions

• DO NOT USE INTERNET PRODUCTs

• Dosages and durations need to be followed

• Potential interactions reviewed – drug, food, supplement

• Monitor labs

• T free, total and bioavailable

• DHT

• SHBG

• Estrone

• Estradiol

• Liver enyzymes, bilirubin

Circadian Rhythm and Genes

• Clocks in cells are run by genes, the proteins CLOCK and BMAL1 act as activators,

and members of the periods (PER) and cryptochrome ( CRY) families are repressors

• Receptors in the retina receive light cues, which are carried through the

hypothalamic optic tract and transmitted to the SCN, resulting in its

SYNCHRONIZATION

• Clocks in organs and tissues ( peripheral clocks) can be changed by feeding

rhythms, exercise, social activity, temperature, humidity

 

 

Circadian Rhythm and synchrony with nature

• Disharmony and disturbance with

the circadian clock will lead us to

disease

• Lifestyle, shift work at night, sleep

cycle, food habits

• Mutation in circadian genes

• Metabolic obesity, cardiovascular

disease, phycological behavioral

 

Circadian Desynchrony

• CNS: depression

• Pancreas: Hyperinsulinemia

• Muscle: Insulin resistance,

sarcopenia

• Adrenals: Chronic Fatigue

• Hematopoietic: Autoimmunity

• Vasculature: thromboembolic

events

• Intestine: Dysbiosis

• Adipose: obesity

• Liver: dyslipidemia

 

Disruption of the circadian Rhythms

• When the circadian rhythms get

broken, dysregulation of the

circadian genes PER,CRY,BMAL1

• Our epigenome starts changing

 

Sleep

• Most individuals should obtain at least 7-9 hours of quality sleep a night

(Centers for Disease Control, CDC, 2011).

Centers for Disease Control (CDC). www.cdc.gov.

• 67% of Americans experience frequent problems sleeping

• 43% say lack of sleep interferes with their daily activities.

• Between 9-12% of the population are clinically diagnosed with insomnia

 

Insomnia or disrupted sleep

• Disruption of the circadian rhythm

• Alters Growth Hormone release

• Increases TNF alpha, IL-6

• Increases insulin resistance

• Contributes to weight gain

• Alters Digestive health

 

Sleep support

Melatonin ( sleep regulator)

• natural hormone supports sleep cycles

• Antioxidant

• decreases w/ age

• Improves circadian insulin production

• Used for sleep problems

• Antioxidant

• 3-20mg 1 hr before bedtime

• Watch for paradoxical effects

 

Stress Reduction:

1. Glycine has been suggested to have an anxiolytic (anti-anxiety) effect,

potentially reducing stress and promoting a calm state conducive to sleep.

2. By modulating neurotransmitter activity, glycine may help individuals unwind

and relax before bedtime, leading to improved sleep outcomes.

Sleep Disorders:

• Glycine supplementation has shown promise in certain sleep disorders. For

example, studies have explored its potential benefits in individuals with insomnia,

sleep apnea, and restless leg syndrome.

 

Intermittent fasting

• Stimulates growth hormone Improved cognition

• Decreased neurodegeneration

• Stimulates brain derived neurotrophic factor (BDNF)

• Weight loss

• Improved blood pressure

• Cancer protective

• Improved insulin sensitivity

• Increased PGC1 alpha

• Decreased inflammation

• Reduces oxidative stress

• Rids body of excess fluid

• Improves adaptive responses

 

• 3 week alternate - day fasting

• Improved fat oxidation

• Improved weight loss

• Improved insulin sensitivity

• Improved HDL

• Triglycerides decreased

• Improved adiponectin (37%)

 

• Glycine

Neurotransmitter Regulation:

• Glycine acts as an inhibitory neurotransmitter in the central nervous system,

playing a role in modulating neuronal activity and promoting relaxation.

• It can counteract the effects of stimulating neurotransmitters, such as glutamate,

and help regulate the balance between excitatory and inhibitory

neurotransmission

 

Melatonin Depleted by

• Beta-blockers

• Calcium channel blockers

• Benzodiazepines

• Estrogen-containing medications

• Hydralazine

• Loop diuretics

• Theophylline

• Antidepressants, including SSRI (Selective serotonin reuptake inhibitors)

• NSAIDs (Non-steroidal anti-inflammatory drugs)

 

Extracellular Matrix

• The extracellular matrix is a supportive network comprised of

connective tissue, collagen fibers, water, lymphatic vessels, and all the

tributaries in the lymphatic system that creates the environment

between and around cells.

• It is not just for the physical support of the cells, but also is integral to

the function and behavior of the cells in many different ways.

• It controls the life cycle of the cells.

• Modulates and influences how growth factors are utilized; 15 - 20

growth factors are regulated in the ECM such as glycoproteins.

 

• The ECM is a three-dimensional network that contains all the organs,

tissues, and cells of the body, playing a fundamental role in

protection, nutrition and cell innervation; it is the substrate where

the response of the immune system takes place, angiogenesis,

fibrosis, and tissue regeneration occur.

• Receives Innervation from the free endings of the ANS fibers, which

behave as a synapse with the cells of the matrix and parenchyma.

• The alteration of the ECM will lead to a loss of its function, affecting a

correct immune response to infectious, tumor and toxic agents.

 

Definition of Neural therapy

• Injections of local anesthetic in low concentrations in specific points

of the nervous system with therapeutic and diagnostic purposes

• Specific points based on the patient’s clinical history

• The main objective is to eliminate irritations of the nervous system,

primarily of the autonomic nervous system to restore its regulatory

function

Procaine

Neural Therapy technique primarily involves the injection of local anesthetic

called Procaine (Novocain) into scars, trigger points, tendon and ligament

insertions, peripheral nerves, autonomic ganglia, and different tissues

It is hydrolytically broken down within a few minutes by plasma

cholinesterase.

It is used in the form of Procaine Hydrochloride diluted to 0.5% or 1%, without

excipients and without mixing

Vasodilation , anti inflammatory, anti rheumatic, improves coronary

perfusion, negative inotrope, antiarrhythmic, antimicrobial anti cancer