Can We Cure NO/ONOO (Feb/March 2010) Townsend Letter for Doctors & Patients

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Can We Cure NO/ONOO (Feb/March 2010)

Townsend Letter for Doctors & Patients

http://www.townsend letter.com/ FebMarch2010/ cureNO0210. html

 

Abstract

The NO/ONOO− cycle is a biochemical vicious

cycle that is thought to cause such diseases as chronic fatigue syndrome/myalgic

encephalomyelitis (CFS/ME), multiple chemical sensitivity (MCS), fibromyalgia

(FM), and possibly a large number of other chronic inflammatory diseases. The

chemistry/biochemis try of the cycle predicts that the primary mechanism is

local

such the depending on where it is localized in the body, it may cause a variety

of different diseases. Previous studies have shown that agents that lower such

cycle elements as oxidative stress, nitric oxide, inflammatory responses,

mitochondrial dysfunction, tetrahydrobiopterin (BH4) depletion and NMDA activity

produce clinical improvements in CFS/ME and FM patients, consistent with the

predictions of the cycle mechanism. Multiagent protocols lowering several

aspects of the cycle appear to be the most promising approaches to therapy.

These include an entirely over-the-counter nutritional support protocol

developed by the author in conjunction with the Allergy Research Group. However,

such mulitagent protocols to date have not produced any substantial numbers of

cures of these presumed NO/ONOO− cycle disease. Why is that? This paper argues

that what is called the central couplet of the cycle, the reciprocal relation

between peroxynitrite elevation and BH4 depletion, is not being adequately

downregulated by these multiagent protocols. Ten agents/classes of agents are

available, each of which downregulates one or the other end of this central

couplet. It is suggested, then, that treatments that simultaneously effectively

downregulate both ends to the central couplet, when used along with multiagent

protocols lowering other aspects of the cycle and avoidance of stressors that

otherwise upregulate the cycle, will lead to substantial numbers of cures of

these chronic diseases.

The basic concept of the NO/ONOO−

vicious cycle mechanism is simple. It is that various short-term stressors can

initiate this cycle which, like all vicious cycles, propagates itself over time.

The cycle then, depending on where it is located in the body, causes various

chronic diseases. But in order to treat chronic diseases caused by the

NO/ONOO−

cycle and hopefully cure them, one needs to understand the details of the cycle

mechanism. And that is where things becomes much more complex.

The

NO/ONOO− cycle is a primarily local biochemical vicious cycle that appears to

be

the central cause of such multisystem diseases as chronic fatigue

syndrome/myalgic encephalomyelitis (CFS/ME), multiple chemical sensitivity

(MCS), fibromyalgia (FM) and posttraumatic stress disorder (PTSD).1-7

Cases of all four of these share many symptoms and signs and are each highly

variable from one patient to another.1-4 These diseases often occur

together in specific patients, that is they are comorbid.1-4,6,7 The

variations among different patients is explained by the primarily local nature

of the cycle, such that the different tissue localization of the NO/ONOO−

cycle

from one case to another produces different tissue impact and therefore

different symptoms and often different diagnoses.1-3

The

NO/ONOO− cycle is diagrammed in Figure 1. Each of the arrows shown represents

one or more mechanisms by which one element of the cycle raises the levels of

another cycle element. There are now a total of 30 specific mechanisms involved

here, most of which are well-documented, well-accepted biochemistry and

physiology.1-3 The three mechanisms that were least documented at the

time my book was published are now substantially better

documented.1,2 Consequently, there is very little that is truly

original about the NO/ONOO− cycle mechanism, except that when taken together,

the individual mechanisms act to produce multiple, interacting vicious cycles

that explain the chronic nature of these diseases, the challenges in treating

them, and many other important features.1-7

Central to the

cycle is the reaction of two free radicals in the body, nitric oxide with

superoxide to form peroxynitrite (abbreviated PRN in Figure 1). Peroxynitrite, a

potent oxidant, produces oxidative stress (lower center, Figure 1). On the right

side of Figure 1 are a number of inflammatory responses, including elevation of

the transcription factor NF-kappa B, increased production of inflammatory

cytokines (upper right box) and also induction of the inducible nitric oxide

synthase (iNOS). These predict that much of the inflammatory cascade will be at

least modestly elevated in NO/ONOO− cycle diseases.

Nitric oxide synthase

activity may be elevated not only from iNOS induction but also from the

calcium-dependent elevation of the other two nitric oxide synthases, nNOS and

eNOS (upper center). Multiple mechanisms lead to increases in superoxide (center

left) both intramitochondrial and extramitochondrial. And mitochondrial

dysfunction leads to lowered energy metabolism and depletion of ATP, the energy

currency of the cell (lower left). Another important cycle element is the

elevated activity of the NMDA receptors which leads, in turn to what has been

called excitotoxicity (Figure 1, top). NMDA receptors have been most studied in

the central nervous system but are widely distributed in both neuronal and

non-neuronal tissues and may, therefore, have widespread roles in the NO/ONOO−

cycle as it affects various regions of the body.8

Figure 1. NO/ONOO− Cycle diagram

Probably the most important part of the

cycle is what I have called the central couplet, the reciprocal relationship

between elevated peroxynitrite (abbreviated PRN) and the depletion of a compound

called tetrahydrobiopterin (BH4) (see Figure 1 center to below center).

Peroxynitrite oxidizes BH4 at physiologically relevant concentrations leading to

a BH4 depletion.9-11 BH4 is a cofactor in nitric oxide synthases,

such that when these NOSs are missing BH4, they become uncoupled, producing

superoxide in place of nitric oxide. In partial uncoupling, this superoxide can

react in turn with the nitric oxide produced by adjacent coupled enzymes,

leading to more peroxynitrite. Because the reaction between superoxide and

nitric oxide is extraordinarily rapid, what is called diffusion controlled, the

production of both molecules by adjacent enzymes may be particularly effective

in raising peroxynitrite levels. Thus, although this partial uncoupling lowers

nitric oxide production, it is expected to increase peroxynitrite production,

the most central part of the wider NO/ONOO− cycle.1-3,11 The

superoxide produced by such partial uncoupling has a special role, then, in

producing peroxynitrite. It should be noted that the production of superoxide

remote from the production of nitric oxide will be much less effective in

raising peroxynitrite levels because there are high amounts of superoxide

dismutase in cells and extracellular fluid, which destroys most of the

superoxide before it travels very far from its site of synthesis.

The

importance of this reciprocal relationship between peroxynitrite elevation and

BH4 depletion, what we are calling the central couplet, has also been proposed

by Foxton et al. in the context of its role in neurodegenerative diseases –

diseases that are also proposed to be consequences of the action of the

NO/ONOO−

cycle.1,11,12

Types of Evidence Supporting the

NO/ONOO− Cycle Mechanism

There are multiple

types of evidence, each of which provides substantial support for a NO/ONOO−

cycle etiology for the multisystem diseases CFS/ME, MCS, FM, and PTSD, including

but not limited to the following:

There are a total of 17 distinct short-term stressors that

are reported to initiate cases of one or more of these diseases, and all 17

are known to be able to stimulate cycle elements, and known or presumed to in

turn increase subsequent nitric oxide and peroxynitrite.1-3 They

can therefore initiate the cycle via these mechanisms.

The various cycle elements have been found to be elevated

in the chronic phase of illness in at least one and in most cases all four of

these diseases.

Several aspects of the cycle are implicated by genetic

studies of susceptibility.1-3

The cycle is supported by animal model studies of CFS/ME,

PTSD, and MCS, with the most extensive such animal model evidence for

MCS.1-3,5

The most important types of evidence, from the standpoint

of patients or care providers, is that on efficacy of possible therapeutic

agents. Studies of individual agents in clinical trials provide evidence for

efficacy of a variety of agents predicted to lower various aspects of the

NO/ONOO− cycle.1-3 This evidence is summarized in Table 1.

Table 1: Agents with Favorable Response in

Clinical Trials Predicted to Lower Aspects of the NO/ONOO− Cycle.

Agent(s)                                 

Probable

Mechanism                       

Comments

flavonoids, ecklonia

cava extract, algal supplements

chain breaking and other antioxidant

activity

Some may act as peroxynitrite

scavengers.

NMDA antagonists, other agents that indirectly

lower NMDA activity; magnesium

All act to lower excessive NMDA activity

 

acetyl carnitine/carnitine , coenzyme Q10, low

hyperbaric or normobaric oxygen

Improved mitochondrial function

Oxygen must be used with caution, particularly

in severe cases of CFS/ME

hydroxocobalamin form of vitamin B12

Reduced in vivo to a form that is a potent

nitric oxide scavenger.

Higher dosage (i.e., 5 to 10 mg) needed than is

needed to treat a B12 deficiency; Typically used via IM injection, as an

inhalant, or via nasal spray to obtain high blood levels; oral or

sublingual should be useful but are clearly suboptimal because of limited

absorption.

high-dose folates

Serves as precursor of 5-methyltetrahydrof olate

(5-MTHF), a potent peroxynitrite scavenger.

Unclear whether folic acid, folinic acid,

5-MTHF and/or other forms of folate should be used; folic and folinic acid

tested in published trials.

D-ribose, RNA, inosine

All act to increase uric acid levels

(peroxynitrite scavenger); all may act to help restore ATP pools.

Published trial on D-ribose; trial currently in

progress suggesting inosine can be helpful.

IV high dose, buffered ascorbate

Lowers both ends of central couplet (see

below); may be particularly helpful agent.

Discussed in detail below.

sauna therapy

Acts to increase BH4 availabiity; mechanism via

increased synthesis of GTP cyclohydrolase I.13

Trials published on MCS, FM and CFS/ME;

discussed further below.

fish oil

Established as anti-inflammatory agent.

May also improve brain

function.

Most studies involved CFS/ME and/or FM;

however studies with sauna therapy and IV ascorbate have been published with MCS

patients.

It can be seen from Table 1 that agents lowering various

aspects of the NO/ONOO− cycle are helpful in treatment of these three apparent

NO/ONOO− cycle diseases. Specifically, agents that lower oxidative stress,

lower

peroxynitrite, improve mitochondrial function, lower NMDA activity, increase BH4

availability, or have anti-inflammatory activity all appear to be helpful in

treatment. It is difficult to see how this could be the case unless the

NO/ONOO−

cycle or something very similar to it is the central cause of these multisystem

diseases.

The evidence summarized in Table 1 also strongly suggests that

the NO/ONOO− cycle makes very useful predictions in terms of therapy. Given

the

complexity of the cycle, as diagrammed in Figure 1, it seems likely that

multiple agents lowering various aspects of the cycle will be most effective in

producing clinical improvements in apparent NO/ONOO− cycle disease.

Multiagent Protocols and the

Allergy Research Group Nutritional Support Protocol

I described the responses to five

multiagent protocols developed by different researchers, one of which I had a

role in developing, in Chapter 15 in my book.1 Each of these five

involved 14 to 18 different agents or classes of agents that are predicted to

downregulate one or more aspects of the NO/ONOO− cycle. Each of these

apparently

produces substantial improvements in many patients suffering from these

multisystem diseases, although four of the five have only been tested on one

disease. In contrast, Teitelbaum's protocol has been tested on both CFS/ME

patients and FM patients with apparent positive results.14

More recently I have developed, in collaboration with the Allergy

Research Group, an entirely over-the-counter protocol based on nutritional

supplements chosen to downregulate the NO/ONOO− cycle. This nutritional

support

protocol is described elsewhere as well as on a page of my website

(thetenthparadigm. org/arg.htm) .2,3 It includes 22 agents chosen for

their ability to downregulate various aspects of the NO/ONOO− cycle as well as

other general nutrients.

The feedback I have gotten from clinical

observations of physicians and others who have used it to treat their CFS/ME,

FM, and/or MCS patients is that 80% to 85% of patients respond positively to it

and that improvements are typically maintained if patients can avoid exposure to

stressors that are predicted to upregulate the cycle.2,3 Even

patients who have been ill for two decades or more often respond positively. It

should be noted, however, that the extent of improvement tends to vary

considerably, from responses described as miraculous to modest improvements.

Furthermore, about 15% to 20% of patients do not improve. Patients with high

levels of mercury in their bodies may react negatively to the protocol,

presumably because mercury can be mobilized by the alpha-lipoic acid found in

the protocol. One group who appear not to respond substantially, either

positively or negatively, are the chronic Lyme disease patients.

Note: I

must point out to the reader that I do have a conflict of interest here. I

receive a small royalty from the Allergy Research Group for designing much of

this nutritional support protocol.

Ingrid Franzon and colleagues in

Sweden have run a small pilot study on the Allergy Research Group protocol with

a group of nine CFS/ME patients (personal communication) . She found,

surprisingly for such a small group, statistically significant improvement in

physical health measures within four weeks, with a further statistically

significant improvement over another four weeks (personal communication;

statistical analysis performed using a paired Student's t test).

In

summarizing the last two sections of this article, there are four important

points to be made: First, individual agents that downregulate specific parts of

the NO/ONOO− cycle have often been reported in clinical studies to produce

improvements in these multisystem- disease patients. Second, multiple parts of

the cycle are implicated from these clinical studies as well as from other

studies, producing strong confirmation that a mechanism like the NO/ONOO−

cycle

is the central etiologic mechanism of these diseases. Third, and not

surprisingly, treatment protocols using multiple agents predicted to

downregulate the cycle seem to be more effective than single agents. Fourth,

these several multiagent protocols are not effective with patients who are

repeatedly or continuously exposed to stressors that otherwise upregulate the

NO/ONOO− cycle.

Clearly, these four points are very important and

exciting, considering that the conventional wisdom has been that there is little

that can be done to treat these illnesses.

My own view is that the Allergy

Research Group nutritional support protocol is the most promising of these

multiagent protocols, because it is relatively inexpensive; it is available over

the counter in the US, Canada, and much of Europe; and it apparently achieves

good responses despite the limitations inherent in over-the-counter approaches.

The NO/ONOO− cycle etiology is best documented for CFS/ME, MCS, FM, and

PTSD, as well as for Gulf War syndrome/illness, which appears to be a

combination of the four.1-7  However, there is also at least a

superficial case to be made that 14 additional diseases, including the classic

neurodegenerative diseases asthma, multiple sclerosis, tinnitus, and autism,

appear to also be caused by the NO/ONOO− cycle.1  The cases that

have been made for each of these 14 are frankly relatively superficial, except

for tinnitus and postradiation syndrome, where more extensive cases have been

made.1,15,16 Thus this approach to the treatment of chronic disease

may not be limited to such diseases as CFS/ME, FM, MCS, and PTSD but have vastly

broader implications.

How

Can We Start Getting Substantial Numbers of Cures?

The use of multiple agent protocols where

individual agents act to lower the NO/ONOO− cycle is an exciting and promising

approach to treating these diseases. However, based on published and (to the

extent I have access to it) unpublished evidence, none of these protocols

produces any substantial numbers of cures.  If we understand the NO/ONOO−

cycle mechanism sufficiently and if we are effectively downregulating it, we

should start seeing substantial numbers of cures. Why has this not happened?

My own view, is that the central couplet is insufficiently downregulated

in these protocols. The main argument explored in this article is that by more

effectively lowering this central couplet mechanism, we may be able to extend

these multiple agent protocols to obtain substantial numbers of cures. As

described, the central couplet is the reciprocal relationship between

peroxynitrite elevation on the one hand and BH4 depletion on the other. We need

to focus, then, on agents that lower peroxynitrite and its products at one end

of the central couplet, and agents that raise BH4 availabliity on the other

end.

There are at least ten available agents that are predicted to

substantially lower the central couplet, summarized in Table 2; and we will

explore each of them one at a time.

Table 2: Agents/Classes of Agents Predicted to

Sustantially Lower the Central Couplet

Agent   

                     

Dosage           

   Presumed Mechanism(S)

IV buffered ascorbate

7–50 g,

repeated

1. Acts as peroxynitrite scavenger; 2. reduces

B back to BH4, helping restore BH4 levels; 3. the very high levels

obtained by IV treatment can lead to increased levels of hydrogen

peroxide, leading to induction of GTP cyclohydrolase I, thus leading to

increased de novo synthesis of BH4.

oral ascorbate

circa 2–3 g, repeated daily

Blood levels obtained are substantially lower

than for IV treatment, above. However such levels may be adequate to

trigger the first two mechanisms outlined immediately above.

sauna therapy

repeated

Induces GTP cyclohydrolase I, leading to

increased de novo synthesis of BH4.

reduced glutathione, liposomal, time release,

nasal spray, IV or inhalant

150–500 mg per day

Reduces BH2 back to BH4, thus helping restore

normal BH4 levels and lowering the partial uncoupling of the nitric oxide

synthases; some, particularly those with asthma-type symptoms, may have

some difficulty tolerating this treatment, depending on dosage

regimen.

Inosine, RNA, or D-ribose

varies

Each of these has the capability of producing

two responses: restoration of adenine nucleotide pools and increased uric

acid levels in blood. The latter will lead to lowered levels of

peroxynitrite breakdown products, NO2 radical and carbonate radical. Each

of these agents have drawbacks (see text).

5-methyl tetrahydro-

folate (5-MTHF) or

precursors folic or folinic acid

300 µg/day for 5-MTHF, higher doses for

precursors

Acts as a potent peroxynitrite scavenger and

will therefore help also restore BH4 pools; high dose folic or folinic

acid will act to help raise 5-MTHF pools. 5-MTHF pools are depleted in

CFS/ME, presumably due to peroxynitrite mediated oxidation.

tetrahydro-

biopterin (BH4) or precursors of

BH4 biopterin or sepiapterin

circa 5 mg or less, oral daily

Helps restore BH4 pools; also acts as

peroxynitrite scavenger. This would be an off-label use of BH4.

vasoactive intestinal peptide (VIP)

IV or inhalant

Induces GTP cyclohydrolase I, leading to

increased de novo synthesis of BH4; this would be an off-label

use.

flavonoids, ellagic acid, other phenolic

antioxidants

??, oral

Probably act to scavenge peroxynitrite and

breakdown products and may also act more directly to help restore BH4;

dosage and optimal sources are unclear.

hydroxocobalamin

IM injection, nasal spray or inhalant

Acts in the reduced form (cobalt II) as a

potent nitric oxide scavenger; this will indirectly lower peroxynitrite

because of the role of nitric oxide as a peroxynitrite

scavenger.

Taken from the author's website with

permission.

General Strategy and Relationship to Lowering

Hypertension

The general strategy is that an effort to lower the

central couplet will be made, as a second phase to a treatment in which the

first phase is a wide-ranging protocol lowering other aspects of the cycle

together with avoidance of stressors that will otherwise upregulate the cycle.

The Allergy Research Group nutritional support protocol for doing this is

described on my website (thetenthpardigm. org/arg/htm) , as well as

elsewhere.2,3 The overall concept is that by lowering various aspects

of the cycle and then focusing on lowering the central couplet, we should start

seeing some cures of NO/ONOO− cycle diseases. Let me remind the reader, that I

am a PhD, not an MD, and nothing I say or write should be viewed as medical

advice.

A second part of this general strategy is that by using

relatively high doses of agents that act collectively to lower both ends of this

central couplet, one may get responses that may go up as much as the square of

the dose of these combinations of agents. Relatively high doses of agents that

are acting at the same time to lower both sides of the couplet may be most

effective. This may be expected because this central couplet is just that, a

couplet wherein lowering peroxynitrite will increase the availability of BH4,

and independently increasing the availability of BH4 will lower peroxynitrite

and its products. Therefore, doing both of these simultaneously can have a major

impact in lowering this central couplet.

The effectiveness of agents in

accomplishing this task may be judged to some extent by their ability to lower

hypertension. Hypertension is thought to be caused by shifting the ratio of

nitric oxide to peroxynitrite, towards excessive peroxynitrite, something that

is produced by the action of the central couplet. This role in hypertension is a

consequence of the following: whereas nitric oxide is a vasodilator,

peroxynitrite is a vasoconstrictor, acting in part by raising the levels of

isoprostanes, which are potent vasoconstrictors. For example, vasopressin II

acts to produce hypertension by inducing higher levels of NADPH oxidase, an

enzyme whose activity produces superoxide.17 The reaction of

superoxide with nitric oxide will produce peroxynitrite and thus turn on the

central couplet. Depletion of BH4 levels has been shown to have an important

role in causing hypertension.18-20

Treatments that lower

hypertension may be suggested to be effective agents in lowering the central

couplet. However, because hypertension occurs outside the central nervous system

but some NO/ONOO− cycle diseases may be localized to a great extent in the

brain, agents that fail to traverse the blood–brain barrier may act on

hypertension but may not effectively lower central nervous system–located

NO/ONOO− cycle diseases. It is important, therefore, to keep this restriction

in

mind, because it may limit the prediction that treatments that lower

hypertension will work to produce improvements in NO/ONOO− cycle diseases.

Let us discuss the apparent mechanisms of action of the 10 agents

discussed in Table 2.

IV

Ascorbate

Intravenous (IV) ascorbate (vitamin C) can produce levels of

ascorbate in the blood of 100 times or more the upper level of

" normal. " 21-24 By doing so, it may produce effects vastly greater

than one will get from normal pools sizes of ascorbate. IV ascorbate, typically

using 7 to 50 g of buffered ascorbate, has been successfully used to treat MCS

or CFS/ME patients; and, in addition, I am aware of a number of physicians who

have reported successfully treating these patients with such doses of buffered

IV ascorbate.25-28 Such IV ascorbate treatments appear to be well

tolerated, even at doses roughly 4 times the highest doses suggested here,

except possibly when two contraindications are present (see

below).21-24,29

There are three effects of ascorbate that may

be expected to occur in response to such high levels:

Ascorbate is a scavenger of peroxynitrite and its breakdown

products, but has only modest scavenging activity at normal ascorbate blood

levels.30-32 It will be expected to have much greater scavenging

activity with levels many times the normal upper level.

When peroxynitrite oxidizes BH4, the initial product is B,

the one electron oxidation product. B can be reduced back to BH4 by ascorbate,

which is, of course, a reducing agent.30,32 However, B is itself

unstable and will probably therefore require high levels of ascorbate to

efficiently produce such reduction.9,10,30 

The very high levels of ascorbate produced by such IV

treatment produces hydrogen peroxide via ascobate oxidation and concomitant

reduction of molecular oxygen.21-24,33,34 Hydrogen peroxide is

known to be able to induce the enzyme GTP cyclohydrolase I, the first and

rate-limiting enzyme in the de novo pathway to synthesize BH4.35-37

It follows that IV ascorbate may be expected to increase the availability of

BH4 by this mechanism, as well as by the preceding one.

It follows that IV ascorbate may be

able to favorably affect both sides of the central couplet, lowering

peroxynitrite and its products and also, via two distinct mechanisms, increasing

availability of BH4. This set of three mechanisms collectively produces a

rationale for the use of IV ascorbate in the treatment of these multisystem

illnesses. To my knowledge, there has been no previous rationale for such

treatment, despite its reported effectiveness.

It will probably be

important to determine that patients to be treated with such IV ascorbate do not

have highly elevated levels of free iron, to avoid triggering extensive Fenton

chemistry with the ascorbate treatment. Typically, this means that serum iron

binding capacity should be no more than the upper limit of " normal " ; that is, no

more than 55% saturated.

In addition, those with a genetic

glucose-6-phosphate dehydrogenase (G6PD) deficiency are susceptible to hemolysis

caused by IV ascorbate because they are less able to detoxify the consequent

hydrogen peroxide, so that treating such patients with IV ascorbate is

contraindicated.38 Patients should therefore be tested for possible

G6PD deficiency and for elevated free iron, and only those lacking both of these

contraindications should be treated with high-dose IV ascorbate.

IV

ascorbate used in such treatment should be buffered to the physiological pH of

the blood (7.4) to avoid shifting the pH. Such buffering particularly important

in those with kidney dysfunction who are less able to regulate the pH of the

blood.

With the exception of cancer treatment, where IV ascorbate is

thought to act mainly via increased production of hydrogen peroxide, there has

been no widely applicable rationale for its reported effectiveness in the

treatment of other diseases. The mechanisms described in this section are

important, therefore, in providing such a rationale, one that makes important

predictions about how IV ascorbate treatment may be useful and what strategies

can maximize its efficacy. 

Oral

Ascorbate

Oral ascorbate can yield levels typically circa three times

the upper range of normal with doses of 2 to 3 g. Such doses and somewhat lower

doses are reported to lower hypertension, suggesting that they may be able to

decrease the central couplet.18,39-41 Typically, such high blood

levels are only maintained for relatively short periods of time, on the order of

4 hours.22 Although 2 to 3 g of oral ascorbate lead to absorption

over 3 to 4 hours, there is also rapid excretion of high blood levels of

ascorbate; that is, of levels well in excess of normal.22 The levels

of ascorbate produced by 2 to 3 g or higher doses of oral ascorbate may be

expected to trigger substantial peroxynitrite scavenging, as well as some

chemical reduction of B to BH4, but not any substantial hydrogen

peroxide–induced increased levels of GTP cyclohydrolase I (see previous

section).30-32

It follows that such doses of oral ascorbate

may be expected to act to lower the central couplet, although they will be less

active in so doing than the much higher IV doses.

Sauna

Therapy

Sauna therapy has been reported to be helpful in the treatment

of MCS, FM, and CFS/ME, as well as with other diseases characterized by BH4

depletion. 42-50 Sauna therapy is thought to act via two distinct

mechanisms to induce higher levels of GTP cyclohydrolase I and thus increased

availability of BH4.50 Substantial increased availability probably

only occurs after repeated sauna treatment.

In terms of strategy,

therefore, it seems likely that sauna therapy could be useful in trying to cure

these diseases, as follows: after several sauna treatments, subsequent sauna

treatments should be accompanied by treatments with one or more agents that

scavenge peroxynitrite and possibly also one or more agents that help reduce

previously oxidized biopterin forms, such as B and/or BH2, to BH4.

Reduced Glutathione

BH4 oxidation by peroxynitrite

produces initially B, much of which is rapidly oxidized further to BH2, the two

electron oxidation products. BH2 can be reduced back to BH4 by reduced

glutathione and other thiol compounds.30 Therefore, raising reduced

glutathione levels may be useful in restoring BH4 availability.

Oral

glutathione typically gets degraded in the GI tract, but a number of approaches

can be used to try to increase it. These include using oral liposomal or

possibly time-release oral glutathione, or reduced glutathione via nasal spray,

IV, or nebulized inhalant. Reduced glutathione has, of course, several other

antioxidant properties that should make it useful in the treatment of NO/ONOO−

cycle diseases, so clearly its actions are not specific to lowering of the

central couplet.

There is one complication to using reduced glutathione

in those who have asthma-type responses: they report that reduced glutathione

treatment may trigger asthma attacks. I think that this is probably due to the

action of reduced thiols in activating some of the transfer receptor potential

(TRP) receptors, including TRPA1. In any case, it can cause problems. This

problem is probably most substantial when using inhaled nebulized glutathione,

but other treatment modalities may occasionally cause such reactions.

Nevertheless, I am aware of reports that reduced glutathione treatment can be

very helpful in the treatment of NO/ONOO− cycle diseases, so it should be

considered as a therapeutic agent.

Inosine, RNA, or D-Ribose

I have lumped these three

agents together because each of them is expected to produce two specific

favorable responses. One of these two responses acts to lower the central

couplet. Let's consider the response unrelated to the central couplet first, and

then the one that lowers the couplet.

Each of these three agents will

raise levels of purine nucleotides in the body, including the adenine

nucleotides that comprise ATP and others (ADP and AMP) that can act as

precursors for ATP. ATP is, of course the " energy currency " in the body, and its

levels will be depleted whenever there is mitochondrial dysfunction. Because

mitochondrial dysfunction is part of the NO/ONOO− cycle, this will occur in

cycle diseases. When it is sufficiently severe, it will lead to accumulation of

fairly large amounts of AMP, which will be degraded further, lowering the levels

of all of these adenine nucleotides (that is, ATP+ADP+AMP) . This causes a

longer-term problem, because when and if there is an improvement in

mitochondrial function, the lowered adenine nucleotide levels mean that the cell

has a problem is producing normal ATP pools, even when the mitochondria are

otherwise capable of doing so. Each of these three agents will allow the

production of increased adenine nucleotides, potentially leading in turn to

increased ATP. This is the interpretation that has been given to the

improvements reported for D-ribose treatment of both CFS/ME and FM, and it may

be partly responsible for that improvement.51

However, there

is a second response to all three of these agents that will directly lower the

central couplet. Increased purine nucleoside and nucleotide pools will

subsequently produce increased purine degradation, the end product of which is

uric acid, an important scavenger of peroxynitrite and its breakdown products in

humans.31,52 Of course, by lowering peroxynitrite and its oxidant

products, uric acid will lower the central couplet.

Uric acid levels in

the blood are often about 4 to 5 times those of ascorbate, although there is

quite a bit of variation around those figures. However the effectiveness of uric

acid in scavenging peroxynitrite and its products, per mole, is roughly similar

to that of ascorbate.31 Consequently, even though it is possible to

raise ascorbate levels by much higher percentages than uric acid levels in vivo,

it seems likely that raising uric acid levels will produce a substantial effect

on peroxynitrite- mediated oxidations in vivo and therefore should be considered

well worth pursuing in lowering the central couplet.

Uric acid has a

half-life of about 20 hours in humans, so it should not take very long to

increase its levels by increasing the availability of purine-containing

compounds in the body, such that when an increase in purine degradation is

obtained, it will be sustained substantially longer than any high-level

ascorbate elevation.53 Consequently, it makes sense to consider each

of these three supplements – inosine, RNA, and D-ribose – as possible agents

to

raise uric acid levels.

While each is expected to be helpful in two ways,

one of which lowers the central couplet, each of these three agents also has a

possibly problematic feature:

D-ribose is a potent glycating agent, being

approximately 50 times more active in glycation than is D-glucose (the normal

sugar in the blood), with substantial possible physiological effects of such

D-ribose mediated glycation.54-56 Protein glycation is associated

with aging and produces dysfunction of many glycated proteins.

The

commercial source of RNA is yeast, and some sufferers of these diseases have

yeast allergies and so may have difficulty in tolerating RNA.

Inosine is

in general a well-tolerated supplement.57 However, it can stimulate

the activation of mast cells, and people with these illnesses often have

problems with excessive mast cell activation. Inosine is known to act to

stimulate mast cell activation via the adenosine A(3)

receptor.58

Of these issues, the one that concerns me the most

is the glycation via D-ribose, although I know that Dr. Teitelbaum, whom I

respect greatly, disagrees with me on this.

People with these diseases tend

to be low in uric acid, presumably because of the oxidation of uric acid by

peroxynitrite and its breakdown products. Because of the important role of uric

acid in lowering peroxynitrite- mediated damage, it seems likely that raising

uric acid levels may be an important approach to lowering the central couplet.

One does need to be careful not to raise uric acid levels too much, because

excessive levels can cause gout. In normal people, this is not a problem,

because uric acid excretion greatly increases as blood levels exceed normal

levels; but it may be a concern in those who are susceptible to gout, where the

excretion mechanism may not function properly.

A second, related issue

is that very high uric acid levels may produce hypertension, and while direct

measurements suggest that uric acid lowers nitric oxide synthase uncoupling,

rather than raising it, this also suggests that we should limit the rise in uric

acid levels in these treatments.

With these two caveats in mind, a

substantial rise in uric acid levels into the mid-to upper-normal range may be

very helpful to people suffering from NO/ONOO− cycle diseases.

5-Methyltetrahydrof olate (5-MTHF)

It has been known for

a number of years now that high-dose folic acid supplements can lower partial

nitric oxide synthase uncoupling (this has been most studied with the eNOS

nitric oxide synthase form), with much of this effect being due to increased

availability of BH4.59-62 This response depends on the reduction of

the folic acid by the enzyme dihydrofolate reductase, showing that a reduced

form of folate probably has a role here. What has been unclear until recently is

the reduced folate's mechanism of action.

It has been shown, however,

that 5-methyltetrahydrof olate (5-MTHF) is an extremely potent peroxynitrite

scavenger, so the probable mechanism of action is the lowering of peroxynitrite

and its breakdown products.63,64 In other words, this is another

situation in which the central couplet is involved, such that by lowering one

end of the couplet (the peroxynitrite end), one also lowers the other end

(increasing BH4). Another reduced folate, tetrahydrofolate, also acted as a

peroxynitrite scavenger, although it was less active than was

5-MTHF.63

This action of 5-MTHF is also supported by its role

in vivo and in vitro as an extremely active scavenger of singlet

oxygen.65 Singlet oxygen is known to share chemical similarities to

peroxynitrite because both molecules have very weak oxygen–oxygen bonds, so

the

similar scavenging of both molecules by 5-MTHF should not be

surprising.

It has been shown that high-dose oral folic acid can lead to

major increases in 5-MTHF. For example, Doshi et al. in their figure 5 showed

that a single 5 mg folic acid supplement in humans led to roughly seven times

the initial blood levels of 5-MTHF in 3 to 4 hours.66 They also

showed that repeated daily 5 mg doses produced still higher 5-MTHF levels,

roughly 15 times the initial levels, an effect that they attributed in part to

an induction of the dihydrofolate reductase enzyme.

son et al.

showed that levels of 5-MTHF in the sera from CFS patients were very low

compared with normals and that other reduced folate pools were also

depressed.67 I am aware of extensive unpublished data on CFS/ME

patients, confirming these results. Gerwin reported that folate deficiency was

one of the three most common systemic factors in myofascial pain syndrome, a

condition closely linked to fibromyalgia.68 These studies strongly

suggests that elevated peroxynitrite levels in CFS/ME and possibly other

multisystem illnesses may produce a substantial loss of 5-MTHF, and that some of

the products of 5-MTHF oxidation are lost to the folate pools, thus leading to

an overall lowering of folates in the body. The lowering of 5-MTHF pools has

also led in the unpublished data to a much more modest (circa 10% to 15%)

lowering of S-adenosylmethionin e levels.

It can be inferred from the

studies discussed in this section that the reaction between 5-MTHF and

peroxynitrite can have substantial impacts on both 5-MTHF levels and

peroxynitrite- mediated responses in real physiological situations. With regard

to the main focus of this article, raising the levels of 5-MTHF can

significantly affect the central couplet by lowering the levels of peroxynitrite

and its breakdown products. The practical question is whether this can be best

accomplished by using high folic acid doses, which act as a precursor for

5-MTHF, or using 5-MTHF itself and/or other reduced folates that can serve as

precursors of 5-MTHF, such as folinic acid. The answer is uncertain.

There are two important complications to this story. I have received

information from two sources to the effect that using doses of 5-MTHF in

substantial excess of 300 mcg leads to negative reactions in patients suffering

from presumed NO/ONOO− cycle diseases. My guess is that this may be due to the

toxicity of some of the oxidation products of peroxynitrite- mediated oxidation

of 5-MTHF. If this interpretation is correct, it may be possible to increase the

well-tolerated dose if one uses other agents that lower peroxynitrite at the

same time.

The second complication is that there must be very rapid

turnover of the methyl group on intracellular 5-MTHF. There are massive amounts

of methylation going on in the body, and even though the great majority of that

does not go through 5-MTHF, there still must be rapid turnover of the methyl

group on 5-MTHF. It follows that the half-life of intracellular 5-MTHF is

probably on the order of few seconds, and while the 5-MTHF can be regenerated

after it acts as a methyl donor, the efficiency of that process is uncertain.

Consequently, the effectiveness of an oral supplement of 5-MTHF on the

scavenging of peroxynitrite may be expected to be greater in the extracellular

space than it is intracellularly.

Folinic acid supplements were shown to

produce major improvements in a group of CFS/ME patients.69 A number

of other studies have reported major improvements in CFS/ME or FM patients with

treatment protocols including high-dose folic acid or other folates, but it is

difficult to determine the role of the folates themselves in such complex

protocols.

Based on the compelling biochemistry, I think that folates,

both folic acid and reduced folates, are among the most attractive agents in

lowering the central couplet.

Tetrahydrobiopterin

(BH4)

Perhaps the most obvious agent to use to lower the central

couplet is BH4 itself, or alternatively precursors such as sepiapterin or

biopterin. BH4 supplements have been reported to be helpful for the treatment of

autism patients, and autism is one of the proposed NO/ONOO− cycle

diseases.1,70-72 There are, however, some complications that need to

be considered in using BH4 to lower the central couplet.

First, it is

known that oral BH4 is largely oxidized and must therefore be reduced back to

BH4 before it can function in target cells. Most of this reduction occurs

intracellularly through enzymatic reduction. However, the rapid peroxidation of

the BH4 leads to questions of whether this oxidation may produce peroxidative

damage. For example, although Parkinson's disease is thought to involve BH4

depletion, an animal model study showed that high doses of BH4 produced

Parkinson's- like symptoms and neuronal damage, providing some support for this

view.73,74 In any case, it may be important to limit the dosage of

BH4 if it is used directly to prevent any major consequences of BH4

peroxidation. It is possible that reducing agents such as high-dose ascorbate

may minimize this peroxidation, and that using BH4 along with high-dose

ascorbate may be helpful in constructing therapeutic strategies.

An

alternative approach is to use precursors such as biopterin or sepiapterin as

oral supplements to provide increased availability of BH4.

Vasoactive

Intestinal Peptide (VIP)

VIP has been used by two physicians to treat

CFS/ME patients or chemically sensitive patients (unpublished data), with

apparently good responses in both. For example, Dr. Rea has used VIP

with his chemically sensitive patients with apparently good responses (personal

communication) . VIP is known to lower several parts of the NO/ONOO− cycle,

and

the most likely mechanism for this, in my view, is the reported role of VIP in

inducing GTP cyclohydrolase I activity and consequently raising BH4

levels.75 This view is supported by the well-documented role of VIP

in improving vasculature function. VIP is known to lower hypertension and

vascular endothelial dysfunction, and both of these are caused in part by BH4

depletion.

Flavonoids, Ellagic

Acid, and Other Phenolic Antioxidants

A number of flavonoids have been

shown to act as scavengers of peroxynitrite, and also its precursor superoxide

it has been suggested that they can be active in vivoin lowering

peroxynitrite- mediated effects.76 Other phenolic antioxidants can

also have important roles here, and perhaps one of the most important may be

ellagic acid, which scavenges peroxynitrite.77 It is not clear to me

which sources of these phenolics are the most likely to be useful here, but

perhaps pomegranate extract, which contains substantial amounts of ellagic acid,

and also several flavonoid-containin g extracts that are reported to lower

hypertension and improve vascular endothelial dysfunction.78-82 Ghosh

and Scheepens list cocoa, wine, grape seed, berries, tea, tomatoes

(polyphenolics and nonpolyphenolics) , soy, hawthorn, and pomegranate as

attractive possibilities for phenolic antioxidants that may lower hypertension

and improve vascular endothelial dysfunction.80 Schmitt and Dirsch

list cocoa, pomegranate, both green and black tea, olive oil, and soy among food

sources. They also list ginkgo, hawthorn, and ginseng among herbal

sources.81 Extracts of each of these should be considered as agents

for possibly lowering the central couplet.

Hydroxocobalamin

Form of Vitamin B12

Hydroxocobalamin has been used for over 70 years

to decrease fatigue in people with chronic fatigue, long before CFS/ME was a

well-defined illness. It was shown in a clinical trial of patients with a

CFS/ME-like illness that 5 mg intramuscular (IM) injections twice a week

produced statistically signficant improvements as compared with

placebo.83 In this study, it was also shown that there was no

correlation between initial B12 levels and response to hydroxocobalamin therapy,

suggesting that the hydroxocobalamin was not acting primarily to allay a B12

deficiency. Lower doses of another form of B12 that were adequate to allay a

possible B12 deficiency produce no clinical improvement, and other evidence also

strongly suggests that high-dose hydroxocobalamin is not acting here to allay a

B12 deficiency.84,85

Other uncontrolled studies have

suggested that the hydroxocobalamin form of vitamin B12 produces clinical

improvement in people with these multisystem diseases.1,86,87 

It has been inferred that B12 is acting as a potent nitric oxide scavenger and

that this is the probable mode of action in the treatment of these multisystem

diseases. 1,87 People with these diseases report essentially

across-the-board improvement in symptoms when treated with hydroxocobalamin,

suggesting that it acts to lower the basic etiologic mechanism of these

diseases, consistent with a nitric–oxide scavenging mechanism.

In order

to act as a nitric oxide scavenger, hydroxocobalamin and the chemically similar

aquacobalamin must have the cobalt at the center of the molecule reduced from

the cobalt III form to cobalt II.88 Such reduction is a process that

occurs in vivo and is necessary for all cobalamins to have vitamin B12 activity

as well as for hydroxocobalamin to serve as a nitric oxide

scavenger.

Nitric oxide does not have a direct role in the central

couplet, but it does serve as a direct precursor of peroxynitrite, such that

nitric oxide scavenging will inevitably lower peroxynitrite levels in vivo. It

can be argued, therefore, that hydroxocobalamin will act to lower the

peroxynitrite end of the central couplet by scavenging nitric oxide.

Summary and Overall

Strategy

Of the 10 agents/classes of agents described above that are

known or predicted to lower the central couplet, nine individually appear to

produce substantial improvements in this group of diseases, based on clinical

trial studies, clinical observations, or both. The only one of the nine for

which this is not true is oral ascorbate. These observations make the central

couplet an attractive part of the cycle to focus on in trying to obtain

substantial numbers of cures for these diseases. The question being raised here

is whether combinations of these ten, especially combinations designed to

effectively lower the central couplet, when added to the strategy that I

previously advocated for treatment of these diseases, will produce such

cures.

That strategy suggested here is as follows: Avoid stressors that

will otherwise upregulate the NO/ONOO− cycle while using multiple agents that

each lower one or more aspects of the cycle and collectively should lower

several of its aspects.1-3 There are multiple approaches, each using

such a multiple agent strategy, although the one that I have most worked on is

the Allergy Research Group nutritional support protocol, which appears to

produce positive responses in 80% to 85% of such patients. In general, such

multiple agent approaches seem to have been effective in producing clinical

improvements in most such patients but have failed to give any substantial

numbers of cures, based on published information

(thetenthparadigm. org/arg.htm) .2,3

I think that the basic

problem has been the failure to effectively downregulate the central couplet of

the NO/ONOO− cycle. The proposal here is that we should add a second phase to

these previous therapeutic approaches, one aimed at lowering that central

couplet. More specifically, this means using agents that lower peroxynitrite

and/or its breakdown products on the one hand; it also means using agents that

increase BH4 availability on the other. Increased BH4 availability can be

produced by using agents that reduce oxidized products of BH4 back to BH4. Such

increased BH4 availability can also be produced by agents that induce the enzyme

GTP cyclohydrolase I, the first and rate-limiting enzyme in the de novo pathway

for the synthesis of BH4. What I have provided, then, is an overall strategy for

getting some cures and a description of ten agents/classes of agents that should

be useful in carrying out such a strategy. I have not, however, provided a

detailed protocol for getting such cures.

I do think that it is possible

that IV buffered ascorbate alone, when added to one of these broad-ranging

protocols lowering the NO/ONOO− cycle and avoiding stressors that will raise

the

cycle, may be effective in obtaining some cures. I suspect, however, that most

of the other agents that lower the central couplet should be used as multiagent

combinations. And it is quite possible that even repeated IV ascorbate will be

improved by using some of the other agents/classes of agents. The general

strategy is to lower both ends of the couplet simultaneously, and probably

repeatedly to progressively lower the cycle into insignificance. There is

predicted to be synergistic interactions when using agents that work

simultaneously to lower both ends of the central couplet.

I would be

delighted to work with physicians and other health-care providers who are

interested in exploring this approach.

If the view proposed in this

article can be shown to be correct, then we will be in a new era in medicine.

That will be true even if the relevance of this approach is limited to such

diseases as CFS/ME, MCS, and FM. If other proposed NO/ONOO− cycle diseases,

such

as tinnitus, Parkinson's, Alzheimers, ALS, asthma, autism, and MS, can also be

cured by this approach, then the impact on medicine will be comparable to the

previous biggest therapeutic breakthrough, the development of wide-spectrum

antibiotics.

Is this all delusional optimism? Clearly, we won't know

until we look. But what we do know is that all of these diseases are chronic

diseases, with cases of each apparently initiated by stressors that should be

able to initiate the cycle. And we have evidence with all of them for important

roles of such cycle elements as oxidative stress, inflammatory biochemistry,

mitochondrial dysfunction, and excessive NMDA activity. Where they have been

looked at, we also have evidence for BH4 depletion and NF-κB elevation. It is

difficult to see how these cycle elements could be involved unless the

NO/ONOO−

cycle or something very similar to it is not central to the etiology of these

diseases.

Mechanisms have consequences. It is time, in my view, for the

sufferers of these diseases to fully benefit from the predictions of the

NO/ONOO− cycle mechanism.

L. Pall, PhD

Professor

emeritus of biochemistry and basic medical sciences, Washington State

University, and research director, the Tenth Paradigm Research Group

638 NE

41st Ave.

Portland, OR 97232-3312

USA

503-232-3883

martin_pall@ wsu.edu

Notes

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The NO/ONOO− cycle is named for two of

its many elements, nitric oxide (NO) and peroxynitrite (ONOO−) and is

pronounced

" no, oh no. "

S-adenosylmethionin e (SAMe) is the main

direct methyl donor in living organisms, being produced by the methylation cycle

and acting in turn to methylate many different substrates in the cell. There

have been many claims that these illnesses are caused by lowered methylation

cycle activity. I think that these claims not valid. There is a modest lowering

of methylation activity caused by peroxynitrite- mediated 5-MTHF oxidation, but

whether such modest lowering of methylation has any causal role is unclear. What

should be clear is that such a modest methylation cycle lowering should be

normalized by an effective downregulation of the NO/ONOO− cycle, including

especially the central couplet. That is the treatment approach explored in this

article is the approach that should be used to normalize various properties of

these NO/ONOO− cycle diseases, including the modest lowering of methylation

cycle activity.