X-Message-Number: 7475 Date: 10 Jan 97 04:31:13 EST From: "Steven B. Harris" <> Subject: Cryopreservation Premedication, prt 5 The following is a BioPreservation, Inc. (BPI) technical briefing on premedication of human cryopreservation patients to mitigate the injury associated with antemortem and post mortem hypoxia/ischemnia. Contents copyright 1997 by BioPreservation, Inc. All rights reserved. Premedication of the Human Cryopreservation Patient, Part V by Michael Darwin Melatonin 10 mg p.o. before retiring (or with the evening meal as the patient desires). Melatonin is a hormone secreted by the pineal gland which is involved in circadian rhythms in a wide range of animals and appears to be central to the initiation of sleep in man and other mammals. Melatonin's biological activity is only now beginning to be understood. Exogenously administered melatonin rapidly crosses the blood brain barrier and induces sleepiness in normal human subjects. Melatonin is also a powerful free radical scavenger and antioxidant which appears to readily cross mitochondrial membranes where it may exert a protective effect in ischemia. Melatonin acts differently from all common chain-breaking antioxidants including the naturally occurring thiol compounds cysteine and glutathione (the two mainstays of water soluble free radical buffering chemistry). In contrast to d-alpha tocopherol, glutathione, and melatonin's precursor (serotonin), melatonin does not participate in redox cycling, cannot generate hydroxyl radicals in the presence of iron or other transition metals (such as ascorbic acid), and is extremely resistant to auto-oxidation. Melatonin specifically interacts only with highly reactive species such as hydroxyl radicals or transition metal complexes which have the same or greater electroreactivity. In short, melatonin is the most potent endogenous hydroxyl radical scavenger identified to date and because of its solubility in both water and lipids, it provides broad spectrum protection to a wide range of biomolecules including proteins, lipids and nucleic acids. Melatonin has been shown to provide in vivo protection against kainate-induced neurotoxicity, inhibiting both the behavioral and biochemical effects of kainate and thus presumably acting as an inhibitor of neuronal excitotoxicity. This neuroprotective effect is apparently a result of the inhibition of hydroxyl radicals which are generated as a result of NMDA receptor activation. Melatonin is currently a "fad" drug used primarily as an OTC treatment for insomnia and jet lag. It is also being used as an "anti-aging" hormone and as an adjunct to the treatment of breast and prostate cancer as well as a primary treatment for benign prostatic hypertrophy (BPH). The most significant side effect to melatonin supplementation is sleepiness and sedation. Inhibition of prostacyclin and gonadatropins has been known to occur during sustained use of high doses with the possibility of sterility and gonadal atrophy. At doses of 20 mg, morning sleepiness is a likely side effect. Sodium Selenite 100 to 250 micrograms per day p.o. with the evening meal or before retiring. Selenium is an essential trace mineral found in drinking water and a wide range of foods. It is essential for the proper functioning of the selenium, glutathione, peroxidase free radical scavenging system. At high doses it is toxic, but it is well tolerated at doses of up 1000 micrograms per day. Selenium has been shown to be cerebroprotective in models of head injury and cerebral ischemia. Selenium is an exceptionally well tolerated nutrient, the only common side effect being a metallic taste at high doses (over 500 mcg per day). Sodium selenite is available inexpensively in capsules from Twinlab Company of Ronkonkoma, New York. Magnesium Oxide 300 mg p.o. t.i.d. with meals. Magnesium is an essential trace mineral which is known to decrease platelet aggregation, decrease cardiac arrhythmias in marasmus and myocardial infarction, stabilize cell membranes and act as a cytoprotectant in cerebral and coronary ischemia. It is also an antihypertensive, decreases vasospasm in catecholamine storm, reduces peripheral vascular resistance and profoundly reduces both acute and 1 year mortality following myocardial infarction. Magnesium should not only provide primary cerebroprotection in ischemia, but it should greatly reduce the chance of a patient dying from wasting disease, congestive heart failure, arrhythmias secondary to increased myocardial irritability and platelet activation from elevated levels of tumor necrosis factor (TNF) and related cytokines. Magnesium is available in many forms as salts and organic chelates (such as magnesium orotate), however the oxide form is by far the cheapest and appears to have adequate bioavailability with minimal side effects. The principal side effect of magnesium oxide is diarrhea, but this occurs infrequently at the doses suggested here. Very high doses of magnesium result in muscle weakness with the possibility of respiratory arrest at very high doses. Magnesium supplementation must be used only with caution and should be monitored in patients with renal disease or in patients with oliguria or anuria secondary to dehydration. Co-Enzyme-Q10 (Co-Q10, ubiquinone) 100 mg in vitamin E oil t.i.d. with meals. Co-Q10 is a mitochondrial electron transport molecule which is critical to aerobic metabolism. It is a potent free radical scavenger that is profoundly protective against myocardial, cerebral, renal and skeletal muscle ischemia, especially when given prior to the insult. Co-Q10 is a quinone, a family of brightly colored cyclic organic compounds that are phylogenetically very old. Co-Q10 is an integral part of the mitochondrial membrane in all eukaryotic cells and of the chloroplasts in plant cells. So common is Co-Q10 that the name ubiquinone refers to its ubiquitousness in living systems. Co-Q10 is closely related to vitamin K1 and vitamin E which have in common with Co-Q10 a number of quinone-like features. Because Co-Q10 is a critical molecule that is central to the generation of ATP in mitochondrial metabolism, serum and tissues levels below 75% of the normal baseline (0.33 micromoles as given in the Pantox panel) are associated with death from infection or cardiac arrythmia. Co-Q10 is known to be a key up-regulator of immune function and is used clinically in Japan as a treatment for myocardial ischemia, atherosclerosis, and idiopathic cardiomyopathy. In fact, Co-Q10 is the most prescribed cardiac drug in Japan. Co-Q10 is only sparingly soluble in water but quite soluble in lipids. Its absorption after p.o. administration is greatly facilitated by consumption with fat containing foods. Not only should Co-Q10 be administered in oil or as micellized product, it should always be given with meals to facilitate absorption. Co-Q10 is remarkably well tolerated even in very high doses. It substantially extends the mean lifespan of animals chronically fed the drug as 0.1% of their diet and its toxicity is essentially zero in doses in the therapeutic range. The only known side effect of Co-Q10 administration is occasional cardiac palpitations. Co-Q10 is available from most health food stores as an OTC nutrient. The drug is a fine granular yellow powder that is usually packaged in gelatin capsules. Recently, Co-Q10 has become available dissolved in oil in soft gelcaps and this the preferred form of the drug for premedication of human cryopreservation patients. If health food stores are used as a source for the product it is recommended that the KAL brand be used (30 mg/capsule in oil). Not only is Co-Q10 likely to be cerebroprotective, it also likely to greatly reduce the risk of sudden cardiac death from arrhythmias during terminal illness (a not uncommon occurrence). Based on the author's personal experience with dying patients, Co-Q10 will usually benefit patients during the course of their terminal illness. Most patients in the end stage of wasting diseases who are supplemented with Co-Q10 report substantial increases in energy and stamina. Ginkgo Biloba extract 80 mg t.i.d. with meals. Ginkgo biloba is one of the few trees surviving from the Mesozoic period (200 million years ago). It is an Asiatic tree of modest proportions with distinctive bi-lobed fan-shaped leaves (hence the name biloba). The leaves contain a variety of biochemically complex and pharmacologically active substances which are profoundly cerebroprotective when administered both before and after cerebral ischemia. A quality ginkgo extract is typically a 50:1 concentration containing a minimum of 24% ginkgo flavonglycosides, 6% terpene lactones, and 0.8% ginkolide B. The ginkolides have been chemically purified into discrete compounds for use as investigational new antiplatelet agents. Structural analysis of these compounds has lead to the synthesis of a variety of derivatives (which have the advantage of being patentable as pharmaceuticals, which naturally occurring ginkolides are not) such as BN 50739 which is an effective antiplatelet agent (platelet activating factor (PAF) inhibitor). Administration of BN 50739 following 14 minutes of global normothermic ischemia in the dog brain facilitates recovery of adenyl nucleotide to levels to 100% of control (versus 50% in controls), reduces polyunsaturated fatty acid (PUFA) levels to 30% of control, and markedly inhibits excitotoxicity and allows for recovery of EEG activity (there is no recovery in control brains). BN 52021 is a naturally occurring ginkolide with antiplatelet and cerebroprotective properties similar to its synthetic cousin BN 50739. It is not as effective as BN 52021 milligram for milligram but its effect is dose dependent and doses of ginkgo extract specified in this protocol should yield a comparable effect. It should also be noted that the natural extract contains many biologically active compounds and other ginkolide variants which have not been evaluated under the same rigorous conditions as the monoagents both isolated from natural sources and synthesized. In addition to its anti-PAF activity, ginkgo extract contains flavonglycosides which have strong anti-inflammatory activity and are especially effective at inhibiting increased capillary permeability, perhaps by preventing the destruction of the normally present inhibitors of elastase and collagenase which occurs during ischemia. Two quality sources of ginkgo biloba extract are Gingold and NOW brands. Ginkgo is extremely well tolerated and the only side effect reported has been insomnia from caffeine-like effects at high doses. While the ginkolides, flavonglycosides and terpene lactones all posses antioxidant and anti-inflammatory activity, the pharmacology of ginkgo is not well understood. Ginkgo acts as a cerebral vasodilator and improves cognitive function in human and animal subjects, both young and old. It's cognitive enhancing effects and it anti-PAF effects increase with the length of administration. Therefore, it is important to start ginkgo administration as early as possible. Despite its anti-PAF effects, ginkgo is not associated with increased bleeding time, coagulopathy or other alterations in hemostasis. FlavonAll (multibioflavonoid supplement) 1 tablet t.i.d. with meals. (10 mg pycnogenol, 65 mg proanthocyanidins, 30 mg anthrocyanins, 180 mg polyphenols, 125 mg citrus bioflavonoids, 140 mg silymarin, and 80 mg ginkgo extract). FlavonAll tablets contain a wide variety of bioflavonoids which are nonessential nutrients that improve capillary integrity (reduce edema formation) in injury from a variety of insults. Bioflavonoids are derived from a variety of botanical sources (primarily citrus, grape seed, ginkgo and green tea). Bioflavonoids are known inhibitors of the pro-inflammatory compounds prostaglandin A2, thromboxane and the leukotrienes all of which are known to play a major role in the pathophysiology of ischemia, particularly the development of interstitial edema and protein leakage through capillary membranes during reperfusion. The bioflavonoids are well tolerated and are not known to have any side effects in the dosages specified in this protocol. The bioflavonoids have antidiarrheal activity by virtue of their anti-inflammatory and capillary hyperpermeability inhibiting effects. End of Part V To be continued. BioPreservation, Inc. 10743 Civic Center Drive Rancho Cucamonga, California 91730 (909)987-3883 Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=7475