The Use of a Complex Flavonoid as a Treatment for ALS

1
The Use of a Complex Flavonoid as a Treatment for
ALS Elijah W. Stommel, Brent T. Harris8, David
J. Graber 8, Jeffrey A. Cohen, Department of
Medicine (Section of Neurology) Department of
Pathology8 Dartmouth-Hitchcock Medical Center
(DHMC), Lebanon, NH 03756 Tel [phone] Fax
603-650-0458 Email elijah.w.stommel_at_hitchcock.or
g
Three recent publications confirm the poor
bioavailability of oral L, two of which describe
the dramatic increased oral bioavailability of L
when combined with R. Orally ingested LutiMax
shows 1.9 to over 10 times greater plasma levels
of L than the same oral dose of L6. R is
hydrolyzed to Quercetin (Q) 4-6 hours after
ingestion7 and plays the role of Trojan Horse for
L as well as having complimentary pharmacokinetic
effects on L6,8. L and Q are some of the best
inhibitors of superoxide generation by xanthine
oxidase9 (XO) and nicotinamide adenine
dinucleotide phosphate (NAPDH) oxidase in
nature10-11, and they block nitric oxide (NO)
synthesis12-13 as well as quench the hydroxyl
radical14-15. L and Q are both active in the
mitochondria, effect apoptosis in cancer cells by
blocking glycolysis16-17, and they both are
neuroprotective to excitotoxins18-19, chemical
oxidants20, neurotoxins21, cytokines5, and
inflammatory molecules22. R also increase the
synthesis of glutathione (GSH), glutathione
peroxidase (GPx), superoxide dismutase (SOD),
catalase (CAT) 23-26 and Q also promotes redox
homeostasis24. L, R, and Q block the reactive
oxygen species (ROS)15,24, cytokine27-28, and LPS
induced expression of inflammatory genes27,
protein signaling molecules2,29, kinases3,30, and
inflammatory mediating enzymes including
phopholipase A231, phospholipase C32, protein
kinase C (PKC)33, cyclooxygenase-2 enzyme
(COX-2)34, inducible nitric oxide synthase (iNOS)
enzyme expression35-36, lipoxygenase37-38,
TNF-alpha39-41,and TNF-alpha induced nuclear
factor-kappa B (NF-KB) activation via I kappa B
kinase beta (IKKB)42-43. The interleukins
IL-1B5,28, IL-244-45, IL-446, IL-547, IL-65,48,
IL-849-50, IL-1044, IL-1242, and IL-1351-52 as
well as IFN-gamma28,53 all show inhibition or
modulation by L or Q or both. Both L and Q are
also strong inhibitors of IgE mediated allergic
reactions54-55. Bioflavonoids Luteolin
Quercetin Rutin
Abstract We propose using sublingual LutiMax, a
molecular complex of the bioflavonoids (luteolin
and rutin) that target many of the pathogenic
mechanisms thought to be important in ALS.
LutiMax was introduced into commerce as a
dietary supplement worldwide in 2002 by SYNORx,
Inc. There is substantial evidence to show that
bioflavonoids are neuroprotective by reducing
neuroinflammation, reducing pro-inflamatory
cytokines and chemokines and reducing neuronal
apoptosis, all of which suggests an important
role for flavonoids in counteracting
neurodegeneration. LutiMax has no known major
side effects. We have followed a relatively
small number of ALS patients who appear to have
stabilized once they started taking LutiMax.
This unexpected observation needs to be verified
with a formal clinical trial. Patients will be
evaluated using the ALS Functional Rating Scale
(ALSFRS) as a primary outcome with secondary
outcomes being, survival, safety and FVC measured
every 3 months. With this phase II trial, 60 ALS
patients will be entered in a double-blind,
placebo-controlled, cross-over study. We plan to
use LutiMax for 12 months vs. placebo in a
cross-over with a latin square technique where
the patient will be switched from real medication
to placebo or visa-versa at six months. A wash
out period of a week between treatments will
occur. Assuming 80 complete both periods (i.e.,
receive both placebo and treatment) the study
will have sufficient power (80) at a type I
error rate of 5 to detect an effect of
treatment such that 75 of patients have a better
ALSFRS score following treatment, than following
placebo. The patients will have to meet strict
inclusion and exclusion criteria for the study
including being able to ingest the pills
sublingually and having been diagnosed with the
disease for less than 1 year. There will be no
need to follow any specific blood labs as
LutiMax TM has not been found to have any major
toxicities. Because the safety profile of
LutiMax is excellent, the expenses of the trial
should be relatively low. We envision involving 5
NEALS associated centers in this trial.
A dose of LutiMax (each lozenge contains 100mg
of luteolin and 100mg of rutin) will ultimately
be 8 lozenges sublingually 4 times a day. We
expect patients to be able to get to this dose
within a week of starting. The sublingual
delivery for LutiMax is a convenient reliable
method which avoids first-pass metabolism in the
liver and pre-systemic elimination in the
gastrointestinal tract67. A washout period of a
week will be initiated between treatments.
LutiMax has made a placebo lozenge which is
indistinguishable by taste, texture and color to
the standard lozenge. The placebo lozenge has
been tested by chromatography. High intakes of
carbohydrate and low intakes of fat and some
kinds of fatty acids may, when combined appear to
increase the risk of ALS68. A ketogenic diet has
been proposed as a therapy for ALS69-70. LutiMax
works best in a low-carbohydrate diet,
especially low in sugars (Thomas Lahey personal
observations). We will recommend a high protein,
high unsaturated fat, low carbohydrate diet with
a target of 3000 calories per day to maintain
weight and muscle mass. To accomplish this, a
nutritionist will provide an integrated shopping
list and meal recommendations and patients will
keep a dietary record. Funding for this project
is still being pursued. The budget for this trial
should be relatively small.
L enhances proteosomal degradation of misfolded
proteins33, and both L and Q increase the redox
sensitive transcription factor (Nrf-2) mRNA and
stabilize Nrf-2 to proteosomal degradation56. L
also activates the cell regulating protein,
Sirtuin57. L and Q block the transcription factor
AP-127,51, and immune activation in experimental
autoimmune encephalitis (EAE)41,58. L and Q
block extracellular signal-regulated kinases
ERK1/2 and the protein kinase Akt59, modulate
intracellular calcium60-61 and increase
mitochondrial efficiency and inhibit glycogen
synthase kinase 3 (GSK-3)30,62. Recent research
on L and Q show these bioflavonoids target
autophagy63 MPTP related Parkinsons disease56,
astrocytic mediated apoptosis, management of
blood brain barrier (BBB) to T Cells and
macrophages41,58, and IL-6 production in
microglia by inhibiting the mitogen-activated
protein kinase JNK phosphorylation and the
activator protein (AP-1)61. (studies sponsored
by SYNORx) The recent research on L and the
synergistic mixtures with R provide a body of
evidence to support the clinical evaluation of
LutiMax in ALS. ALS is a multifactorial disease
with multiple pharmacologic targets, and the
multifactorial pharmacodynamics of L, R, and Q
match many of the same targets at the
transcriptional to the enzymatic and metabolic
level. Overall, there are compelling arguments to
try LutiMax in a clinical trial with ALS
patients. Proposed Trial We feel that there is
potential for LutiMax as a treatment for ALS
after observing some patients who appear to have
stabilized on this compound. We propose treating,
through a multi-center trial, 60 ALS patients
with LutiMax. With this phase II trial,
patients will be entered in a double-blind,
placebo-controlled, cross-over study. We plan to
use LutiMax for 12 months vs. placebo in a
cross-over with a latin square technique where
the patient will be switched form real medication
to placebo or visa-versa at six months. Assuming
80 complete both periods (i.e., receive both
placebo and treatment) the study will have
sufficient power (80) at a type I error rate of
5 to detect an effect of treatment such that
75 of patients have a better ALSFRS score
following treatment, then following placebo. The
patients will have to meet strict inclusion and
exclusion criteria for the study including being
able to ingest the pills sublingually. Patients
would be evaluated using the ALSFRS as a primary
outcome with secondary outcomes being survival
and FVC, measured every 3 months. A neurological
screening exam will be done on initial visit and
then every three months. There will be no need
to follow any specific blood labs as LutiMax has
not been found to be toxic in rats nor in
humans64-66. No acute oral toxicity was found
with testing in mice using LutiMax at 5.0
grams/kg of body weight and 7.5 grams/kg of body
weight as performed by the Chinese Academy of
Sciences, Institute of Materia Medica, National
Institute of Pharmacological Screening in Beijing
in 2007 (SYNORx, Inc.,unpublished data). The lack
of toxicity should make compliance better and
will reduce the budget for the trial.


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Introduction LutiMax is a molecular complex
of the bioflavonoids Luteolin(L) and Rutin(R).
LutiMax was introduced into commerce as a
dietary supplement worldwide in 2002 by SYNORx,
Inc. LutiMax has not been shown to have any
serious side effects. LutiMax has many targets
for neurodegenerative disease. The response
appears to be dose dependent, and there have been
no demonstrable biological effects to either pure
L or R1. We, at DHMC, have personally seen
several ALS patients who appear to have
clinically stabilized while taking LutiMax.
There is substantial evidence to show that
flavonoids are neuroprotective by reducing
neuroinflammation, reducing pro-inflamatory
cytokines and chemokines and reducing neuronal
apoptosis all of which suggests an important role
for flavinoids in counteracting
neurodegeneration2-5. As no rigorous clinical
trial has been undertaken, we propose to look at
this potentially promising compound in the
setting of ALS.
2
LutiMax vs. Controls (MGH study)