The NO! OH NOO! Theory and Suggestions For Treatment

by Martin Pall Ph.D

(Posted by Martin Pall on the CFSFMResearch chat group at Yahoogroups.com on March 27th, 2006)

"This is going to be long post. It contains the most important information on the cause of [chronic fatigue syndrome] CFS, [fibromyalgia] FM, [multiple chemical sensaitivity] MCS and related illnesses and how to effectively treat them.

I have been working to the cause of these illnesses for almost 8 years and will have a book coming out on this and many related topics from Haworth Medical Press that will provide much more information than is in this post. Cases of each of these illnesses are initiated by short term stressors, but instead of recovering after exposure, people become ill with one or more these chronic illnesses. The stressors implicated include viral, bacterial and in a few cases, protozoan infections, physical trauma (most commonly to the head and neck but also including physical trauma to other regions of the body), chemical exposure to such chemicals a volatile organic solvents or such pesticides as organophosphorus/carbamates, organochlorine pesticides or pyrethroid pesticides, carbon monoxide exposure, severe psychological stress, certain mold toxins or ciguatoxin exposure. Each of these diverse stressors can initiate a process leading to increased nitric oxide levels. In some cases (infection) the iNOS form of nitric oxide synthase is involved but in most others, excessive NMDA activity is involved leading to increased nNOS activity. It follows that no single form of nitric oxide synthase is involved, but rather the common factor is nitric oxide. I have argued that the most important consequences of this are mediated not through nitric oxide itself but rather through the action of the oxidant product of nitric oxide, peroxynitrite.

Peroxynitrite synthesis

NO. + OO.- -------> ONOO-
(nitric (superoxide) (peroxynitrite)
oxide)

How does this initiate these chronic illnesses? They act by initiating a biochemical vicious cycle which is responsible for these chronic illnesses: These arrows represent 22 distinct biochemical mechanisms whereby one of the parameters listed stimulate the next parameter connected by an arrow. Of these 19 are very well documented in the biochemical literature and the remaining three appear to be correct but are less well documented. This vicious cycle, which we are now calling the NO/ONOO- cycle (based on the structures of nitric oxide and peroxynitrite (but pronounced, no, oh no!) is responsible for the chronic nature of these illnesses.

The NO/ONOO- cycle is based on five distinct principles, two of which I have already described. These principles are as follows:

The NO/ONOO- cycle mechanism, can be summarized in five different principles:

1. Short-term stressors that initiate cases of multisystem illnesses act by stimulating nitric oxide synthase (NOS) activity and consequently produce increased levels of nitric oxide and its oxidant product peroxynitrite.

2. Initiation is converted into a chronic illness through the action of vicious cycle mechanisms, through which chronic elevation of nitric oxide and peroxynitrite is produced and maintained.

3. Symptoms and signs of these illnesses are generated by elevated levels of nitric oxide and/or other important consequences of the proposed mechanism, i.e. elevated levels of peroxynitrite or inflammatory cytokines, oxidative stress and elevated NMDA and vanilloid receptor activity.

4. Because the compounds involved, nitric oxide, superoxide and peroxynitrite have quite limited diffusion distances in biologicaltissues and because most of the mechanisms involved in maintaining the NO/ONOO- cycle act at the level of individual cells, the fundamental mechanisms are local. The consequence of this is that one tissue may be impacted by this underlying biochemistry while an adjacent tissue may be largely unaffected. The tissue distribution may be propagated indefinitely over time by these local vicious cycle mechanisms. This can lead to many differences in symptoms, depending on the tissue distribution variation, from one case to another. This is such an important principle that I have devoted an entire chapter to it (Chapter 4).

5. Therapy should focus on down-regulating elements of the NO/ONOO- cycle, rather than on just on providing symptomatic relief.

Let me comment on principles 4 and 5. The local nature of the NO/ONOO- cycle means that impact of the cycle on different tissues may be largely independent of each other. Because of this, the symptoms and signs shown by different sufferers of these illnesses are highly variable, depending on which tissues are impacted in which individuals. This variation has been a source of much concern in trying to understand these illnesses but is easily understood as being a consequence of the NO/ONOO- cycle mechanism.

Principle 5 states that therapy should focus on down-regulating NO/ONOO- cycle biochemistry, rather than on symptomatic therapy. The difficulty in doing so can be seen from the complexity of the cycle (Figure 1). Because the cycle has such high level complexity and because scavengers for peroxynitrite, the most central compound in the cycle are inefficient, the approach that may have the most traction is to use multiple agents, particularly well-tolerated nutritional agents, to down-regulate NO/ONOO- cycle biochemistry. This is likely to be the most promising approach to such therapy.

In Chapter 15 of my book, the longest chapter in the book, I discuss 30 different agents or classes of agents that are available today and are predicted to down-regulate NO/ONOO- cycle biochemistry. These are summarized in the table below. I follow with descriptions of treatment protocols independently developed by five different physicians, each of whom use from 14 to 18 agents or classes of agents predicted to down-regulate this biochemistry. While some of these use additional agents, not linked or less obviously linked to NO/ONOO- cvcle biochemistry, I would argue that this pattern is not coincidental. In other words, I argue that:

1. These protocols are largely effective because so many agents in them down-regulate NO/ONOO- cycle biochemistry.
2. The NO/ONOO_ cycle makes useful predictions in terms of therapy and this helps confirm its role as the central cause of these chronic illnesses.

Thirty agents or classes of agents predicted to down-regulate NO/ONOO cycle biochemistry:

Agent or Class of Agents Clinical Trial Data or Clinical Observation/Anecdotal Reports

Vitamin C (ascorbic acid) - Clinical Trial Data
Tocopherols/Tocotrienols - Anecdotal Reports
Selenium - None
Carotenoids - None
Flavonoids - Clinical Trial Data
Reductive stress relieving agents - Clinical Trial Data
Mitochondrial regeneration agents - Clinical Trial Data
L-Carnitine/Acetyl-L-carnitine - Clinical Trial Data
Hydroxocobalamin/B12 - Clinical Trial Data
Folic acid - Clinical Trial Data
Vitamin B6/pyridoxal phosphate - Anecdotal Reports
Riboflavin - None
Other B vitamins - None
Glutathione/glutathione precursors - Clinical Observations
alpha-Lipoic acid - None
Magnesium - Clinical Trial Data
SOD minerals/zinc,manganese, copper - None
NMDA antagonists - Clinical Trial Data
Riluzole - None
Taurine - None
Inosine/uric acid - None
Long chain omega-3 fatty acids - Clinical Trial Data
Agents that lower NF-kappa B activity - Anecdotal Reports
Curcumin - None
Algal supplements - Clinical Trial Data
Hyperbaric oxygen - Clinical Trial Data
Minocycline and Other Tetracyclines - Clinical Observations
Creatine - None
Lowered vanilloid activity - None
Carnosine - None
TRH - Clinical Observations

You will note that there is clinical trial data on the efficacy of 12 of these agents or classes of agents, and there are clinical observations and/or anecdotal evidence of efficacy of six others. Nonetheless, each of these individually, have limited efficacy, suggesting that combinations may be more effective than are individual agents.

Treatment protocols of five different physicians

The comments after some of these agents are mine, not those of the physicians involved: These are listed in no particular order.

Agents from Cheney Protocol Predicted to Down-Regulate NO/ONOO- Cycle Biochemistry

High dose hydroxocobalamin (B12) injections - nitric oxide scavenger
Whey protein - glutathione precursor
Guaifenesin - vanilloid antagonist?
NMDA blockers
Magnesium - lowers NMDA activity
Taurine - antioxidant and acts to lower excitotoxicity including NMDA activity
GABA agonists - GABA acts as an inhibitory neurotransmitter to lower NMDA activity - these include the drug neurotin (gabapentin)
Histamine blockers - mast cells which release histamine are activated by both nitric oxide and vanilloid stimulation and may therefore be part of the cycle mechanism
Betaine hydrochloride (HCl) - Betaine lowers reductive stress, the hydrochloride form should only be used in those with low stomach acid. Betaine (trimethylglycine) is also listed separately in the protocol description
Flavonoids, including "bioflavonoids," olive leaf extract, organic botanicals, hawthorn extract
Vitamin E (forms not listed)
Coenzyme Q10 - acts both as antioxidant and to stimulate mitochondrial function
A-lipoic acid
Selenium
Omega-3 and -6 fatty acids
Melatonin - as an antioxidant
Pyridoxal phosphate - improves glutamate/GABA ratio
Folic acid - lowers uncoupling of nitric oxide synthases

Agents from Teitelbaum Protocol Predicted to Down-Regulate NO/ONOO Cycle Biochemistry

Daily energy B-complex - B vitamins including high dose B6, riboflavin, thiamine, niacin and also folic acid. These fall into four categories that I have listed earlier in the chapter
Betaine hydrochloride (HCl) - lowers reductive stress, hydrochloride -form should only be taken by those deficient in stomach acid
Magnesium as magnesium glycinate and magnesium malate - lowers NMDA activity - often uses magnesium injections
A-Lipoic acid - important antioxidant helps regenerate reduced glutathione
Vitamin B12 IM injections, 3 mg injections (does not state whether this is hydroxocobalamin) - may act as potent nitric oxide scavenger
Eskimo fish oil - excellent source of long chain omega-3 fatty acids. Lowers iNOS induction, anti-inflammatory
Vitamin C
Grape seed extract (flavonoid)
Vitamin E, natural - does not state whether this includes g-tocopherol or tocotrienols
Physician's protein formula, used as glutathione precursor
Zinc - antioxidant properties and copper/zinc superoxide dysmutase precursor
Acetyl-L-carnitine - important for restoring mitochondrial function
Coenzyme Q10 - both important antioxidant properties and stimulates mitochondrial function

Agents from Nicolson Protocol Predicted to Down-Regulate NO/ONOO- Cycle Biochemistry

Other phosphatidyl polyunsaturated lipids - this and the phosphatidyl choline are predicted to help restore the oxidatively damaged mitochondrial inner membrane
Magnesium - lowers NMDA activity, may aid in energy metabolism
Taurine - antioxidant activity and lowers excitoxicity including NMDA activity
Artichoke extract - as flavonoid source?
Spirulina - blue-green alga is a concentrated antioxidant source
Natural vitamin E - does not tell us whether this includes g-tocopherol or tocotrienols
Calcium ascorbate - vitamin C
a-Lipoic acid - important antioxidant, key role in regeneration of reduced glutathione, but also has role in energy metabolism
Vitamin B6 - balance glutamate and GABA levels, lowers excitotoxicity
Niacin - role in energy metabolism
Riboflavin - important in reduction of oxidized glutathione back to reduced glutathione; also has important role in mitochondrial function
Thiamin - role in energy metabolism
Vitamin B12 - as nitric oxide scavenger?
Folic acid - lowers nitric oxide synthase uncoupling

Agents from Petrovic Protocol Predicted to Down-Regulate NO/ONOO- Cycle Biochemistry

Valine and isoleucine - branched chain amino acids known to be involved in energy metabolism in mitochondria, and may be expected,therefore, to stimulate energy metabolism; modest levels may also lower excitotoxicity
Pyridoxine (B6) - improves balance between glutamate and GABA, lowers excitotoxicity
Vitamin B12 in the form of cyanocobalamin - cyanocobalamin is converted to hydroxocobalamin in the human body but the latter form will be more active as a nitric oxide scavenger, since it does not require such conversion
Riboflavin - helps reduce oxidized glutathione back to reduced glutathione
Carotenoids (alpha-carotene, bixin, zeaxanthin and lutein) - lipid (fat) soluble peroxynitrite scavengers
Flavonoids (flavones, rutin, hesperetin and others)
Ascorbic acid (vitamin C)
Tocotrienols - forms of vitamin E reported to have special roles in lowering effects of excitotoxicity
Thiamine (aneurin) - B vitamin involved in energy metabolism
Magnesium - lowers NMDA activity; may aid energy metabolism
Zinc - precursor of SOD
Betaine hydrochloride (HCl) - lowers reductive stress, hydrochloride form should only be used by those deficient in stomach acid
Essential fatty acids including long chain omega-3 fatty acids
Phosphatidyl serine - reported to lower iNOS induction

Agents from Pall/Ziem Protocol Predicted to Down-Regulate NO/ONOO- Cycle Biochemistry

Nebulized, inhaled reduced glutathione
Nebulized, inhaled hydroxocobalamin (some use sublingual)
Mixed, natural tocopherols including g-tocopherol
Buffered vitamin C
Magnesium as malate
Four different flavonoid sources: Ginkgo biloba extract, cranberry extract, silymarin, and bilberry extract
Selenium as selenium - grown yeast
Coenzyme Q10
Folic acid
Carotenoids including lycopene, lutein and b-carotene
a-Lipoic acid
Zinc (modest dose), manganese (low dose) and copper (low dose)
Vitamin B6 in the form of pyridoxal phosphate
Riboflavin 5'-phosphate (FMN)
Betaine (trimethylglycine)
Dr. Ziem has recently added two additional agents: green tea extract (flanonoids) and acetyl L-carnitine.

Let me add three additional important points:

It is important, with all of these treatments, to avoid up-regulating NO/ONOO- cycle biochemistry. A number of things will tend to produce such up-regulation. These include chemical exposure in MCS patients, excessive exercise in CFS patients, excitotoxin exposure (including MSG and aspartame) in all of these diseases/illnesses, exposure to food allergens in those who have food intolerances and psychological stress in those sensitive to such stress. These treatments are only effective when the agents down-regulating NO/ONOO- cycle biochemistry are taken along with avoidance of stressors predicted to up-regulate such biochemistry.

The second point is that I think that all of these protocols can be improved and I suspect that the physicians who developed them would agree with this. Nevertheless, I would argue that we now know how to effectively treat these diseases/illnesses and that such treatment consistently involves down-regulating the fundamental etiologic cycle that causes them.

The third is that we now have sufficient evidence supporting the NO/ONOO cycle etiology of these diseases/illnesses. This is the only detailed explanation for the many overlaps among these illnesses, their substantial comorbidity with each other and the extraordinary variation in symptoms and signs from one case to another. In other words these are true diseases, with a defined morbid process and etiology, albeit ones with unusual variation from case to case due to the local nature of the underlying biochemistry. This is a major new paradigm of human disease, and there are other diseases/illnesses that are candidates for inclusion under this paradigm."

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Martin L. (Marty) Pall
Professor of Biochemistry and Basic Medical Sciences
Washington State University
phone 509-335-1246
fax 509-335-9688