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provided by Elsevier - Publisher Connector Journal of Medical Hypotheses and Ideas (2013) 7, 50–53

Available online at www.sciencedirect.com Journal of Medical Hypotheses and Ideas

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Synergistic effect of , butyrate and L- in treatment of IBD

Mahsa Moeinian, Seyedeh Farnaz Ghasemi-Niri, Shilan Mozaffari, Mohammad Abdollahi *

Department of Toxicology and Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Tehran University of Medical sciences, Tehran, Iran

Received 23 December 2012; revised 14 February 2013; accepted 27 February 2013 Available online 14 March 2013

KEYWORDS Abstract Genetic, environmental factors, dysregulation of immune system, intestinal microbes and

L-Carnitine; oxidative stress are the most important factors that play the role in the pathogenesis of inflamma- Inflammatory bowel disease; tory bowel disease (IBD). Current treatments do not always result in complete remission and usu- IjB kinase; ally accompanied with several adverse effects. Recent studies showed that nuclear factor-kappa B Butyrate; (NF-jB), tumor necrosis factor-a (TNF-a) and oxidative stress play the pivotal role in the induction Probiotics; of inflammation. Butyrate, L-Carnitine, and probiotics have the potential to control inflammation Oxidative stress by reduction of main inflammatory cytokines, including NF-jB and TNF-a. They also stimulate antioxidant and inhibit IjB kinase (IKK). Regarding the beneficial effects of these three compounds in inflammation via several mechanisms, we hypothesize that the mixture of these com- pounds would be synergistically effective in reduction of inflammation and alleviation of IBD. Fur- ther experimental investigations are needed, to evaluate the hypothesis. ª 2013 Tehran University of Medical Sciences. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.

Introduction the main causes to the disease, but the exact pathophysiology of IBD is under debate yet [1–4]. The most of currently used Inflammatory bowel disease (IBD), representing as ulcerative medicines can only reduce the severity of IBD symptoms and colitis (UC) or Crohn’s disease (CD), with an increasing cannot cure the disease or do not result in complete remission incidence, can be debilitating in affected patients. It associates [5]. Conventional treatments are accompanied with several with colonic mucosal inflammation that causes bloody adverse effects resulting in less tolerability and compliance in diarrhea and abdominal pain. Although, activation of patients [2,6,7]. Therefore, in the recent years, many investiga- inflammatory process and oxidative stress are believed to be tions have been done to develop new natural, non-synthetic

* Corresponding author. Tel./fax: +98 21 66959104. E-mail addresses: [email protected], [email protected] (M. Abdollahi).

2251-7294 ª 2013 Tehran University of Medical Sciences. Published by Elsevier Ltd. Open access under CC BY-NC-ND license. URL: www.tums.ac.ir/english/ doi:http://dx.doi.org/10.1016/j.jmhi.2013.02.003 Synergistic effect of probiotics, butyrate and L-Carnitine in treatment of IBD 51 compounds to be safer with lesser adverse effects besides more myeloperoxidase (MPO) and malondialdehyde (MDA), two efficacies [4,8,9]. Previous studies have shown the efficacy of active elements of oxidative stress. L-Carnitine up-regulates butyrate, L-Carnitine, and probiotics in IBD when used alone SOD and prevents reduction of glutathione (GSH). It also or in combination with conventional therapies [10–13]. These inhibits accumulation of lipid peroxides. Therefore, it sup- compounds have the potential to control inflammation by presses the formation and the activation of ROS, resulting in reduction of main inflammatory cytokines, the nuclear fac- inhibition of NF-jB pathway [15,20,23,26] (Fig. 1). tor-kappa B (NF-jB) and tumor necrosis factor-a (TNF-a), which play the pivotal role in induction and progress of IBD The hypothesis [14–17]. The protective effect of butyrate, L-Carnitine, and pro- biotics against oxidative stress, is well documented based upon It is revealed that suppression of NF-jB through inhibition of the results from previous studies. IKK or via stimulating of antioxidant enzymes may suppress Butyrate is produced naturally by bacterial fermentation in oxidative stress. Based on the beneficial effects of butyrate, colonocytes. It affects IkB kinase (IKK) by suppressing phos- L-Carnitine and probiotics in inflammation, via mentioned k k phorylation of I B-a or I B-b. This results in reducing the mechanisms, we hypothesize that combination of these com- stimulation of NF-jB pathway and thus decreases the level pounds would be synergistically effective in reduction of of reactive oxygen (ROS) [2,16,18–23]. In addition, inflammation. butyrate prevents elevation of TNF-a which occurs during Some studies support the present idea. For instance, probi- the process of inflammation. Then, silencer of death domain otics cause an over expression in -coupled mono car- (SODD) dissociates from adaptor protein so called TNF boxylate transporter 1 (SMCT1) gene, which is responsible receptor type 1-associated death domain protein (TRADD), for butyrate’s absorptions. This gene is down regulated by which finally activates the ribosome inactivating protein TNF-a. In addition, over expression of L-Carnitine’s trans- (RIP) and TNF receptor associated factor 2 (TRAF2). These porter (OCTN2) by Saccharomyces boulardii (a type of probi- activated proteins stimulate IKK and NF-jB [14,24]. otics), and enhancement in the metabolism of butyrate (b On the other hand, probiotics have preventive effects on the oxidation) by L-Carnitine have been demonstrated. Therefore, induction of NF-jB, either directly or indirectly. They can de- by considering these interactions, the combination effect might k lay degradation of I B-a, so they inhibit the activation of NF- be a more advantageous in IBD treatment [22]. jB, expression of TNF-a and other pro-inflammatory cyto- kines. In addition, by producing anti-oxidant enzymes such Evaluation of the hypothesis as superoxide dismutase (SOD) and catalase (CAT), probiotics act against ROS, which induces IKK [18,25]. The third compound L-Carnitine (b-hydroxy-c trimethyla- To evaluate the efficacy of combination treatment, first, an mino butyrate) has anti-oxidant activity as mainly reduces appropriate experimental model of IBD should be set up.

Figure 1 The effects of butyrate, L-Carnitine, and probiotics on IKK. SOD: Superoxide Dismutase; CAT: Catalase; IKK: IjB Kinase; iNOS: inducible Nitric Oxide Synthase; NO: Nitric Oxide; NF-jB: Nuclear Factor-kappa B; RIP: Ribosome Inactivating Protein; ROS: Reactive Oxygen Species; TNF: Tumor Necrosis Factor; TNF-R: Tumor Necrosis Factor Receptor; TRADD: Tumor Necrosis Factor Receptor Type 1-Associated Death Domain Protein; TRAF2: Tumor Necrosis Factor Receptor Associated Factor 2; SODD: Silencer of Death Domain. 52 M. Moeinian et al.

Among several models, dextran or trinitrobenzene sulfonic via down regulation of TNF-a, inhibition of NF-jB, or sup- acid (TNBS) induced colitis, are similar models to human pression of ROS [19,20,23,25,27,28]. These benefits would be IBD with the most reproducibility. To set up the study, seven considered in therapy of IBD. groups, including, sham, negative, positive control, and four treatment groups (each compound alone or in combination) Conflict of interest statement should be assigned. To prepare the mixture, containing these three compounds, a proper formulation should be provided. The authors have no conflict of interest. Authors try to test the idea The effective doses of each compound and duration of treat- in animal models. Authors acknowledge assistance of INSF and ment should be adjusted based on literature and previous stud- TUMS. Since Editor-in-Chief of the journal is one of authors, all ies [27]. After the treatment period, macroscopic, microscopic review process was conducted by one of section editors. and biochemical bio markers of colon should be evaluated. The main factors of bowel inflammation such as oxidative stress markers and inflammatory cytokines, including TNF-a Overview Box and NF-jB, should be measured and compared among treat- ment groups [14,16,21,23,28,29]. Given that dextran and First Question: What do we already know about TNBS-induced colitis models are acute models, comparison subject? with dexamethasone as a positive control is proposed. There are some information about pathogenesis of IBD, therapeutic methods and alternative therapies. Discussion Recent studies have shown positive effects of butyrate, L-Carnitine and probiotics in IBD when used with con- Current treatments of IBD such as corticosteroids, immunosup- ventional therapies. pressive agents and 5-aminosalicylic acid (5-ASA) are not com- pletely curative and satisfying. Recent studies have focused upon Second Question: What does your proposed theory add theroleofNF-jB, TNF-a and oxidative stress in the induction to the current available knowledge and what benefits does it have? of inflammation. Regarding the positive effects of butyrate, L-Car- nitine and probiotics via regulation of main inflammatory cyto- Mixture of butyrate, L-Carnitine and probiotics can be kines and anti-oxidant enzymes, we hypothesize that the safely used in IBD patients as a novel and desirable com- combination of these compounds would be synergistically effec- bination. By adding this combination to chemical therapy tive in reducing inflammation and alleviation of IBD. of patients, then the doses of chemicals and thus chance of These compounds have protective effects against oxidative adverse effects might be reduced. stress through several mechanisms. Butyrate inhibits degrada- tion of IkBa bound NF-jB (inhibitory protein) by suppression Third question: Among numerous available studies, what of IKK. In colonic tropism, butyrate stimulates the prolifera- special further study is proposed for testing the idea? tion of immature epithelial cells at the base of colonic crypts Evaluation of inflammatory cytokines such as TNF-a, and improves electrolyte absorption that leads to colonic re- NFjB, oxidative stress markers and, macroscopic and pair stimulation [30]. biochemical factors by setting up an appropriate colitis Several investigations have reported that probiotics such as model is proposed. casei, Bifidobacterium bifidum, and Saccharomy- ces boulardii recover immune colitis and reduce pro-inflamma- tory mediators inside the lamina propria of inflamed mucosa [31,32]. They activate T-cells via Th1 or Th2 immune re- References sponses. 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