NAD+ and Deficiency Diseases

Georg Harald Mehlhorn NAD+

Functions and Deficiency Diseases

GHM 27.04.2020

1 NAD+ and Deficiency Diseases

Contents Summary ...... 3 Introduction ...... 3 Working Hypotheses ...... 3 Deficiency Diseases ...... 3 Conclusions ...... 3 Abbreviations/Registry ...... 4 Introduction: NAD+ - Biosynthesis and-Metabolism ...... 5 Overview ...... 5 NAD+ Anabolism Biosynthesis and Catabolism ...... 9 Substrates/Anabolites ...... 9 Pathways I ...... 10 Pathways II ...... 11 Metabolism ...... 13 Catabolites of NAD+ ...... 14 Cofactors ...... 16 Catabolism of the NAD(P)(H) Pool and NAD+ Deficiency ...... 16 Side Effects of NAD+ - Anabolites ...... 18 NA Flush ...... 19 Liver and Kidneys (all substrates) ...... 20 NA ...... 20 NAM ...... 21 NR and NAR ...... 21 Tolerable Upper Limits (UL) ...... 22 Interaction with Medications ...... 22 Immunosuppressive Medications ...... 23 Degenerated and Waste Products from Necrosis ...... 23 Dosages ...... 23 Outlook: What to do? ...... 25 Thesis ...... 25 Diagnosis of NAD+ Deficiency ...... 25 Appendix ...... 26 (1) A Case Study in the “Letters to the Editor” ...... 26 (2) More Case Studies ...... 27 (3) NAD+ and Tryptophan ...... 30

2 NAD+ and Deficiency Diseases

Summary

Introduction Nicotinamide Adenine Dinucleotide 1 (NAD+) is a coenzyme that is essential for energy balance and supply in every living being. It ensures the energy supply into the TCA-cycle from the respiratory chain in the mitochondria of all cells. Affected cells deteriorate and die without sufficient mitochondrial2 energy. The possible results could be diseases based on deficiency of NAD+. NAD+ deficiency arises when the energy use overwhelms humans, i.e. in competitive sports, viral and bacterial infections, parasites, stress, exposure to pollution, and last not least in pregnancy, at birth and during lactation - but always based on malnutrition and following deficiencies. Working Hypotheses 1. Eliminating deficiency in NAD+ is the prerequisite for successful therapies. 2. Eliminating of a NAD+ deficiency is not a therapy, but a diet. 3. Chronic deficiency of NAD+ creates chronic diseases. 4. NAD+- deficiency creates non-specific symptoms, which are characteristic for many diseases. Deficiency Diseases Lack of NAD+ inevitably means a lack of energy in the cells. This may lead to disorders, including • Fatigue illnesses, for example in CFS or ME3 and depression, • Many psychiatric disorders (for example schizophrenia and ADHD),  Metabolic diseases, for example type 2 diabetes and metabolic syndrome, • Some prenatal genetic / chromosome disorders due to a defective methylation and DNA repair, some so-called inherited diseases, possibly the Down syndrome4 as well, • Cardiovascular diseases, • Changing stress response, necrosis instead of apoptosis /autophagy,  Disruptions of the immune response and immune tolerance, autoimmune disorders, • Cancerous diseases that arise on the basis of a lack of cell energy, that is: a lack of NAD+5.

The list is not exhaustive; it grows practically every day with new research.

Conclusions Eliminating the NAD+ deficiency does not mean healing automatically, but it is the precondition of prevention, healing, or self-healing. The physician starts after the elimination of the NAD+ deficiency. Mostly several potential causes come together, i.e. previous illnesses and the life style (habits, diets, epigenetics), which must be known if effective help for a therapy shall be provided for. Refusal to apply a balancing of the NAD+ levels at the begin of a therapy is akin to the violation of the oath of Hippocrates.

1 https://www.ncbi.nlm.nih.gov/pubmed/29477227 2 The mitochondria probably do not attract a disease; they starve. 3 CFS and ME start in many cases with an infection causing a collapse of the immune system. The following symptoms may depend on the species of pathogens. After ramping up the NAD+ supply, all these following infections should be counteracted one by one. 4 Down syndrome was chosen as an example because the frequency of chromosomal defects in the child increases with the age of the mother - when the NAD+ level decreases due to mother’s age. Experience has shown that increasing the NAD+ level during pregnancy protects the infant from such syndromes. 5 https://www.ncbi.nlm.nih.gov/pubmed/29883761 3 NAD+ and Deficiency Diseases

Abbreviations/Registry Abbreviation means/comment Page ADHD, ADHS Attention Deficit Hyperactivity Disorder (D = Disorder, S = Syndrom) 4;5;9;16 ADP AdeninosinDiPhosphat (Energy Transmitter in the TCA cycle) 5;16 ADPR Adenosine DiPhosphoRibose (activates the TRPM2 ion channel, DNA-repair) 14 ART ADP-ribosyltransferase, signals gene distortions to the PARPs 6;16 ATP AdeninosinTriPhosphat (Energy Transmitter in the TCA cycle) 15;18 Asp Aspartic acid 6;10 CNS Central Nervous System 7;9;15 CoA Coenzyme A 18 DNA Desoxyribonucleic Acid 4;6;7;16 DGE Deutsche Gesellschaft für Ernährung e.V. (German Association for Nutrition) 19 EFSA European Food Safety Authority 19 EBM Evidence based medicine. Denotes the introduction of statistical means as an interpretation method of results in medicinal research. 23;25 ER Extended Release (applies mostly to NAM) 19;25 FAD++ Flavin adenine dinucleotide, energy transfer into mitochondriae (similar to NAD+) 14;15;16

FADH2 FAD reduced, energy transfer into mitochondriae (similar to NAD+) 14;15;16 GTP Guanosintriphosphate 16;17 GDP Guanosindiphosphate 16;17 ICD International Statistical Classification of Diseases and Related Health Problems 6 IHN Inositol Hexanicotinate 10 MS Multiple Sclerosis 6;15 N-Me-2PYR N-methyl-2-pyridone-5-carboxamide 15 N-Me-4PYR N-methyl-4-pyridone3-carboxamide 15 NA Nicotinic Acid (synonymous Vitamin B3, niacin) 5ff NAD+ Nicotinamide Adenine Dinucleotide, extremely important coenzym in the 2ff energy supply to cells, oxidized NAD(H)(P) Pool of functional cofactors derived from NA and NAM (vitamin B3) 5ff NAAD Nicotinic acid adenine dinucleotide 5ff NAADP Nicotinic acid adenine dinucleotide phosphate 5ff NADH 1,4-dihydronicotinamide adenine dinucleotide, extremely important coenzyme in the energy supply to cells, reduced (biological hydrogen) 5ff NADP nicotinamide adenine dinucleotide phosphate NAFLD Non Alcoholic Fatty Liver Disease 5;6;7 NAM Nicotinamide (synonymous Vitamin B3, niacin) 5ff NAMN Nicotinic Acid Mononucleotide (intermediary step in the NAD+ metabolism) 5ff NAR Nicotinic Acid Riboside (synonymous Vitamin B3) 9;10;17;22 NC Nicotine 10 NMN Nicotinamide Mononukleotide, (synonymous Vitamin B3) 10 ff NR Nicotinamide Riboside (synonym Vitamin B3 as well) 10 ff NUA Nicotinuric Acid (Catabolite of NA, strongly detoxifying) 14 PARP poly(ADP-ribose)-polymerase, protects cells from genetic instability 5;9;16;21 PRPP 5-phospho-D ribosyl-α-1-diphosphate 10;16;30 RDA Recommended Daily Allowance 10;15;21 SNRI Serotonin-Noradrenalin-Reuptake-Inhibitor 8;11 SSRI Selective-Serotonin-Reuptake-Inhibitor 8;11 TCA TriCarboxylic Acid cycle (Krebs Cycle) 2;15;16 Trp Tryptophan (essential amino acid) 10;11;16;20

4 NAD+ and Deficiency Diseases

Introduction: NAD+ - Biosynthesis and-Metabolismw)

Overviewmm) yy) Aspartic Trypto- Nicotinic- Nicotin- Nicotinamide- Inositol Nicotinic Acid Acid phan acid amide mononucleotide Hexanicotinate Riboside

Nicotine Nicotinamide riboside

NAD+ ss) tt)

Dopamine NAD(H)(P)

Pool

Redox Sirtuines PARPs Reactions (ARTs) Cell Energy

Energy Metabolism - DNA-Repair – Gene Expression – Cell Stress response – CD38/157 Ectoenzyme

Deficiency/ Psychiatric Neurode- Genetic and Metabolism Cancers c) aa) Fatigue- Disorders generative www) e), j), o), p) zz) ), q) Hereditary Disorders Diverse Diseases Disorders dd) rrr) uuu) vvv) a1) b1) Diseases bbb) aa) aaa) qqq) ttt) Metabolic CFS/ME Schizo- y) bb) jj) ee) t) ii) tt) fff) C1) Congenital syndrome Burnout phreny qqq) ggg) Mal- Skin Cancer rr) ppp) Depres- Alzhei- d) formations a) g) zzz) c) x) bb) dd) Addictionsccc) mer’s, Diabetes sion ss) f1) g1) a1) hhh) b) r) Posttrauma- ADHS Dementia Some hh) oo) vv) c) tic Stress Hunting- Dislipidemia autoimmune xx) Disorder) ton’snn) MS NAFLD (Nonal- diseaseseee) yy) vvv) Bipolar Parkin- cohlic Fatty yyy) ll) pp) ddd) m) uu) ww) Disorderv) cc) son’s Liver) sss) xxx)

Insulin- resistancez)

Cardiovascular Agingh) k) gg) kk) Ischemia, Acute Mitochondrial iii) JJJ) kkk) lll) Diseases nn) ttt) Strokei) myeolid Myopathy qq) mmm) nnn) ooo) ppp) d1) u) Longevityn) ff) Leucemia

Picture 1: The current level of knowledge (April 2020) shows that NAD+ metabolism is based on 8 predecessor substances (substrates). Perhaps more will be discovered, because with such an important substance as NAD+, there are inevitable evolutionary advantages through functioning NAD+ biosynthesis if many others already suffer from NAD+ deficiency and become unable to react. The assignments of NAD+ deficiency diseases in the picture above are nothing better than any other suggestion. The category "NAD+ deficiency diseases" will not be found in the future ICD 11, let alone previous versions, or anywhere else in allopathic medicine. Such a categorization will not exist either very likely, because the associated variety of conditions and diagnoses exceeds by far the scope of a mono-causal classification and guideline – and, in most cases, they are not even medical, but

5 NAD+ and Deficiency Diseases nutritional. The symptoms apply to hundreds of non-infectious diseases. Often a NAD+ deficiency is possibly the base, but rarely the single cause of a NAD+ deficiency disease. a) Diabetes: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869616/ b) Alzheimer’s: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5795269/pdf/f1000research-7- 13118.pdf c) Several Disorders: https://www.ncbi.nlm.nih.gov/pubmed/18429699 d) Several Disorders: https://www.nejm.org/doi/full/10.1056/NEJMoa1616361 e) Several Cancers: https://www.ncbi.nlm.nih.gov/pubmed/26126285 f) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/26374109 g) Diabetes: https://www.ncbi.nlm.nih.gov/pubmed/27274295 h) Aging and NAD+: https://www.ncbi.nlm.nih.gov/pubmed/26725653 i) Ischemia, Stroke: https://www.ncbi.nlm.nih.gov/pubmed/30838484 j) Cancer: https://www.ncbi.nlm.nih.gov/pubmed/19109034 k) Aging: https://www.ncbi.nlm.nih.gov/pubmed/19897060 l) Neurodegnerative Diseases: https://www.ncbi.nlm.nih.gov/pubmed/18629638 m) NAFLD: https://www.ncbi.nlm.nih.gov/pubmed/27174364 n) Longevity: https://www.ncbi.nlm.nih.gov/pubmed/31954874 o) Cancer: https://www.ncbi.nlm.nih.gov/pubmed/28780936 p) Cancer: https://www.ncbi.nlm.nih.gov/pubmed/29334761 q) Neurodegenerative Diseases: https://www.ncbi.nlm.nih.gov/pubmed/31280708 r) NAD+ and Alzheimers’s https://www.ncbi.nlm.nih.gov/pubmed/18522897 s) Fatigue Diseases: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5609866/ t) Schizophrenia: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023707/ u) Acute Myeolid Leukemia: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952987/ v) Bipolar Disorder: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6252326/ w) NAD+ Metabolism: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5521000/ x) Depression: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4955923/ y) Metabolic Syndrom: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779535/ z) Insulin Resistanz: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779535/ aa) Disorders of the CNS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6412771/ bb) Metabolic Syndrom, Depression: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4814520/ cc) Bipolar Disorder and Mitochondria. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007750/ dd) Comorbidity, Cancer and Depression/pathways: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820591/ ee) There is currently no viable study associating NAD+ deficiency with burnout; however, the etiology and the symptoms of burnout show it as a fatigue disorder. There are also enough studies and reports on burnout as a preliminary stage for depression. ff) Aging: https://www.ncbi.nlm.nih.gov/pubmed/17482543 gg) Aging – Retina: https://www.ncbi.nlm.nih.gov/pubmed/29905535 hh) Alzheimer‘s: https://www.ncbi.nlm.nih.gov/pubmed/30523581 ii) Schizophrenia: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889309/ jj) Metabolic Disorders: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511662/ kk) Aging: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482912/ ll) Parkinson‘s, Alzheimer‘s, Physical Body https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850382/ mm) Overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279435/ nn) Huntigton’s https://www.ncbi.nlm.nih.gov/pubmed/20307564 oo) Alzheimer’s, Demenz https://www.ncbi.nlm.nih.gov/pubmed/24071780 pp) Parkinson’s https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6770365/ qq) Mitochondrial Myopathy: https://www.ncbi.nlm.nih.gov/pubmed/24711540 rr) Skin Cancer https://www.ncbi.nlm.nih.gov/pubmed/28888216 ss) DNA-Repair https://www.ncbi.nlm.nih.gov/pubmed/25837229

6 NAD+ and Deficiency Diseases

tt) Schizophrenia https://www.isom.ca/wp-content/uploads/2012/12/The-Niacin-Flush-Pathway- in-Recovery-from-Schizophrenia-and-How-Arginine-and-Glutamine-May-Provide-Added- Benefit-27.1.pdf uu) Metabolic Disorders, NAFLD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686634/ vv) Alzheimer’s, Dementia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854586/ ww) Metabolic Disorders, NAFLD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362104/ xx) Multiple Sclerosis https://www.researchgate.net/publication/23796702_The_Importance_of_NAD_in_Multiple_ Sclerosis yy) Autoimmune Diseases https://www.ncbi.nlm.nih.gov/pubmed/17430113 zz) Schizophrenia https://www.europeanreview.org/wp/wp-content/uploads/988-997.pdf aaa) Neurodegenerative Disorders https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4192966/ bbb) CFS https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3460668/ , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3729338/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4136529/ , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027464/ The effect of NAD+ (NADH) in CFS/ME has been sufficiently documented in several studies since 2013 (Google search "cfs nadh"). The effect of NADH-supplementation should be excellent, but we didn't test it because NADH supplements are very expensive, and the same results can be achieved with quite inexpensive means. Filling the NAD+ - storage in the liver with NADH supplements could be afforded by very few sufferers only, because even with moderate doses, at least 120 capsules or lozenges 20 mg would be necessary per day, i.e. some EUR 80 per day, and for at least 3 months - without funds of the health insurance. In addition, NADH as a supplement is not as well researched as the B3 vitamins, and even naturopaths who know more about it sometimes shy away, and, of course, there are sometimes business interests to suppress the link. Physicians who finished their education before 2013 do not know about these facts except they would have attended a post gradual educational course. ccc) The role of NAD+ deficiency in the development of addiction has been known since the 1960s. Unfortunately, this knowledge could not prevail, although it found highly prominent supporters and very diligent promoters. Little has changed since then – and there are only a few doctors taking a junkie in, who is often not even insured, and therefore fails as a source of income. And last but not least: the practical knowledge about NAD+ and NA is disguised. Nobody speaks about a connection between those two, and nobody would make a business out of it. Neither NAD+ nor NA is mentioned in the guidelines anywhere. Since the problem of drug addiction has massively worsened in recent years (SSRI, SNRI, opiate crisis, etc.), the old knowledge has come to the fore, but even the most prominent pharmaceutical critics (i.e. Breggin, Gøtzsche) do not mention the links between addiction and NAD+, and do not respond to inquiries. Anyway; we think they’d know. -

We had one case, a 35-year-old man who had been dependent on venlafaxine for 8 years. Under medical supervision, with massive doses of NA and a radical change in his diet, he ramped up his NAD+ storage. He felt no hangover, and after 3 days, he had no desire to take a venlafaxine anymore. He could easily endure the withdrawal symptoms; they were not worse than the general feeling on a bad day with venlafaxine. The emergency phone to our medical staff didn’t ring. He is currently (6 months later) taking 3x 1g NA per day (about € 0.60) and does not want to reduce it because he feels wonderful and was able to take an important step in his career without any problems. Of course, he is educated about the risks of high dosages of NA. Experience has shown that he will reduce the dosage to the amounts actually used by his body anyway, within a year. ddd) Several cancers: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723628/ eee) Autoimmune diseases: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5476425/

7 NAD+ and Deficiency Diseases fff) Schizophrenia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3977058/ : “To our knowledge this is the first report that provides a mechanistic justification between mitochondrial events and neurodegeneration in the Schizophrenia.” This statement could apply to other neurodegenerative diseases as well. ggg) Schizophrenia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889085/ hhh) „ADHD is not a disease; it is a nutritional deficiency“ Lendon H. Smith, M.D. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900218/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2889842/: “Children with attention- deficit/hyperactivity disorder (ADHD) show a marked temporal variability in their display of symptoms and neuropsychological performance. This could be explained in terms of an impaired glial supply of energy to support neuronal activity.“ - As we know today, the therapy for ADHS certainly depends on the functioning energy transport to the mitochondria of the CNS. However, the villain is not the disabled supply via glia cells, but the lack of NAD+. There is also a German study in this case: Gunter P. Eckert Pharmakologisches Institut für Naturwissenschaftler, Goethe-Universität Frankfurt/Main, in https://www.researchgate.net/publication/263591913_Nutrition_and_ADHD. A curious example of manipulation by omission in the treatment of ADHD: NA and other B3 vitamins, the only inexpensive and effective dietary supplements as the basis for NAD+ synthesis is completely omitted in: https://www.medicalnewstoday.com/articles/325885 iii) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/19149606 jjj) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/26707577 kkk) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/26485210 lll) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/28661724 mmm) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/29351465 nnn) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/29968072 ooo) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/30875255 ppp) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/30593894 qqq) Cardiovascular Diseases: https://www.ncbi.nlm.nih.gov/pubmed/30974124 rrr) Cancer https://www.ncbi.nlm.nih.gov/pubmed/31280708 sss) Parkinson’s https://www.ncbi.nlm.nih.gov/pubmed/30631755 ttt) Neurodegenerative Disorders https://www.ncbi.nlm.nih.gov/pubmed/28548540 uuu) Cancer: https://www.ncbi.nlm.nih.gov/pubmed/29719225 vvv) Cancer: https://www.ncbi.nlm.nih.gov/pubmed/29203587 www) Metabolic Disorders https://www.ncbi.nlm.nih.gov/pubmed/29744033 xxx) NAFLD https://www.ncbi.nlm.nih.gov/pubmed/29264533 yyy) NAFLD https://www.ncbi.nlm.nih.gov/pubmed/27663419 zzz) Diabetes https://www.ncbi.nlm.nih.gov/pubmed/27002158 a1) Diabetes https://www.ncbi.nlm.nih.gov/pubmed/27173464 b1) Cancer https://www.ncbi.nlm.nih.gov/pubmed/27186719 c1) Neurodegenerative Disorders https://www.ncbi.nlm.nih.gov/pubmed/27018006 d1) Arteriosclerosis http://www.heartfixer.com/CHC%20-%20Medical%20Topics%20- %20Niacin.htm e1) Coronary Heart Disease https://isom.ca/article/niacin-coronary-disease-longevity/ f1) Congenital malformations due to NAD+ deficiency in https://www.mdedge.com/obgyn/article/144173/obstetrics/researchers-identify-congenital-nad- deficiency-disorders The malformations mentioned here are probably not the only ones. If defective genes are identified, they could be due to incorrect gene expression as a result of missing PARP or signaling ART deficiency. g1) Miscarriages in NA / NAD+ deficiency (mouse model).

8 NAD+ and Deficiency Diseases

NAD+ Anabolism, Biosynthesis and Catabolism Addressing a NAD+ deficiency is to increase the supply of NAD+ or one of the other cofactors in the NAD(H)(P) pool, preferably by nutrition, until the NAD+ balance is established with satisfactory conditions, and maintained (see "Outlook: What to do?" and Appendix “(3) NAD+ and Tryptophan”). Further reading about the cofactors in the NAD(H)(P) pool in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411094/pdf/nihms-1006625.pdf and Wikipathway (Common License see chapter “Biosynthesis”. We checked it against the explanations in http://vm- trypanocyc.toulouse.inra.fr/pwy-search.shtml and in http://modelseed.org/biochem/compounds/cpd00218.

Substrates/Anabolites Eight substrates or anabolites of NAD+ are known:  Nicotinic acid amide (NAM). Called “nicotinamide” in America, a non-essential amide of NA, hydrolytically broken down in NA and the amide group for desorption into the plasma;  Nicotinamide riboside6 (NR). Is intermediate in the NAD+ Salvage Pathway, is ingested through certain animal foods (cow milk). Can be chemically synthesized today;  Nicotinic Acid (NA), non-essential amino acid, called “niacin” in America. Can be chemically synthesized as a dietary supplement;  Nicotinic Acid Riboside7 (NAR), byproduct from NAMN synthesis as a precursor of NAD+, if there is an intracellular NAD+- deficiency. Was found in cow milk, not a dietary supplement;  Tryptophan (Trp), an essential amino acid, substrate of serotonin and other proteins. Is an important anabolite of NA;  Nicotinamide mononucleotide (NMN), an intermediate stage in the Preiss Handler Pathway and in the De Novo Pathway. It disintegrates at ambient temperature; newer formulations are stabilized; however, with stabilization come other risks;  Aspartic acid8 (Asp) is a non-essential amino acid. As an anabolite of NA in mammals found only in one reference9; A substance that is not a biochemical anabolite of NAD+ but that releases esterified NA hydrolytically:  Inositol hexanicotinate (IHN) consists of one molecule of inositol (earlier called vitamin B8) that bound six molecules of esterified NA. Inositol releases the NA via hydrolysis in the blood plasma. That reaches a peak after 6 to 10 hours. The complete dissolution of IHN may take as long as 48 hours. This prevents flushes, see below, but the effectiveness is questionable. Some authors classify IHN as a B3 vitamin. IHN is approved in Europe for the treatment of Raynaud’s disease and peripheral arterial disease. IHN is a legal nutritional supplement in America and Europe. The effective content is turned down to the levels of the RDA for NA10. The release in 48 hours prevents it from side effects, and it has no detectable effect in the case of dyslipidemia11 as well. Furthermore, esterified NA (as in IHN) is not bioavailable. The Mayo clinic doesn’t call it the “flush free niacin”, but the “effect free niacin”12.

6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5876407/ 7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646395/ 8 https://www.semanticscholar.org/paper/Current-status-and-prospects-for-the-study-of-and-Wang- Bennetzen/b3079045e317b0fc77497b1da45e4a4e6fb17003 9 https://www.wikipathways.org/index.php/Pathway:WP106 10 https://pubchem.ncbi.nlm.nih.gov/compound/Inositol-niacinate, https://efsa.onlinelibrary.wiley.com/doi/pdf/10.2903/j.efsa.2009.949 11 https://www.ncbi.nlm.nih.gov/pubmed/23351578 12 https://www.mayoclinicproceedings.org/article/S0025-6196(11)60429-1/fulltext 9 NAD+ and Deficiency Diseases

Out of these eight we consider following only six, because IHN is useless, and the biosynthesis of NAD+ from aspartic acid and from NAR are possibly without higher significance in humans. NA, NAM, NR, and NAR are water soluble. Following we call them B3-Vitamins. The half-lives in blood plasma for the B3-Vitamins are less than one hour; however, desorption takes only minutes. The effect comes before the B3-Vtamins are metabolized. The body can also store some NAD(H)(P) in the liver, which is sufficient for 2 to 6 weeks, depending on the use and the health conditions. NADH could act as an emergency aid in the case of suicidal moods, because the effect starts immediately. It would be way more safely than the usually prescribed SSRI / SNRI13, which would reach an effective level four weeks later only, when the user is possibly already addicted to them.

Picture 2: Energy supply in the mitochondria. Source: https://de.wikipedia.org/wiki/Nicotinamidadenindinukleotid Pathways I Five different biochemical pathways of the NAD+ synthesis were in the focus of research: 1. Salvage I (based on NR), 2 steps up to NAD+; 2. Salvage II (based on NAR); 2 steps up to NAD+; 3. Salvage III (based on NAM), 3 steps up to NAD+; 4. Preiss Handler, (based on NA), 3 steps up to NAD+; 5. De Novo (aka Kyrunenic Pathway, based on Trp), 9 steps up to NAD+. The biosynthesis of NAD+ in the Salvage II and De Novo pathways depend on the availability of PRPP. The body synthesizes a sufficient amount of PRPP, if there are sufficient amounts of vitamins B1, B2, and B6 available.14

Picture 3: Biosynthesis of NAD+. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411094/pdf/nihms-1006625.pdf

13 Peter C. Gøtzsche, “Deadly Medicines and Organized Crime”, ISBN-13; 978184619884 7, 2013 14 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411094/pdf/nihms-1006625.pdf 10 NAD+ and Deficiency Diseases

The three steps mentioned in Salvage II are a consequence of the specific NAM desorption, which happens after hydrolysis to NA only. The Preiss-Handler and De Novo pathways merge at the NMN and form one common pathway to NAD+. Trp is the primary anabolite for the biosynthesis of serotonin, and of some urgently needed proteins. Trp is present in large quantities in food. Deficiencies usually arise in the event of a disease or of malnutrition only. Pathways II This picture is taken under common license from Wikipathways, issued by Kristina Hanspers; Alexander Pico und Jonathan Mélius (GenMAPP, Conklin lab, The Gladstone Inst, UCSF, and https://www.wikipathways.org/index.php/Pathway:WP3645#nogo2).

Picture 4: Biosynthesis of NAD+

In theory, all anabolites of NAD+ could serve as food supplements to replenish NAD+ loss. Practically, there are some difficulties:

11 NAD+ and Deficiency Diseases

1. Some combination supplements were taken from the market15, 16. 2. The unmodified B3 vitamins as NAD+ substrates are very safe and hardly cause any impairment of the liver (see “Liver and Kidneys”, and in the Appendix). None of the catabolites of the B3 vitamins is toxic; however, some waste products belong to the uremic toxins. They are designed for that, and are naturally excreted via kidneys. 3. The NAD+ substrates do not cause any metabolic or organic damage, as for NA has been falsely claimed for about 70 years. These claims are supported by studies / observations with modified substrates, or NA combined with a medication, using the name of “niacin” for the compound17. 4. There are also unusual effects caused by previous diseases and co-morbidities. The damage of these previous diseases was blamed on NA. 5. High dosages were given omitting the detoxification. 6. Verification studies often did use much lower dosages, than in the original study. 7. The study design was made to disprove the original study. Studies with flaws as noted above have never been really significant. However, “Science advances one funeral at a time.”18 False hypotheses are not refuted, they die off. There are reports for NA application up to 18 g daily intake, but there is no death reported from using any vitamin - regardless of pre-existing conditions. Damage caused by excessive high dosing has not been reported with humans, if there was applied only the clean substrate. Damage was always from blends or stabilized servings, or from pre- conditions. There is one report with a dog that was given 1 g NA per kg body weight. There was actually a massive liver damage. Nobody did an analog experiment with humans, because that would translate to dosages of about 100 g per day. Maybe, somebody would survive that. But: Why should somebody risk the health of volunteers with such a dosage, if the effectiveness can be achieved with much lower servings?

15 Here is one example. Quotation Wikipedia „Laropripant“: (https://de.wikipedia.org/wiki/Laropiprant) “Laropiprant is a drug from the group of prostaglandin antagonists. In combination with the lipid-lowering agent NA used to treat lipid metabolism disorders, it should reduce the side effects of the flush syndrome (“flushing”). ... In December 2012, it was announced that the cardiovascular endpoint study HPS2-THRIVE (Heart Protection Study 2 - Treatment of HDL to Reduce the Incidence of Vascular Events) did not meet the primary endpoint "reduction of serious vascular events". Even in combination with a statin, Tredaptive (name under which Laropripant / NA was approved in Europe) did not reduce the risk of serious vascular events. With this combination, however, the incidence of some serious non-fatal undesirable side effects was statistically significantly increased compared to statin monotherapy, which is why Merck & Co., Inc. stopped selling Tredaptive worldwide and anticipated an expected ban. ”- - - The key question is: Was this study really about a very successful and cheap lipid-lowering agent (NA), or a substance that works on prostaglandins and avoids flushing (Laropripant)? Or was it about proving the safety and effectiveness of the statins? Or to discredit NA? The real success of the study is to know that NA should always be utilized in its pure form of nicotinic acid powder. However, this study is frequently quoted to show the dangerousness of NA. 16 https://www.aerzteblatt.de/nachrichten/59420/NA-Publikation-der-HPS2-Thrive-Studie-beziffert-Toxizitaet: It is worth reading this article carefully: When is it about NA, when about Laropripant? 17 https://www.mayoclinicproceedings.org/article/S0025-6196(11)60429-1/fulltext 18 Max Planck 12 NAD+ and Deficiency Diseases

Metabolism Bild: https://www.wikipathways.org/index.php/Pathway:WP3644

Picture 5: NAD+ metabolism in different organelles of human cells. NADH cannot penetrate the membrane of mitochondria Nikotinsäureamid itself. A vehicle (NAM) is required: hat hinsichtlich for this. There der are NADtwo, the;o Malate / Aspartate Shuttle, which does not chemically change the NADH, and the Glyceraldehyde-3-Phosphate Shuttle, which converts NADH to FADH2.

13 NAD+ and Deficiency Diseases

Catabolites of NAD+ The contents of this and the following chapter are excerpts from “The Chemistry of the Vitamin B3 Metabolome”19. The show the significance of the NAD+ metabolism.

The catabolites of NAD+ and NADP+ are substrates for enzymes, that are capable of cleaving a glycosidic linkage(autophagy)20 This cleavage is a finely orchestrated process, leading to derivatives regulating sirtuins and ADPRs21.

NAADP is synthesized from NAAD or from NADP+, regulating intracellular Ca2+ signaling processes22.

Cyclic ADPR (cADPR) is synthesized by a cyclase and mobilizes Ca2+. Linear ADPR is generated from NAD+ and promotes Ca2+ cellular uptake23,24. The polymeric forms of ADPR act as recruiting agents in DNA repair25, 26, 27.

The most important NA catabolite is the methylation product of NAM. That is N-methyl-NAM (N-Me- NAM), utilizing S-adenosylmethionine (SAMe) 28,29.

Excess NA is converted to NUA30 which is adamant in detoxification processes.

Excess NAM is oxidized to N-oxide-NAM by cytochrome P45031,32, and eventually excreted. The functions of N-oxide-NAM are not clear; however, its metabolism could be the reason why NAM might cause liver problems.

Trigonelline is N-methyl nicotinic acid, found abundantly in fenugreek and is generated during coffee roasting33,34. Trigonelline’s physiological properties remain widely unexplored; however, it might work as an NA-supply.

The oxidation of N-methyl-NAM creates N-Me-4PY, and N-Me-2PY,35,36,37,38. N-Me-2PY could be an inhibitor of PARP functions39, 40.

19 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411094/ 20 https://pubmed.ncbi.nlm.nih.gov/26975537/ https://pubmed.ncbi.nlm.nih.gov/20176146/, https://pubmed.ncbi.nlm.nih.gov/28302504/ https://pubmed.ncbi.nlm.nih.gov/21443875/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4911708/ https://pubmed.ncbi.nlm.nih.gov/29443986/, https://pubmed.ncbi.nlm.nih.gov/25027823/ https://pubmed.ncbi.nlm.nih.gov/29954836/, https://pubmed.ncbi.nlm.nih.gov/25955411/ 21 https://pubmed.ncbi.nlm.nih.gov/27825999/ 22 https://pubmed.ncbi.nlm.nih.gov/19387438/ 23 https://scholar.google.de/scholar?q=Cyclic+ADP- ribose+and+nicotinic+acid+adenine+dinucleotide+phosphate+(NAADP)+as+messengers+for+calcium+mobiliz ation&hl=en&as_sdt=0&as_vis=1&oi=scholart https://scholar.google.de/scholar?q=Cyclic+ADP- ribose+and+nicotinic+acid+adenine+dinucleotide+phosphate+(NAADP)+as+messengers+for+calcium+mobiliz ation&hl=en&as_sdt=0&as_vis=1&oi=scholart

24 https://pubmed.ncbi.nlm.nih.gov/26614649/ 25 https://pubmed.ncbi.nlm.nih.gov/27240471/ 26 https://pubmed.ncbi.nlm.nih.gov/28202539/ 27 https://pubmed.ncbi.nlm.nih.gov/25774719/ 28 https://www.ncbi.nlm.nih.gov/pubmed/24717514 29 https://www.ncbi.nlm.nih.gov/pubmed/26168293 30 https://www.ncbi.nlm.nih.gov/pubmed/14407738 31 https://pubmed.ncbi.nlm.nih.gov/24975217/ 32 https://www.ncbi.nlm.nih.gov/pubmed/6220720 33 https://www.ncbi.nlm.nih.gov/pubmed/22680628 34 https://www.ncbi.nlm.nih.gov/pubmed/28589997 14 NAD+ and Deficiency Diseases

N-Me-2PY has been described as a uremic toxin41 N-Me-4PY, and N-Me-2PY are produced systemically42, 43. The elimination requires healthy kidneys.

Another catabolite of NA is N-ribosyl-3-carboxamide 4-pyridone (4PYR). 4PYR is also found abundantly in uremic patients. 4PYR is easily endogenous converted to its nucleotide formulations (4PYR-MP, 4PYR-DP, 4PYR-TP) or adenylated to generate pyridone adenine dinucleotide species [NAD(P)O]44, 45, 46, 47, 48, 49, 50.

The synthesis of NADPO is a side-reaction of NAD(P)+51, 52, 53.

In vitro, the nucleotide forms inhibit ATP-dependent kinases. The dinucleotides are inhibitors of NAD(P)+-dependent metabolic redox enzymes54, 55.

A similar class of NAD(P)+ catabolites capable of inhibiting key metabolic enzymes are hydroxylated NAD(P)H. The generation of these catabolites is sufficiently critical to warrant a repair mechanism in all forms of life. The regeneration of NAD(P)H causes central metabolomic perturbations56,57.

The catabolites of the NAD(P)(H) metabolome are rarely researched, except for N-Me-NAM and N- Me-2PY 58, 59, 60. These compounds react readily under standard analytical conditions, hence they occur undetected very often.

Furthermore, mammalian cells employ at least two known repair mechanisms to control dinucleotidic catabolite levels. These are renalase, and NAD(P)HX dehydratase/ epimerase61, 62, 63.

35 https://www.ncbi.nlm.nih.gov/pubmed/25130730 36 https://www.ncbi.nlm.nih.gov/pubmed/27854278 37 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5127135/ 38 https://www.ncbi.nlm.nih.gov/pubmed/24096677 39 https://www.ncbi.nlm.nih.gov/pubmed/16604373 40 https://www.ncbi.nlm.nih.gov/pubmed/16021911 41 https://www.ncbi.nlm.nih.gov/pubmed/27854278 42 https://www.ncbi.nlm.nih.gov/pubmed/24077178 43 https://www.ncbi.nlm.nih.gov/pubmed/18089445 44 https://www.ncbi.nlm.nih.gov/pubmed/24940690 45 https://www.ncbi.nlm.nih.gov/pubmed/27906624 46 https://www.ncbi.nlm.nih.gov/pubmed/22069723 47 https://www.ncbi.nlm.nih.gov/pubmed/16920716 48 https://www.ncbi.nlm.nih.gov/pubmed/18600548 49 https://www.ncbi.nlm.nih.gov/pubmed/24940689 50 https://www.ncbi.nlm.nih.gov/pubmed/21312056 51 https://www.ncbi.nlm.nih.gov/pubmed/29177972 52 https://www.ncbi.nlm.nih.gov/pubmed/17635583 53 https://www.ncbi.nlm.nih.gov/pubmed/12102623 54 https://www.ncbi.nlm.nih.gov/pubmed/24940690 55 https://www.ncbi.nlm.nih.gov/pubmed/28323211 56 https://www.ncbi.nlm.nih.gov/pubmed/30098110 57 https://www.ncbi.nlm.nih.gov/pubmed/24611804 58 https://www.ncbi.nlm.nih.gov/pubmed/27721479 59 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6102308/ 60 https://www.ncbi.nlm.nih.gov/pubmed/29599478 61 https://www.ncbi.nlm.nih.gov/pubmed/30098110 62 https://www.ncbi.nlm.nih.gov/pubmed/24611804 63 https://www.ncbi.nlm.nih.gov/pubmed/28558965 15 NAD+ and Deficiency Diseases

Cofactors Tryptophan, NA and NAM employ three convergent pathways. All three require the cofactor PRPP64. The anabolites of PRPP are thiamine (B1), NADP+, riboflavin (vitamin B2)65, and pyridoxine (vitamin B6)66.

NAD(P)(H) Pool and NAD+ Deficiency (1) NAD+ - energy metabolism67, 68 is the condition of life. It transfers electrical potentials between the Krebs cycle (TCA) in the mitochondrion69, and the respiratory chain70. Deficient NAD+ causes a lack of energy in nearly all mitochondria, most vulnerable the mitochondria in the CNS71, because there is the highest need for energy. The mother's depression could have its cause here.  The mitochondria are starving and damaged, and the cells may die in necrosis or apoptosis/autophagy causing probably symptoms (fatigue diseases) such as a starting CFS72, or burnout, or depression.  The waste products of necroses may be denatured proteins, which could act as a cell poison. This might lead to various diseases, including schizophrenia73,74, perhaps epilepsy and other neurodegenerative diseases. The references to these statements are given under “Overview”.  The Recommended Daily Allowances (RDA), are tables giving an information about a minimum for any nutrient or vitamin to prevent the known deficiency diseases. An RDA for NAD+ does not exist, because not long ago, there was no way to supplement it. Instead, NA, NAM, NAR, and NR are limited. This minimum prevents in any case the side effects of those vitamins; however, the effects are prevented, too. The number of studies75,76 is multiplying that clearly show that RDAs are rather useless in the

64 https://www.ncbi.nlm.nih.gov/pubmed/29685734 65 https://www.ncbi.nlm.nih.gov/pubmed/6076241 66 https://www.ncbi.nlm.nih.gov/pubmed/13475359 67 https://www.ncbi.nlm.nih.gov/pubmed/28648096 68 https://www.ncbi.nlm.nih.gov/pubmed/27825999 69 https://www.ncbi.nlm.nih.gov/pubmed/30559273 70 https://www.ncbi.nlm.nih.gov/pubmed/30559273: “The functional cofactors derived from vitamin B3 are nicotinamide adenine dinucleotide (NAD+), its phosphorylated form, nicotinamide adenine dinucleotide phosphate (NADP+) and their reduced forms NADP(H). These cofactors, together referred as the NAD(P)(H) pool, are intimately implicated in all essential bioenergetics, anabolic and catabolic pathways in all forms of life. This pool also contributes to post- translational protein modifications and second messenger generation. Since NAD+ seats at the cross-road between cell metabolism and cell signaling, manipulation of NAD+ bioavailability through vitamin B3 supplementation has become a valuable nutritional and therapeutic avenue. Yet, much remains unexplored regarding vitamin B3 metabolism. The present review highlights the chemical diversity of the vitamin B3- derived anabolites and catabolites of NAD+ and offers a chemical perspective on the approaches adopted to identify, modulate and measure the contribution of various precursors to the NAD(P)(H) pool.” 71 That could be the reason for Mother’s Depression. 72 A hypothesis regarding the etiology of ME and CFS: It would always start with an event weakening and hijacking the immune system, and slowing down resp. interrupting the energy flow between the respiratory chain and the TCA-cycle. This event ispossibly caused by a virus attack. The result is an energy deficiency in the TCA cycle, and further weakening of the immune system, opening the door to many other attackers, i.e. enteroviruses, which are successful and force the cells into the survival mode increasingly. 73 https://www.ncbi.nlm.nih.gov/pubmed/27665001, 74 See adenochrome hypothesis in schizophrenia. 75 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750202/ 76 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863271/ 16 NAD+ and Deficiency Diseases

context of modern lifestyles and civilization diseases. However, the medicinal legend persists that vitamins are ineffective, useless, and produce expensive urine only. An early study shows far more effects of deficient NA and NAD+ on some disorders77. This coincides with our experience, but has gradually been withdrawn from the main stream, and conveniently forgotten over the time. (2) NAD+ is the anabolite for sirtuins78. These proteins / enzymes are represented by a family of seven genes (Sirt1 - Sirt7) in humans. They regulate cell survival, senescence, proliferation, apoptosis, DNA repair, cell metabolism, and caloric restriction. (3) NAD+ is the substrate for PARPs79, which are utilized, among other things, for preparation of DNA repair and thus help to prevent disorders in epigenetically modulated gene expressions, including inherited diseases, serious genetic defects, fundamental physiological processes in the cell and at the organism, and regulate cellular stress responses80. (4) NAD+ is the substrate for the ectoenzyme CD38 - this is cyclic ADP-ribose hydrolase. It is responsible for various immune responses, indigestion, behavioral changes including social amnesia81. There is indication that a lack of CD38 is the base condition for autism and ADHD82. (5) NAD+ is the substrate for the ectoenzymes CD157 or ADP-rybosyl cyclase 2 and DAMP-1 on gene BST-1. The lack of CD157 inflicts the immune system, and contributes to the etiology of cancerous diseases83, anxiety, depression, and Parkinson’s disease. (6) Furthermore, NAD+ is a coenzyme that controls some redox reactions in glycolysis, in the citrate cycle (TCA), in β-fatty acid oxidation and in oxidative phosphorylation (NAD+ / NADP+), and maintains the energy flow in the anabolic metabolism.84 (7) In addition to the tasks mentioned, PARPs / sirtuins / ectoenzymes also regulate the stress responses at the cellular level up to necrosis, or apoptosis - autophagy85. These functions make it clear that there is a constant consuming86 of NA+. Therefore it must be replenished to a considerable extent, especially in the event of illness87. The De Novo Synthesis of NAD+ on Trp alone cannot supply the necessary amounts.

77 “The NAD deficiency diseases. Journal ArticleDatabase: APA PsycInfo / Cleary, John P. Citation: Cleary, J. P. (1986). The NAD deficiency diseases. Journal of Orthomolecular Medicine, 1(3), 149–157. Abstract Argues that oral nicotine acid therapy provides an effective biological treatment for addiction to both alcohol and opiate drugs when given in daily doses of 500 mg or more. It is also purported that there is considerable evidence that this same treatment is effective for other manifestations of the nicotinamide adenine dinucleotide (NAD) deficiency disease like anorexia nervosa, early diabetes mellitus, heart failure, essential hypertension, schizophrenia (substrate pellagra), and even the problems of predatory behavior such as crime and violence. The author hypothesizes that NAD and the endorphins are the only 2 physiological substances that bind the so-called opiate receptors in the brain and since the development of agriculture, humans have been susceptible to what he calls the NAD deficiency diseases, through a partial adaptation to less meat in the diet. (PsycINFO Database Record (c) 2019“ 78 https://www.ncbi.nlm.nih.gov/pubmed/17456799 79 Co-operation of PARPs and ARTs: https://pubmed.ncbi.nlm.nih.gov/23489378-beyond-dna-repair-the- immunological-role-of-parp-1-and-its-siblings/ 80 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050489/ 81 https://www.sciencedirect.com/science/article/abs/pii/S0306453016308381 82 https://www.frontiersin.org/articles/10.3389/fimmu.2019.01187/full 83 https://www.frontiersin.org/articles/10.3389/fnbeh.2014.00133/full 84 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5521000/ 85 Necrosis is the unregulated dying of a damaged cell. Apoptosis is the targeted cell death (somewhat a cell suicide) followed by autophagy, a recycling process of disintegrated cell tissues, fat, and proteins. 86 https://skeletalmusclejournal.biomedcentral.com/articles/10.1186/s13395-018-0154-1 17 NAD+ and Deficiency Diseases

In rare cases NAD+ doesn’t work sufficiently as a transporter of energy between the TCA cycle88 and 89 the respiratory chain , indicating a Q10 and adenine deficiency. These are the substrates for Coenzym A (CoA). Such deficiency comes often with a myopathy90. Impairments of the TCA cycle and the respiratory chain occur more often: + ++ CH3CO-SCoA + 3NAD + FAD + GDP + Pi + 2H2O ->

+ 2CO2 + 3NADH + 3H + FADH2 + GTP + CoA-SH Acetyl-Coenzym A (CH3CO-SCoA) is a derivative of the acetic acid, wherein the acetic acid residue CH3CO- is bound to the free SH-group of the CoA. The Acetyl-CoA is adamant for the carbohydrate, fatty acid, and protein metabolisms. Acetyl-CoA cannot function, if here is not enough NAD+. Consequently, chronic fatigue follows. The energy metabolism decreases to the absolute necessary minimum to keep the body alive. Maybe, that is another one of the causes for ME and CFS. GTP is the precursor of ATP, an energy supplier in the RNA synthesis and to ATP, and transports proteins into the mitochondrial matrix. GDP is left after the energy delivery.

Side Effects of NAD+ - Anabolites91 NAD+ deficiency cause symptoms and diseases as described above, which have become the focus of research in recent years92. NAD+ deficiency can best be remedied with the three B3 vitamins NA, NAM, NR, and also with NMN or NADH supplementation. In the time being, there is no preparation of NAR available. The diet with increased NADH is the most expensive, with NA the cheapest. In addition, NA has the most positive effects compared to NAM93, NR, NMN, and NADH because it can dissolve lipids, sanitizing the vascular system.

87 https://www.ncbi.nlm.nih.gov/pubmed/30626706 88 https://link.springer.com/chapter/10.1007/978-3-662-46430-4_15 89 https://viamedici.thieme.de/lernmodule/biochemie/atmungskette+prinzip+und+komponenten 90 i.e. deteriorating muscles. 91 The following descriptions of side effects are essentially based on the texts of the Micronutrient Information Center, Linus Pauling Institute, Oregon State University. 92 https://journals.sagepub.com/doi/pdf/10.1177/2156587211399579 93 Niacinreviews.com provides for the following compare (found in the Journal of the Canadian Medical Association: Nicotinic Acid versus Nicotinamide (NA) (NAM) Yes Flush (vasodilatation) No Yes Excess sweating Yes Yes Pellagra Therapy Yes Yes Support at Osteoarthritis Yes Yes Therapy in psychiatric diseases Yes Yes Support of Metabolism No Yes Help at Adipositas No Yes Decrease of LDL No Yes Support of human growth hormones No Yes Opening of the inner blood vessels Yes Yes Supports blood circulation in capillaries No Yes Increases blood circulation in the muscles No Yes Enhances physical abilities No Yes Aging, beautiful skin Yes 18 NAD+ and Deficiency Diseases

The information below is based on quotations from the Oregon State University's Linus Pauling Institute fact sheet94 and other sources. NA Flush The flush is a vasodilatation (from vas 'vessel' and dilatatio 'enlargement', dilatare 'widening') and is important in that it temporarily enlarges all blood vessels by about 10%. The blood pressure then drops by nearly 10%, because the muscles around the blood vessels work against the pressure drop. NA is not a blood pressure lowering means, despite this short drop. There is a conclusive explanation considering the prostaglandins95. A histamine hypothesis has proven to be incorrect. Nevertheless, NA also may stimulate histamine production96. When flushing occurs, mast cells and Langerhans cells in the skin are triggered to release prostaglandins97, which are messengers of the immune system and involved in the development of inflammation (healing reaction of the skin). After distribution caused by NA, the prostaglandins must be replaced. The time required for this determines whether the next flush is weaker or even no longer occurs. According to our experiences will a flush happen again after three days of abstinence from NA. We didn’t observe an effect caused by low levels of prostaglandins after 6 years of heavy use of NA. If the flush is felt being uncomfortable - this is usually the case with people for whom the flush does not seem to end or always turns out to be very violent - this may be due to underlying inflammation, or the prostaglandin synthesis is constantly stimulated (indicating chronic Inflammation) or accelerated, or the blood vessels are inflamed by arteriosclerosis, or the epithelium irritated by plaques. Only appropriate diagnoses and analyzes can provide sufficient information about this. As a result, there are several strategies to take the flush under control: 1. You accept and get used to this because of the health effects. 2. You may take the NA dose after each meal and in several small portions. 3. It is advisable to take the same amounts vitamin C and NA. 4. A half an hour before taking NA you may take less than 375 mg aspirin. 5. There are drugs that inhibit the prostaglandin synthesis. 6. Prostaglandins are metabolites of omega 3 oils and arachidonic acid. There are strategies to reduce the dietary intake of these substrates or suppress their metabolic predecessors. By experience, successful strategies we found according to points 1, 2, and 3 above. The other strategies could cause undesirable side effects. Especially strategy 6 is a distortion of the natural metabolism. The flush is often described as a harmful side effect to be avoided. However, this is very dependent on the conditions of the user, because the flush is not harmful, but also a sign of a successful fight against arteriosclerosis. Who is able to stand one flush every other or third day will not show any sign of arteriosclerosis98 after 3 months. We know people who provoke a flush on a regular basis; they are talked about as “medical miracle”, especially, if they are older than 50 years of age without any sign of arteriosclerosis.

94 https://lpi.oregonstate.edu/mic/vitamins/niacin 95 https://www.researchgate.net/publication/23249979_NA- induced_Flush_Involves_Release_of_Prostaglandin_D- 2_from_Mast_Cells_and_Serotonin_from_Platelets_Evidence_from_Human_Cells_in_Vitro_and_an_Animal_M odel 96 https://www.ncbi.nlm.nih.gov/pubmed/23426511 97 https://www.ncbi.nlm.nih.gov/pubmed/17008386 98 https://www.mpg.de/1076524/Nikotin_Immunzellen_Arteriosklerose 19 NAD+ and Deficiency Diseases

Even if the flush99 is felt by many to be uncomfortable, it is not advisable to block the flush at all100,101, instead a strategy according to points 1 – 3 is advisable. Liver and Kidneys (all substrates) Since the B3 vitamins have detoxifying effects, everything necessary must be done before starting a fortified B3 diet to ensure the functionality of the liver and the kidneys, and that the waste products can be eliminated without problems102. All these steps supposed to be taken under supervision of an experienced physician, who will determine the blood values as well. The effort for these absolutely necessary steps is usually done with a single visit, but requires an intensive cooperation of the patient. Consequently, it might be clear that NA is not a cause of kidney and liver damage, but the waste products from the body during detoxifying may overwhelm the liver and the kidneys. The best method to avoid that is to start with little dosages, and increase as fast as possible. NAD+ Anabolites

NA Other side effects of NA include gastrointestinal disorders such as nausea and vomiting. We heard about such subclinical incidents at doses of two times 500 mg NA a day. However, we did not experience that in ten years of use. Transient episodes of low blood pressure (hypotension) and headache have also been reported, probably due to vasodilatation, but that is quickly resolved after the flush ended. Hepatotoxicity (damage to liver cells), including increased liver enzymes and jaundice, has been already observed with an intake of only 750 mg / day NA103, especially if the preliminary examinations did not meet the standards mentioned above or the patients took additional medication.No NA catabolite is toxic to the liver. Hepatotoxicity must have other reasons. Hepatitis (jaundice) with NA ER (probably NAM) has been observed in doses of only 500 mg / day for two months. Severe hepatitis occurred with doses of 3 to 9 g / day applied for months or years104. Nevertheless, the tolerance of NA is far higher than that of NAM in very high dosages. This is also because the body only absorbs as much NA as it actually needs. Excess amounts are excreted as catabolites in the urine. What is going to happen with the amide group is not researched sufficiently. There is evidence that pure NA, NR, NMN and NADH are less or non-toxic to the liver, in contrast to NAM105 and other ER formulations.

99 “Interactions between niacin and GPR109A receptors on epidermal Langerhans cells result in increased cytosolic calcium; this increase triggers increases in phospholipase A2 activity and expression of prostaglandin (PG) D2 synthase, with elevated mobilization of arachidonic acid into vasodilator eicosanoids and prostanoids. Lipid-lowering doses of niacin are associated with 430- to 800-fold increases in circulating levels of a stable PGD2 metabolite (9-α-11-β-PGF2 ).38 PGD2 binds to DP1 receptors on local capillary smooth muscle cells, causing capillary vasodilatation in the papillae of the upper dermis. Acetylsalicylic acid (aspirin) and nonsteroidal anti-inflammatory drugs (NSAIDs) can prevent or blunt flushing by blocking PGD2 synthesis via cyclooxygenase (chiefly, cyclooxygenase). However, other PGs (eg, PGE1 ), other mediators (eg, serotonin), and other signaling pathways may also be involved.”: https://www.mayoclinicproceedings.org/article/S0025- 6196(11)60429-1/pdf 100 https://www.sciencedaily.com/releases/2012/04/120409103950.htm 101 https://www.pennmedicine.org/news/news-releases/2012/april/penn-study-cautions-use-of-dru 102 https://www.testingcancer.com/the-role-of-niacin-in-detoxification/ 103 https://www.ncbi.nlm.nih.gov/pubmed/22646128 104 https://www.nap.edu/read/6015/chapter/8 105 https://www.nap.edu/read/6015/chapter/8 20 NAD+ and Deficiency Diseases

Large doses of NA can affect glucose tolerance, probably due to a decrease in insulin sensitivity. This can lead to increased blood sugar levels and clinical type 2 diabetes mellitus in pre-diabetic people. Any carbohydrates should be avoided during an NA cure. Increased blood concentrations of uric acid have been observed with high-dose NA therapy, which can lead to gout attacks in susceptible individuals. This may be supported by eating too much oxalate. Any oxalate-rich foods during an NA diet should be avoided. Doses of 1.5 to 5 g / day have led to visual disturbances and other eye problems, which were reversible after discontinuation or reduction in the dosage. People with abnormal liver function or a history of liver disease, diabetes, active ulcers, gout, irregular heartbeat, inflammatory bowel disease, medication cocktails, migraine headache or alcoholism may be more susceptible to the adverse effects of excessive NA intake than the general population. It is always advisable to consult a specialist doctor to conduct an NA supplementation in therapeutic doses.

NAM NAM is generally better tolerated than NA in doses below 5 g per day. It rarely causes a flush. However, nausea, vomiting and signs of liver toxicity (increased liver enzymes, jaundice) have been observed at therapeutic doses106. This result suggests that NAM can cause liver damage. Since NAM can only be absorbed into the bloodstream as NA, NAM is hydrolyzed into NA and the amide group. Consequently, there is an excess of amide in the digestive tract. Except Trp, only NA is sufficiently present in food, not NAM, NR, NAR or NMN, and not NADH. Almost 100% of the absorption occurs with animal B3 sources. All other formulations could cause oversupply with the side effects noted above.

NR and NAR A study of 12 healthy volunteers found that NR in three single doses (100 mg, 300 mg and 1,000 mg) safely increased the blood NAD+ level. Two of the participants reported reddening of the skin after taking the 300 mg dose, and two others reported feeling feverish after taking 1,000 mg NR107. We conclude that NR could also trigger a flush with high doses108. In a recent randomized, placebo-controlled study in 120 healthy adults (ages 60-80 years), NR (250 mg or 500 mg) and pterostilbene (a SIRT activator; 50 mg or 100 mg) were administered daily for eight weeks. They showed a favorable side effect profile with no evidence of a higher incidence of side effects compared to placebo109. Most recently, a randomized, placebo-controlled study in 40 overweight men (ages 40-70 years) found that a daily supplementation with NR (2,000 mg / day, divided into two daily doses) over 12 weeks with few reports of side effects such as excessive sweating, Itching and mild gastrointestinal symptoms such as bloating was associated110. In the time being, there is no supplement based on NAR on the market.

106 Hendler SS, Rorvik DR. PDR for Nutritional Supplements. 2nd ed. Montvale: Thomson Reuters; 2008. 107 https://www.ncbi.nlm.nih.gov/pubmed/27721479 108 From the report “Niacin, the Internet, and Urine Drug Testing: A Cause of Acute Liver Failure”. Sheila Eswaran, Nicole Alvey, Sameh Fayek, Nikunj Shah and Edie Chan* Rush University Medical Center, USA. Quote: Eswaran et al., J Clin Toxicol 2013, 3:4 http://dx.doi.org/10.4172/2161-0495.1000167 109 https://www.ncbi.nlm.nih.gov/pubmed/29184669 110 https://www.ncbi.nlm.nih.gov/pubmed/29992272 21 NAD+ and Deficiency Diseases

Tolerable Upper Limits (UL) Blushing the skin (flush) mainly on the face, arms and chest is a common side effect of NA and can initially occur at doses as low as 30 mg / day. Although the flush is rare when NA is applied, the Food and Nutrition Board (USA) 111 has set the tolerable upper intake value for niacin (NA and NAM) in adults to 35 mg / day to avoid the adverse effects of the flush112. In Germany, the recommendation for both is at 15 mg. The EFSA advises 15 mg/day for NA and 900 mg/day NAM. The upper limit applies to the general population and not to people who are treated with a nutrient under medical supervision (e.g. high-dose NA for increased cholesterol levels in the blood).

Interaction with Medications In the three-year randomized controlled HATS study, antioxidant therapy113 (1,000 mg / day vitamin C, 800 IU / day RRR-α-tocopherol, 100 µg / day selenium and 25 mg / day β-carotene) was carried out at the same time. Carotene reduced the protective effect of the simvastatin-NA combination114. Although the mechanism for these effects is not known, the benefits of concomitant antioxidant therapy in patients with lipid-lowering agents have been questioned115. This study was seemingly designed to prove the usefulness of simvastatin.

In our experience, it is expedient to take NA and Vitamin C together, as advised throughout nearly all of the literature. Both are antioxidants and water-soluble, and the co-enzymatic reactions of the substances support each other. We have not checked the other components of the protocol listed. We have seen cases where the statins were easily replaced by NA.

The adverse effects of high doses of NA can be exacerbated by concomitant use of certain medications.

The risk of myopathy (muscle decrease) may be further increased in patients taking NA together with bile acid sequestrants or an antilipid. NA alone has the opposite effect. The risk of hepatotoxicity observed with NA may be increased with medication. Dangers may arise with use of paracetamol, amiodarone (cordarone) or carbamazepine (tegretol) 116. The drugs listed above place a heavy burden on the liver, so that NA could lead to a noticeable liver reaction due to the increase in blood circulation and the additional burden on the liver when converting NA <-> NAM, and because of the detoxifying effect of NA, which results in a higher liver load. In addition, large doses of NA can reduce uric acid excretion and thus counteract the effects of uricosuric agents. Several other drugs can interact with NA therapy or with the absorption and metabolism of the vitamin117. Estrogen and estrogen-containing oral contraceptives increase the efficiency of NA synthesis from tryptophan, which leads to a reduced need for NA through food118.

111 Food and Nutrition Board association inside of the National Academy of Medicine (NAM).- Wikipedia https://www.ncbi.nlm.nih.gov/books/NBK114304/#ch6.s38 112 https://www.nap.edu/read/6015/chapter/8 113 1000 mg / day vitamin C, 800 IE / day RRR-α-Tocopherol, 100 µg / day selenium und 25 mg / day β-Carotin 114 https://www.ncbi.nlm.nih.gov/pubmed/11498460 115 https://www.ncbi.nlm.nih.gov/pubmed/12377728 116 https://naturalmedicines.therapeuticresearch.com/ 117 Hendler SS, Rorvik DR. PDR for Nutritional Supplements. 2nd ed. Montvale: Thomson Reuters; 2008. 22 NAD+ and Deficiency Diseases

Long-term administration of chemotherapy drugs has been reported to cause symptoms of pellagra. NA supplementation may therefore be required. The same applies to SSRI/SNRI according to our observation.

Immunosuppressive Medications Since the ingestion of NAD+ substrates also leads to a strengthening of the immune system, the ways discussed here for increasing the NAD+ level cannot be recommended for patient groups medicated with immunosuppressive substances. Degenerated and Waste Products from Necrosis Another important group of NAD+ related diseases are triggered by the cell toxins from degeneration and decay products of dying and dead cells (necrosis). Apoptosis and following autophagy119. doesn’t cause inflammation by poisoning with waste products, because this process is regulated by sirtuins and the immune system / PARPs. Autophagy leads to a recycling of all waste products. Waste products generated during necrosis as the root cause for diseases has been only researched for schizophrenia, but has not been verified by EBM (Hoffer's adenochrome hypothesis is supported by anecdotal evidence only). In the case of epilepsy, it is obvious to suspect a NAD+ deficiency, because epilepsy can be alleviated by increasing the NA intake. The underlying metabolic processes are not known yet. Faulty DNA repairs120 due to the lack of PARPs create genetic defects during cell division. These could include birth defects and other genetic disorders that are today considered hereditary disorders.

Dosages The intake of vegetable NA to support healthy NAD+ - levels should be seen critically, because the bioavailability of vegetable origin NA is usually only 30%, which means that only 30% of the NA intake is converted to NAD+. NA in plants has another formulation: Niacytin121. Food preparation increases the bioavailability to about 70%. Conversely, it follows that it is very difficult for vegans to achieve a NAD+ balance by food only. In case of illnesses, or unhealthy lifestyle, the need for NAD+ increases up to 300 times of the recommandations of the German RDA. In the beginning of a Na supplementation, this value could increase easily to 600 times.

The NADH dosages on the market are 20 and 50 mg. Flushes are not known, but a flush isn’t very likely at 50 mg NA anyway. So you may calculate how much NADH supplement you would need to refill your NAD+ storage.

The dosages below are proposals of The Renegade Pharmacist. He adapted the amounts mostly from the writings of Dr. Abram Hoffer. Dr. Hoffer had lifelong experiences with applications of NA.

118 https://www.ncbi.nlm.nih.gov/pubmed/25527663 119 The Nobel Prize in Physiology or Medicine 2016, Yoshinori Ohsumi, 120 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5365133/ There is evidence that PARP1 suppression reduces damage from high blood pressure and reduces the risk of heart disease. How many of these damages result from faulty gene expression is not known. However, no DNA repairs without PARPs. 121 ”The bound forms of the vitamin NA, found in cereals. Complexes of NA with polysaccharides and peptides or glycopeptides; not hydrolyzed by intestinal enzymes, so biologically unavailable, but can be liberated by acid or alkaline hydrolysis or by baking the cereal, especially with an alkaline baking powder.” (from the Oxford Reference) 23 NAD+ and Deficiency Diseases

Picture 6: Consequences of ingestion of NA (niacin, B3). Picture © The Renegade Pharmacist.

24 NAD+ and Deficiency Diseases

Outlook: What to do?

Thesis We hope our working hypotheses regarding NAD+ - deficiency 1. Eliminating deficiency in NAD+ is the prerequisite for successful therapies. 2. Eliminating of a NAD+ deficiency is not a therapy, but a diet. 3. Chronic deficiency of NAD+ creates chronic diseases. 4. NAD+- deficiency creates non-specific symptoms, which are characteristic for many diseases. are verified sufficiently. Our working hypothesis on NAD+ deficiency offers anecdotal explanations for a surprising number of problems, in literally thousands of anecdotal cases, some of them with EBM standard. However, regarding EBM: We are talking about dietary means, not about statistical standards in medical research. The next steps should include the following theses:  Balancing the NAD+ levels would address probably a majority of non-infectious diseases that are associated with a lack of energy, failures in gene expression, and physical and mental weakness.  Further studies should focus on the effects of NAD+ on other diseases than previously researched, and on interactions between NAD+ and medications. The substrates mentioned are endogenous substances, or essential to humans. Effects of overdoses are known and on average exaggerated.  Everyone can try safely these dietary supplements even in higher doses than officially recommended when accompanied by a specialist health care provider. It would be suitable for everybody who suspects a suffering by a deficiency.  The true cause of any disease becomes apparent only after the NAD+ deficiency has been eliminated. Differential diagnoses would be more efficient and more correct.  Balancing NAD+ levels could be easily achieved by simple and inexpensive means. It would also make sense to set up a database, maintained by users and moderated by experts, similar to Wikipedia, in which everyone could enter experiences. Corresponding “anecdotal” information is available on the web, in Twitter and in some private Facebook groups, but scattered over the Web. It would also be very helpful if the problems surrounding the NAD+ deficiency were a topic in medical postgraduate training.

Diagnosis of NAD+ Deficiency Beside rather complicated and lengthy methods to prove NAD+ deficiencies, the team led by Nicholas J. Miller, Roger J.D. Burr, Peter Saffu from the Biolab Medical Unit, London W1W 6DB United Kingdom122,, use a simple measurement determining the NAD+ deficiency. They propose a chromatography with a Cobas Mira apparatus to measure the ratio of NAD+ and NADP+. If this ratio is above 2.5, then there is no NAD+ deficiency, and an upper limit cannot be established. There is a serious NAD + deficiency if this ratio is measured below 2.1. The ratio between 2.1 and 2.5 indicates the onset of some deficiency diseases.

122 “Erythrocyte niacin co-enzymes as a measure of vitamin B3 status” Biolab Ltd., 9 Weymouth Street, London WIW 6DB England, +44 20 7636 5959, [email protected] 25 NAD+ and Deficiency Diseases

Appendix

(1) A Case Study in the “Letters to the Editor” Niacin-Associated Acute Hepatotoxicity Leading to Emergency Liver Transplantation Schaffellner, Silvia MD1; Stadlbauer, Vanessa MD2; Sereinigg, Michael MD1; Mìller, Helmut MD1; Högenauer, Christoph MD2; Fickert, Peter MD2; Krumnikl, Jakub MD3; Lackner, Carolin MD4; Kniepeiss, Daniela MD1; Stauber, Rudolf E MD2

1Division of Transplantation Surgery, Department of Surgery, Medical University of Graz, Graz, Austria 2Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria 3Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria 4Institute of Pathology, Medical University of Graz, Graz, Austria Correspondence:Rudolf E Stauber, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, Graz 8036, Austria. E-mail: [email protected] Guarantor of the article: Rudolf E. Stauber, MD. Specific author contributions: Silvia Schaffellner, Vanessa Stadlbauer, Michael Sereinigg, Christoph Högenauer, Peter Fickert, Carolin Lackner, and Rudolf E. Stauber collected and interpreted the data. Helmut Mìller, Jakub Krumnikl, and Daniela Kniepeiss performed emergency liver transplantation. Carolin Lackner performed histopathologic work-up of the explanted liver. Silvia Schaffellner, Vanessa Stadlbauer, Michael Sereinigg, Christoph Högenauer, Carolin Lackner, and Rudolf E. Stauber drafted the manuscript. All authors approved the final draft. Financial support: None. American Journal of Gastroenterology: August 2017 - Volume 112 - Issue 8 - p 1345-1346 doi: 10.1038/ajg.2017.171

Nicotinic acid is an essential coenzyme and daily recommended dose is 15 mg. Nicotinamide is the amide of nicotinic acid, an important precursor of nicotinamide adenine dinucleotide, and its phosphate. The acid and amide are identical in their function123 and are also termed Vitamin B3124. Flush symptoms and hepatoxicity are important adverse effects of nicotinic acid125 but not of the amide126.The mechanism of hepatoxicity is unknown127, as a toxic metabolite of nicotinic acid has not been identified128. Competitive athletes frequently use niacin at higher doses of 300 – 400 mg to increase their performance in an attempt to enhance muscle regeneration. Even higher doses of 3,000 – 6,000 mg per day may be toxic, causing liver injury with jaundice and coagulopathy129. Several cases of acute niacin-associated hepatotoxicity leading to emergency lever transplantation (LT) have been reported for long-acting niacin preparations, but not for “native niacin”.

123 NA and NAM have similar functions, but by no means identical ones. The mechanisms of action differ significantly as well. 124 As previously stated, there are known (and were known already in 2017) way more substances that were designated as vitamin B3, see "Substrates" above. 125 A) Even the pioneers of NA applications were certain that substances that would result from detoxification with NA would have to be removed via the liver, which could cause liver problems. B) Hepatotoxicity is clearly shown for NAM only. The assignment of hepatotoxicity to NA is questionable. 126 It is the other way around. These effects have only been demonstrated valid for NAM at doses of 3 to 5 g / day. There is no clear evidence in case of using NA. 127 Liver damage as a result of NA was only tested on dogs with 1g per kg body weight, whereby there was actually a liver damage. In humans, the experiments were interrupted at 18 g per day because the desired effects were achieved practically always below dosages of 10 g/day. 128 There are no poisonous metabolites of NA, but of NAM. 129 If there is no toxic metabolite of NA, then there is no reason to believe in hepatotoxicity from NA. Furthermore, an influence of NA on coagulopathy is highly questionable. 26 NAD+ and Deficiency Diseases

We report a 22-years old female athlete who presented with abdominal pain after ingestion of a single dose of 20,000 mg native niacin to improve her performance and developed acute liver failure within 3 days130 ...

From here, no further reading is necessary for the reader who wants to learn something about a correlation between NA and aLiver transplantation. Anyway, the headline suggests a case study of an acute hepatotoxicity caused by niacin.

Athletes are known to try everything to enhance their performance as long as there is no evidence of doping. A whole industry lives out of this. And NA is often used to "mask" a drug test. It doesn’t work, but the myth persists.

1. We do not know which cocktail the young woman wanted to mask at the time of taking NA. 2. The athlete obviously took this high dose without expert supervision. Any medical doctor / alternative practitioner / physiotherapist with special knowledge in orthomolecular medicine would have strongly advised against it. An allopathic doctor wouldn’t even consider. 3. It is unclear what is meant by "native niacin". Out of the context, it is nicotinic acid as a clean powder131. How did the young woman measure the 20 g? Estimation? 4. The letter should probably warn about taking NA in higher dosage without supervision.

(2) More Case Studies By 2013 there were 6 cases of severe, acute liver toxicity after 100 years of use of NA. Four of these were to mask a drug test in the urine. The 2017 case described above belongs into this category. In two cases, it is suspected that high doses were taken to end dependency on an SSRI/SNRI, but without the guidance of a knowledgeable doctor / therapist.

However, there is a greater number of side effects of NA administration with lighter, subclinical findings, even if therapeutic rules have been followed. These are "flushing, nausea, vomiting, itching, hives / hives, weak increase in serum aminotransferases (the first sign of liver stress) and constipation. One case of muscle wasting has been reported. Caution should be exercised with NA if the patient has gout because the uric acid level increases132.”

These side effects vanish without consequence. They last some time depending on the size of the dosage, and the time line. Approximately after about 1 hour or more will perish flushing, nausea, vomiting and itching; and up to one day for hives or constipation.

That one case of muscle wasting (myopathy) is not very well reported. We don’t know the circumstances and the conditions. According to our experiences, people affected by myopathies were long term exposed to herbicides and pestizides.

130 20 g niacin in one portion? How did she swallow that? The pioneers of vitamin research didn’t dare to apply that amount. 131 Minimum, it seems to be clear that she didn’t take an ER formulation. 132 From the case studie “NA, the Internet, and Urine Drug Testing: A Cause of Acute Liver Failure”. Sheila Eswaran, Nicole Alvey, Sameh Fayek, Nikunj Shah and Edie Chan* Rush University Medical Center, USA. Zitate: Eswaran et al., J Clin Toxicol 2013, 3:4 http://dx.doi.org/10.4172/2161-0495.1000167 27 NAD+ and Deficiency Diseases

Since 2013, there are some case studies more about side effects of NA:

Niacin‐Induced Anicteric Microvesicular Steatotic Acute Liver Failure133

“We present the case of a 74‐year‐old Hispanic woman who developed acute liver failure (anicteric encephalopathy and coagulopathy) after her home dose of immediate‐release niacin was replaced with an extended‐release formulation during an inpatient hospital stay.” 134

This Diagnosis excludes expressively NA as the reason for a liver failure. There was a change in therapy from NA to NAM, which is always risky.

“However, within the last few years, it is being advertised on the Internet as a quick way to detoxify the human body in an attempt to evade urine drug tests. This claim is without any medical or scientific evidence and as a result, many cases have been reported where young adults have ended up with niacin toxicity.” 135

This was not a “niacin” toxicity. It was a reaction of the drugs already consumed: There are no toxic metabolites of NA.

The detoxifying effects of NA are well documented ("See "Catabolites of NAD+”).

Table 1. Reported cases of niacin overdose in attempts to pass drug tests, since 2013.

Source Clinical features Ingested dose Outcome Paopairochanakorn et al Metabolic acidosis, hepatotoxicity Not reported Recovered Metabolic acidosis, hepatotoxicity, Not reported Recovered coagulopathy Mittal et al. Diabetic ketoacidosis, hepatotoxicity, 5.5 g in 36 h Recovered prolonged QT interval. Lactic acidosis, hypoglycemia, coagulopathy. 2.5 g in 48 h Recovered Flushing Not reported Recovered Skin rash Not reported Recovered Arcinegas-Rodriguez et al. Metabolic acidosis, hypoglycemia, myopathy. 13 g in 48 h Recovered Daul et al. [ Acute renal failure, haemolytic anaemia, 22.5 g in 48 h Recovered thrombocytopenia. Fox et al. [ Lactic acidosis, hepatotoxicity 8.25 g in 48 h Recovered Ellsworth et al. Acute Liver Failure Not reported Recovered Sheila et al. Hepatotoxicity 7.5 g in 48 h Recovered Hepatotoxicity 500 mg twice Recovered daily

133 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211325/ 134 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211325/ 135 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5906759/ 28 NAD+ and Deficiency Diseases

Table 3. Formulations and dosage of niacin.

Formulation Initial dose Maximum dose OTC availability Immediate release 250 mg once daily 6 g daily in 3 divided doses Yes Sustained release 250 mg once daily 750 mg once daily Yes Extended release 500 mg once daily 2 g once daily No

Comment 1. Nearly all above mentioned cases came up after a change in the legal background: Employers were required to ask for a drug test. Aspirants have to show a valid certificate. 2. There is a fast release caused by NA of already ingested toxins, the so called detoxifying effect that hits the liver and causes the hepatotoxicity.

29 NAD+ and Deficiency Diseases

(3) NAD+ and Tryptophan Several references point to tryptophan being the main source of NAD+. As shown above, that is not correct. The metabolites of tryptophan produce NAD+ under certain conditions only, limiting the generation of NAD+.

Under best conditions, 35 mg of Tryptophan convert to 1 mg of NAD+.

Under worst conditions, 84 mg of Tryptophan convert to 1 mg of NAD+.

On average are converted 60 mg of Tryptophan to 1 mg of NAD+.

Tryptophan 5 – 90% Up to 94% Vit B 1 to HEM Mg 10% Protein Biosynthesis 5-HTP N-Formylkynurenine Vit B6 KAT Vit B6 Serotonine Kynurenine Kyrunenic

Vit B6 KMO Acid Acetyl-Serotonine 3-OH-Kynurenine Vit B6 SAM Fe

Melatonine Quinolinic Acid PRPP

NAD+

Picture 6: Tryptophan as substrate for NAD+. Picture adapted from “Der Tryptophanstoffwechsel” from biovis’ Diagnostik MVZ GmbH, Limburg, 2018.

TDO Tryptophan-2,3-Dioxygenase (mostly liver, heart, lung, brain) IDO Indolamine 2,3 Dioxygenase (all other tissues) 5-http 5-Hydroxyy-Tryptophan

KMO Kynurenine-Monooxygenase KAT Kynurenine-Oxyglutarat-Transaminase SAM S-Adenosylmethionin PRPP α-5’-Phosphribosyl-1’-pyrophosphat] HEM Heme

30