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Nutrients and HIV: Part Three – N-Acetylcysteine, Alpha-Lipoic Acid, L-Glutamine, and L-Carnitine Lyn Patrick, ND

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Nutrients and HIV: Part Three – N-Acetylcysteine, Alpha-Lipoic Acid, L-Glutamine, and L-Carnitine Lyn Patrick, ND Nutrients and HIV: Part Three – N-Acetylcysteine, Alpha-Lipoic Acid, L-Glutamine, and L-Carnitine Lyn Patrick, ND Abstract The role of antioxidants in preventing apoptosis and viral activation in HIV is well documented. N-acetylcysteine, glutathione, and alpha-lipoic acid have been shown to interrupt the process of viral activation and CD4 cell death. L-glutamine has been shown to improve glutathione levels and significantly increase lean body mass in HIV infection. The literature on the use of L-carnitine and acetyl-L-carnitine in treating mitochondrial toxicity, both in muscle and nerve pathologies is relevant in nutritional treatment of HIV, given the mitochondrial toxicity of nucleoside analog reverse transcriptase inhibitor therapy. The current use of highly-active antiviral therapies, their toxicity, and significant failure rates have created the need for a more conservative reassessment of HIV treatment. The adjunctive use of nutrient therapy in the treatment of HIV is reviewed here. (Altern Med Rev 2000;5(4):290-305) The Importance of Redox Homeostasis in HIV HIV infection and the progression to AIDS involves a long period of latent infection characterized by low levels of viral replication that slowly increase to the point of immunosup- pression.1 This progression is accelerated if the latent (non-reproducing) provirus in the nuclei of the lymphocyte is activated.2 Oxidative stress induces both viral activation of HIV and DNA damage, leading to immunosuppression.3-5 It is now generally accepted that a central pathologic feature of HIV disease involves oxidative stress, leading to programmed cell death (apoptosis) and depletion of CD4 cells.6,7 It has been hypothesized by Montagnier and others8,9 that the majority of T-helper (CD4+) cell loss (the cell most susceptible to fatal injury by HIV) actually occurs by apoptosis and not by direct HIV infection. This phenomenon has been seen in in vitro culture and in peripheral blood lymphocytes from HIV-infected patients.10 Evidence of increased oxidation reactions,11 depletion of the glutathione-based antioxi- dant defense system,12 and increased levels of oxygen radicals have been demonstrated in the blood and tissues of HIV-infected individuals.6 Elevated levels of hydroperoxides,13 malondialdehyde,14 and deficiencies of the critical antioxidant enzymes manganese superoxide dismutase, glutathione peroxidase, thioredoxin, and catalase have been demonstrated in plasma, lung lining, erythrocytes, and lymphocytes in HIV-infected individuals.4,7,13 Nutrient malab- sorption, glutathione and selenium depletion, and reduction of total thiol (cysteine) levels have all been observed to be associated with the pathology of free radical overload that leads to the cellular apoptosis of T lymphocytes.15 Lyn Patrick, ND – Associate Editor, Alternative Medicine Review; Private Practice, Tucson, AZ. Correspondence address: 540 W Prince, Ste A, Tucson, AZ 85705. Page 290 Alternative Medicine Review ◆ Volume 5 Number 4 ◆ 2000 Copyright©2000 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission Nutrients and HIV Glutathione: Antioxidant and levels in plasma or lymphocytes of infected 27,28 Antiviral individuals, levels of reduced glutathione do appear to be disturbed in HIV.29 Research Glutathione, the most abundant cellu- assessing ratios of reduced-to-oxidized glu- lar thiol, provides the major antioxidant de- tathione in HIV-positive patients found signifi- fense mechanism in all mammalian cells by cantly increased levels of oxidized glutathione neutralizing toxic peroxides.16 It also helps to and subsequently lower levels of reduced glu- maintain levels of ascorbate and tocopherol by tathione when compared to HIV-negative con- acting as a reducing agent.17 Glutathione is trols.30 These disturbances were greater in pa- necessary for maintaining immune mediated tients with more advanced disease, the ratios T-cell activation and phagocytosis, in addition being higher than have been found in human to cellular and antibody mediated cytotoxic- lymphocytes in any other disease state.30 Low ity,18 and a normal balance between the T- serum thiol levels (precursors to glutathione) helper cell 1 (IL-2, IL-12, gamma-interferon) have been shown in HIV-infected, injecting and the T-helper cell 2 (IL-6, IL-4, tumor ne- drug users (IDU) to be associated with an in- crosis factor-alpha, IL-10, IL-1) cytokine re- creased risk of mortality: IDU with low se- sponse profile.19 Glutathione conjugation is rum thiol levels are 5.65 times more likely to also the primary mechanism of eliminating experience an accelerated time-to-death.5 electrophilic xenobiotics (some of which are carcinogens) in the liver.20 Glutathione deficiency has been theo- Mechanisms of Apoptosis rized to be the cause of the increased sensitiv- The response to antigenic material and ity HIV-infected individuals have to high doses the presence of cytokines, hydroxyl radicals of acetaminophen and sulphamethoxazole, a or other viruses can trigger the activation of medication used in the prevention of nuclear factor kappaB (NF-kB).2 A gene- Pneumocystis pneumonia. The metabolic fate transcription regulating factor present in of these medications, the hepatic glutathione- lymphocytes, macrophages, and monocytes, S-transferase/mercapturic acid pathway, is less NF-kB activates genes in the nuclear material efficient in individuals with glutathione defi- of these cells, resulting in production of ciency.21-24 Plasma glutathione levels in HIV- cytokines and major histocompatibility (MHC) infected individuals, even in the asymptom- agents.31 NF-kB also binds to HIV proviral atic state, have been found to be depressed as gene material in the nucleus of HIV-infected early as three weeks post-infection.10 Glu- cells and activates HIV replication.32 Viral tathione levels in lung epithelial fluid have replication, in turn, increases cellular levels of been found to be depressed as much as 60 per- cytokines, like tumor necrosis factor-alpha cent when compared to HIV-negative con- (TNFα), that promote the production of free trols.25 Intracellular glutathione levels in both radicals and the activation of NFkB, initiating infected CD4 and CD8 lymphocyte subsets are a vicious cycle of viral replication and free also significantly depressed; levels from 62- radical production.23 The presence or absence 69 percent of normal have been found in the of reducing thiols (sulfhydryl groups that form CD4 and CD8 lymphocytes of HIV and AIDS the basis for antioxidant enzymes, glutathione, patients.12 These figures become relevant in etc.) appears to directly affect this cycle. In light of studies that show glutathione reduc- cell cultures where glutathione levels or thiol tion of 10-40 percent is capable of completely levels have been depleted, the TNFα- inhibiting T-cell activation in vitro.26 While not stimulated activation of HIV is enhanced.26 In all studies have found depressed glutathione cell cultures where N-acetylcysteine (NAC) Alternative Medicine Review ◆ Volume 5, Number 4 ◆ 2000 Page 291 Copyright©2000 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission Figure 1: Synergistic Effects of Thiol-Enhancing Substances and Anti-retroviral Drugs on HIV Infections. HIV (RNA virus) inhibits AZT Reverse Transriptase Provirus (ds DNA) DNA integration Latent in host genome Cytokines (TNF, IL-1, IL-6) inhibit NF-κB NAC, GSH, GSE Activation (H2O2) Reactive oxygen HIV transcription species and replication Adapted from Staff FJ, et al. Lancet 1992;339:909-912. copyright ©, 1992. Lancet. All rights reserved. (an efficient thiol source and glutathione or “Procysteine.” While OTC has been shown precursor) is added, the activation of NF-kB to increase lymphocyte glutathione levels in is blocked (Figure 1).26 Glutathione has also healthy subjects, it is not itself an antioxidant been shown to directly inhibit the activity of and has not been shown to be as effective as reverse transcriptase (a major enzyme N-acetylcysteine.35 When OTC was compared necessary for HIV replication) by 80-90 to NAC, NAC was more effective at decreas- percent in cell cultures.33 ing cytokine-induced HIV replication in dif- ferent cell lines and replenishing intracellular Glutathione Restoration glutathione levels.35 The attempt to find antioxidants or glu- Glutathione, administered orally, has tathione “pro-drugs” that recreate normal glu- been demonstrated to be absorbed by rat tathione states and block production of TNF- intestine, kidney and lung epithelium,36 but α and NF-kB has led to the creation of anti- intact glutathione cannot be absorbed by T- oxidant strategies for preventing CD4 cell de- cells, unless it is given as a glutathione cline.34 Data showing that cysteine, N- monoester.37 Glutathione monoesters, acetylcysteine (NAC), reduced glutathione, however, have been associated with significant and ascorbic acid all suppress NF-kB activity toxicity.38 Studies with oral dosing of and HIV activation in cell lines33 has resulted glutathione in healthy human volunteers have in the production of drugs like shown no increase in cysteine, glutathione, or L-2-oxothiazolidine-4-carboxylic acid (OTC) glutamate levels after a 3-gram dose,39 leading Page 292 Alternative Medicine Review ◆ Volume 5, Number 4 ◆ 2000 Copyright©2000 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission Nutrients and HIV the authors to conclude: “It is not possible to N-acetylcysteine (at 5, 10 and 20 mM) restored increase glutathione
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