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PEA: The Multiple Target Molecule

Palmitoylethanolamide (PEA): The Multiple Target Molecule KEY PLAYER IN THE By Dr. Traj Nibber, Founder and CEO of Advanced Orthomolecular Research

BACKGROUND: THE ENDOCANNABINOID SYSTEM

The body has multiple systems that help regulate and referred to as the Endocannabinoidome. maintain normal housekeeping – nervous, circulatory, In common parlance, however, it is still referred immune, endocrine and gastrointestinal systems, to to as the Endocannabinoid System, hence the name a few. These systems not only modulate different title of this White Paper. tissues and organs to function properly, but also facilitate communications both within the system and INTRODUCTION: (PEA) with other systems. Palmitoylethanolamide (PEA) is an 18-carbon long- As recent as the 1990s, another system was identified chain fatty acid that is typically found in eggs, milk, and termed the Endocannabinoid System. It also cheese, meats and peanuts, and is especially abundant helps with communication, and it prepares the body in soy lecithin (Appendix 1). against attack by a variety of harmful insults: stress, carcinogens, pain, , infections, UV PEA is an intriguing health molecule that has been damage, etc. Initially the definition was confined to studied for over eighty years. What makes it unique what were referred to as the endocannabinoids (ECs), is being a natural molecule made by the body that being two molecules – arachidonoylethanolamide whenever the demand arises; for example, during or (AEA) and 2-arachidonoylgycerol stress (psychological and physical), infections (viral (2-AG) – produced by the body which act on the and bacterial [e.g., colds and flu]), various forms of two receptors (CB1 and CB2) located inflammation, trauma, allergies, pain, cardiac disease, throughout the body (mainly the central nervous kidney disease and obesity. It is responsible for system and immune system, respectively). The maintaining overall cellular health or homeostasis. that help in the synthesis and breakdown of ECs were included as part of the system. In the body, PEA is synthesized from the phospholipids which make up all membranes. Since all cells are Further research has since identified more players made up of membranes, it is no wonder PEA is found thought to have critical roles in this system, including everywhere in the body and is available to all cells additional enzymes, other receptors (including efficiently and quickly. PEA is significant not only as a some “orphan” receptors), as well as other molecules cellular messenger, relaying information to and fro in that the body produces including fatty acids the body, but also in acting as a quick fix or solution to palmitoylethanolamide (PEA), oleolylethanolamide cellular needs. In short, PEA is a go-to-molecule which (OEA), stearolyethanolamide (SEA), linoylethanolamide maintains optimal cellular health throughout the body. (LEA) etc. As a result, the definition of this vital system has been expanded within the scientific Synthesis of PEA takes place by the community to be more encompassing, and now is N-acylated –phospholipase

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D (NAPE-PLD). Once PEA has performed its function, researcher Rita Levi-Montalcini and her work in the it is rapidly broken down by two enzymes, fatty acid early 1990s. Italian scientists remain world leaders in amide hydrolase (FAAH) and N-acylethanolamine acid the field of PEA research. amide hydrolase (NAAA) (Fig. 1). PEA has actions both in the and the peripheral nervous system. However, PEA does not have a direct effect on CB1 or CB2 receptors, which differentiates it from the action of specific phytocannabinoids derived from marijuana or hemp (e.g., [CBD] or [THC]). Instead, PEA works through a number of different mechanisms (Fig. 2).

• Direct action by down-regulating the mast cells. Mast cells are present throughout the body and play a key role in immunity, inflammation, allergies and neural health. PEA has been shown to either prevent their recruitment to the site of damage and/or inhibit their degranulation or release of and other key inflammatory mediators in many pathological conditions. Researchers have shown that when treated with PEA, mast cells switch from an “active” stage to a “resting” phenotype, meaning they become Figure 1. Diagrammatic representation of the synthesis dormant. This suggests PEA could be a powerful and breakdown of PEA. molecule for immune health, inflammation, pain, (Source: Skaper et al., 2018, p. 15) neuro-protection and especially allergies. • Direct action on orphan receptors like GPCR55 and GPR119 that produce results similar to the ORIGIN classical activation of the CB1 and CB2 receptors by phytocannabinoids like THC and CBD. Alvin F. Coburn first studied PEA while researching the effects of egg yolk in preventing the recurrence • Direct action on the perioxisome proliferator of rheumatic fever in poor children living in New York activated alpha and delta and gamma in 1939. He found that the phospholipid fraction in (PPAR-alpha, delta and gamma). PPARs are egg yolk could effectively prevent streptococcal transcription factors in the nucleus that can switch infection. Additional follow-up studies in New York as on and off genes that control pain and inflammation. well as Chicago confirmed the effectiveness of the PPARs also have other functions in obesity and phospholipid fraction during outbreaks of infection. glucose metabolism. Later, soy phospholipids were found to be a more plentiful and cheaper source, and it was confirmed • Indirect action on other receptors like transient that PEA was indeed the active fraction. Since then, receptor potential vanilloid-type 1 (TRPV1, also PEA has been extensively studied in numerous health known as capsaicin receptor), which opens or closes conditions (Appendix 2). ion channels allowing a flow of sodium, magnesium and potassium ions into cells and is associated with MECHANISM OF ACTION transferring pain signals. • Direct action by inhibiting enzymes such as fatty It is important to know how a drug works, especially acid amide hydrolase (FAAH) and monoacylglycerol at the molecular level. Knowing a drug’s “mechanism (MAGL) that degrade the naturally produced of action” allows researchers to develop optimal endocannabinoids (ECs) AEA and 2-AG respectively, formulations, dose and delivery systems to be tested thus allowing for prolonged therapeutic action of in clinical trials. It took almost fifty years after PEA’s these ECs on CB2 receptors. initial discovery before its mechanism of action was finally worked out. The credit for this goes to Italian

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FIGURE 2. DIAGRAMMATIC REPRESENTATION OF MECHANISMS OF ACTION OF PEA.

A shows synthesis and breakdown. B depicts a direct effect of PEA on PPAR-alpha and GPR55 receptors. C depicts a direct effect of PEA by inhibiting FAAH enzyme, thereby elevating AEA and 2-AG levels which activate CB2 and TRPV1 receptors. D depicts an indirect effect on TRPV1 by having a direct effect on AEA and 2AG. E shows a direct effect of PEA on PPAR-alpha. (Source: Petrosino & Di Marzo, 2017, p. 1351)

UNIQUE EFFECTS OF PEA Cannabinomimetic effects A remarkable feature of PEA is that its chemical structure is very similar to the ECs (both AEA and 2-AG), even more so than the phytocannabinoids The entourage effect is an indirect mechanism of (derived from various sources, chiefly hemp and action whereby the biological effects of ECs and marijuana) (Fig. 3). In fact, the structural similarities phytocannabinoids are enhanced by related naturally allow PEA to produce effects similar to the produced molecules like PEA, which do not produce ECs as well as enhancing the effects of those effects by themselves. The enhanced effect exogenous phytocannabinoids. may occur either by preventing the breakdown of ECs or phytocannabinoids through inhibiting the enzymes that degrade them, or by increasing the receptor PEA Formulation and Bioavailability binding affinity of ECs or phytocannabinoids. PEA PEA is a lipid molecule so it has poor solubility, has been shown to display the entourage effect in absorption and overall bioavailability. In order to different health conditions. An elegant demonstration overcome these hurdles, novel delivery systems are of this occurred in hypertensive rats, where it was required, including nano-emulsions, liposomes, solid observed that blood pressure was reduced with the lipid particles and other nano-delivery systems (Conte addition of PEA to otherwise ineffective doses of AEA et al., 2017). Alternatively, bioavailability may also be (Garcia et al., 2009). improved through by-passing the first-pass effect of the liver, so that absorption occurs via the lymphatic system as opposed to the circulatory system (Zgair et al., 2017).

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FIGURE 3. CHEMICAL STRUCTURES OF PEA, ENDOCANNABINOIDS AND PHYTOCANNABINOIDS.

(Source: Tsuboi et al., 2018, p. 2)

CLINICAL APPLICATIONS (Ghaufori et al., 2013). This deficiency theory is not unlike the hypothesis of Ethan Russo, a long time As stated previously, PEA is the body’s go-to- researcher of , who first proposed in molecule and is made on demand when required under 2004 that a deficiency in the ECs may exist and be disease conditions. Due to its ubiquitous nature the causative factor in many pathological conditions and presence in all cells, PEA has wide-ranging (Russo, 2004). Several studies have shown that when therapeutic applications. PEA is used concurrently with opioid-type drugs (e.g., Tapentadol) for lower back pain, the dose of the opioid was significantly reduced, which alleviated 1. Analgesic Effects some of the side-effects of the drug PEA is produced by the body as a “compensatory (Passavanti et al., 2017). factor” when confronted with pain. At least 6,000 patients with chronic pain and inflammation have been entered into clinical trials of PEA since the 2. Chronic Pain first studies in the 1970s. PEA has shown to be an One of the most important public health problems important therapeutic molecule with an impressively worldwide, chronic pain remains a major challenge in positive risk/benefit ratio. Further, recent data medicine and can have serious impact on quality of support the hypothesis of deficient synthesis of life. While acute pain is self-limiting and usually easily PEA in pathologic states. For example, a study on dealt with, chronic pain is more difficult to address fibromyalgia described deficient synthesis of PEA and causes significant personal and social issues. in the trapezius muscles in patients, and proposed Depending on its origin, chronic pain can be classified that supplementation with PEA might be a useful as inflammatory (e.g., osteoarthritis, rheumatoid therapeutic intervention in this chronic condition arthritis) or neuropathic. Neuropathic pain can arise

AOR Canada AOR US 3900 - 12 Street NE 30 Industrial West Calgary, AB Canada T2E 8H9 Clifton, NJ 07012 1-800-387-0177 | aor.ca 1-866-215-0450 | aorhealth.com PEA: The Multiple Target Molecule from a disease or injury to the central or peripheral helping to modulate their behavior. In this regard, nervous systems; thermal and mechanical pain PEA acts as a local enforcer of the very cells that stimuli are amplified (hyperalgesia), while stimuli produce it. Deficiency of PEA may lead to cognitive which were previously undetected are now perceived issues like dementia, and other motor as aching (allodynia). PEA was found to exert pain abnormalities. Animal studies have shown improved relief in various animal models of inflammatory and neuronal survival with PEA supplementation, as well neuropathic pain (Luongo et al., 2017). In all these as prevention of localized neuro-inflammation via models of pain, there was a significant decrease in multiple pathways. plasma PEA levels. Increasing ECs and/or PEA levels lessened pain perception and also increased pain 5. PEA for Preventing Flu, Colds and threshold levels. The analgesic effects of PEA were found to be due to either increasing AEA levels via Upper Respiratory Infections inhibiting its breakdown by FAAH enzymes, or direct Between 1969 and 1975 six large human clinical action on PPAR receptors and opening up TRPV1 studies to evaluate the effectiveness of PEA to channels, with the cumulative effect being reduce the number of days lost to colds and flu were reduction of pain signals. conducted in the former Czechoslovakia. Five of these were in adults (groups of factory workers and soldiers) and one in children. In these double blind 3. Anti-Inflammatory Action placebo controlled studies, patients were monitored Numerous animal models have documented the anti- for high temperature, headaches, sore throats, inflammatory action of PEA, including rat paw edema, muscle pain, coughs and general malaise and fatigue. phorbol ester-induced ear edema, colitis, as well as topical application of various irritants. There is likely The effectiveness of PEA in reducing all the symptoms a two-pronged approach to this action. First, PEA and days lost to illness was very impressive (Appendix prevents activation and release of numerous 4), and effects were evident usually within the second contents (degranulation), including histamine, week of the treatment. In all six studies, PEA had inflammatory cytokines, chemokines, tryptases and clear treatment effect in reducing the incidence and proteases. Second, PEA stimulation of PPAR-alpha frequency of respiratory infections and was found to likely also mediates the anti-inflammatory action be an effective prophylaxis. No side-effects by preventing NF-kappaB translocation from the were observed. Health authorities observed the cytoplasm into the nucleus that would otherwise ease of application of PEA, and noted its potential activate the inflammatory cascade. in flu epidemics. 4. Neuro-Protection 6. Antioxidant Inflammation can be especially perilous where PEA has been shown to neutralize the damaging the nervous system is involved, that is, neuro- effects of free radicals by binding to them and inflammation. The , mast cells and preventing their destructive action. This is play a critical role in the health of the particularly important for the extra sensitive and nervous system. However, it can be a Jekyll and Hyde highly prone neurons. scenario – when acutely activated these cells help resolve the inflammation, but if the inflammation is chronic (e.g., diabetes, obesity or other conditions) then these cells create havoc in the brain and may be 7. Allergies causative factors in various neurological disorders Due to its powerful mast cell stabilization properties, like Alzheimer’s, Parkinson’s, multiple sclerosis, PEA should be useful in all forms of allergies, autism, amyotrophic lateral sclerosis, cerebral including airborne, food and contact allergic ischemia and traumatic brain injury. All three cells dermatitis. When activated, mast cells are key communicate with each other or cross-talk, with initiators of allergic responses through their release each apprising the other of any changes in the local of inflammatory and allergic mediators like histamine, environment (Appendix 3). prostaglandins and other growth factors. Additionally, mast cells interact or cross-talk with other key PEA levels are three times higher than EC levels in the players in the inflammatory process, including central nervous system, suggesting PEA plays a major dendritic cells, macrophages, lymphocytes etc. role in neuro-protection. PEA is locally produced Antihistamines work by preventing histamine release. and broken down in mast cells and microglia, PEA should be a powerful alternative with

AOR Canada AOR US 3900 - 12 Street NE 30 Industrial West Calgary, AB Canada T2E 8H9 Clifton, NJ 07012 1-800-387-0177 | aor.ca 1-866-215-0450 | aorhealth.com PEA: The Multiple Target Molecule its inhibiting action on mast cell degranulation, 10. Digestive Disorders and a Key Role of and without the side-effect of drowsiness caused by antihistamines. PEA in Gut-Brain Axis The gastrointestinal tract has a dense concentration of cannabinoid receptors for AEA and 2-AG to 8. Migraine maintain gut homeostasis and modulate gut motility Traditional phytocannabinoids like CBD and THC, and secretion of digestive enzymes. These play a and/or their combination, have been documented to key role in intestinal inflammatory diseases like produce anti-migraine effects. With migraines, EC inflammatory bowel diseases (IBD) such as Crohn’s levels decrease, and increasing ECs has been shown disease and ulcerative colitis, and inflammatory to reduce migraine episodes. Due to its structural bowel syndrome (IBS). Recently, a double blind similarity to ECs, it is conceivable that PEA may be placebo controlled study has shown the efficacy helpful in migraine management. of PEA in reducing pain severity in IBS patients (Barbara et al., 2014). This is consistent with PEA’s 9. Depression anti-inflammatory and analgesic effects. In previous Over 350 million people world-wide are affected by animal models it has been shown that PEA is depression, with women at twice the risk as men. It produced by the colon in response to inflammatory is estimated one in twenty people in the Western insults, and that PEA supplementation exerts anti- world suffer from at least one depressive episode inflammatory effects in the gut; colon weight and in a year. Despite the use of antidepressants, less length, which are considered a reliable and sensitive than one-third achieve remission, and many still have indicator of severity of inflammation, were markedly residual depressive symptoms. Antidepressants reduced by PEA (Borrelli et al., 2014). A more recent work by increasing monoamines like twelve-week study in IBS patients showed that PEA and in the central nervous system. (dose of palmithoylethanolamide/polydatin 200 PEA has been shown to exert antidepressant and mg/20 mg twice a day) significantly reduced pain anxiolytic properties in animal models of depression severity and improved quality of life (Cremon et al., (Crupi et al., 2013; Yu et al., 2011). It has also been 2017). Additional animal studies seem to suggest that shown to prevent the spreading of cortical depression PEA may also play a protective role in liver fibrosis wave following traumatic brain injury or cerebral and liver damage (Ohara et al., 2018). ischemia. Notably, antidepressants have been found to increase levels of PEA in the brain, suggesting a The gut microbiome and the endocannabinoid system protective role of PEA during depression. There is seem to be intertwined and cross-talk with each also a link between stress and low plasma PEA levels. other on matters of energy utilization, thus impacting obesity and diabetes. Additional research suggests Animal studies have demonstrated that PEA can that PEA may also influence the gut microbiome in produce antidepressant effects similar to the drug a positive manner, especially in affecting intestinal fluvoxamine. Researchers in Iran studied the effect permeability (e.g., leaky gut syndrome). PEA seems to of PEA as an adjunct to the popular antidepressant act as “gate keeper” and reduces permeability through drug citalopram in a double blind placebo controlled the tight junctions of any pathogenic gut microbes, study. By week two, the citalopram plus PEA group preventing their entry into circulation which could experienced significantly greater antidepressant cause low grade inflammation affecting various effect than the citalopram alone group organs like the liver. (Ghazizadeh-Hashemi et al., 2018). (Cani et al., 2016) (Appendices 5 and 6).

The antidepressant effect of PEA is likely to be multifactorial with TRPV1 receptor activation of The gut-brain axis refers to the link between the TRPV1 and PPAR’s alpha, delta and gamma, but gut and brain and the bidirectional communication possibly other receptors like GPR55 as well. Finally, and interactions that have physiological and PEA’s inhibition of FAAH and NAAA enzymes that psychological effects. Due to the strong interaction degrade AEA may also contribute to its of the endocannabinoid system with both the antidepressant effect. gastrointestinal tract and the brain, PEA is an ideal molecule for addressing gut-brain axis issues.

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11. Cardiovascular and the key mechanisms involved. In addition, there is overactivity of mast cells. This excessive activation Cerebrovascular Role may be controlled by PEA since it helps modulate Recently, plasma PEA has been shown to have strong mast cells. A recent human clinical trial showed association with, and may be predictive of, coronary that PEA may augment the effects of risperidone, dysfunction in morbidly obese individuals, and as a prescription drug used to treat autism-related such has been proposed as a novel bio-marker in irritability and hyperactivity disorder, thus allowing heart disease. Moreover, due to its non-invasiveness, reduction of the required dose. With PEA, the plasma PEA level testing may be more acceptable microglial cells were protected and there was and cost effective compared to coronary angiography evidence of improved synaptic plasticity and higher (Quercioli et al., 2017). However, more work needs levels of . A reduced dose of risperidone to be done to establish whether the sensitivity and meant fewer side-effects of the prescription specificity of PEA could reach the standards for drug (Khalaj et al., 2018). Other case reports have clinical application. confirmed PEA having beneficial effects (Bertolino et al., 2017; Antonucci et al., 2015). Large scale studies Numerous animal studies have shown that PEA need to be conducted. plays a major role in neuro-protection. PEA acts on the glial cells which are the key immune cells in CONCLUSIONS the brain that constantly survey the environment (immunosurveillance) in preparation for insult and This fat-derived signalling compound has a long injury, especially neuro-inflammation of the brain history, with PEA’s effects on pain being known for (e.g., cerebrovascular injury like stroke). Recently, a half a century. It is not a classic endocannabinoid, combination of PEA and the antioxidant flavonoid despite having some metabolic and structural luteolin was evaluated in 250 stroke patients for similarities to other so-called ‘signalling’ molecules. neurological improvement in cognition, pain, degree It is now receiving more attention in the areas of of spasticity and quality of life. There was significant chronic pain, inflammation and other diseases. improvement in all the clinical indices, and evidence Because it interacts with several receptors it has suggests a role for this formulation in stroke potential in numerous applications requiring ‘multiple prevention and recovery (Caltagirone et al., 2016). target’ approaches. 12. Dependency PEA may be an innovative treatment for cannabis dependency since it has remarkable chemical structural similarities to the endogenous cannabinoids (AEA and 2-AG), even more structurally similar than phytocannabinoids derived from cannabis (THC or CBD). PEA may act as an antagonist and/or agonist to block various receptors and have a powerful entourage effect (Coppola and Mondola, 2013). This hypothesis needs to be confirmed. Some predicted effects of PEA include: 1) clinically significant reduction in withdrawal symptoms in cannabis dependent patients; 2) clinically significant reduction of craving in cannabis dependent patients; 3) clinically significant reduction of cannabis consumption; and 4) prevention of cannabis-induced neurotoxicity and neuro-psychiatric disorders. Whether PEA may play an important role in reducing dependency and help in the opioid crisis remains to be seen. 13. Autism Spectrum Disorder Whilst the exact mechanism for autism is not fully understood, glutamate excitotoxicity of the neurons and neuro-inflammation are thought to be

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REFERENCES

1. Antonucci, N., Cirillo, A. et Siniscalco, D. (2015). Beneficial effects of dell’Istituto superiore di sanità, 53, 125-134. palmitoylethanolamide on expressive language, cognition, and behaviors in 23. Iuvone, T. et al. (2016). Ultramicronized palmitoylethanolamide reduces autism: A report of two cases. Case Reports in Psychiatry, 2015:325 061. http:// viscerovisceral hyperalgesia in a rat model of endometriosis plus ureteral dx.doi.org/10.1155/2015/325061 Barbara, G., Cremon, C. et Stanghellini, V. (2014). calculosis: Role of mast cells. Pain, 157, 80-91. Inflammatory bowel disAntonucciease and irritable bowel syndrome: Similarities and 24. Kahlich, R. et al. (1979). Studies on prophylactic effcacy of N-2-hydroxyethyl differences. Current Opinion in Gastroenterology, 30, 352-358. palmitamide (Impulsin) in acute respiratory infections. Serologically controlled 2. Barry, A. et al. (2018). Plasma N-acylethanolamine and endocannabinoid levels in field trials. Journal of Hygiene Epidemiology Microbiology and Immunology, 23, burning mouth syndrome: Potential role in disease pathogenesis. Journal of Oral 11-24. Pathology and Medicine, 47, 440-442. 25. Keppel Hesselink, J.M., de Boer, T. et Witkamp, R.F. (2013). 3. Bertolino, B. et al. (2017). Beneficial effects of co-ultramicronized Palmitolyethanolamide: A natural body-own anti-inflammatory agent, palmitoylethanolamide/luteolin in a mouse model of autism and in a case report of effective and safe against influenza and . International Journal of autism. CNS Neuroscience and Therapuetics, 23, 87-98. Inflammation, 2013:151028. http://dx.doi.org/10.1155/2013/151028 4. Borrelli, F. et al. (2015). Palmitoylethanolamide, a naturally occurring lipid, is an orally 26. Khalaj, M. et al. (2018). Palmitoylethanolamide as adjunctive therapy for autism: effective intestinal anti-inflammatory agent. British Journal of Pharmacology, 172, Efficacy and safety results from a randomized controlled trial. Journal of 142-158. Psychiatric Research, 103, 104-111. 5. Brotini, S., Schievano, C. et Guidi, L. (2017). Ultra-micronized palmitoylethanolamide: 27. Kilaru, A., Blancaflor, E. B., Venables, B. J., Tripathy, S., Mysore, K. S. et An efficacious adjuvant therapy for Parkinson’s disease. CNS and Neurological Chapman, K.D. (2007). The N-acylethanolamine-mediated regulatory pathway in Disorders Drug Targets, 16, 705-713. plants. Chemistry and Biodiversity, 4, 1933-1955. 6. Bruun, S. et al. (2018). Satiety factors oleylethanolamide, , and 28. Lam, P.M., Marczylo, T. H. et Konje, J.C. (2010). Simultaneous measurement palmitoylethanolamide in mother’s milk are strongly associated with infant weight at of three N-acylethanolamides in human bio-matrices using ultra performance four months of age–data from the Odense Child Cohort. Nutrients, 10:1747. https://doi. liquid chromatography–tandem mass spectrometry. Analytical and Bioanalytical org/10.3390/nu10111747 Chemstry, 398, 2089-2097. 7. Caltagirone, C. et al. (2016). Co-ultramicronized palmitoylethanolamide/luteolin in the 29. Luongo, L., Starowicz, K., Maione, S. et Di Marzo, V. (2017). Allodynia lowering treatment of cerebral ischemia: From rodent to man. Translational Stroke Research, 7, induced by cannabinoids and endocannabinoids (ALICE). Pharmacological 54-69. Research, 119, 272-277. 8. Cani, P.D., Plovier, H., Van Hul, M., Geurts, L., Delzenne, N.M., Druart, C. et Everard, 30. Masek, K., Perlik, F., Klima, J. et Kahlich, R. (1974). Prophylactic efficacy of A. (2016). Endocannabinoids–at the crossroads between the gut microbiota and host N-2-hydroxyethyl palmitamide (Impulsin) in acute respiratory tract infections. metabolism. Nature Reviews – Endocrinology, 12, 133-143. European Journal of Clinical Pharmacology, 7, 415-419. 9. Chirchiglia, D., Chirchiglia, P. et Signorelli, F. (2018). Nonsurgical lumbar 31. Mounessa, J. S., Siegel, J. A., Dunnick, C.A. et Dellavalle, R.P. (2017). The role of radiculopathies treated with ultramicronized palmitoylethanolamide (umPEA): A series cannabinoids in dermatology. Journal of the American Academy of Dermatology, of 100 cases. Neurologia i neurochirurgia polska, 52, 44-47. 77, 188-190. 10. Clemente, S. (2012). Amyotrophic lateral sclerosis treatment with ultramicronized 32. Ohara, M. et al. (2018). Palmitoylethanolamide ameliorates carbon tetrachloride- palmitoylethanolamide: A report of two cases. CNS and Neurological Disorders Drug induced liver fibrosis in rats. Frontiers in Pharmacology, 9:709. http://dx.doi. Targets, 11, 933-936. org/10.3389/fphar.2018.00709 11. Conte, R., Marturano, V., Peluso, G., Calarco, A. et Cerruti, P. (2017). Recent advances in 33. Orefice, N. S., Alhouayek, M., Carotenuto, A., Montella, S., Barbato, F. et Comelli, nanoparticle-mediated delivery of anti-inflammatory phytocompounds. International A. (2016). Oral palmitoylethanolamide treatment is associated with reduced Journal of Molecular Sciences, 18, 709-732. cutaneous adverse effects of interferon-β1a and circulating proinflammatory 12. Coppola, M. et Mondola, R. (2013). Palmitoylethanolamide: From endogenous cytokines in relapsing-remitting multiple sclerosis. Neurotherapeutics, 13, 428- cannabimimetic substance to innovative medicine for the treatment of cannabis 438. dependence. Medical Hypotheses, 81, 619-622. 34. Paladini, A., Fusco, M., Cenacchi, T., Schievano, C., Piroli, A. et Varrassi, G. (2016). 13. Cordaro, M. et al. (2017). Effects of a co-micronized composite containing Palmitoylethanolamide, a special food for medical purposes, in the treatment of palmitoylethanolamide and polydatin in an experimental model of benign prostatic chronic pain: A pooled data meta-analysis. Pain Physician, 19, 11-24. hyperplasia. Toxicology and Applied Pharmacology, 329, 231-240. 35. Palma, E., Reyes-Ruiz, J.M., Lopergolo, D., Roseti, C., Bertollini, C. et Ruffolo, G. 14. Cremon, C. et al. (2017). Randomised clinical trial: The analgesic properties of (2016). receptors from human muscle as pharmacological targets dietary supplementation with palmitoylethanolamide and polydatin in irritable bowel for ALS therapy. Proceedings of the National Academy of Sciences of the U.S.A., syndrome. Alimentary Pharmacology and Therapeutics, 45, 909-922. 113, 3060-3065. 15. Crupi, R., Paterniti, I., Ahmad, A., Campolo, M., Esposito, E. et Cuzzocrea, S. (2013). 36. Passavanti, M.B. et al. (2017). The beneficial use of ultramicronized Effects of palmitoylethanolamide and luteolin in an animal model of anxiety/ palmitoylethanolamide as add-on therapy to Tapentadol in the treatment of low depression. CNS and Neurological Disorders Drug Targets, 12, 989-1001. back pain: A pilot study comparing prospective and retrospective observational 16. Del Giorno, R., Skaper, S., Paladini, A., Varrassi, G. et Coaccioli, S. (2015). arms. BMC Anesthesiology, 17, 171-178. Palmitoylethanolamide: Results from prospective and retrospective observational 37. Petrosino, S. et Di Marzo, V. (2017). The pharmacology of palmitoylethanolamide studies. Pain and Therapy, 4, 169-178. and first data on the therapeutic efficacy of some of its new formulations. 17. Eberlein, B., Eicke, C., Reinhardt, H.W. et Ring, J. (2008). Adjuvant treatment of atopic British Journal of Pharmacology, 174, 1349-1365. eczema: assessment of an emollient containing N-palmitoylethanolamine (ATOPA 38. Phan, N. Q., Siepmann, D., Gralow, I. et Ständer S. (2010). Adjuvant topical therapy study). Journal of the European Academy of Dermatology and Venereology, 22, 73-82. with a agonist in facial postherpetic neuralgia. Journal of 18. Garcia, M.C., Adler-Graschinsky, E. et Celuch, S.M. (2009). Enhancement of the the German Society of Dermatology, 8, 88-91. hypotensive effects of intrathecally injected endocannabinoids by the entourage 39. Plesnik, V., Havrlantova, M., Jancova, J., Januska, J. et Macková, O. (1977). compound palmitoylethanolamide. European Journal of Pharmacology, 610, 75-80. Impulsin in the prevention of acute respiratory diseases in school children. 19. Ghaufori, N., Ghafouri, B., Larsson, B., Stensson, N., Fowler, C. J. et Gerdle, B. (2013). Ceskoslovenská Pediatrie, 32, 365-369. Palmitoylethanolamide and stearoylethanolamide levels in the interstitium of the 40. Quercioli, A. et al. (2017). Plasma palmitoylethanolamide (PEA) as a potential trapezius muscle of women with chronic widespread pain and chronic neck-shoulder biomarker for impaired coronary function. International Journal of Cardiology, pain correlate with pain intensity and sensitivity. Pain, 154, 1649-1658. 231, 1-5. 20. Ghazizadeh-Hashemi, M. et al. (2018). Palmitoylethanolamide as adjunctive therapy in 41. Russo, E. (2004). Clinical endocannabinoid deficiency (CECD): Can this concept major depressive disorder: A double blind, randomized and placebo-controlled trial. explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable Journal of Affective Disorders, 232, 127-133. bowel syndrome and other treatment-resistant conditions? Neuro Endocrinology 21. Gouveia-Figueira, S. et Nording, M.L. (2014). Development and validation of a sensitive Letters, 25, 31-39. UPLC-ESI-MS/MS method for the simultaneous quantification of 15 endocannabinoids 42. Schuel, H. et al. (2002). N-acylethanolamines in human reproductive fluids. and related compounds in milk and other biofluids. Analytical Chemistry, 86, 1186-1195. Chemisty and Physics of Lipids, 121, 211-227. 22. Indraccolo, U., Indraccolo, S. R. et Mignini, F. (2017). Micronized palmitoylethanolamide/ 43. Sharma, C., Sadek, B., Goyal, S.M., Sinha, S., Kamal, M.A. et Ojha, S. (2015). Small trans-polydatin treatment of endometriosis-related pain: A meta-analysis. Annali molecules from nature targeting G-protein coupled cannabinoid receptors:

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REFERENCES

Potential leads for drug discovery and development. Evidence-Based Complementary and Alternative Medicine, 2015: 238482. http://dx.doi.org/10.1155/2015/238482 44. Skaper, S.D. et al. (2014). Palmitoylethanolamide, a naturally occurring disease- modifying agent in neuropathic pain. Inflammopharmacology, 22, 79-94. 45. Skaper, S.D., Facci, L., Zusso, M. et Giusti, P. (2018). An inflammation-centric view of neurological disease: Beyond the neuron. Frontiers in Cellular Neuroscience, 12:72. http://dx.doi.org/10.3389/fncel.2018.00072 46. Tsuboi, K., Uyama, T., Okamoto, Y. et Ueda, N. (2018). Endocannabinoids and related N-acylethanolamines: Biological activities and metabolism. Inflammation and Regeneration, 38:28. https://doi.org/10.1186/s41232-018-0086-5 47. Venables, B.J., Waggoner, C.A. et Chapman, K.D. (2005). N-aAcylethanolamines in seeds of selected legumes. Phytochemistry, 66, 1913-1918. 48. Visse, K., Blome, C., Phan, N. Q., Augustin, M. et Ständer, S. (2017). Efficacy of body lotion containing N-palmitoylethanolamide in subjects with chronic pruritus due to dry skin: a dermatocosmetic study. Acta Dermato-Venerologica, 97, 639-641. 49. Yu, H. L., Deng, X.Q., Li, Y. J., Li, Y. C., Quan, Z. S. et Sun, X.Y. (2011). N-palmitoylethanolamide, an endocannabinoid, exhibits antidepressant effects in the forced swim test and the tail suspension test in mice. Pharmacological Reports, 63, 834-839. 50. Zgair, A. et al. (2017). Oral administration of cannabis with lipids leads to high levels of cannabinoids in the intestinal lymphatic system and prominent immunomodulation. Nature Scientific Reports, 7:14542. http://doi.org/10.1038/s41598-017-15026-z

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APPENDIX 1. COMMON FOOD SOURCES OF PALMITOYLETHANOLAMIDE (PEA)

Concentration of PEA Food Source References (ng·g—1 fresh weight)

Bovine Milk 0.25 Gouveia-Figueira & Nording, 2014 Elk Milk 1.81 Gouveia-Figueira & Nording, 2014 Human 8.98 ± 3.35 nmol·L—1 Lam et al., 2010 Human breast milk 23.4 ± 7.2 nmol·L—1 Schuel et al., 2002 (110 ± 32.3 lactation days) Common bean 53.5 Venables et al., 2005 (Phaseoulus vulgaris) Garden pea (Pisum sativum) 100 Venables et al., 2005; Kilaru et al., 2007 Southern or black-eyed peas 138 Venables et al., 2005 (Vigna unguiculata) Tomato 100 Kilaru et al., 2007 Medicago sativa 1150 Venables et al., 2005 Corn 200 Kilaru et al., 2007 Soybean ( max) 6700 Venables et al., 2005; Kilaru et al., 2007 Soy lecithin 950 000 Kilaru et al., 2007 Peanut (Arachis hypogaea) 3730 Venables et al., 2005; Kilaru et al., 2007

APPENDIX 2. PALMITOYLETHANOLAMIDE (PEA) EFFICACY IN CLINICAL STUDIES AND CLINICAL APPLICATIONS

Pathology References

Amyotrophic lateral sclerosis Amyotrophic lateral sclerosis Autism Antonucci et al., 2015; Bertolino et al., 2017 Benign prostatic hyperplasia (especially a Cordaro et al., 2017 combination of PEA with R+Lipoic acid) Burning mouth syndrome Barry et al., 2018

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Pathology References

Chronic pain (including neuropathic pain) of Skaper et al., 2014; Paladini et al., 2016 differing etiologies Dermatological uses including pruritus, facial Visse et al., 2017; Phan et al., 2010; postherpetic neuralgia, atopic eczema, contact Eberlein et al., 2008; Mounessa et al., 2017 dermatitis and non-specified itch Endometriosis Iuvone et al., 2016; Indraccolo et al., 2017 Fibromyalgia Del Giorno et al., 2015 Improving satiety and thus supporting Bruun et al., 2018 weight loss Non-surgical lumbar radiculopathies Chirchiglia et al., 2018 Parkinson’s disease (adjuvant therapy) Brotini et al., 2017 Relapsing-remitting multiple sclerosis (add-on Orefice et al., 2016 therapy for the treatment of interferon-β1a- related adverse effects) Stroke (adjuvant therapy) Caltagirone et al., 2016

APPENDIX 3. DIAGRAMMATIC REPRESENTATION OF THE CROSS- TALK BETWEEN MAST CELL AND MICROGLIA, TWO KEY PLAYERS IN NEURO-INFLAMMATION

(Source: Skaper et al., 2018, p. 7)

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APPENDIX 4. EFFECTIVENESS OF PALMITOYLETHANOLAMIDE (PEA) ON COLDS AND FLU IN A SERIES OF CLINICAL STUDIES CONDUCTED IN CZECHOSLOVAKIA

Study year PEA (n) Placebo (n) % Protection Significance (p) References

1972a 223 221 45% <0.05 Masek et al., 1974 1972b 436 463 32% <0.0005 Masek et al., 1974 1973 436 465 34% <0.0002 Kahlich et al., 1979 1974 411 199 52% <0.002 Kahlich et al., 1979 1975 235 118 59% <0.004 Kahlich et al., 1979 19771 196 224 16% NS Plesnik et al., 1977

1 The last of these six studies was conducted in children aged 11 to 15 (all the others were in adults). The lack of significance was attributed to the short duration of intake of PEA (8 weeks) and the absence an influenza epidemic during the trial period. (Source: Keppel Hesselink et al., 2013, p. 4)

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APPENDIX 5. SHOWING CERTAIN “GATEKEEPERS” OF THE TIGHT JUNCTIONS ALLOW ENTRY OF MICROBES INTO THE CIRCULATION CAUSING LOW GRADE INFLAMMATION

(Source: Cani et al., 2016, p.3)

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APPENDIX 6. SHOWING PALMITOYLETHANOLAMIDE (PEA) ACTS AS A “GATEKEEPER” TO MAINTAIN THAT THE TIGHT JUNCTIONS REMAIN LOCKED AND PREVENT ENTRY OF MICROBES INTO THE CIRCULATION

(Source: Cani et al., 2016, p. 5)

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APPENDIX 7. SHOWING THE EFFECTS OF NATURALLY PRODUCED MOLECULES LIKE PALMITOYLETHANOLAMIDE (PEA) ON VARIOUS DISEASES

Anti-Inflammatory Antiapoptotic

Antioxidant Alcohol Addiction Anticancer

Depression Chemogenic Pain

Anxiety Renal Injury

Neuropathic Pain Obesity

Lipid Dysregulation Alzheimer’s Disease

Cerebral Ischemia Diabetes

Ulcerative Brain Cancer Colitis Glucose Homeostasis Inflammatory Bowel Disease Endometriosis

(Source: Sharma et al., 2015, p. 3)

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