Effects of diazepam on neutrophil (PMN) free amino acid profiles and immune functions in vitro. Metabolical and immunological consequences of L-alanyl-L-glutamine supplementation

Sedation & immunomodulation

As the armamentarium for sedation in the critically ill expands, opportunities will develop to modulate the immune responses of patients by way of the direct immune and neural-immune interactions of the sedatives. Control of autonomic activity through the use of appropriate sedation may be critical in this matter. Likewise analgesic-based sedation, with increased opioid dosage, may not prove beneficial in the setting of infection; whether avoidance of morphine in preference for a fentanyl derivative will help is unclear. However, as the immune effects seem dependent on the m receptor, it is improbable that a significant difference would be uncovered. Similarly, the present evidence suggests benzodiazepines are deleterious in infection; further studies are required urgently to evaluate this evidence. As an alternative to benzodiazepine-based sedation, dexmedetomidine has shown a remarkable 70% mortality benefit in a small secondary analysis of septic patients from the MENDS trial. Further powered clinical studies should now be undertaken to investigate the potential benefit of the α2-adrenoceptor agonist in this setting, with comparisons with propofol.

Effect of disodiumN,N-dialanyl protoporphyrinate, diarginine protoporphyrinate and diarginineN,N-dialanyl protoporphyrinate on respiratory burst of human neutrophilsin vitro

The effect of three amino acid protoporphyrin IX (PPIX) derivatives evaluated as sensitizers in photodynamic therapy — disodium N,N -dialanyl protoporphyrinate ( PP(Ala)2Na2), diarginine protoporphyrinate (PPArg2) and diarginine N,N -dialanyl protoporphyrinate (PP(Ala)2Arg2) – non-irradiated and pre-irradiated with UV-A, on respiratory burst of non-stimulated and opsonized zymosan stimulated neutrophils was studied. A potential synergistic effect of diazepam (7-chloro-1-methyl-5-phenyl-1,3-dihydro-2H-1,4-benzodiazepin-2-one) was also examined. PP(Ala)2Na2showed strong pro-oxidant effect towards non-stimulated neutrophils, while PPArg2and PP(Ala)2Arg2revealed no significant effect. In the case of stimulated neutrophils all studied porphyrins showed antioxidant effect, although for PP(Ala)2Na2this effect was significantly weaker than that of PPArg2and PP(Ala)2Arg2. After pre-irradiation with UV-A (λ = 365 nm, fluence 2.0 J.cm-2, fluence rate 6.7 mW.cm-2) the antioxidant activity of all studied sensitizers towards non-stimulated granulocytes did not change significantly when compared to effects of non-irradiated porphyrins, while in the case of stimulated cells, only PPArg2caused significant decrease of respiratory burst. Non-irradiated diazepam showed significant antioxidant effect and enhanced antioxidant effect of all studied porphyrins towards stimulated neutrophils, while after UV-A pre-irradiation it revealed no significant antioxidant effect on non-stimulated and stimulated neutrophils, both alone and in combination with porphyrin sensitizers.

Sedation & immunomodulation

The management of critically ill patients necessitates the use of sedatives and analgesics to provide patient comfort and cooperation. These drugs exert profound effects on all organ systems, not only the central nervous system, and this article describes the immunologic effects of the commonly used critical care sedatives: propofol, the benzodiazepines, opioids, and alpha(2)-adrenoceptor agonists. Benzodiazepines, opioids, and possibly even propofol worsen outcome in animal models of infection, whereas preliminary evidence suggests that the alpha(2)-adrenoceptor agonist, dexmedetomidine, may improve outcomes in the setting of infection. Given the burden of sepsis and secondary infections in critical care, choice of sedation may need to be carefully considered to preserve immune responses in critically ill patients.

Nutraceuticals: a pharmaceutical viewpoint: I

PURPOSE OF REVIEW

To review pharmaceutical aspects of selected amino acids, antioxidants and related nutraceuticals, deemed to be important for clinical nutrition.

RECENT FINDINGS

New clinical applications of nutraceuticals are increasingly being reported, but there are fundamental differences between formulation, production and the evidence supporting clinical use. Nutraceuticals generally fall within the novel foods and ingredients regulations but their purity, dosage requirements and clinical consequences exceed those of most 'healthfoods'. Replacement of one nutrient or antioxidant is unlikely to correct the cascade of interconnected metabolic abnormalities associated with many diseases. However, it is difficult to ascertain whether the reported benefits of complex mixtures, with little published stability data, are due to one or more individual substrates or some in-vitro interaction between them. Many clinical studies have suffered from inconsistencies of dose, formulation discrepancies and unproven outcome. These contradictory results weaken any firm evidence base to substantiate their effectiveness.

SUMMARY

Nutraceuticals are destined to play an important role in future therapeutic developments but their success will be governed by control of purity, safety and efficacy without inhibiting innovation. The straightforward application of pharmaceutical standards, especially across national borders, is likely to be a difficult challenge and could effectively paralyse the industry. Nevertheless more standardized formulations, dosage forms and production controls are called for. A place for nutraceuticals in clinical practice is emerging, but important pharmaceutical and clinical issues need to be addressed by further research.