Effect of N-acetylcysteine on cycling performance after intensified training

The impact of N-acetylcysteine on lactate, biomarkers of oxidative stress, immune response, and muscle damage: A systematic review and meta-analysis

N-acetylcysteine (NAC) is a compound whose mechanism of action is intricately linked to the provision of cysteine for glutathione synthesis. It has been used in medicine and has also made significant inroads into sports, as it can modify the levels of several biomarkers, including those of oxidative processes, inflammation and muscle damage after exercise. Because the effectiveness of NAC supplementation is unclear, the primary objective of the present study was to perform a meta-analysis elucidating how NAC supplementation alters the concentrations of GSH (glutathione), GSSG (glutathione disulfide), TBARS (thiobarbituric acid reactive substances), IL-6 (interleukin 6), TNF-α (tumour necrosis factor alpha), CK (creatine kinase), lactate, and muscle soreness after physical exertion. Suitable studies were searched for from February to September 2023, and the results of those included (n = 20) indicate that NAC supplementation significantly diminishes both muscle soreness (p = 0.03; the mean difference (MD) of NAC's effect was -0.43 with a 95% confidence interval (CI), -0.81, -0.04) and lactate concentrations after exercise (p = 0.03; the MD -0.56 mmol/L; 95% CI, -1.07, -0.06). A substantial decrease was observed in concentrations of IL-6 (p = 0.03; the standardized MD (SMD) was -1.71; 95% CI, -3.26, -0.16) and TBARS (p = 0.02; SMD was -1.03, 95% CI, -1.90, -0.15). Furthermore, an elevation in GSH concentration was observed following supplementation. However, we saw no significant effect of NAC on TNF-α, CK or GSSG concentrations. NAC supplementation holds promise for attenuating muscle soreness, lactate, TBARS and IL-6 concentrations and increasing GSH level following physical exertion.

N-acetylcysteine in the Donor, Recipient, or Both Donor and Recipient in Liver Transplantation: A Systematic Review With Meta-analysis and Trial Sequential Analysis

BACKGROUND

N-acetylcysteine (NAC) is a potentially effective drug for treating ischemia-reperfusion injury in transplanted livers, but its effect remains controversial.

METHODS

A systematic review and meta-analysis of relevant clinical trials published and registered in the Cochrane Library, MEDLINE, EMBASE, ClinicalTrial.gov , WHO ICTRP, etc, before March 20, 2022 were conducted and registered with PROSPERO (CRD42022315996). Data were pooled using a random effects model or a fixed effects model based on the amount of heterogeneity.

RESULTS

Thirteen studies with 1121 participants, 550 of whom received NAC, were included. Compared with the control, NAC significantly reduced the incidence of primary graft nonfunction (relative risk [RR], 0.27; 95% confidence interval [CI], 0.08-0.96), the incidence of postoperative complications (RR, 0.52; 95% CI, 0.41-0.67), the peak postoperative aspartate transferase level (mean difference [MD], -267.52; 95% CI, -345.35 to -189.68), and the peak alanine transferase level (MD, -293.29; 95% CI, -370.39 to -216.20). NAC also improved 2-y (RR, 1.18; 95% CI, 1.01-1.38) graft survival rate. However, NAC increased the intraoperative cryoprecipitate (MD, 0.94; 95% CI, 0.42-1.46) and red blood cell (MD, 0.67; 95% CI, 0.15-1.19) requirements. Moreover, NAC was administered in various modes in these studies, including to the donor, recipient, or both. Subgroup analysis and network meta-analysis showed that NAC administration to recipients could play a more significant role than the other 2 administration modes.

CONCLUSIONS

Our study supports the protective effect of NAC against LT-induced ischemia-reperfusion injury and shows better clinical outcomes of NAC administration to recipients.

Influence of N-Acetylcysteine Supplementation on Physical Performance and Laboratory Biomarkers in Adult Males: A Systematic Review of Controlled Trials

N-acetylcysteine (NAC) is used as a sports supplement for its ability to modulate exercise-induced oxidative damage through its antioxidant actions and maintenance of glutathione homeostasis, positioning NAC as a strategy to improve physical performance. We aimed to evaluate the current evidence on the benefits of NAC supplementation on physical performance and laboratory biomarkers in adult men. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically reviewed studies indexed in the Web of Science, Scopus, and PubMed to assess the effects of NAC on physical performance, laboratory biomarkers, and adverse effects in adult men. Original articles published up to 30 April 2023 with a controlled trial design comparing NAC supplementation with a control group were included. The modified McMaster Critical Review Form for Quantitative Studies was used as an assessment tool and the Cochrane Risk of Bias was applied. Of the 777 records identified in the search, 16 studies met the inclusion and exclusion criteria. Overall, most of the trials reported beneficial effects of NAC supplementation and no serious adverse events were reported. Participants supplemented with NAC showed significant improvements in exercise performance, antioxidant capacity, and glutathione homeostasis. However, there was no clear evidence of beneficial effects of NAC supplementation on haematological markers, inflammatory response, and muscle behaviour. NAC supplementation appears to be safe and may regulate glutathione homeostasis, have antioxidant effects, and improve exercise performance. However, further studies are needed to clarify the relevance of its use.

Endogenous and Exogenous Antioxidants in Skeletal Muscle Fatigue Development during Exercise

Muscle fatigue is defined as a decrease in maximal force or power generated in response to contractile activity, and it is a risk factor for the development of musculoskeletal injuries. One of the many stressors imposed on skeletal muscle through exercise is the increased production of reactive oxygen species (ROS) and reactive nitrogen species (RNS), which intensifies as a function of exercise intensity and duration. Exposure to ROS/RNS can affect Na⁺/K⁺-ATPase activity, intramyofibrillar calcium turnover and sensitivity, and actin-myosin kinetics to reduce muscle force production. On the other hand, low ROS/RNS concentrations can likely upregulate an array of cellular adaptative responses related to mitochondrial biogenesis, glucose transport and muscle hypertrophy. Consequently, growing evidence suggests that exogenous antioxidant supplementation might hamper exercise-engendering upregulation in the signaling pathways of mitogen-activated protein kinases (MAPKs), peroxisome-proliferator activated co-activator 1α (PGC-1α), or mammalian target of rapamycin (mTOR). Ultimately, both high (exercise-induced) and low (antioxidant intervention) ROS concentrations can trigger beneficial responses as long as they do not override the threshold range for redox balance. The mechanisms underlying the two faces of ROS/RNS in exercise, as well as the role of antioxidants in muscle fatigue, are presented in detail in this review.

Blood oxidative stress biomarkers in women: influence of oral contraception, exercise, and N-acetylcysteine

Purpose

To compare physiological responses to submaximal cycling and sprint cycling performance in women using oral contraceptives (WomenOC) and naturally cycling women (WomenNC) and to determine whether N-acetylcysteine (NAC) supplementation mediates these responses.

Methods

Twenty recreationally trained women completed five exercise trials (i.e., an incremental cycling test, a familiarisation trial, a baseline performance trial and two double-blind crossover intervention trials). During the intervention trials participants supplemented with NAC or a placebo 1 h before exercise. Cardiopulmonary parameters and blood biochemistry were assessed during 40 min of fixed-intensity cycling at 105% of gas-exchange threshold and after 1-km cycling time-trial.

Results

WomenOC had higher ventilation (β [95% CI] = 0.07 L·min⁻¹ [0.01, 0.14]), malondialdehydes (β = 12.00 mmol·L⁻¹ [6.82, 17.17]) and C-reactive protein (1.53 mg·L⁻¹ [0.76, 2.30]), whereas glutathione peroxidase was lower (β =  22.62 mU·mL⁻¹ [− 41.32, − 3.91]) compared to WomenNC during fixed-intensity cycling. Plasma thiols were higher at all timepoints after NAC ingestion compared to placebo, irrespective of group (all p < 0.001; d = 1.45 to 2.34). For WomenNC but not WomenOC, the exercise-induced increase in malondialdehyde observed in the placebo trial was blunted after NAC ingestion, with lower values at 40 min (p = 0.018; d = 0.73). NAC did not affect cycling time-trial performance.

Conclusions

Blood biomarkers relating to oxidative stress and inflammation are elevated in WomenOC during exercise. There may be an increased strain on the endogenous antioxidant system during exercise, since NAC supplementation in WomenOC did not dampen the exercise-induced increase in malondialdehyde. Future investigations should explore the impact of elevated oxidative stress on exercise adaptations or recovery from exercise in WomenOC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00421-022-04964-w.

The effects of N-acetylcysteine on recovery biomarkers: A systematic review and meta-analysis of controlled trials

N-acetylcysteine (NAC) is one of the antioxidant supplements which is thought to improve recovery. Existing studies regarding NAC and recovery presented conflicting results. This systematic review and meta-analysis evaluated the existing trials and determined the efficacy of acute and chronic NAC administration on recovery biomarkers. PubMed, Web of Science, and Scopus were searched up to July 2021. The random effects or fixed effects model was applied in the meta-analysis. Sensitivity and subgroup analyses were performed. In case of the presence of publication bias, standard methods were applied. The meta-analysis comprised 37 papers (1,388 participants). All included studies were in English language. Acute NAC administration indicated no significant effects on lactate, pH, VO₂ , and CPK-MB ([SMD = -0.06 mmol/L; 95% CI: -0.40, 0.28; p = .714], [SMD = 0.17; 95% CI: -0.28, 0.62; p = .454], [SMD = -0.11 L/min; 95% CI: -0.63, 0.41; p = .686], and [SMD = -0.19 units/L; 95% CI: -0.62, 0.24; p = .395]). Additionally, no evidence of significant influence of chronic NAC administration on lactate, pH, VO₂ , and CK was revealed ([SMD = 0.01 mmol/L; 95% CI: -0.25, 0.27; p = .950], [SMD = -0.51; 95% CI: -1.73, 0.70; p = .424], [SMD = -0.18 L/min; 95% CI: -0.56, 0.20; p = .361], and [SMD = -0.04 units/L; 95% CI: -0.36, 0.29; p = .821]). No considerable effect of NAC on recovery was found. PRACTICAL APPLICATIONS: Previous studies on the influence of NAC administration on recovery biomarkers have presented conflicting results. This systematic review and meta-analysis offers a broad range of detailed information on the influence of chronic and acute NAC supplementation outcomes regarding recovery biomarkers. Overall, the results support that NAC supplementation may not be effective in improving recovery biomarkers. However, subgroup analyses based on NAC dosage indicated the meaningful effect of NAC on CK-MB at the dosage of ≥100 mg/kg.

Cardiorespiratory and metabolic fitness indicators in novice volleyball trainees: effect of 1-week antioxidant supplementation with N-acetyl-cysteine/zinc/vitamin C

OBJECTIVES

This study aimed to determine the effect of 7-day dietary supplementation of N-acetylcysteine (NAC)/zinc/vitamin C on the time-to-exhaustion (TTE), the cardiorespiratory fitness (CRF) index, and metabolic indicators.

METHODS

This study enrolled volleyball student trainees (n = 18 men) who took NAC/zinc/vitamin C (750 mg/5 mg/100 mg) for 7 days at Jouf University, Saudi Arabia. The CRF index and TTE were determined. Serum concentrations of metabolic regulators (insulin, betatrophin, and hepatocyte growth factor), biomarkers of cellular damage/hypoxia, and indicators of lipid and glycemic control were measured.

RESULTS

Supplementation improved the TTE and CRF index, and lowered cytochrome c, C-reactive protein, hypoxia-inducible factor-1α (HIF-1α), total cholesterol, insulin, and glycated hemoglobin values. Before and after supplementation, the CRF index was negatively correlated with body mass index and positively correlated with the TTE. Before supplementation, the CRF index was positively correlated with betatrophin concentrations, and hepatocyte growth factor concentrations were positively correlated with betatrophin concentrations and negatively correlated with the homeostasis model assessment of insulin resistance index. After supplementation, the CRF index was negatively correlated with HIF-1α concentrations and metabolites. Additionally, the TTE was negatively correlated with HIF-1α, cytochrome c, and triacylglycerol concentrations.

CONCLUSION

Supplementation of NAC/zinc/vitamin C improves metabolic and CRF performance.

How N-Acetylcysteine Supplementation Affects Redox Regulation, Especially at Mitohormesis and Sarcohormesis Level: Current Perspective

Exercise frequently alters the metabolic processes of oxidative metabolism in athletes, including exposure to extreme reactive oxygen species impairing exercise performance. Therefore, both researchers and athletes have been consistently investigating the possible strategies to improve metabolic adaptations to exercise-induced oxidative stress. N-acetylcysteine (NAC) has been applied as a therapeutic agent in treating many diseases in humans due to its precursory role in the production of hepatic glutathione, a natural antioxidant. Several studies have investigated NAC’s possible therapeutic role in oxidative metabolism and adaptive response to exercise in the athletic population. However, still conflicting questions regarding NAC supplementation need to be clarified. This narrative review aims to re-evaluate the metabolic effects of NAC on exercise-induced oxidative stress and adaptive response developed by athletes against the exercise, especially mitohormetic and sarcohormetic response.

Redox-dependent regulation of satellite cells following aseptic muscle trauma: Implications for sports performance and nutrition

Skeletal muscle satellite cells (SCs) are indispensable for tissue regeneration, remodeling and growth. Following myotrauma, SCs are activated, and assist in tissue repair. Exercise-induced muscle damage (EIMD) is characterized by a pronounced inflammatory response and the production of reactive oxygen species (ROS). Experimental evidence suggests that SCs kinetics (the propagation from a quiescent to an activated/proliferative state) following EIMD is redox-dependent and interconnected with changes in the SCs microenvironment (niche). Animal studies have shown that following aseptic myotrauma, antioxidant and/or anti-inflammatory supplementation leads to an improved recovery and skeletal muscle regeneration through enhanced SCs kinetics, suggesting a redox-dependent molecular mechanism. Although evidence suggests that antioxidant/anti-inflammatory compounds may prevent performance deterioration and enhance recovery, there is lack of information regarding the redox-dependent regulation of SCs responses following EIMD in humans. In this review, SCs kinetics following aseptic myotrauma, as well as the intrinsic redox-sensitive molecular mechanisms responsible for SCs responses are discussed. The role of redox status on SCs function should be further investigated in the future with human clinical trials in an attempt to elucidate the molecular pathways responsible for muscle recovery and provide information for potential nutritional strategies aiming at performance recovery.

The effects of N-Acetylcysteine on serum level of inflammatory biomarkers in adults. Findings from a systematic review and meta-analysis of randomized clinical trials

PURPOSE

Randomized Clinical Trials (RCTs) have provided varied and conflicting findings regarding the effect of N-acetylcysteine (NAC) on inflammatory biomarkers. This study was conducted to review existing literature to determine whether NAC supplementation can affect inflammatory biomarkers in adults.

METHODS

Bibliographic databases of Scopus, and PubMed were used for relevant papers published until October 2019. Results were reported as weighted mean differences (WMD) with 95% confidence intervals (CI) using multi-level models. Cochrane's Q and I-squared (I2) tests were used to determine heterogeneity among studies.

RESULTS

Twenty-four RCTs which include 1057 sample size were entered to analysis. NAC doses and intervention duration ranged from 400 to 2000 mg/d, and 1 to 80 weeks, respectively. Oral supplementation of NAC reduced serum level of C-reactive protein (CRP) [WMD: -0.61 mg/L, 95% CI: -1.18 to -0.03, P = 0.039, I2 = 79.6%], and interleukin-6 (IL-6) [WMD: -0.43 pg/mL, 95% CI: -0.69 to -0.17, P = 0.001, I2 = 89.3%]. However, the effect of oral NAC supplementation on other inflammatory biomarkers was nonsignificant. Dose-response investigation showed a non-linear association between oral NAC supplementation with CRP.

CONCLUSION

Oral NAC supplementation reduced serum level of CRP and IL-6, but did not affect other inflammatory biomarkers. Nevertheless, more RCTs seems to be required to explore how NAC in different dosage and different routes of administration can affect inflammatory biomarkers.

Effects of Dietary Supplements on Adaptations to Endurance Training

Endurance training leads to a variety of adaptations at the cellular and systemic levels that serve to minimise disruptions in whole-body homeostasis caused by exercise. These adaptations are differentially affected by training volume, training intensity, and training status, as well as by nutritional choices that can enhance or impair the response to training. A variety of supplements have been studied in the context of acute performance enhancement, but the effects of continued supplementation concurrent to endurance training programs are less well characterised. For example, supplements such as sodium bicarbonate and beta-alanine can improve endurance performance and possibly training adaptations during endurance training by affecting buffering capacity and/or allowing an increased training intensity, while antioxidants such as vitamin C and vitamin E may impair training adaptations by blunting cellular signalling but appear to have little effect on performance outcomes. Additionally, limited data suggest the potential for dietary nitrate (in the form of beetroot juice), creatine, and possibly caffeine, to further enhance endurance training adaptation. Therefore, the objective of this review is to examine the impact of dietary supplements on metabolic and physiological adaptations to endurance training.

Antioxidant supplements and endurance exercise: Current evidence and mechanistic insights

Antioxidant supplements are commonly consumed by endurance athletes to minimize exercise-induced oxidative stress, with the intention of enhancing recovery and improving performance. There are numerous commercially available nutritional supplements that are targeted to athletes and health enthusiasts that allegedly possess antioxidant properties. However, most of these compounds are poorly investigated with respect to their in vivo redox activity and efficacy in humans. Therefore, this review will firstly provide a background to endurance exercise-related redox signalling and the subsequent adaptations in skeletal muscle and vascular function. The review will then discuss commonly available compounds with purported antioxidant effects for use by athletes. N-acetyl cysteine may be of benefit over the days prior to an endurance event; while chronic intake of combined 1000 mg vitamin C + vitamin E is not recommended during periods of heavy training associated with adaptations in skeletal muscle. Melatonin, vitamin E and α-lipoic acid appear effective at decreasing markers of exercise-induced oxidative stress. However, evidence on their effects on endurance performance are either lacking or not supportive. Catechins, anthocyanins, coenzyme Q10 and vitamin C may improve vascular function, however, evidence is either limited to specific sub-populations and/or does not translate to improved performance. Finally, additional research should clarify the potential benefits of curcumin in improving muscle recovery post intensive exercise; and the potential hampering effects of astaxanthin, selenium and vitamin A on skeletal muscle adaptations to endurance training. Overall, we highlight the lack of supportive evidence for most antioxidant compounds to recommend to athletes.

Nutrition and Altitude: Strategies to Enhance Adaptation, Improve Performance and Maintain Health: A Narrative Review

Training at low to moderate altitudes (~ 1600-2400 m) is a common approach used by endurance athletes to provide a distinctive environmental stressor to augment training stimulus in the anticipation of increasing subsequent altitude- and sea-level-based performance. Despite some scientific progress being made on the impact of various nutrition-related changes in physiology and associated interventions at mountaineering altitudes (> 3000 m), the impact of nutrition and/or supplements on further optimization of these hypoxic adaptations at low-moderate altitudes is only an emerging topic. Within this narrative review we have highlighted six major themes involving nutrition: altered energy availability, iron, carbohydrate, hydration, antioxidant requirements and various performance supplements. Of these issues, emerging data suggest that particular attention be given to the potential risk for poor energy availability and increased iron requirements at the altitudes typical of elite athlete training (~ 1600-2400 m) to interfere with optimal adaptations. Furthermore, the safest way to address the possible increase in oxidative stress associated with altitude exposure is via the consumption of antioxidant-rich foods rather than high-dose antioxidant supplements. Meanwhile, many other important questions regarding nutrition and altitude training remain to be answered. At the elite level of sport where the differences between winning and losing are incredibly small, the strategic use of nutritional interventions to enhance the adaptations to altitude training provides an important consideration in the search for optimal performance.

The redox-dependent regulation of satellite cells following aseptic muscle trauma (SpEED): study protocol for a randomized controlled trial

Background

Muscle satellite cells (SCs) are crucial for muscle regeneration following muscle trauma. Acute skeletal muscle damage results in inflammation and the production of reactive oxygen species (ROS) which may be implicated in SCs activation. Protection of these cells from oxidative damage is essential to ensure sufficient muscle regeneration. The aim of this study is to determine whether SCs activity under conditions of aseptic skeletal muscle trauma induced by exercise is redox-dependent.

Methods/design

Based on the SCs content in their vastus lateralis skeletal muscle, participants will be classified as either high or low respondents. In a randomized, double-blind, crossover, repeated-measures design, participants will then receive either placebo or N-acetylcysteine (alters redox potential in muscle) during a preliminary 7-day loading phase, and for eight consecutive days following a single bout of intense muscle-damaging exercise. In both trials, blood samples and muscle biopsies will be collected, and muscle performance and soreness will be measured at baseline, pre-exercise, 2 and 8 days post exercise. Biological samples will be analyzed for redox status and SCs activity. Between trials, a 4-week washout period will be implemented.

Discussion

This study is designed to investigate the impact of redox status on SCs mobilization and thus skeletal muscle potential for regeneration under conditions of aseptic inflammation induced by exercise. Findings of this trial should provide insight into (1) molecular pathways involved in SCs recruitment and muscle healing under conditions of aseptic skeletal muscle trauma present in numerous catabolic conditions and (2) whether skeletal muscle’s potential for regeneration depends on its basal SCs content.

Trial registration

ClinicalTrials.gov, ID: NCT03711838. Registered on 19 Oct 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3557-3) contains supplementary material, which is available to authorized users.

Impairment between Oxidant and Antioxidant Systems: Short- and Long-term Implications for Athletes' Health

The role of oxidative stress, an imbalance between reactive oxygen species production (ROS) and antioxidants, has been described in several patho-physiological conditions, including cardiovascular, neurological diseases and cancer, thus impacting on individuals' lifelong health. Diet, environmental pollution, and physical activity can play a significant role in the oxidative balance of an organism. Even if physical training has proved to be able to counteract the negative effects caused by free radicals and to provide many health benefits, it is also known that intensive physical activity induces oxidative stress, inflammation, and free radical-mediated muscle damage. Indeed, variations in type, intensity, and duration of exercise training can activate different patterns of oxidant-antioxidant balance leading to different responses in terms of molecular and cellular damage. The aim of the present review is to discuss (1) the role of oxidative status in athletes in relation to exercise training practice, (2) the implications for muscle damage, (3) the long-term effect for neurodegenerative disease manifestations, (4) the role of antioxidant supplementations in preventing oxidative damages.

Redox homeostasis in sport: do athletes really need antioxidant support?

Supplementation with antioxidants received interest as suitable tool for preventing or reducing exercise-related oxidative stress possibly leading to improvement of sport performance in athletes. To date, it is difficult to reach a conclusion on the relevance of antioxidants supplementation in athletes and/or well-trained people. The general picture that emerges from the available data indicates that antioxidants requirement can be covered by dosage equal or close to the recommended dietary allowance (RDA) provided by consumption of a balanced, well-diversified diet. Nevertheless, it remains open the possibility that in specific context, such as in sports characterized by high intensity and/or exhaustive regimes, supplementation with antioxidants could be appropriated to avoid or reduce the damaging effect of these type of exercise. This review will discuss the findings of a number of key studies on the advantages and/or disadvantages for athletes of using antioxidants supplementation, either individually or in combination.

Effects of N-acetylcysteine supplementation on cellular damage and oxidative stress indicators in volleyball athletes

The purpose of this study was to evaluate the effects of N-acetylcysteine (NAC) supplementation on cellular damage and oxidative stress indicators in volleyball athletes. Twenty male volleyball athletes at national level performed a physical training session and were divided into 2 groups, which for 7 days took the placebo substance or NAC. After 7 days the athletes repeated the same training session. In both sessions, blood samples were collected 30 min before and immediately after the training session to measure cellular damage and oxidative stress markers. The main results show that, although higher concentrations of glutathione peroxidase and superoxide dismutase were observed in post-session 1 than those in postsession 2, the other markers showed an increase in antioxidant action after supplementation of NAC, once the effect of experimental conditions (P=0.030) were observed in: time effect (P<0.001) and interaction (P=0.019) for total glutathione; time effect (P<0.001) and interaction (P<0.001) for reduced glutathione; and time effect (P<0.001) for ferric-reducing antioxidant potential. The oxidant action indicated by the protein carbonyl was higher in the placebo group than in the NAC group (P=0.028), but a time effect (P<0.001) for the thiobarbituric acid reactive substances showed lower values in presession 1 than in presession 2. For the cellular damage markers, antagonistic results between markers were found. Based in the results, the supplementation of NAC during a short period was effective in reducing oxidant action and increasing antioxidant action. However, conclusive alterations in the responses of the cellular damage markers were not obtained.

The effect of chronic soluble keratin supplementation in physically active individuals on body composition, blood parameters and cycling performance

Background

Keratins are structural, thiol-rich proteins, which comprise 90% of total poultry feather weight. Their favourable amino acid profile suggests the potential for use as a protein source and ergogenic aid for endurance athletes, following treatment to increase digestibility. This study investigated whether 4 weeks of soluble keratin (KER) consumption (0.8 g/kg bodyweight/day) by 15 endurance-trained males would have favourable effects on body composition, blood and cardiorespiratory variables, and cycling performance, compared to casein protein (CAS).

Methods

Supplementation was randomized, blinded and balanced, with a minimum eight-week washout period between trials. An exercise test to measure oxygen consumption during submaximal and maximal cycling exercise was completed at the start at and end of each intervention. Anthropometric (DEXA) and blood measures were made prior to and following each intervention period.

Results

Total body mass and percentage body fat did not change significantly (p > 0.05). However, a significantly greater increase in bone-free lean mass (LM) occurred with KER compared to CAS (0.88 kg vs 0.07 kg; p < 0.05). While no change in LM was evident for the trunk and arms, leg LM increased (0.45 ± 0.54 kg; p = 0.006) from baseline with KER. KER was not associated with changes in blood parameters, oxygen consumption, or exercise performance (p > 0.05).

Conclusions

These data suggest that KER is not useful as an ergogenic aid for endurance athletes but may be a suitable protein supplement for maximizing increases in lean body mass.

Multiday Pomegranate Extract Supplementation Decreases Oxygen Uptake During Submaximal Cycling Exercise, but Cosupplementation With N-acetylcysteine Negates the Effect

Pomegranate extract (POMx) has been suggested as an ergogenic aid due to its rich concentration of polyphenols, which are proposed to enhance nitric oxide bioavailability, thereby improving the efficiency of oxygen usage and, consequently, endurance exercise performance. Although acute POMx supplementation improves aerobic exercise performance in untrained individuals, trained athletes appear to require chronic supplementation for a similar effect. Furthermore, the combination of POMx with a thiol antioxidant may prove more effective than POMx alone, due to the protective effects of thiols on nitric oxide. Thus, this study hypothesized that multiday POMx supplementation would decrease the oxygen uptake (VO₂) required by trained cyclists to perform submaximal exercise and increase performance during a time trial, and that thiol (N-acetylcysteine [NAC]) cosupplementation would enhance these effects. Eight cyclists completed four 8-day supplementation periods: POMx only, NAC only, POMx + NAC (BOTH), and placebo. Following supplementation, they performed submaximal cycling and a 5-min time trial, with VO₂ and muscle oxygen saturation (SmO₂) being recorded. A three-way (POMx × NAC × Intensity) repeated-measures analysis of variance with a Fisher's least significant difference post hoc assessment was performed for dependent variables (p ≤ .05). VO₂ during submaximal exercise was reduced with POMx versus placebo (-2.6 ml·min^-1·kg^-1, p = .009) and BOTH (-2.5 ml·min^-1·kg^-1, p < .05) and increased with NAC (+1.9 ml·min^-1·kg^-1, p < .03), despite no main effect of treatment on SmO₂ or performance. It appears that POMx's high polyphenol content reduced the VO₂ required during submaximal exercise. However, NAC cosupplementation annulled this effect; thus, NAC may interact with nitric oxide to reduce its bioavailability.

Acute Effect of Oral N-Acetylcysteine on Muscle Soreness and Exercise Performance in Semi-Elite Rugby Players

N-acetylcysteine (NAC) supplementation may enhance performance and reduce soreness from acute, repeated-sprint, high-intensity exercise. Our aim was to investigate whether semi-elite rugby union athletes may benefit. In a randomized block design, 17 semi-elite male rugby players were assigned to receive either 1 g oral NAC (n = 8) or placebo (n = 9) for six days. The mean percentage effect of NAC on exercise performance was assessed through completion of a broken bronco exercise test on days 5 and 6 of supplementation. Players self-reported muscle soreness and tolerability to supplements using a modified Muscle Pain and Treatment Satisfaction Questionnaire throughout the supplement duration. NAC produced a likely beneficial performance effect on maximum shuttle sprint time (2.4%; 90% confidence limit ± 4.8%) but was unclear on total time during back-to-back broken bronco tests compared to placebo. NAC had a likely protective effect on subjective muscle soreness during days 1-4 of supplementation (-19% ± 27%) but a very likely harmful effect on days 5 and 6 of supplementation (71% ± 59%). Daily supplementation with 1 g of oral NAC for six days produced no adverse side effects, reduced muscle soreness after one bout of damaging exercise, but increased soreness following the second bout. The performance effects were generally unclear apart from maximal sprint time.

Performance and Side Effects of Supplementation with N-Acetylcysteine: A Systematic Review and Meta-Analysis

BACKGROUND

N-Acetylcysteine (NAC) is a promising antioxidant supplement with potential as an acute strategy to enhance performance in elite sport, but there are concerns about its side effects with high doses.

OBJECTIVE

To review the current literature and evaluate the effects of NAC supplementation on sport performance and the risk of adverse effects.

METHODS

The literature up to May 2016 was searched on MEDLINE (PubMed), EMBASE, SPORTDiscus, Google Scholar and Scopus databases to identify all studies investigating the effects of NAC supplementation on exercise performance and/or side effects experienced. Performance outcomes from each study were converted to the percent effect equivalent to mean power output in a time trial. All pooled analyses were based on random-effects models generated by Review Manager (RevMan) [Computer program], version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014).

RESULTS

A total of seven studies met criteria for inclusion in the sport performance meta-analysis, and 17 for inclusion in the side effects meta-analysis. The typical daily dose of NAC reported was 5.8 g·d^-1; with a range between 1.2 and 20.0 g·d^-1. The mean increase in performance was 0.29% (95% confidence interval -0.67 to 1.25). The difference in the odds ratio of side effects on NAC compared with placebo was 1.11 (95% confidence interval 0.88-1.39). The sub-analysis of NAC dose suggested an increase in side effects as the dosage of NAC increased; however, this observation requires further investigation.

CONCLUSIONS

Despite initial research publications reporting positive performance effects with NAC, at this stage it cannot be recommended further. The risk of side effects from NAC supplementation also remains unclear owing to significant variations in effects. Suboptimal reporting and documentation in the literature creates difficulties when meta-analysing outcomes and generating conclusions.

Effects of the Usage of l-Cysteine (l-Cys) on Human Health

This review summarizes recent knowledge about the use of the amino acid l-Cysteine (l-Cys) through diet, nutritional supplements or drugs with the aim to improve human health or treat certain diseases. Three databases (PubMed, Scopus, and Web of Science) and different keywords have been used to create a database of documents published between 1950 and 2017 in scientific journals in English or Spanish. A total of 60,885 primary publications were ultimately selected to compile accurate information about the use of l-Cys in medicine and nutritional therapies and to identify the reported benefits of l-Cys on human health. The number of publications about the use of l-Cys for these purposes has increased significantly during the last two decades. This increase seems to be closely related to the rise of nutraceutical industries and personalized medicine. The main evidence reporting benefits of l-Cys usage is summarized. However, the lack of accurate information and studies based on clinical trials hampers consensus among authors. Thus, the debate about the role and effectiveness of supplements/drugs containing l-Cys is still open.

Skeletal muscle signaling, metabolism, and performance during sprint exercise in severe acute hypoxia after the ingestion of antioxidants

The aim of this study was to determine if reactive oxygen species (ROS) could play a role in blunting Thr¹⁷²-AMP-activated protein kinase (AMPK)-α phosphorylation in human skeletal muscle after sprint exercise in hypoxia and to elucidate the potential signaling mechanisms responsible for this response. Nine volunteers performed a single 30-s sprint (Wingate test) in two occasions while breathing hypoxic gas ([Formula: see text] = 75 mmHg): one after the ingestion of placebo and another following the intake of antioxidants (α-lipoic acid, vitamin C, and vitamin E), with a randomized double-blind design. Vastus lateralis muscle biopsies were obtained before, immediately after, and 30- and 120-min postsprint. Compared with the control condition, the ingestion of antioxidants resulted in lower plasma carbonylated proteins, attenuated elevation of the AMP-to-ATP molar ratio, and reduced glycolytic rate (P < 0.05) without significant effects on performance or V̇o₂ The ingestion of antioxidants did not alter the basal muscle signaling. Thr¹⁷²-AMPKα and Thr^184/187-transforming growth factor-β-activated kinase 1 (TAK1) phosphorylation were not increased after the sprint regardless of the ingestion of antioxidants. Thr²⁸⁶-CaMKII phosphorylation was increased after the sprint, but this response was blunted by the antioxidants. Ser⁴⁸⁵-AMPKα1/Ser⁴⁹¹-AMPKα2 phosphorylation increased immediately after the sprints coincident with increased Akt phosphorylation. In summary, antioxidants attenuate the glycolytic response to sprint exercise in severe acute hypoxia and modify the muscle signaling response to exercise. Ser⁴⁸⁵-AMPKα1/Ser⁴⁹¹-AMPKα2 phosphorylation, a known mechanism of Thr¹⁷²-AMPKα phosphorylation inhibition, is increased immediately after sprint exercise in hypoxia, probably by a mechanism independent of ROS.NEW & NOTEWORTHY The glycolytic rate is increased during sprint exercise in severe acute hypoxia. This study showed that the ingestion of antioxidants before sprint exercise in severe acute hypoxia reduced the glycolytic rate and attenuated the increases of the AMP-to-ATP and the reduction of the NAD⁺-to-NADH.H⁺ ratios. This resulted in a modified muscle signaling response with a blunted Thr²⁸⁶-CaMKII but similar AMP-activated protein kinase phosphorylation responses in the sprints preceded by the ingestion of antioxidants.

Caffeine and Bicarbonate for Speed. A Meta-Analysis of Legal Supplements Potential for Improving Intense Endurance Exercise Performance

A 1% change in average speed is enough to affect medal rankings in intense Olympic endurance events lasting ~45 s to 8 min which for example includes 100 m swimming and 400 m running (~1 min), 1,500 m running and 4000 m track cycling (~4 min) and 2,000 m rowing (~6-8 min). To maximize the likelihood of winning, athletes utilizes legal supplements with or without scientifically documented beneficial effects on performance. Therefore, a continued systematic evidence based evaluation of the possible ergogenic effects is of high importance. A meta-analysis was conducted with a strict focus on closed-end performance tests in humans in the time domain from 45 s to 8 min. These test include time-trials or total work done in a given time. This selection criterion results in a high relevance for athletic performance. Only peer-reviewed placebo controlled studies were included. The often applied and potentially ergogenic supplements beta-alanine, bicarbonate, caffeine and nitrate were selected for analysis. Following a systematic search in Pubmed and SportsDiscuss combined with evaluation of cross references a total of 7 (beta-alanine), 25 (bicarbonate), 9 (caffeine), and 5 (nitrate) studies was included in the meta-analysis. For each study, performance was converted to an average speed (km/h) from which an effect size (ES; Cohens d with 95% confidence intervals) was calculated. A small effect and significant performance improvement relative to placebo was observed for caffeine (ES: 0.41 [0.15–0.68], P = 0.002) and bicarbonate (ES: 0.40 [0.27–0.54], P < 0.001). Trivial and non-significant effects on performance was observed for nitrate (ES: 0.19 [−0.03–0.40], P = 0.09) and beta-alanine (ES: 0.17 [−0.12–0.46], P = 0.24). Thus, caffeine's and bicarbonate's ergogenic effect is clearly documented for intense endurance performance. Importantly, for all supplements an individualized approach may improve the ergogenic effect on performance.

Dietary thiols in exercise: oxidative stress defence, exercise performance, and adaptation

Endurance athletes are susceptible to cellular damage initiated by excessive levels of aerobic exercise-produced reactive oxygen species (ROS). Whilst ROS can contribute to the onset of fatigue, there is increasing evidence that they play a crucial role in exercise adaptations. The use of antioxidant supplements such as vitamin C and E in athletes is common; however, their ability to enhance performance and facilitate recovery is controversial, with many studies suggesting a blunting of training adaptations with supplementation. The up-regulation of endogenous antioxidant systems brought about by exercise training allows for greater tolerance to subsequent ROS, thus, athletes may benefit from increasing these systems through dietary thiol donors. Recent work has shown supplementation with a cysteine donor (N-acetylcysteine; NAC) improves antioxidant capacity by augmenting glutathione levels and reducing markers of oxidative stress, as well as ergogenic potential through association with delayed fatigue in numerous experimental models. However, the use of this, and other thiol donors may have adverse physiological effects. A recent discovery for the use of a thiol donor food source, keratin, to potentially enhance endogenous antioxidants may have important implications for endurance athletes hoping to enhance performance and recovery without blunting training adaptations.

Redox interventions to increase exercise performance

Skeletal muscle continually produces reactive oxygen species (ROS) and nitric oxide (NO) derivatives. Both oxidant cascades have complex effects on muscle contraction, metabolic function and tissue perfusion. Strenuous exercise increases oxidant production by muscle, limiting performance during endurance exercise tasks. Conversely, redox interventions that modulate ROS or NO activity have the potential to improve performance. Antioxidants have long been known to buffer ROS activity and lessen oxidative perturbations during exercise. The capacity to enhance human performance varies among antioxidant categories. Vitamins, provitamins and nutriceuticals often blunt oxidative changes at the biochemical level but do not enhance performance. In contrast, reduced thiol donors have been shown to delay fatigue or increase endurance under a variety of experimental conditions. Dietary nitrate supplementation has recently emerged as a second redox strategy for increasing endurance. Purified nitrate salts and nitrate-rich foods, notably beetroot and beetroot juice, are reported to lessen the oxygen cost of exercise, increase efficiency, and enhance performance during endurance tasks. These findings are exciting but enigmatic since nitrate per se has little bioactivity and cannot be converted to NO by mammalian cells. Overall, the available data suggest exercise endurance can be augmented by redox-active supplements, either reduced thiol donors or dietary nitrates. These findings have clear implications for athletes seeking a competitive edge. More importantly, interventions that increase endurance may benefit individuals whose physical activity is limited by illness, ageing, or frailty.

Acute supplementation of N-acetylcysteine does not affect muscle blood flow and oxygenation characteristics during handgrip exercise

N‐acetylcysteine (NAC; antioxidant and thiol donor) supplementation has improved exercise performance and delayed fatigue, but the underlying mechanisms are unknown. One possibility is NAC supplementation increases limb blood flow during severe‐intensity exercise. The purpose was to determine if NAC supplementation affected exercising arm blood flow and muscle oxygenation characteristics. We hypothesized that NAC would lead to higher limb blood flow and lower muscle deoxygenation characteristics during severe‐intensity exercise. Eight healthy nonendurance trained men (21.8 ± 1.2 years) were recruited and completed two constant power handgrip exercise tests at 80% peak power until exhaustion. Subjects orally consumed either placebo (PLA) or NAC (70 mg/kg) 60 min prior to handgrip exercise. Immediately prior to exercise, venous blood samples were collected for determination of plasma redox balance. Brachial artery blood flow (BABF) was measured via Doppler ultrasound and flexor digitorum superficialis oxygenation characteristics were measured via near‐infrared spectroscopy. Following NAC supplementaiton, plasma cysteine (NAC: 47.2 ± 20.3 μmol/L vs. PLA: 9.6 ± 1.2 μmol/L; P = 0.001) and total cysteine (NAC: 156.2 ± 33.9 μmol/L vs. PLA: 132.2 ± 16.3 μmol/L; P = 0.048) increased. Time to exhaustion was not significantly different (P = 0.55) between NAC (473.0 ± 62.1 sec) and PLA (438.7 ± 58.1 sec). Resting BABF was not different (P = 0.79) with NAC (99.3 ± 31.1 mL/min) and PLA (108.3 ± 46.0 mL/min). BABF was not different (P = 0.42) during exercise or at end‐exercise (NAC: 413 ± 109 mL/min; PLA: 445 ± 147 mL/min). Deoxy‐[hemoglobin+myoglobin] and total‐[hemoglobin+myoglobin] were not significantly different (P = 0.73 and P = 0.54, respectively) at rest or during exercise between conditions. We conclude that acute NAC supplementation does not alter oxygen delivery during exercise in men.

Muscle redox signalling pathways in exercise. Role of antioxidants

Recent research highlights the importance of redox signalling pathway activation by contraction-induced reactive oxygen species (ROS) and nitric oxide (NO) in normal exercise-related cellular and molecular adaptations in skeletal muscle. In this review, we discuss some potentially important redox signalling pathways in skeletal muscle that are involved in acute and chronic responses to contraction and exercise. Specifically, we discuss redox signalling implicated in skeletal muscle contraction force, mitochondrial biogenesis and antioxidant enzyme induction, glucose uptake and muscle hypertrophy. Furthermore, we review evidence investigating the impact of major exogenous antioxidants on these acute and chronic responses to exercise. Redox signalling pathways involved in adaptive responses in skeletal muscle to exercise are not clearly elucidated at present, and further research is required to better define important signalling pathways involved. Evidence of beneficial or detrimental effects of specific antioxidant compounds on exercise adaptations in muscle is similarly limited, particularly in human subjects. Future research is required to not only investigate effects of specific antioxidant compounds on skeletal muscle exercise adaptations, but also to better establish mechanisms of action of specific antioxidants in vivo. Although we feel it remains somewhat premature to make clear recommendations in relation to application of specific antioxidant compounds in different exercise settings, a bulk of evidence suggests that N-acetylcysteine (NAC) is ergogenic through its effects on maintenance of muscle force production during sustained fatiguing events. Nevertheless, a current lack of evidence from studies using performance tests representative of athletic competition and a potential for adverse effects with high doses (>70mg/kg body mass) warrants caution in its use for performance enhancement. In addition, evidence implicates high dose vitamin C (1g/day) and E (≥260 IU/day) supplementation in impairments to some skeletal muscle cellular adaptations to chronic exercise training. Thus, determining the utility of antioxidant supplementation in athletes likely requires a consideration of training and competition periodization cycles of athletes in addition to type, dose and duration of antioxidant supplementation.

The Effect of Protandim® Supplementation on Athletic Performance and Oxidative Blood Markers in Runners

The purpose of this study determined if oral supplementation of Protandim® (a nutraceutical) for 90 days improved 5-km running performance and reduced serum thiobarbituric acid-reacting substances (TBARS) at rest, an indicator of oxidative stress. Secondary objectives were to measure whole blood superoxide dismutase (SOD), glutathione (GSH), and glutathione peroxidase (GPX), at rest and 10 minutes after completion of the race before and after supplementation as well as quality of life. In a double-blind, randomized, placebo controlled trial, 38 runners [mean (SD) = 34 (7) yrs; BMI = 22 (2) kg/m2] received either 90 days of Protandim® [1 pill a day, n = 19)] or placebo (n = 19). Randomization was done in blocks of two controlling for sex and 5-km baseline performance. A 5-km race was performed at baseline and after 90 days of supplementation, with blood samples taken before and 10-min after each race. Fasting blood samples were acquired at baseline, after 30, 60, and 90 days of supplementation. TBARS, SOD, GPX, and GSH were assayed in an out-of-state accredited lab. Running performance was not altered by Protandim® or placebo [20.3 (2.1) minutes, with an -8 (33) seconds change in 5-km time regardless of group]. There was no change in TBARS, SOD, or GPX (at rest) after three months of Protandim® supplementation compared to placebo. However, in a subgroup ≥ 35 years of age, there was a 2-fold higher increase in SOD in those taking Protandim® for three months compared to those on placebo (p = 0.038). The mean post-race change in TBARS (compared to pre-race) increased by about 20% in half of the subjects, but was not altered between groups, even after three months of supplementation. Quality of life was also not different between the two conditions. In conclusion, Protandim® did not (1) alter 5-km running time, (2) lower TBARS at rest (3) raise antioxidant enzyme concentrations compared to placebo (with exception of SOD in those ≥ 35 years old) or, (4) affect quality of life compared to placebo.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02172625.

Redox modulation of mitochondriogenesis in exercise. Does antioxidant supplementation blunt the benefits of exercise training?

Physical exercise increases the cellular production of reactive oxygen species (ROS) in muscle, liver, and other organs. This is unlikely due to increased mitochondrial production but rather to extramitochondrial sources such as NADPH oxidase or xanthine oxidase. We have reported a xanthine oxidase-mediated increase in ROS production in many experimental models from isolated cells to humans. Originally, ROS were considered as detrimental and thus as a likely cause of cell damage associated with exhaustion. In the past decade, evidence showing that ROS act as signals has been gathered and thus the idea that antioxidant supplementation in exercise is always recommendable has proved incorrect. In fact, we proposed that exercise itself can be considered as an antioxidant because training increases the expression of classical antioxidant enzymes such as superoxide dismutase and glutathione peroxidase and, in general, lowering the endogenous antioxidant enzymes by administration of antioxidant supplements may not be a good strategy when training. Antioxidant enzymes are not the only ones to be activated by training. Mitochondriogenesis is an important process activated in exercise. Many redox-sensitive enzymes are involved in this process. Important signaling molecules like MAP kinases, NF-κB, PGC-1α, p53, heat shock factor, and others modulate muscle adaptation to exercise. Interventions aimed at modifying the production of ROS in exercise must be performed with care as they may be detrimental in that they may lower useful adaptations to exercise.

Potential molecular mechanisms underlying muscle fatigue mediated by reactive oxygen and nitrogen species

Intense contractile activity causes a dramatic decline in the force and velocity generating capacity of skeletal muscle within a few minutes, a phenomenon that characterizes fatigue. Much of the research effort has focused on how elevated levels of the metabolites of ATP hydrolysis might inhibit the function of the contractile proteins. However, there is now growing evidence that elevated levels of reactive oxygen and nitrogen species (ROS/RNS), which also accumulate in the myoplasm during fatigue, also play a causative role in this type of fatigue. The most compelling evidence comes from observations demonstrating that pre-treatment of intact muscle with a ROS scavenger can significantly attenuate the development of fatigue. A clear advantage of this line of inquiry is that the molecular targets and protein modifications of some of the ROS scavengers are well-characterized enabling researchers to begin to identify potential regions and even specific amino acid residues modified during fatigue. Combining this knowledge with assessments of contractile properties from the whole muscle level down to the dynamic motions within specific contractile proteins enable the linking of the structural modifications to the functional impacts, using advanced chemical and biophysical techniques. Based on this approach at least two areas are beginning emerge as potentially important sites, the regulatory protein troponin and the actin binding region of myosin. This review highlights some of these recent efforts which have the potential to offer uniquely precise information on the underlying molecular basis of fatigue. This work may also have implications beyond muscle fatigue as ROS/RNS mediated protein modifications are also thought to play a role in the loss of muscle function with aging and in some acute pathologies like cardiac arrest and ischemia.

Effects of vitamin D and quercetin, alone and in combination, on cardiorespiratory fitness and muscle function in physically active male adults

Introduction

Vitamin D and the antioxidant quercetin, are promising agents for improving physical performance because of their possible beneficial effects on muscular strength and cardiorespiratory fitness.

Purpose

The purpose of this study was to determine the effects of increased intakes of vitamin D, quercetin, and their combination on antioxidant status, the steroid hormone regulators of muscle function, and measures of physical performance in apparently healthy male adults engaged in moderate-to-vigorous-intensity exercise training.

Methods

A total of 40 adult male participants were randomized to either 4,000 IU vitamin D/d, 1,000 mg/d quercetin, vitamin D plus quercetin, or placebo for 8 weeks. Measures of cardiorespiratory fitness and muscle function, blood markers for antioxidant and vitamin D status, and hormones 1,25-dihydroxyvitamin D₃ (1,25(OH)₂D₃) and testosterone were measured pre- and postsupplementation.

Results

At enrollment, 88.6% of participants were vitamin D sufficient (serum 25-hydroxyvitamin D >50 nmol/L) and had normal serum testosterone levels. Supplementation with vitamin D significantly increased serum 25(OH)D concentration (by 87.3% in the vitamin D group, P<0.001) and was associated with an increasing trend of testosterone concentration. There were no changes in concentration of 1,25(OH)₂D₃ and markers of antioxidant status associated with vitamin D or quercetin supplementation. No improvements in physical performance measures associated with vitamin D and quercetin supplementation were found.

Conclusion

The findings obtained demonstrate that long-term vitamin D and quercetin supplementation, alone or in combination, does not improve physical performance in male adults with adequate vitamin D, testosterone, and antioxidant status.

Effects of oral N-acetylcysteine on walking capacity, leg reactive hyperemia, and inflammatory and angiogenic mediators in patients with intermittent claudication

Increased oxidative stress and inflammation contribute to impaired walking capacity and endothelial dysfunction in patients with intermittent claudication (IC). The goal of the study was to determine the effects of oral treatment with the antioxidant N-acetylcysteine (NAC) on walking capacity, leg postocclusive reactive hyperemia, circulating levels of inflammatory mediators, and whole blood expression of angiogenic mediators in patients with IC. Following a double-blinded randomized crossover design, 10 patients with IC received NAC (1,800 mg/day for 4 days plus 2,700 mg before the experimental session) and placebo (PLA) before undergoing a graded treadmill exercise test. Leg postocclusive reactive hyperemia was assessed before and after the test. Blood samples were taken before and after NAC or PLA ingestions and 5 and 30 min after the exercise test for the analysis of circulating inflammatory and angiogenic markers. Although NAC increased the plasma ratio of reduced to oxidized glutathione, there were no differences between experimental sessions for walking tolerance and postocclusive reactive hyperemia. Plasma concentrations of soluble vascular cell adhesion protein-1, monocyte chemotactic protein-1, and endothelin-1 increased similarly following maximal exercise after PLA and NAC (P < 0.001). Whole blood expression of pro-angiogenic microRNA-126 increased after maximal exercise in the PLA session, but treatment with NAC prevented this response. Similarly, exercise-induced changes in whole blood expression of VEGF, endothelial nitric oxide synthase and phosphatidylinositol 3-kinase R2 were blunted after NAC. In conclusion, oral NAC does not increase walking tolerance or leg blood flow in patients with IC. In addition, oral NAC prevents maximal exercise-induced increase in the expression of circulating microRNA-126 and other angiogenic mediators in patients with IC.