XP-828L in the Treatment of Mild to Moderate Psoriasis: Randomized, Double-Blind, Placebo-Controlled Study

Background:

XP-828L, a protein extract obtained from sweet whey, has demonstrated potential benefit for the treatment of mild to moderate psoriasis in an open-label study.

Objective:

To study in a randomized, double-blind, placebo-controlled study the safety and efficacy of XP-828L in the treatment of mild to moderate psoriasis.

Design:

XP-828L 5 g/d (group A, n = 42) or placebo (group B, n = 42) was given orally for 56 days followed by XP-828L 5 g/d in group A and by XP-828L 10 g/d in group B for an additional 56 days.

Results:

Patients receiving XP-828L 5 g/d for 56 days had an improved Physician's Global Assessment (PGA) score compared with patients under placebo ( p < .05). Considering the data of group A only, the PGA score improved from day 1 to day 56 ( p < .01); the Psoriasis Area and Severity Index score improved as well, but to a lesser extent ( p < .05).

Conclusion:

Oral administration of 5 g/d XP-828L compared with a placebo significantly improved the PGA score of patients with mild to moderate psoriasis.

A double-blind, placebo-controlled, randomized trial of XP-828L (800 mg) on the quality of life and clinical symptoms of patients with mild-to-moderate psoriasis

In a placebo-controlled clinical trial, the dietary supplement XP-828L (commercialized as Dermylex) demonstrated potential to reduce symptoms associated with mild-to-moderate psoriasis at a dose regimen of 5 g daily for 56 days. However, recent in vivo data in humans and animals suggest a daily dose of 800 mg could be more efficient than a 5-g dose. However, no well-structured clinical study has confirmed this hypothesis. The goal of the present study is to examine the effect of XP-828L at a daily dose of 800 mg on the quality of life and disease severity in patients with mild-to-moderate psoriasis. XP-828L at 800 mg per day (n=16) or placebo (n=10) was given orally for 56 days. Efficacy was measured by the Dermatology Life Quality Index (DLQI), Psoriasis Area and Severity Index (PASI), and itching sensation scores at day 1 and day 56. The DLQI and PASI scores and itching sensation decreased significantly by day 56 in subjects taking XP-828L compared to placebo (p less than 0.05). In summary, daily administration of 800 mg XP-828L for 56 days is adequate to improve the quality of life and decrease disease severity in patients with mild-to-moderate psoriasis.

XP-828L in the treatment of mild to moderate psoriasis: randomized, double-blind, placebo-controlled study

BACKGROUND

XP-828L, a protein extract obtained from sweet whey, has demonstrated potential benefit for the treatment of mild to moderate psoriasis in an open-label study.

OBJECTIVE

To study in a randomized, double-blind, placebo-controlled study the safety and efficacy of XP-828L in the treatment of mild to moderate psoriasis.

DESIGN

XP-828L 5 g/d (group A, n=42) or placebo (group B, n=42) was given orally for 56 days followed by XP-828L 5 g/d in group A and by XP-828L 10 g/d in group B for an additional 56 days.

RESULTS

Patients receiving XP-828L 5 g/d for 56 days had an improved Physician's Global Assessment (PGA) score compared with patients under placebo (p less than 0.05). Considering the data of group A only, the PGA score improved from day 1 to day 56 (p less than 0.01); the Psoriasis Area and Severity Index score improved as well, but to a lesser extent (p less than 0.05).

CONCLUSION

Oral administration of 5 g/d XP-828L compared with a placebo significantly improved the PGA score of patients with mild to moderate psoriasis.

XP-828L (Dermylex), a new whey protein extract with potential benefit for mild to moderate psoriasisThis article is one of a selection of papers published in this special issue (part 1 of 2) on the Safety and Efficacy of Natural Health Products

Natural health products (NHPs) or complementary and alternative medicine (CAM) are commonly used to prevent disorders or support the usual treatments of many diseases. XP-828L, a whey protein extract, has demonstrated potential benefits for the treatment of mild to moderate psoriasis. The aim of this study was to analyze further clinical data that demonstrated the clinical benefits and safety of the XP-828L in patients with psoriasis and the potential mechanism of action of this product in vitro. Oral administration (2.5 g, twice a day, over 112 days) of XP-828L in 42 human subjects with mild to moderate psoriasis improved their PGA scores (physician’s global assessment). Moreover, no significant changes in haematology or hepatic and renal parameters were observed throughout the study period, indicating the safety of the product. In vitro experiments showed that XP-828L decreased the proliferation of concanavalin A (ConA)-stimulated murine splenocytes and their production of interleukin (IL)-2 and interferon (IFN)-γ. Although the in vivo mechanism of action of XP-828L remains unknown, XP-828L represents an NHP to be used as an alternative or concomitant treatment for mild to moderate psoriasis and potentially for other immune-mediated diseases.

Antiangiogenic properties of a novel shark cartilage extract: potential role in the treatment of psoriasis

BACKGROUND

A number of inflammatory and immune diseases are associated with vascular changes. Psoriasis, as an example, is a common inflammatory skin disease with dilation of capillaries as an early histological change. In more developed psoriatic lesions there is proliferation of blood vessels and neovascularization. The use of agents that target these vascular changes represents a novel therapeutic strategy in the treatment of inflammatory diseases. Since cartilage is an avascular tissue, it has been hypothesized that there may be factors found in cartilage that inhibit blood vessel formation.

OBJECTIVE

The objectives of this study were 1) to determine whether extracts of cartilage could inhibit angiogenesis, and 2) since altered angiogenesis is associated with certain diseases, including psoriasis, to examine whether inhibition of angiogenesis could potentially contribute to the treatment of psoriasis.

METHODS

Extracts of shark cartilage were prepared by homogenization and ultrafiltration to derive the active agent termed AE -941. This agent was tested for antiangiogenesis activity using the embryonic vascularization test, which is a modification of the ex vivo chick embryo culture (CAM). Since one of the first steps in angiogenesis is degradation by metalloproteinases of the basement membrane of capillaries, AE -941 was tested for collagenase activity using a fluorogenic peptide substrate. Anti-inflammatory properties were tested using a cutaneous irritation model in humans.

RESULTS

A dose dependent inhibition in embryonic neovascularization as well as in collagenase activity by AE -941 was demonstrated. When test compounds were applied on the forearms of test subjects, AE -941 was shown to have anti-inflammatory properties. Anecdotal data suggested that topical AE -941 had a beneficial effect in psoriasis.

CONCLUSION

Our results show that AE -941 has anti-angiogenic and anti-inflammatory properties. Antiangiogenesis agents such as AE -941 provide an entirely new class of agents to treat cutaneous and systemic diseases associated with altered vascularity.

Ontogenesis of 3 beta-hydroxysteroid dehydrogenase delta 5-delta 4 isomerase in the rat ovary as studied by immunocytochemistry and in situ hybridization

The enzyme complex 3 beta-hydroxy-5-ene-steroid dehydrogenase and steroid 5-4-ene isomerase (3 beta-HSD) is involved in the biosynthesis of all classes of active steroids, namely glucocorticoids, mineralocorticoids, and sex steroids. To obtain more information about the age-specific expression and localization of 3 beta-HSD during development in the rat ovary, two complementary cytochemical techniques were used, immunocytochemical localization with antibodies against purified human placental 3 beta-HSD, and 3 beta-HSD mRNA localization achieved by in situ hybridization with a [35S]-labeled cDNA encoding 3 beta-HSD. In the fetal ovary, no significant immunolabeling or hybridization signal could be observed. The first expression of the enzyme was observed 6 days after birth, immunolabeling as well as autoradiographic reaction being found in a few interstitial gland cells. At the 10th day of postnatal life, the theca interna cells of growing follicles appeared to be labeled with both techniques. The granulosa cells of growing follicles also exhibited hybridization signal, whereas no immunostaining could be detected in these cells at any of the time intervals studied. At puberty, 3 beta-HSD was localized in theca interna and granulosa cells of the growing and mature follicles as well as in the interstitial gland and corpus luteum cells. Similar results were obtained in 40-day-old and adult animals. The present data indicate a progressive expression of 3 beta-HSD in different morphological structures during ovarian development in the rat.

Myocardial beta-adrenergic and mechanical properties in pacing-induced heart failure in dogs

Forty-eight dogs had pacing overdrive at 250 beats/min for 4-6 wk until heart failure developed. Myocardium from pacing dogs had a decrease in tension and maximum unloaded velocity of shortening (Vmax). Pacing dogs had an increase in circulating catecholamines during exercise but a lower maximal heart rate (214 +/- 19 vs. 241 +/- 26 beats/min, P less than 0.05). A blunted chronotropic response to isoproterenol was also found. However, despite a decrease in beta-adrenergic receptor density (80 +/- 14 vs. 122 +/- 14 fmol/mg, P less than 0.001) and a decrease in beta-adrenergic signal transduction [isoproterenol-induced adenosine 3',5'-cyclic monophosphate (cAMP) production 230 +/- 45 vs. 339 +/- 64 pmol.mg-1.min-1, P less than 0.001], Vmax normalized in response to isoproterenol in pacing dogs (2.3 +/- 0.6 vs. 2.2 +/- 0.5 Lmax/s, NS, where Lmax is length at which maximum developed tension occurs). Tension did not normalize (8 +/- 2 vs. 12 +/- 2 g/mm2, P less than 0.001). Thus in this model of heart failure, despite widespread evidence of decreased beta-adrenergic signal transduction, indexes of shortening but not force generation normalize in response to isoproterenol.

Dysfunction of the beta- and alpha-adrenergic systems in a model of congestive heart failure. The pacing-overdrive dog

The functional integrity of the beta- and alpha-adrenergic stimulatory pathways in a rapid ventricular pacing model of congestive heart failure in dogs was investigated; normal dogs served as controls. Total beta-adrenergic receptor density was 35% lower (p less than 0.01) in the pacing-overdrive dogs, and the beta-adrenergic receptor-mediated stimulation of adenylate cyclase (Vmax) was found to be 68% and 72% lower (p less than 0.01) in the left and right ventricles of the paced dogs. In addition, the basal adenylate cyclase activity was found to be 56% and 68% lower (p less than 0.01) in the left and right ventricles of the failing heart. Similarly, the Vmax of 5'-guanylylimidodiphosphate (GppNHp) and forskolin stimulation of adenylate cyclase activity was significantly lower, 70% and 55%, respectively (p less than 0.01), in both ventricles of the paced dogs. However, although the concentration yielding half-maximal velocity for beta-agonist and GppNHp stimulation of adenylate cyclase was similar in both groups, that for forskolin stimulation of the enzyme was significantly increased (p less than 0.01). Pertussis toxin-mediated ADP-ribosylation of membranes from control and failing hearts revealed a significant decrease in the inhibitory guanine nucleotide binding protein content (48 +/- 9%, p less than 0.01) in the hearts of the paced dogs. Moreover, although the pertussis toxin treatment increased the basal and the forskolin-stimulated adenylate cyclase activity in both normal and failing heart membranes, the adenylate cyclase activity remained significantly depressed in the failing heart after pertussis toxin treatment (p less than 0.01). Consistent with the depressed adenylate cyclase activity, mechanical studies on isolated papillary muscles and trabeculae revealed a decrease in baseline total tension (from 7.0 +/- 0.7 to 3.8 +/- 0.4 g/mm2, p less than 0.01) and dT/dt (from 26 +/- 8 to 13 +/- 1 g/mm2/sec, p less than 0.01) in the pacing-overdrive model. Tension generation and dT/dt observed in the paced dogs in response to increasing concentrations of forskolin demonstrated a rightward shift in the dose-response curve and a decrease in maximal forskolin stimulation (p less than 0.01). Similarly, maximal tension and dT/dt in the presence of isoproterenol was significantly lower than in the normal dogs (p less than 0.01). The decrease in beta-adrenergic responsiveness was accompanied by a decrease and rightward shift in alpha 1-adrenergic responsiveness (increase in tension was 1.1 +/- 0.1 g/mm2 in paced dogs versus 2.1 +/- 0.1 g/mm2 in controls, p less than 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of taurine depletion on intrinsic contractility of rat ventricular papillary muscles

Contractile parameters in Krebs-Henseleit media containing various calcium concentrations were compared in left ventricular papillary muscles of two groups of rats: control and taurine depleted. All tests were carried out with the muscles at initial length, Lmax, the length that produced maximal active tension. From measurements of after- and un-loaded contractions, the velocity-tension curves and the derived maximum velocity of shortening were not different between the groups. Time to peak shortening and extent of shortening were not altered, while relaxation times and contraction duration were significantly prolonged for taurine-depleted muscles. Peak isometric tension and its rate of development were significantly reduced in taurine-depleted muscles compared with controls. Postrest (3 min) stimuli and paired stimuli (200-ms interval) evoked similar potentiated contractile responses in both groups, such that the ratio of their peak tensions remained unchanged. For taurine-depleted muscles the force-frequency relationship (a negative staircase) was parallel to, but lower than, control. These experiments suggest that taurine deficiency leads to reductions in action potential triggered calcium release from internal stores, and deficits in calcium sequestration. This may result from disfacilitation of calcium binding to the sarcoplasmic reticulum and other storage sites during taurine deficiency.

Functional and morphological characteristics of compensated and decompensated cardiac hypertrophy in dogs with chronic infrarenal aorto-caval fistulas

The relation between cardiac hypertrophy, shunt size, myocardial contractility, capillary density, adrenergic responsiveness, and neurohumoral stimulation was evaluated in dogs with compensated and decompensated cardiac hypertrophy caused by an infrarenal aorto-caval shunt. Shunt size varied from 5 to 35 mm2 due to an inability to create a uniform size. Dogs that developed heart failure within 4 months had 25 +/- 2 mm2 shunts, whereas those that developed it after 4 months had 19 +/- 3 mm2 shunts; those that did not develop heart failure had 10 +/- 1 mm2 shunts. Hypertrophy developed at the same rate in all the dogs that developed heart failure, which occurred at a critical heart weight (hypertrophy) for a given load (shunt size). In the dogs with heart failure there was a decrease in myocardial contractility (tension = 5.7 +/- 0.6 vs. 7.3 +/- 0.3 g/mm2, p less than 0.05), a decrease in adrenergic responsiveness (maximal heart rate with isoproterenol = 203 +/- 7 vs. 249 +/- 5 beats/min, p less than 0.01), an increase in circulating neurohormones, and a decrease in urinary sodium excretion (0.4 +/- 0.1 vs. 5.0 +/- 1.3 meq/3 hr, p less than 0.01). None of these abnormalities occurred in dogs with compensated hypertrophy. There were no differences in cardiac capillary density between the control dogs and the dogs with compensated cardiac hypertrophy or heart failure. Thus, it would appear that if heart failure is to develop after an initial toleration of a sudden volume overload, it will develop at a given combination of cardiac hypertrophy and volume overload, with cardiac hypertrophy developing at the same rate in all cases. In this model, once heart failure develops, myocardial contractility and cardiac adrenergic responsiveness are decreased and there is pronounced neurohumoral activation. All these changes are absent in hearts with compensated hypertrophy.

Use of norepinephrine uptake to measure lung capillary recruitment with exercise

We used the multiple indicator-dilution technique with norepinephrine, a vascular endothelium surface marker, to study the pulmonary vascular changes in awake exercising dogs. The vascular space tracers, labeled erythrocytes and albumin, and a water space tracer, 1,8-octanediol, were injected with the norepinephrine, and right atrium-aortic root dilution curves were obtained in nine dogs, at rest and at two increasing levels of exercise. Extravascular lung water multiple tracer dilutional estimates increased with flow and rapidly approached a maximal asymptotic value representing 75% of the postmortem lung weight. The ratio of the extravascular lung water measured in this way to that measured gravimetrically also increased, to reach an asymptotic proportion of close to 100%. The transit time-defined central vascular space increased linearly with flow; the ratio of lung tissue space to lung vascular space, therefore, decreased with increasing flow. The mean tracer upslope norepinephrine extractions at rest and at the two levels of exercise were 17 +/- 1.2, 14 +/- 0.8, and 15 +/- 0.8% (SE). With the use of the Crone approximation, we computed permeability-surface area products for norepinephrine; these increased linearly with flow. If permeability does not change, the increase in the permeability-surface area product with flow can be attributed to capillary recruitment. We conclude that when all lung tissue has become accessible to 1,8-octanediol delivered via the perfused vascular space, there is nevertheless further recruitment, with increase in flow, of vascular surface that can extract norepinephrine.

The use of angiotensin-converting enzyme inhibitors in congestive heart failure

The development of angiotensin-converting enzyme (ACE) inhibitors has been important in furthering our understanding of the pathophysiology of congestive heart failure and improving the care of these patients. ACE inhibitors have been shown to improve the longevity and quality of life of patients with congestive heart failure. They decrease neurohumoral over-activation, they restore baroreceptor reactivity, and in many cases they increase sodium and water excretion. If hypovolemia and an excessive decrease in renal perfusion pressure can be avoided, ACE inhibitors generally do not cause a deterioration of renal function and may even improve it. By decreasing myocardial metabolic demand, ACE inhibitors appear to have generally beneficial effects on myocardial metabolic balance. At low perfusion pressures, they also appear to maintain cerebral blood flow.

Long-term predictors of sudden and low output death in chronic congestive heart failure secondary to coronary artery disease

Clinical, hemodynamic and neurohumoral variables in 238 patients with chronic congestive heart failure (CHF) secondary to coronary artery disease were analyzed to determine potential predictors of mortality in a large population and to allow analysis according to mode of death (sudden or low output death). All variables were assessed before initiation of treatment with vasodilators (converting enzyme inhibitors, direct acting vasodilators) or with the nonglycoside, noncatecholamine class of inotropic agents. Survival outcome was determined as alive, sudden death or low output death. When all variables except ejection fraction were analyzed by Cox multiple regression analysis, the most important independent predictor of all deaths was the baseline plasma renin activity (p less than 0.001). When subdivided by cause of cardiovascular death, baseline plasma renin activity was retained as the most important determinant of low output death (p less than 0.001), whereas baseline left ventricular stroke work index (p less than 0.001), pulmonary capillary wedge pressure (p less than 0.002) and absence of sinus rhythm (p less than 0.006) were the most powerful independent predictors of sudden death. Plasma norepinephrine was markedly elevated in the group dying of low output, but only modestly elevated in the group of survivors and the group dying suddenly. However, baseline norepinephrine was not found to be an important independent predictor of mortality in any of the subgroups. Plasma renin activity, but not plasma norepinephrine, is a powerful independent prognostic determinant of mortality in this group of patients with CHF.

Mechanical properties of papillary muscle in cardiac failure: importance of pathogenesis and of ventricle of origin

In an attempt to better understand what causes impairment of failing myocardium, the mechanical characteristics of papillary muscles from three different models of congestive heart failure were compared at varying stages of hypertrophy and failure: adriamycin cardiotoxic rabbit, cardiomyopathic hamster and infra-renal aorto-caval shunted dog. Except for right ventricular muscles from the shunted dogs, in all groups there was a significant decrease in total twitch tension, +dT/dt, -dT/dt, Vmax, +dL/dt, and -dL/dt. However, there were major differences in twitch duration between the three models with time to attain peak tension and peak shortening and time to attain half tension decline decreasing in right ventricular papillary muscles from adriamycin rabbits but increasing in right ventricular papillary muscles from shunted dogs and no change occurring in left ventricular papillary muscles from cardiomyopathic hamsters or shunted dogs. Load dependence as assessed by time to relaxation index for 30% afterload contractions was decreased in all but right ventricular muscles from shunted dogs. These results indicate that despite some common characteristics, major differences exist between papillary muscles from different models of congestive heart failure depending on the pathophysiological process involved and the ventricle of origin.

Chronic renal and neurohumoral effects of the calcium entry blocker nisoldipine in patients with congestive heart failure

Nisoldipine, a calcium entry blocker, was given to 10 patients with congestive heart failure. During a 2 month follow-up period, 7 of the 10 patients were readmitted with pulmonary edema; daily furosemide doses were increased (128 +/- 87 to 192 +/- 135 mg/day, p less than 0.01), and plasma creatinine increased (1.5 +/- 0.5 to 1.8 +/- 0.6 mg/dl, p less than 0.05) (all values mean +/- SD). Despite this unfavorable clinical course, nisoldipine caused some beneficial chronic (1 month) hemodynamic effects. It decreased systemic vascular resistance (from 1,781 +/- 229 to 1,306 +/- 345 dynes X s X cm-5, p less than 0.01), decreased mean arterial pressure (from 88 +/- 0 to 74 +/- 4 mm Hg, p less than 0.001) and increased stroke volume index (from 27 +/- 6 to 33 +/- 9 ml/min per m2, p less than 0.02). Heart rate, pulmonary capillary wedge pressure and stroke work index did not change. However, nisoldipine's chronic renal and neurohumoral effects were not as favorable. These were assessed during a 5 hour water load (15 ml/kg body weight of 5% dextrose in water) and compared with the effects of a water load before therapy. Nisoldipine did not change creatinine clearance or sodium excretion, but decreased water excretion (from 58 +/- 35 to 46 +/- 40% of water load in 5 hours). Over this 5 hour study, mean plasma vasopressin was also higher with nisoldipine (1.9 +/- 2.3 versus 2.7 +/- 3.2 pg/ml, p less than 0.05), but mean plasma aldosterone was lower (67 +/- 31 to 47 +/- 27 mg/dl, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Faster time to peak tension and velocity of shortening in right versus left ventricular trabeculae and papillary muscles of dogs

Some of the mechanical characteristics of papillary muscles and trabeculae (n = 14) isolated from the free wall of the right ventricle of dogs were compared to those obtained from the free wall of the left ventricle (n = 14). Peak total tension (7.2 +/- 1.6 versus 7.9 +/- 1.7 g/mm2, p = NS) and peak velocity of tension development (31 +/- 8 vs. 28 +/- 4 g/mm2/sec, p = NS) were similar in both groups of muscles. However, right ventricular muscles shortened faster over nearly all loading conditions, and during isometric contraction, their time to attain peak total tension was shorter (336 +/- 26 vs. 401 +/- 42 msec, p less than 0.005) than that of left ventricular muscles. Varying stimulation rates (6, 12, 24, and 36 stimuli/min), increasing calcium concentration from 2.54 to 6.35 mM or adding norepinephrine 50 microM, did not significantly alter these differences. There were no differences in myosin isozymes (V1, V2, or V3) between ventricles to explain these differences. These results indicate that important mechanical differences exist between right and left ventricular myocardium and that these differences should be considered when extrapolations are made from myocardium of one area of the heart to another.

Sodium and water excretion abnormalities in congestive heart failure. Determinant factors and clinical implications

The renal hemodynamic and neurohumoral determinants of sodium and water excretion abnormalities were studied in 66 patients with severe chronic congestive heart failure. Abnormalities were not closely related to any one variable but were the result of the convergence of a number of determinants. The most important determinants for sodium excretion were activation of the renin-angiotensin system and ventricular function; and the most important for water excretion were plasma vasopressin, plasma norepinephrine, and renal and ventricular functions. In a subgroup of patients, neurohumoral overactivation led to severe sodium and water excretion abnormalities and to increased furosemide requirements. A 17-month follow-up of all 66 patients showed a less favorable clinical course for this subgroup even when compared with hemodynamically matched patients.