L-carnitine modified nanoparticles target the OCTN2 transporter to improve the oral absorption of jujuboside B

As a bioactive saponin derived from the seeds of Ziziphus jujuba Mill. var. spinosa (Bunge) Hu ex H. F. Chow, jujuboside B (JuB) shows great potential in anti-anxiety, anti-depression and improving learning and memory function. However, its oral bioavailability is very poor. In this study, a novel drug-loading nanoparticles system was prepared with polyethylene glycol and polylactic-co-glycolic acid copolymer (PEG-PLGA), and further modified with L-carnitine (LC) to target intestinal organic cation/carnitine transporter 2 (OCTN2) to improve the oral absorption of JuB. Under the optimized preparation conditions, the particle sizes of obtained JuB-PEG-PLGA nanoparticles (B-NPs) and LC modified B-NPs (LC-B-NPs) were 110.67 ± 11.37 nm and 134.00 ± 2.00 nm with the entrapment efficiency (EE%) 73.46 ± 1.26 % and 76.01 ± 2.10 %, respectively. The pharmacokinetics in SD rats showed that B-NPs and LC-B-NPs increased the bioavailability of JuB to 134.33 % and 159.04 % respectively. In Caco-2 cell model, the prepared nanoparticles significantly increased cell uptake of JuB, which verified the pharmacokinetic results. The absorption of LC-B-NPs mainly depended on OCTN2 transporter, and Na+ played an important role. Caveolin and clathrin were involved in the endocytosis of the two nanoparticles. In conclusion, both B-NPs and LC-B-NPs can improve the oral absorption of JuB, and the modification of LC can effectively target the OCTN2 transporter.

Effects of Reducing L-Carnitine Supplementation on Carnitine Kinetics and Cardiac Function in Hemodialysis Patients: A Multicenter, Single-Blind, Placebo-Controlled, Randomized Clinical Trial

L-carnitine (LC) supplementation improves cardiac function in hemodialysis (HD) patients. However, whether reducing LC supplementation affects carnitine kinetics and cardiac function in HD patients treated with LC remains unclear. Fifty-nine HD patients previously treated with intravenous LC 1000 mg per HD session (three times weekly) were allocated to three groups: LC injection three times weekly, once weekly, and placebo, and prospectively followed up for six months. Carnitine fractions were assessed by enzyme cycling methods. Plasma and red blood cell (RBC) acylcarnitines were profiled using tandem mass spectrometry. Cardiac function was evaluated using echocardiography and plasma B-type natriuretic peptide (BNP) levels. Reducing LC administration to once weekly significantly decreased plasma carnitine fractions and RBC-free carnitine levels during the study period, which were further decreased in the placebo group (p < 0.001). Plasma BNP levels were significantly elevated in the placebo group (p = 0.03). Furthermore, changes in RBC (C16 + C18:1)/C2 acylcarnitine ratio were positively correlated with changes in plasma BNP levels (β = 0.389, p = 0.005). Reducing LC administration for six months significantly decreased both plasma and RBC carnitine levels, while the full termination of LC increased plasma BNP levels; however, it did not influence cardiac function in HD patients.

l-Carnitine conjugated chitosan-stearic acid polymeric micelles for improving the oral bioavailability of paclitaxel

A delivery system based on l-carnitine (LC) conjugated chitosan (CS)-stearic acid polymeric micelles has been developed for improving the oral bioavailability of paclitaxel (PTX) through targeting intestinal organic cation/carnitine transporter 2 (OCTN2). Stearic acid grafted chitosan (CS-SA), as micelle skeleton material, was synthesized by 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC)-mediated coupling reaction. The PTX-loaded micelles were prepared by solvent evaporation-hydration method, and the ligand LC was conjugated onto the micelle surface by anchoring its derivative stearoyl group to the lipophilic core of micelle. The modified polymeric micelles showed regular spherical shapes with small particle size of 157.1 ± 5.2 nm and high drug loading capacity of 15.96 ± 0.20 wt%, and the micelle stability in water was supported by low critical micelle concentration of 14.31 ± 0.21 μg/ml. The drug-loaded micelles presented a slow and incomplete in vitro release, and the pharmacokinetic studies indicated the micelle carriers increased the relative bioavailability of PTX to 165.8% against the commercial formulation. The enhancement effect on intestinal absorption was also confirmed by the intracellular uptake of Caco-2 cells. The proposed micelle carrier system manifested a prospective tool for oral drug delivery.

Fine Mapping and Functional Analysis Reveal a Role of SLC22A1 in Acylcarnitine Transport

Genome-wide association studies have identified a signal at the SLC22A1 locus for serum acylcarnitines, intermediate metabolites of mitochondrial oxidation whose plasma levels associate with metabolic diseases. Here, we refined the association signal, performed conditional analyses, and examined the linkage structure to find coding variants of SLC22A1 that mediate independent association signals at the locus. We also employed allele-specific expression analysis to find potential regulatory variants of SLC22A1 and demonstrated the effect of one variant on the splicing of SLC22A1. SLC22A1 encodes a hepatic plasma membrane transporter whose role in acylcarnitine physiology has not been described. By targeted metabolomics and isotope tracing experiments in loss- and gain-of-function cell and mouse models of Slc22a1, we uncovered a role of SLC22A1 in the efflux of acylcarnitines from the liver to the circulation. We further validated the impacts of human variants on SLC22A1-mediated acylcarnitine efflux in vitro, explaining their association with serum acylcarnitine levels. Our findings provide the detailed molecular mechanisms of the GWAS association for serum acylcarnitines at the SLC22A1 locus by functionally validating the impact of SLC22A1 and its variants on acylcarnitine transport.

Relationship between Carnitine Pharmacokinetics and Fatigue in Patients Treated with Cisplatin-Containing Chemotherapy

BACKGROUND

Approximately 70% of the patients who receive chemotherapy suffer from fatigue, which lowers their quality of life and also has a negative influence on therapeutic efficacy. Previous studies have suggested a relationship between blood carnitine levels and fatigue. We conducted a prospective observational study to examine the relationship between carnitine pharmacokinetics and chemotherapy-induced fatigue in patients receiving cancer chemotherapy regimens that include cisplatin.

PATIENTS AND METHODS

11 patients receiving chemotherapy including cisplatin (60-80 mg/m2) were included in the study. We performed 24-h urine collections and took blood samples on day 1 (before the initiation of chemotherapy) and days 2, 3, 4, and 8 in order to measure the carnitine concentrations in the serum and urine. These were compared with measures of self-reported fatigue. The primary endpoint was the change in self-reported fatigue subscales from baseline to day 8.

RESULTS

Urinary carnitine concentrations differed significantly on days 2 and 3 (p = 0.003). The Functional Assessment of Chronic Illness Therapy-Fatigue scale version 4A score on day 8 indicated significantly higher levels of fatigue as compared to day 1 (p = 0.013).

CONCLUSION

This study suggests that there is an association between urinary carnitine levels and self-reported fatigue.

The Use of Carnitine in Pediatric Nutrition

Carnitine is synthesized endogenously from methionine and lysine in the liver and kidney and is available exogenously from a meat and dairy diet and from human milk and most enteral formulas. Parenteral nutrition (PN) does not contain carnitine unless it is extemporaneously added. The primary role of carnitine is to transport long-chain fatty acids across the mitochondrial membrane, where they undergo beta-oxidation to produce energy. Although the majority of patients are capable of endogenous synthesis of carnitine, certain pediatric populations, specifically neonates and infants, have decreased biosynthetic capacity and are at risk of developing carnitine deficiency, particularly when receiving PN. Studies have evaluated for several decades the effects of carnitine supplementation in pediatric patients receiving nutrition support. Early studies focused primarily on the effects of supplementation on markers of fatty acid metabolism and nutrition markers, including weight gain and nitrogen balance, whereas more recent studies have evaluated neonatal morbidity. This review describes the role of carnitine in metabolic processes, its biosynthesis, and carnitine deficiency syndromes, as well as reviews the literature on carnitine supplementation in pediatric nutrition.

[L-carnitine: properties and perspectives for use in sports practice]

The analysis of published data relating to the use in sports practice metabolic non-doping agent--L-carnitine. The review discusses some aspects of the mechanism of its action on the human body. The information is given about the role of carnitine in the energy processes, mechanisms of carnitine deficiency. On the basis of the literature is given scientific rationale for applying this metabolite in athletes, particularly with cardiovascular and immune disorders.

Bioavailabilty of a liquid Vitamin Trace Element Composition in healthy volunteers

BACKGROUND

Many Vitamins and minerals for dietary supplements lack a standard scientific and regulatory definition that accurately reflects the bioavailabilities in humans. Especially the bioavailability of natural compounds in complex mixtures, where the different ingredients may interfere with each other, is unknown.

METHODS

To learn more about the bioavailability of the ingredients in the complex compound LaVita® we examined blood levels of subjects, who ingested the multivitamin and trace element composition for 6 month continuously. Blood samples for the analysis of the ingredients were taken before, during, and after administration.

RESULTS

Our data indicated a significant increase of most ingredients after 3 month, and additional three months, except for Vitamin (B9 Folic acid). The semivitamins Q10 and carnitine increased in the first 3 month (both p<0.001). While carnitine dropped during the second term, Q10 levels increased further slowly. After three months a significant increase was observed for iron (serum p=0.039; blood cells p=0.025), Selenium (serum p=0.048; cells p=0.006), and chromium (serum p=0.029). Zinc - known to interfere with the iron resorption - increased slowly in the first term of 3 months, but was raised significantly after 6 months (serum and blood cells, each p<0.001). The Copper/Zink ratio dropped accordingly (p<0.001).

CONCLUSION

We conclude that resorption interference between specific ingredients, and after resorption redistribution of specific ingredients to various tissue compartments precludes a linear increase of the respective serum parameters. We observed no deleterious resorption competitions for individual compounds. No parameter reached critical levels. We conclude that the test substance (LaVita®) is a sufficiently safe composite for long term consumption.

Disposition and Metabolite Kinetics of Oral L-carnitine in Humans

The pharmacokinetics of L-carnitine and its metabolites were investigated in 7 healthy subjects following the oral administration of 0, 0.5, 1, and 2 g 3 times a day for 7 days. Mean plasma concentrations of L-carnitine across an 8-hour dose interval increased significantly (P < .05) from a baseline of 54.2 +/- 9.3 microM to 80.5 +/- 12.5 microM following the 0.5-g dose; there was no further increase at higher doses. There was a significant increase (P < .001) in the renal clearance of L-carnitine indicating saturation of tubular reabsorption. Trimethylamine plasma levels increased proportionately with L-carnitine dose, but there was no change in renal clearance. A significant increase in the plasma concentrations of trimethylamine-N-oxide from baseline was evident only for the 2-g dose of L-carnitine (from 34.5 +/- 2.0 to 149 +/- 145 microM), and its renal clearance decreased with increasing dose (P < .05). There was no evidence for nonlinearity in the metabolism of trimethylamine to trimethylamine-N-oxide. In conclusion, the pharmacokinetics of oral L-carnitine display nonlinearity above a dose of 0.5 g 3 times a day.

Expression and functional analysis of intestinal organic cation/L-carnitine transporter (OCTN) in Crohn's disease

BACKGROUND

The IBD5 locus is a genetic risk factor for IBD, particularly Crohn's Disease, coding for the organic cation/carnitine transporters (OCTN1 and 2). Two variants of OCTN are associated with susceptibility to Crohn's Disease. Modified transport of carnitine in vitro has been reported for a polymorphism of OCTN1. The aim was to investigate the function of intestinal OCTNs in IBD in relation to genetic polymorphisms.

METHODS

Intestinal tissue was obtained from endoscopic biopsies and surgical resections from IBD patients (n=33 and 14, resp.) and controls (n=22 and 14, resp.). OCTN protein levels were measured in intestinal biopsies and carnitine transport was quantified in intestinal resections.

RESULTS

OCTN1 protein levels were significantly higher in ileal versus colonic tissue (2.95% ± 0.4 vs 0.66% ± 0.2, resp.; p<0.0002). OCTN1 expression was higher in Crohn's disease patients with mutant homozygous or heterozygous genotypes (0.6% ± 0.1 vs 3% ± 0.8, resp., p<0.02). Carnitine transport was very rapid and Na+ dependent (10s). It was not different comparing Crohn's Disease and control groups (0.45 ± 0.12 vs 0.51 ± 0.12 nM carnitine/mg prot/min, resp.). Carnitine transport tended to be higher in subjects with mutant homozygous and heterozygous OCTN1 and OCTN2 genotypes (0.19 vs 0.59 and 0.25 vs 0.6, respectively).

CONCLUSIONS

The present data reveal that OCTN protein levels appear to be similar in intestinal tissue from Crohn's Disease patients and controls. Overall, ileal carnitine transport appears to as well equal in Crohn's Disease and control groups. However, there was a trend towards higher carnitine transport in subjects with OCTN1 and OCTN2 mutations.

Effects of low oxygen levels on the expression and function of transporter OCTN2 in BeWo cells

Although hypoxia is normal in early pregnancy, low placental oxygen concentrations later in pregnancy are often linked to complications such as pre-eclampsia and intrauterine growth restriction. The effects of low oxygen levels on drug and nutrient uptake via the organic cation transporter OCTN2 has been studied in BeWo cells, an in-vitro model of human trophoblast. BeWo cells were cultured under 20% (control) or 2% O2 (hypoxia) for 48 h before each experiment. In-vitro hypoxia was also simulated by the addition of CoCl2 to the cell culture medium. RT-PCR indicated increased transcription of OCTN2 in BeWo cells cultured under hypoxia, but Western blots did not show a corresponding increase in the amount of OCTN2 protein in the hypoxic cells compared with control. Hypoxia resulted in significant reductions in OCTN2-mediated carnitine uptake. Decreased placental transport of carnitine may lead to symptoms of carnitine deficiency in infants from hypoxic pregnancies, whether caused by high altitude, pre-eclampsia or other factors. The OCTN1 substrate ergothioneine reversed the effects of hypoxia on carnitine transport, but identical concentrations of N-acetylcysteine, another water-soluble intracellular antioxidant, did not have the same effect.

Safety and efficacy of clomiphene citrate and L-carnitine in idiopathic male infertility: a comparative study

PURPOSE

To compare the effects of L-carnitine with clomiphene citrate in idiopathic infertile men.

MATERIALS AND METHODS

Fifty-two men with idiopathic infertility were recruited in this randomized controlled trial. They were randomly assigned into 2 treatment groups, group 1 (n = 20) and group 2 (n = 32), who received L-carnitine 25 mg/day and clomiphene citrate 2 gr/day, respectively, for a period of 3 months.

RESULTS

Comparing the effect of L-carnitine and clomiphene on sperm parameters before and after the treatment, both medications had influence on sperm count and motility (P = .01). L-carnitine significantly increased the semen volume (P = .001), while clomiphene citrate was significantly associated with the motility percentage and normal morphology (P = .008).

CONCLUSION

It seems that the use of clomiphene citrate and L-carnitine, either individually or in combination, as the first step of idiopathic male infertility treatment is reasonable, safe, and effective.

Transport of butyryl-L-carnitine, a potential prodrug, via the carnitine transporter OCTN2 and the amino acid transporter ATB(0,+)

L-carnitine is absorbed in the intestinal tract via the carnitine transporter OCTN2 and the amino acid transporter ATB(0,+). Loss-of-function mutations in OCTN2 may be associated with inflammatory bowel disease (IBD), suggesting a role for carnitine in intestinal/colonic health. In contrast, ATB(0,+) is upregulated in bowel inflammation. Butyrate, a bacterial fermentation product, is beneficial for prevention/treatment of ulcerative colitis. Butyryl-L-carnitine (BC), a butyrate ester of carnitine, may have potential for treatment of gut inflammation, since BC would supply both butyrate and carnitine. We examined the transport of BC via ATB(0,+) to determine if this transporter could serve as a delivery system for BC. We also examined the transport of BC via OCTN2. Studies were done with cloned ATB(0,+) and OCTN2 in heterologous expression systems. BC inhibited ATB(0,+)-mediated glycine transport in mammalian cells (IC(50), 4.6 +/- 0.7 mM). In Xenopus laevis oocytes expressing human ATB(0,+), BC induced Na(+) -dependent inward currents under voltage-clamp conditions. The currents were saturable with a K(0.5) of 1.4 +/- 0.1 mM. Na(+) activation kinetics of BC-induced currents suggested involvement of two Na(+) per transport cycle. BC also inhibited OCTN2-mediated carnitine uptake (IC(50), 1.5 +/- 0.3 microM). Transport of BC via OCTN2 is electrogenic, as evidenced from BC-induced inward currents. These currents were Na(+) dependent and saturable (K(0.5), 0.40 +/- 0.02 microM). We conclude that ATB(0,+) is a low-affinity/high-capacity transporter for BC, whereas OCTN2 is a high-affinity/low-capacity transporter. ATB(0,+) may mediate intestinal absorption of BC when OCTN2 is defective.

Determination of highly soluble L-carnitine in biological samples by reverse phase high performance liquid chromatography with fluorescent derivatization

This study was performed in order to validate an effective high performance liquid chromatograpy (HPLC) method to determine L-carnitine in biological samples such as plasma, milk and muscle in cows. An L-carnitine derivative for fluorescence absorption was synthesized with 1-aminoanthracene (16 mg/mL in acetone) and 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDAC; 160 mg/mL in 0.01 M NaH2PO4 buffer) as a precolumn fluorescent derivative reagent. gamma-Butyrobetaine HCI was used as an internal standard. A reversed-phase column with fluorescence detection at the excitation and emission wavelengths of 248 and 418 nm were used. The mobile phase consisted of 30% acetonitrile with 0.1 M ammonium acetate in water (pH 3.5) adjusted with acetic acid and delivered at a flow rate of 1.5 mL/ min. The L-carnitine concentration in plasma, milk and muscle samples of cows after oral feeding with 24 g L-carnitine/day for 2 months was then determined. All biological samples were deproteinated by barium hydroxide and zinc sulfate heptahydrate before the derivative reaction. Blank cow plasma was dialyzed using cellulose membrane for standard calibration. The calibration curve showed good linearity (r2 > 0.999) over the concentration range of 50 to 5000 ng/mL. The precision and accuracy were also satisfactory with less than 15% intra- and interday coefficiency of variations. The peaks of L-carnitine and internal standard in HPLC chromatography were successfully separated in plasma, milk and muscle samples of cows. The current derivatization method of L-carnitine for fluorescence detection was simple and adequately sensitive and could be applied to determine L-carnitine in biological samples.

L-Carnitine in the treatment of fatigue in adult celiac disease patients: a pilot study

BACKGROUND

Fatigue is common in celiac disease. L-Carnitine blood levels are low in untreated celiac disease. L-Carnitine therapy was shown to improve muscular fatigue in several diseases.

AIM

To evaluate the effect of L-carnitine treatment in fatigue in adult celiac patients.

METHODS

Randomised double-blind versus placebo parallel study. Thirty celiac disease patients received 2 g daily, 180 days (L-carnitine group) and 30 were assigned to the placebo group (P group). The patients underwent clinical investigation and questionnaires (Scott-Huskisson Visual Analogue Scale for Asthenia, Verbal Scale for Asthenia, Zung Depression Scale, SF-36 Health Status Survey, EuroQoL). OCTN2 levels, the specific carnitine transporter, were detected in intestinal tissue.

RESULTS

Fatigue measured by Scott-Huskisson Visual Analogue Scale for Asthenia was significantly reduced in the L-carnitine group compared with the placebo group (p=0.0021). OCTN2 was decreased in celiac patients when compared to normal subjects (-134.67% in jejunum), and increased after diet in both celiac disease treatments. The other scales used did not show any significant difference between the two celiac disease treatment groups.

CONCLUSION

L-Carnitine therapy is safe and effective in ameliorating fatigue in celiac disease. Since L-carnitine is involved in muscle energy production its decreased absorption due to OCTN2 reduction might explain muscular symptoms in celiac disease patients. The diet-induced OCTN2 increase, improving carnitine absorption, might explain the L-carnitine treatment efficacy.

Effect of chronic stress and L-carnitine on rat stomach

BACKGROUND AND AIM

L-Carnitine is an essential cofactor in the mitochondrial transfer of fatty acids, and it is also a scavenger of free radicals in mammalian tissues. The aim of the study was to determine the effect of L-carnitine on chronic restraint stress-induced gastric mucosal injury.

METHODS

Wistar rats were applied restraint stress (1 h/day) and L-carnitine (50 mg/kg) for 21 days. The lesion index, prostaglandin E(2) and mucus content, lipid peroxidation, superoxide dismutase, and catalase activity in gastric mucosa were evaluated.

RESULTS

Chronic restraint stress increased the lesion index, lipid peroxidation, and superoxide dismutase activity in gastric mucosa, and it decreased prostaglandin E(2) and mucus content. L-Carnitine treatment prevented the stress-induced increase in lesion index, lipid peroxidation and a stress-induced decline in prostaglandin E(2), and mucus content in gastric mucosa, but it increased catalase activity.

CONCLUSIONS

L-Carnitine prevents the occurrence of lesion by strengthening the gastric mucosal barrier and by reducing lipid peroxidation against the harmful effects of chronic restraint stress.

A pharmacokinetic model for L-carnitine in patients receiving haemodialysis

AIMS

Patients requiring chronic haemodialysis may develop a secondary carnitine deficiency through dialytic loss of L-carnitine. A previous report has described the plasma concentrations of L-carnitine in 12 such patients under baseline conditions and after L-carnitine administration (20 mg kg(-1)). A three-compartment pharmacokinetic model was developed to describe these data to make inferences about carnitine supplementation in these patients.

METHODS

L-carnitine removal was mediated solely by intermittent haemodialysis, which was incorporated into the model as an experimentally derived dialysis clearance value that was linked to an on-off pulse function. Data were described by a model with a central compartment linked to 'fast'- and 'slow'-equilibrating peripheral compartments.

RESULTS

The model adequately described the changing plasma concentrations of endogenous L-carnitine in individual haemodialysis patients. Based on pooled data (mean +/- SD; n = 12), the volume of the central compartment was 10.09 +/- 0.72 l and the transfer rate constants into and out of the slowly equilibrating pool were 0.100 +/- 0.018 h(-1) and 0.00014 +/- 0.00016 h(-1), respectively. The turnover time of L-carnitine in the slow pool (which was assumed to represent muscle) was approximately 300 days. The model was in general agreement with separate data on the measured loss of carnitine from muscle in dialysis patients.

CONCLUSIONS

Haemodialysis causes rapid reductions in plasma L-carnitine concentrations with each dialysis session. Plasma concentrations are restored between sessions by redistribution from peripheral compartments. However, during chronic haemodialysis, the ongoing dialytic loss of L-carnitine may lead to a slow depletion of the compound, contributing to a possible secondary deficiency.

Fructose-induced hepatic gluconeogenesis: Effect of l-carnitine

High fructose feeding (60 g/100 g diet) in rodents induces alterations in both glucose and lipid metabolism. The present study was aimed to evaluate whether intraperitoneal carnitine (CA), a transporter of fatty acyl-CoA into the mitochondria, could attenuate derangements in carbohydrate metabolizing enzymes and glucose overproduction in high fructose-diet fed rats. Male Wistar rats of body weight 150-160 g were divided into 4 groups of 6 rats each. Groups 1 and 4 animals received control diet while the groups 2 and 3 rats received high fructose-diet. Groups 3 and 4 animals were treated with CA (300 mg/Kg body weight/day, i.p.) for 30 days. At the end of the experimental period, levels of carnitine, glucose, insulin, lactate, pyruvate, glycerol, triglycerides and free fatty acids in plasma were determined. The activities of carbohydrate metabolizing enzymes and glycogen content in liver and muscle were assayed. Hepatocytes isolated from liver were studied for the gluconeogenic activity in the presence of substrates such as pyruvate, lactate, glycerol, fructose and alanine. Fructose-diet fed animals showed alterations in glucose metabolizing enzymes, increased circulating levels of gluconeogenic substrates and depletion of glycogen in liver and muscle. There was increased glucose output from hepatocytes of animals fed fructose-diet alone with all the gluconeogenic substrates. The abnormalities associated with fructose feeding such as increased gluconeogenesis, reduced glycogen content and other parameters were brought back to near normal levels by CA. Hepatocytes from these animals showed significant inhibition of glucose production from pyruvate (74.3%), lactate (65.4%), glycerol (69.6%), fructose (56.2%) and alanine (63.6%) as compared to CA untreated fructose-fed animals. The benefits observed could be attributed to the effect of CA on fatty acyl-CoA transport.

Relative bioavailability of carnitine supplementation in premature neonates

BACKGROUND

Carnitine is an important nutrient in the infant diet. We compared total plasma carnitine concentrations in premature neonates supplemented with carnitine via parenteral and enteral nutrition.

METHODS

This is a post hoc analysis of plasma total carnitine concentrations and carnitine intake in neonates randomized in a previous study to receive 20 mg/kg/d carnitine supplementation over 8 weeks. Neonates received l-carnitine initially via parenteral nutrition (PN). When neonates were fed enterally, oral supplementation of l-carnitine was given in divided doses with each feeding.

RESULTS

Sixteen neonates (27 +/- 2 weeks gestation; 2.9 +/- 1.0 days postnatal age at enrollment; 965.6 +/- 279.1 g birth weight) are included. Concentrations were below reference range (31.1-60.5 nmol/mL) at baseline and exceeded reference range from week 1 through the last study period. Concentrations were not different from week 1 (108 +/- 49) through weeks 4 (87 +/- 34) and 8 (83 +/- 31). Carnitine intakes and concentrations were compared in neonates receiving 100% parenteral carnitine at week 1 (n = 6) and 100% enteral carnitine at week 8 (n = 8). Concentrations at week 1 (100.1 +/- 27.9) were not different (p = .19) from week 8 (78.6 +/- 29.3); an estimate of relative bioavailability was 78.6%. Bioavailability with paired analysis of neonates (n = 5) receiving 100% parenteral carnitine at week 1 and 100% enteral carnitine at week 8 was 83.7% +/- 41.2% (30.1%-140.6%).

CONCLUSIONS

Parenteral and enteral supplementation of 20 mg/kg/d carnitine results in plasma total carnitine concentrations that exceed the reference range. Concentrations are not different between parenteral to enteral supplementation, suggesting that enteral carnitine is well absorbed when given daily in divided doses with enteral feedings.

Oral L-carnitine: metabolite formation and hemodialysis

L-Carnitine has important roles in intermediary metabolism and patients with end-stage renal disease who are undergoing hemodialysis may develop a secondary L-carnitine deficiency. The extent of accumulation of the metabolites trimethylamine and trimethylamine-N-oxide when L-carnitine is administered orally has not been investigated previously in this population. Oral L-carnitine at a dose of 1 g daily was administered for twelve days to six patients with end-stage renal disease undergoing hemodialysis thrice weekly. Pre-dialysis plasma concentrations of L-carnitine (mean +/- SD) increased significantly (P < 0.05) from day 1 (baseline; 32.4 +/- 6.1 microM) to day 8 (66.1 +/- 13.8 microM) remaining constant thereafter. Although plasma levels of trimethylamine remained unaltered, the pre-dialysis plasma concentrations of trimethylamine-N-oxide increased significantly (P < 0.05) from day 1 (289.1 +/- 236.1 microM) to day 12 (529.0 +/- 237.9 microM). The hemodialysis clearances for L-carnitine, trimethylamine and trimethylamine-N-oxide were 14.3 +/- 8.2, 14.1 +/- 10.6 and 12.4 +/- 5.4 L/h, respectively, indicating their efficient removal by dialysis. Oral administration of L-carnitine at a dose of 1 g daily increases plasma concentrations of this substance to physiological levels in patients with end-stage renal disease who are undergoing hemodialysis. However, concerns about the possible deleterious consequences of such a dosage regimen still remain given that plasma concentrations of trimethylamine-N-oxide were continually rising and approximately doubled in a two-week period.

Novel localization of OCTN1, an organic cation/carnitine transporter, to mammalian mitochondria

Carnitine is a zwitterion essential for the beta-oxidation of fatty acids. We report novel localization of the organic cation/carnitine transporter, OCTN1, to mitochondria. We made GFP- and RFP-human OCTN1 cDNA constructs and showed expression of hOCTN1 in several transfected mammalian cell lines. Immunostaining of GFP-hOCTN1 transfected cells with different intracellular markers and confocal fluorescent microscopy demonstrated mitochondrial expression of OCTN1. There was striking co-localization of an RFP-hOCTN1 fusion protein and a mitochondrial-GFP marker construct in transfected MEF-3T3 and no co-localization of GFP-hOCTN1 in transfected human skin fibroblasts with other intracellular markers. L-[(3)H]Carnitine uptake in freshly isolated mitochondria of GFP-hOCTN1 transfected HepG2 demonstrated a K(m) of 422 microM and Western blot with an anti-GFP antibody identified the expected GFP-hOCTN1 fusion protein (90 kDa). We showed endogenous expression of native OCTN1 in HepG2 mitochondria with anti-GST-hOCTN1 antibody. Further, we definitively confirmed intact L-[(3)H]carnitine uptake (K(m) 1324 microM), solely attributable to OCTN1, in isolated mitochondria of mutant human skin fibroblasts having <1% of carnitine acylcarnitine translocase activity (alternate mitochondrial carnitine transporter). This mitochondrial localization was confirmed by TEM of murine heart incubated with highly specific rabbit anti-GST-hOCTN1 antibody and immunogold labeled goat anti-rabbit antibody. This suggests an important yet different role for OCTN1 from other OCTN family members in intracellular carnitine homeostasis.

Effect of Shiga-like toxin II from Escherichia coli O157:H7 on intestinal clearance of norfloxacin in rats

Enterohemorrhagic Escherichia coli (EHEC) O157:H7 infection causes severe clinical symptoms, due to its bacterial toxin, called Shiga-like toxin (SLT). However, little is known about the information to establish a safe and efficient prescription to treat for EHEC O157:H7 patients. Thus, we investigated the effect of SLT-II on intestinal function in rats by using the antibiotic norfloxacin (NFLX) as a model drug. The intestinal clearance (CLi) of NFLX, determined by loop method in the jejunum, was significantly decreased by SLT-II. In histopathological experiment, epithalaxia was observed in SLT-II-treated rats without structural changes of tight junction suggesting the deterioration of active transport systems by SLT-II. CLi of NFLX in normal rats was decreased by carnitine (CAR), suggesting the possible involvement of CAR-sensitive transporter in CLi of NFLX. Taken together, these results suggest that the EHEC O157:H7 infection might affect the intestinal disposition of NFLX due to the changing intestinal expression/function of drug transporters by SLT-II.

Functional expression of the organic cation/carnitine transporter 2 in rat astrocytes

In this study, we sought to identify the transporters that mediate the uptake of L-carnitine and acetyl-L-carnitine in cultured rat cortical astrocytes. L-[(3)H]carnitine and acetyl-L-[(3)H]carnitine uptake were both saturable, and mediated by a single Na(+)-dependent transport system. Uptake of both was inhibited by L-carnitine, D-carnitine, acetyl-L-carnitine and various organic cations. Acylcarnitines (acetyl-, butyryl-, hexanoyl-, octanoyl- and palmitoyl-L-carnitine) also interacted with L-[(3)H]carnitine and acetyl-L-[(3)H]carnitine transport. 2-Amino-2-norbornane carboxylic acid, a known inhibitor of amino acid transporter B(0,+) (ATB(0,+)), did not cause any significant inhibition. A highly significant correlation was found between the potencies of acylcarnitines in the inhibition of L-[(3)H]carnitine and acetyl-L-[(3)H]carnitine uptake and the acyl chain length of acylcarnitines. The expression of mRNA for organic cation/carnitine transporters (OCTNs), carnitine transporter 2 (CT2) and ATB(0,+) in astrocytes was investigated by reverse transcription (RT)-PCR. OCTN2 mRNA was expressed in astrocytes, whereas the expression of OCTN1, OCTN3 and CT2 mRNA could not be detected. ATB(0,+) mRNA was expressed at very low levels in astrocytes. Western blotting analysis indicated that anti-OCTN2 polyclonal antibody recognized a band of 70 kDa in both kidney and astrocyte preparations. OCTN2 immunoreactivity was detected in rat astrocytes by immunocytochemical staining. Inhibition of OCTN2 expression by RNA interference significantly inhibited L-[(3)H]carnitine and acetyl-L-[(3)H]carnitine uptake into astrocytes. These results suggest that OCTN2 is functionally expressed in rat astrocytes, and is responsible for L-carnitine and acetyl-L-carnitine uptake in these cells.

Carnitine/xenobiotics transporters in the human mammary gland epithelia, MCF12A

The barrier function of the human mammary gland collapses if challenged with cationic drugs, causing their accumulation in milk. However, underlying molecular mechanisms are not well understood. To gain insight into the mechanism, we characterized transport of organic cations in the MCF12A human mammary gland epithelial cells, using carnitine and tetraethylammonium (TEA) as representative nutrient and xenobiotics probes, respectively. Our results show that the mammary gland cells express mRNA and proteins of human (h) novel organic cation transporters (OCTN) 1 and hOCTN2 (a Na+-dependent carnitine carrier with Na+-independent xenobiotics transport function), which belong to the solute carrier superfamily (SLC) of transporters. Other SLC OCTs such as hOCT1 and extraneuronal monoamine transporter (EMT)/hOCT3 are also expressed at mRNA levels, but hOCT2 was undetectable. We further showed mRNA expression of ATB0+ (an amino acid transporter with a Na+/Cl−-dependent carnitine transport activity), and Fly-like putative transporter 2/OCT6 (a splice variant of carnitine transporter 2: a testis-specific Na+-dependent carnitine transporter). TEA uptake was pH dependent. Carnitine uptake was dependent on Na+, and partly on Cl−, compatible with hOCTN2 and ATB0+ function. Modeling analyses predicted multiplicity of the uptake mechanisms with the high-affinity systems characterized by Km of 5.1 μM for carnitine and 1.6 mM for TEA, apparently similar to the reported hOCTN2 parameter for carnitine, and that of EMT/hOCT3 for TEA. Verapamil, cimetidine, carbamazepine, quinidine, and desipramine inhibited the carnitine uptake but required supratherapeutic concentrations, suggesting robustness of the carnitine uptake systems against xenobiotic challenge. Our findings suggest functional roles of a network of multiple SLC organic cation/nutrient transporters in human mammary gland drug transfer.

Developmental maturation and segmental distribution of rat small intestinal L-carnitine uptake

Oral L-carnitine supplementation is commonly used in sports nutrition and in medicine; however, there is controversy regarding the mechanisms that mediate intestinal L-carnitine transport. We have previously reported that the Na(+)/L-carnitine transporter OCTN2 is present in the small intestinal apical membrane. Herein we aimed to find out if this step of intestinal L-carnitine absorption is ontogenically regulated, and if so, to determine the molecular mechanism(s) involved. L-[(3)H]-Carnitine uptake was measured in the jejunum and ileum of fetuses (E17 and E21), newborn (1 day-old), suckling (15 day-old), weaning (1 month-old) and adult (2 and 6 month-old) Wistar rats. Both, Na(+) -dependent and Na(+) -independent L-carnitine uptake rates, normalized to intestinal weight, significantly increased during the late gestation period, and then declined during the suckling period. After weaning, the rate of Na(+) -dependent L-carnitine uptake is no longer measurable. In E21- fetuses and newborn rats, L-carnitine uptake was higher in the ileum than in the jejunum. The decline in Na(+) -dependent L-carnitine uptake with maturation was mediated via a decrease in the V(max) of the uptake process with no change in its apparent K(m). Semi-quantitative RT-PCR assays showed that OCTN2 mRNA levels were significantly higher in E21-fetuses and newborn rats compared to suckling rats, which were in turn significantly higher than that in adult rats. Neither retardation of weaning nor L-carnitine supplementation prevented the down-regulation of Na(+)/L-carnitine transport activity. The results demonstrate for the first time that intestinal Na(+) -dependent L-carnitine uptake activity is under genetic regulation at the transcriptional level.

Propionyl-L-carnitine improves hemodynamics and metabolic markers of cardiac perfusion during coronary surgery in diabetic patients

Diabetic hearts are particularly vulnerable to ischemia-reperfusion injury during cardiac surgery. Application of carnitine derivatives could be beneficial not only because of metabolic effects but also by protecting vasculature. This study aimed to evaluate hemodynamic changes associated with propionyl-L-carnitine and L-carnitine administration and its correlation with biochemical markers of cardiac vascular function.

METHODS

Sixty-eight diabetic patients undergoing cardiopulmonary bypass coronary operation were given intravenously 20 mg/kg b.w. L-carnitine (LC), 24 mg/kg b.w. propionyl-L-carnitine (PC), or placebo (Cont). Endothelin and nucleotide metabolites were determined intraoperatively in arterial and coronary sinus blood and heart biopsies.

RESULTS

Cardiac index at 6 and 12 h after cardiopulmonary bypass was significantly higher in PC (3.30 +/- 0.12 and 3.47 +/- 0.15 L/min/m2) as compared to Cont (2.92 +/- 0.13 and 2.91 +/- 0.16 L/min/m2; P = 0.04 and P = 0.01, respectively). Mean pulmonary artery pressure was lower in PC at 6 (20.8 +/- 0.91 mmHg) and 12 h (20.7 +/- 0.81 mmHg) in comparison to Cont (23.5 +/- 0.75 and 23.4 +/- 0.75 mmHg; P = 0.03 and P = 0.02, respectively). Trans-cardiac endothelin difference on reperfusion was higher in Cont (0.33 +/- 0.26 pmol/L) than in LC (-0.61 +/- 0.24 pmol/L, P = 0.012) and tended to be higher than in PC (-0.29 +/- 0.17 pmol/L, P = 0.056). Trans-cardiac hypoxanthine difference after 10 min reperfusion was significantly higher in Cont (6.22 +/- 1.08 micromol/L) in comparison to LC (3.17 +/- 0.66 micromol/L, P = 0.025) and PC (2.36 +/- 0.73 micromol/L, P = 0.006). Myocardial hypoxanthine concentration was lowest in PC.

CONCLUSIONS

Significant improvement of hemodynamics following propionyl-L-carnitine administration in diabetic patients undergoing on-bypass coronary surgery was accompanied by reduced trans-cardiac endothelin difference and rapid hypoxanthine washout during reperfusion suggesting improvement of metabolism or vascular function.

l-Carnitine suppresses the onset of neuromuscular degeneration and increases the life span of mice with familial amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a fatal disease caused by progressive degeneration of motor neurons in the spinal cord and motor cortex. Although the etiology of ALS remains unknown, a mutation of the gene encoding Cu,Zn-superoxide dismutase (SOD1) has been reported in 20% of familial cases of ALS (FALS). Transgenic mice that overexpress a mutated human SOD1 exhibit a phenotype and pathology similar to those observed in patients with FALS. Mitochondrial abnormality has been reported in patients with ALS and in animal models of FALS. We recently reported that L-carnitine, an essential cofactor for the beta-oxidation of long-chain fatty acids, effectively inhibits various types of mitochondrial injury and apoptosis both in vitro and in vivo. The present study demonstrates that oral administration of L-carnitine prior to disease onset significantly delayed the onset of signs of disease (log-rank P=0.0008), delayed deterioration of motor activity, and extended life span (log-rank P=0.0001) in transgenic mice carrying a human SOD1 gene with a G93A mutation (Tg). More importantly, subcutaneous injection of L-carnitine increased the life span of Tg mice (46% increase in male, 60% increase in female) even when given after the appearance of signs of disease.

Mutation in an Adaptor Protein PDZKI Affects Transport Activity of Organic Cation Transporter OCTNs and Oligopeptide Transporter PEPT2

Genetic polymorphisms in xenobiotic transporters have recently been clarified to be associated with change in drug distribution and disposition. To expand on recent identification of direct interaction and functional regulation of several transporters by a PDZ (PSD95, Dlg and ZO1) domain containing protein PDZK1, the effect of mutation in PDZK1 on transport activity and subcellular localization of organic cation/carnitine transporters OCTN1 and OCTN2, and oligopeptide transporter PEPT2 was examined in the present study. HEK293 cells stably expressing a mutant transcript PDZK1-E195K (HEK293/PDZK1-E195K) were constructed, followed by transient transfection of cDNA for each transporter. Uptake of tetraethylammonium by OCTN1 was much higher in HEK293/PDZK1 cells, compared with that in the parent HEK293 cells, the uptake in HEK293/PDZK1-E195K cells showing middle range between the two values. Such difference in transport activity was accounted for the difference in transport capacity, with minimal change in affinity of OCTN1 to the substrate or other compounds. The similar difference among HEK293/PDZK1, HEK293/PDZK1-E195K and HEK293 cells was also observed in transport property of OCTN2 and PEPT2, whereas the difference was not so remarkable in each transporter with the last four amino acids deleted, that has much lower interaction potential with PDZK1. Immunohistochemical analysis indicated that OCTN1 was colocalized with PDZK1 on cell-surface, whereas colocalization with PDZK1-E195K was partially observed in cytoplasmic region. These results suggest a novel hypothesis that mutation in PDZK1 potentially changes transport property of various types of xenobiotic transporters by affecting their subcellular localization, possibly leading to change in disposition of various types of substrate drugs.

Effects of dietary ruminally protected l-carnitine on plasma metabolites in sheep following a sub-lethal ammonia challenge

In Experiment 1, lambs were randomly assigned to 0.25, 1.00, 2.50, 5.00 and 10.00 g/day of dietary ruminally protected L-carnitine (RPLC) and were allowed to adapt for 20 days. Plasma samples were obtained at 0, 120 and 240 min after RPLC feeding. Plasma L-carnitine (LC) concentrations increased (p<0.01) for all levels of RPLC treatment, however, no differences were observed due to level of RPLC or time. Plasma LC concentrations were 27.05 and 57.83 micromol/l for baseline and pooled RPLC treated sheep, respectively. In Experiment 2, lambs were randomly assigned to 0, 0.125, 1.06 and 2.0 g/day of RPLC and were adapted as in Experiment 1. Plasma was collected at 0, 15, 30, 60, 90, 180, 240 and 360 min after oral ammonia challenge (300 mg/kg BW urea). Plasma LC concentrations increased with treatment relative to control (p<0.01). Plasma LC concentrations were 35.7, 44.2, 60.5 and 65.7 micromol/l for the 0, 0.125, 1.06 and 2.0 g/day treatments, respectively. RPLC tended to decrease plasma ammonia at some time points (time x treatment; p=0.10). We conclude that RPLC increased plasma LC concentrations, but had only modest effects on plasma ammonia concentrations and had no effect on plasma urea or glucose concentrations.

[Stereopharmacology of carnitine]

L-Carnitine (L-beta-hydroxy-gamma-N,N,N-trimethylaminobutyric acid) plays an essential role in fatty acid transport in the mitochondrion. Conditions that appear to benefit from exogenous supplementation of L-carnitine include anorexia, chronic fatigue, cardiovascular disease, hypoglycemia, male infertility, muscular myopathies, renal failure and dialysis. D-Carnitine is not biologically active and might interfere with the proper utilization of the L isomer, and so there are claims that the racemic mixture (DL-carnitine) should be avoided. Despite the fact that it is known about the systemic manifestations of oral intake of this compound, oral supplementation with DL-carnitine for treatment of primary and secondary carnitine deficiency syndromes has been used in Russia for 25 years. The purpose of the present review was to contrast the differences in pharmacokinetics, phannacodynamics, biochemistry, and toxicity between treatments of L- and DL-carnitine. There is some evidence that L-carnitine and D-carnitine compete for uptake in small intestine and tubular re-absorption in kidneys. After intestinal absorption, L- and D-carnitine is transferred to organs whose metabolism is dependent on fatty acid oxidation, such as heart and skeletal muscle, and D-carnitine competitively depletes muscle level of L-carnitine. Whereas L-carnitine is found to be essential for the oxidation of fatty acids, D-carnitine causes a depletion of L-carnitine, and hindered fatty acid oxidation and energy formation. Pharmacological effects of carnitine are stereospecific, since L-carnitine was effective in various animals and clinical studies, while D- and DL-carnitine was found to be ineffective or toxic, for example, to muscle cells and to the myocardium. DL-Carnitine causes symptoms of myasthenia and cardiac arrhythmias, which disappeared after L-carnitine administration. Clinically toxic effect of D-carnitine was described in patients with renal failure on long-term haemodialysis, in adriamycin (doxorubicin) cardiotoxicity and in stable angina pectoris.

Free and total carnitine concentrations in pig plasma after oral ingestion of various L-carnitine compounds

This study was undertaken to investigate the bioavailability of various L-carnitine esters (acetyl-L-carnitine and lauroyl-L-carnitine) and salts (L-carnitine L-tartrate, L-carnitine fumarate, L-carnitine magnesium citrate) relative to base of free L-carnitine. Six groups of five or six piglets each were administered orally a single dose of 40 mg L-carnitine equivalents/kg body weight of each of those L-carnitine compounds. A seventh group served as a control. Free and total plasma carnitine concentrations were determined 1, 2, 3.5, 7, 24, and 32 hours after administration of the single dose. Area-under-the-curve (AUC) values were calculated to assess the bioavailability of the L-carnitine compounds. AUC values, calculated for the time interval between 0 and 32 hours, for both free and total carnitine were similar for base of free L-carnitine and the three L-carnitine salts (L-carnitine L-tartrate, L-carnitine fumarate, L-carnitine magnesium citrate) while those of the two esters (acetyl-L-carnitine, lauroyl-L-carnitine) were lower. Administration of L-carnitine L-tartrate yielded a higher plasma free carnitine AUC value for the time interval between 0 and 3.5 hours than administration of the other compounds. The data of this study suggest that L-carnitine salts have a similar bioavailability to that of free L-carnitine while L-carnitine esters have a lower one. The study also suggests that L-carnitine L-tartrate is absorbed faster than the other L-carnitine compounds.

Effects of Acute versus Chronic L-Carnitine L-tartrate Supplementation on Metabolic Responses to Steady State Exercise in Males and Females

Twelve healthy active subjects (6 male, 6 female) performed 60 min of exercise (60% VO2max) on 3 occasions after supplementing with L-Carnitine L-tartrate (LCLT) or placebo. Each subject received a chronic dose, an acute dose, and placebo in a randomized, double-blind crossover design. Dietary intake and exercise were replicated for 2 d prior to each trial. In males there was a significant difference in rate of carbohydrate (CHO) oxidation between placebo and chronic trials (P = 0.02) but not placebo and acute trials (P = 0.70), and total CHO oxidation was greater following chronic supplementation vs. placebo (mean ± standard deviation) of 93.8 (17.3) g/hr and 78.2 (23.3) g/h, respectively). In females, no difference in rate of, or total, CHO oxidation was observed between trials. No effects on fat oxidation or hematological responses were noted in either gender group. Under these experimental conditions, chronic LCLT supplementation increased CHO oxidation in males during exercise but this was not observed in females

Science review: carnitine in the treatment of valproic acid-induced toxicity - what is the evidence?

Valproic acid (VPA) is a broad-spectrum antiepileptic drug and is usually well tolerated, but rare serious complications may occur in some patients receiving VPA chronically, including haemorrhagic pancreatitis, bone marrow suppression, VPA-induced hepatotoxicity (VHT) and VPA-induced hyperammonaemic encephalopathy (VHE). Some data suggest that VHT and VHE may be promoted by carnitine deficiency. Acute VPA intoxication also occurs as a consequence of intentional or accidental overdose and its incidence is increasing, because of use of VPA in psychiatric disorders. Although it usually results in mild central nervous system depression, serious toxicity and even fatal cases have been reported. Several studies or isolated clinical observations have suggested the potential value of oral L-carnitine in reversing carnitine deficiency or preventing its development as well as some adverse effects due to VPA. Carnitine supplementation during VPA therapy in high-risk patients is now recommended by some scientific committees and textbooks, especially paediatricians. L-carnitine therapy could also be valuable in those patients who develop VHT or VHE. A few isolated observations also suggest that L-carnitine may be useful in patients with coma or in preventing hepatic dysfunction after acute VPA overdose. However, these issues deserve further investigation in controlled, randomized and probably multicentre trials to evaluate the clinical value and the appropriate dosage of L-carnitine in each of these conditions.

Effect of methanol on endogenous and exogenous carnitine levels in rat plasma

The effect of methanol on the levels of endogenous carnitine and its derivatives was studied in male Sprague-Dawley rats aged three months. In addition, the effect of L-carnitine supplementation on metabolic disturbances caused by methanol intoxication was studied. The rats were randomized into six groups, including two control groups. Methanol was given at 1/4 LD(50) and 1/2 LD(50)/kg b.w. (or water in control) through an intragastric tube, and L-carnitine (or 0.9% NaCl in the control) was injected intraperitoneally. The levels of plasma L-carnitine and its derivatives were measured at selected time points for four days. Following methanol administration, the rats exhibited dose-dependent increases in L-carnitine levels and altered ratios of L-carnitine and its derivatives. L-carnitine supplementation accelerated the normalization of metabolic disturbances, as indicated by the acylcarnitine to free carnitine ratio (AC/FC). The protective effect of L-carnitine is supported by the fact that 100% of the methanol-treated rats supplemented with carnitine survived, while 8/60 rats and 27/101 rats died at methanol doses of 1/4 LD(50) and 1/2 LD(50), respectively, in groups without L-carnitine supplementation.

Kinetics, pharmacokinetics, and regulation of L-carnitine and acetyl-L-carnitine metabolism

In mammals, the carnitine pool consists of nonesterified L-carnitine and many acylcarnitine esters. Of these esters, acetyl-L-carnitine is quantitatively and functionally the most significant. Carnitine homeostasis is maintained by absorption from diet, a modest rate of synthesis, and efficient renal reabsorption. Dietary L-carnitine is absorbed by active and passive transfer across enterocyte membranes. Bioavailability of dietary L-carnitine is 54-87% and is dependent on the amount of L-carnitine in the meal. Absorption of L-carnitine dietary supplements (0.5-6 g) is primarily passive; bioavailability is 14-18% of dose. Unabsorbed L-carnitine is mostly degraded by microorganisms in the large intestine. Circulating L-carnitine is distributed to two kinetically defined compartments: one large and slow-turnover (presumably muscle), and another relatively small and rapid-turnover (presumably liver, kidney, and other tissues). At normal dietary L-carnitine intake, whole-body turnover time in humans is 38-119 h. In vitro experiments suggest that acetyl-L-carnitine is partially hydrolyzed in enterocytes during absorption. In vivo, circulating acetyl-L-carnitine concentration was increased 43% after oral acetyl-L-carnitine supplements of 2 g/day, indicating that acetyl-L-carnitine is absorbed at least partially without hydrolysis. After single-dose intravenous administration (0.5 g), acetyl-L-carnitine is rapidly, but not completely hydrolyzed, and acetyl-L-carnitine and L-carnitine concentrations return to baseline within 12 h. At normal circulating l-carnitine concentrations, renal l-carnitine reabsorption is highly efficient (90-99% of filtered load; clearance, 1-3 mL/min), but displays saturation kinetics. Thus, as circulating L-carnitine concentration increases (as after high-dose intravenous or oral administration of L-carnitine), efficiency of reabsorption decreases and clearance increases, resulting in rapid decline of circulating L-carnitine concentration to baseline. Elimination kinetics for acetyl-L-carnitine are similar to those for L-carnitine. There is evidence for renal tubular secretion of both L-carnitine and acetyl-L-carnitine. Future research should address the correlation of supplement dosage, changes and maintenance of tissue L-carnitine and acetyl-L-carnitine concentrations, and metabolic and functional changes and outcomes.

Carnitine and Sports Medicine: Use or Abuse?

Carnitine has important roles in skeletal muscle bioenergetics. Skeletal muscle carnitine deficiency is associated with profound impairment of muscle function. It has thus been natural to ask if carnitine supplementation can improve skeletal muscle function and athletic performance in healthy individuals. Oral carnitine doses of several grams cause no significant clinical toxicity, further encouraging the use of carnitine as a supplement. Despite this strong foundation and 20 years of research, no compelling evidence exists that carnitine supplementation can improve physical performance in healthy subjects. The available data have been reviewed in recent publications. Several key issues are relevant to a potential therapeutic benefit of carnitine supplementation, and addressing these may provide insight into trials of carnitine therapy in healthy subjects: (1) Can carnitine supplementation increase skeletal muscle carnitine content in healthy subjects? Muscle carnitine content is not easily increased with carnitine supplementation. This reflects both the systemic pharmacokinetics of carnitine and the systems controlling transmembrane transport of carnitine in skeletal muscle. (2) How much carnitine is required to support optimal metabolism in skeletal muscle? Data are not available to definitively define the relationship between muscle carnitine content and muscle metabolic function. Extrapolation of data from several models suggests that very low amounts of carnitine are required to support muscle function. (3) Does carnitine supplementation alter energy homeostasis in healthy subjects? Several, but not all, studies suggest that subjects on carnitine supplementation have altered regulation of fuel homeostasis. However, the mechanisms of these changes, the tissues affected, and the relevance of these phenomena to exercise performance are all ill defined. (4) How can changes in performance be assessed in healthy subjects? Most studies have failed to demonstrate an objective performance improvement in healthy subjects taking carnitine. However, these negative studies must be interpreted with caution. Performance studies in athletes are conducted against a background of aggressive training regimens and nutritional interventions. Small changes, which may be very important to the athlete, may be very hard to objectify in the laboratory. Assessments must differentiate between changes in maximal aerobic capacity, ability to sustain effort at varied workloads, and the subject's perception of exertion. The interaction of carnitine supplementation with exercise training may be particularly important on theoretical and experimental bases. Systematic research in each of these areas is required to better understand the physiology, biochemistry, and pharmacology of carnitine supplementation. While data do not allow a conclusion to be drawn that carnitine is beneficial, the negative has not been proven either.

l-Carnitine transport in human placental brush-border membranes is mediated by the sodium-dependent organic cation transporter OCTN2

Maternofetal transport of l-carnitine, a molecule that shuttles long-chain fatty acids to the mitochondria for oxidation, is thought to be important in preparing the fetus for its lipid-rich postnatal milk diet. Using brush-border membrane (BBM) vesicles from human term placentas, we showed that l-carnitine uptake was sodium and temperature dependent, showed high affinity for carnitine (apparent Km= 11.09 ± 1.32 μM; Vmax= 41.75 ± 0.94 pmol·mg protein−1·min−1), and was unchanged over the pH range from 5.5 to 8.5. l-Carnitine uptake was inhibited in BBM vesicles by valproate, verapamil, tetraethylammonium, and pyrilamine and by structural analogs of l-carnitine, including d-carnitine, acetyl-d,l-carnitine, and propionyl-, butyryl-, octanoyl-, isovaleryl-, and palmitoyl-l-carnitine. Western blot analysis revealed that OCTN2, a high-affinity, Na+-dependent carnitine transporter, was present in placental BBM but not in isolated basal plasma membrane vesicles. The reported properties of OCTN2 resemble those observed for l-carnitine uptake in placental BBM vesicles, suggesting that OCTN2 may mediate most maternofetal carnitine transport in humans.

Levocarnitine administration in elderly subjects with rapid muscle fatigue: effect on body composition, lipid profile and fatigue

AIM

Levocarnitine is an important contributor to cellular energy metabolism. This study aims to evaluate the effects of levocarnitine supplementation on body composition, lipid profile and fatigue in elderly subjects with rapid muscle fatigue.

METHOD

This was a placebo-controlled, randomised, double-blind, two-phase study. Eighty-four elderly subjects with onset of fatigue following slight physical activity were recruited to the study. Prior to randomisation all patients entered a 2-week normalisation phase where they were given an 'ad libitum'diet, according to the National Cholesterol Education Program (Step 2). Subjects were asked to record their daily food intake every 2 days. Before the 30-day treatment phase, subjects were randomly assigned to two groups (matched for male/female ratio, age and body mass index). One group received levocarnitine 2g twice daily (n = 42) and the other placebo (n = 42). Efficacy measures included changes in total fat mass, total muscle mass, serum triglyceride, total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), apolipoprotein (apo)A1, and apoB levels. The Wessely and Powell scale was used to evaluate physical and mental fatigue. Subjects were assessed at the beginning and end of the study period.

RESULTS

At the end of the study, compared with placebo, the levocarnitine-treated patients showed significant improvements in the following parameters: total fat mass (-3.1 vs -0.5 kg), total muscle mass (+2.1 vs +0.2 kg), total cholesterol (-1.2 vs +0.1 mmol/L), LDL-C (-1.1 vs -0.2 mmol/L), HDL-C (+0.2 vs +0.01 mmol/L), triglycerides (-0.3 vs 0.0 mmol/L), apoA1 (-0.2 vs 0.0 g/L), and apoB (-0.3 vs -0.1 g/L). Wessely and Powell scores decreased significantly by 40% (physical fatigue) and 45% (mental fatigue) in subjects taking levocarnitine, compared with 11% and 8%, respectively, in the placebo group (p < 0.001 vs placebo for both parameters). No adverse events were reported in any treatment group.

CONCLUSION

Administration of levocarnitine to healthy elderly subjects resulted in a reduction of total fat mass, an increase of total muscle mass, and appeared to exert a favourable effect on fatigue and serum lipids.

Pharmacokinetics of L-carnitine

L-Carnitine is a naturally occurring compound that facilitates the transport of fatty acids into mitochondria for beta-oxidation. Exogenous L-carnitine is used clinically for the treatment of carnitine deficiency disorders and a range of other conditions. In humans, the endogenous carnitine pool, which comprises free L-carnitine and a range of short-, medium- and long-chain esters, is maintained by absorption of L-carnitine from dietary sources, biosynthesis within the body and extensive renal tubular reabsorption from glomerular filtrate. In addition, carrier-mediated transport ensures high tissue-to-plasma concentration ratios in tissues that depend critically on fatty acid oxidation. The absorption of L-carnitine after oral administration occurs partly via carrier-mediated transport and partly by passive diffusion. After oral doses of 1-6g, the absolute bioavailability is 5-18%. In contrast, the bioavailability of dietary L-carnitine may be as high as 75%. Therefore, pharmacological or supplemental doses of L-carnitine are absorbed less efficiently than the relatively smaller amounts present within a normal diet.L-Carnitine and its short-chain esters do not bind to plasma proteins and, although blood cells contain L-carnitine, the rate of distribution between erythrocytes and plasma is extremely slow in whole blood. After intravenous administration, the initial distribution volume of L-carnitine is typically about 0.2-0.3 L/kg, which corresponds to extracellular fluid volume. There are at least three distinct pharmacokinetic compartments for L-carnitine, with the slowest equilibrating pool comprising skeletal and cardiac muscle.L-Carnitine is eliminated from the body mainly via urinary excretion. Under baseline conditions, the renal clearance of L-carnitine (1-3 mL/min) is substantially less than glomerular filtration rate (GFR), indicating extensive (98-99%) tubular reabsorption. The threshold concentration for tubular reabsorption (above which the fractional reabsorption begins to decline) is about 40-60 micromol/L, which is similar to the endogenous plasma L-carnitine level. Therefore, the renal clearance of L-carnitine increases after exogenous administration, approaching GFR after high intravenous doses. Patients with primary carnitine deficiency display alterations in the renal handling of L-carnitine and/or the transport of the compound into muscle tissue. Similarly, many forms of secondary carnitine deficiency, including some drug-induced disorders, arise from impaired renal tubular reabsorption. Patients with end-stage renal disease undergoing dialysis can develop a secondary carnitine deficiency due to the unrestricted loss of L-carnitine through the dialyser, and L-carnitine has been used for treatment of some patients during long-term haemodialysis. Recent studies have started to shed light on the pharmacokinetics of L-carnitine when used in haemodialysis patients.

Betaine and carnitine uptake systems in Listeria monocytogenes affect growth and survival in foods and during infection

AIMS

To establish the relative importance of the osmo- and cryoprotective compounds glycine betaine and carnitine, and their transporters, for listerial growth and survival, in foods and during infection.

METHODS AND RESULTS

A set of Listeria monocytogenes mutants with single, double and triple mutations in the genes encoding the principal betaine and carnitine uptake systems (gbu, betL and opuC, respectively) was used to determine the specific contribution of each transporter to listerial growth and survival. Food models were chosen to represent high-risk foods of plant and animal origin i.e. coleslaw and frankfurters, which have previously been linked to major human outbreaks of listeriosis. BALB/c mice were used as an in vivo model of infection. Interestingly, while betaine appeared to confer most protection in foods, the hierarchy of transporter importance differs depending on the food type: Gbu>BetL>OpuC for coleslaw, as opposed to Gbu>OpuC>BetL in frankfurters. By contrast in the animal model, OpuC and thus carnitine, appears to play the dominant role, with the remaining systems contributing little to the infection process.

CONCLUSIONS

This study demonstrates that the individual contribution of each system appears dependent on the immediate environment. In foods Gbu appears to play the dominant role, while during infection OpuC is most important.

SIGNIFICANCE AND IMPACT OF THE STUDY

It is envisaged that this information may ultimately facilitate the design of effective control measures specifically targeting this pathogen in foods and during infection.

Effect of salt stress on crotonobetaine and D(+)-carnitine biotransformation into L(-)-carnitine by resting cells of Escherichia coli

The biotransformation of crotonobetaine and D(+)-carnitine into L(-)-carnitine is affected by salt stress in the resting cells of E. coli O44 K74 and the transformed E. coli K38 pT7-5KE32. A yield of 65 and 80% of L(-)-carnitine, respectively, were obtained with 0.5 M NaCl with the wild and transformed strain compared with the 40% obtained with the control. Higher salt levels reduced the conversion. In L(-)-carnitine transport studies using both strains, the transformed strain presented slightly lower apparent K(m) and V values. Arsenate reduced both the transport and biotransformation of crotono-betaine in the presence or absence of 0.5 M NaCl, whereas vanadate only inhibited these processes under salt stress conditions. Hg(II) inhibited both the transport and biotransformation and Pb(II) reduced the biotransformation only under salt stress conditions. Cu(II) produced a significantly higher decrease than Pb(II) in the biotransformation with both substrates in the absence of salt stress conditions, but only affected transport in the presence of such conditions. Furthermore, salt stress affected the CaiT transporter for L(-)-carnitine and crotonobetaine and induced ProU and ProP in the absence of the inducer of the L(-)-carnitine metabolism. It is highly likely that the increase in L(-)-carnitine production was not only due to improved transport but also to the permeabilization effect caused by NaCl, as transport and 1-N-phenylnaphthylamine uptake studies revealed.

L-carnitine transport in kidney of normotensive, Wistar-Kyoto rats: effect of chronic L-carnitine administration

PURPOSE

To examine the effect of long-term administration of L-carnitine on L-carnitine transport in renal brush-border membrane vesicles (BBMVs) from normotensive, Wistar-Kyoto rats.

METHODS

Rats (n = 20) were orally administered 0.2 g carnitine/kg body weight per day for a total period of 8 weeks. Kinetic parameters of L-carnitine uptake were calculated by non-linear regression, and the relative abundance of the carnitine transporter, OCTN2, was determined by Western blot analysis.

RESULTS

Initial rates and maximal overshoot levels of Na+-dependent L-carnitine transport were significantly reduced in BBMVs from L-carnitine-treated rats compared with untreated animals. Similarly, the maximal transport rate (Vmax) of OCTN2 was lower in treated rats. However, no differences were observed in the Michaelis constant (Km) or the diffusion constant (Kd) between the two groups of animals. The amount of OCTN2 protein was also decreased in L-carnitine-fed rats, this reduction being similar to that of the Vmax. These results were accompanied by an increase in the serum levels and also in the renal excretion of both free and esterified carnitine in treated rats, indicating that the long-term administration of L-carnitine leads to increased renal carnitine clearance.

CONCLUSION

These findings suggest a downregulation of OCTN2 at the renal level, in the presence of high levels of carnitine.

Molecular cloning and functional characterization of the OCTN2 transporter at the RBE4 cells, an in vitro model of the blood-brain barrier

The transport of L-carnitine (4-N-trimethylamino-3-hydroxybutyric acid), a compound known to be transported by the organic cation transporter/carnitine transporter OCTN2, was studied in immortalized rat brain endothelial cells (RBE4). The cells were found to take up L-carnitine by a sodium-dependent process. This uptake process was saturable with an apparent Michaelis-Menten constant for L-carnitine of 54+/-10 microM and a maximal velocity of 215+/-35 pmol/mg protein/h. Besides L-carnitine, the cells also took up acetyl-L-carnitine and propionyl-L-carnitine in a sodium-dependent manner and TEA in a sodium-independent manner. RT-PCR with primers specific for the rat OCTN2 transporter revealed the existence of OCTN2 mRNA in RBE4 cells. Screening of a cDNA library from RBE4 cells with rat OCTN2 cDNA as a probe identified a positive clone which showed, when expressed in HeLa cells, the functional characteristics of OCTN2. The HeLa cells expressing the RBE4 OCTN2 cDNA showed a sixfold increase in L-carnitine uptake and a fourfold increase in TEA uptake in a sodium-containing buffer. Typical inhibitors for organic cation transporters (e.g. MPP(+) or TEA) showed an inhibitory effect on the transport of L-carnitine and TEA into the transfected cells. Similarly, unlabeled L-carnitine inhibited the transport of [3H]-L-carnitine and [14C]TEA in transfected HeLa cells. It is concluded that RBE4 cells, a widely used in vitro model of the blood-brain barrier (BBB), express the organic cation/carnitine transporter OCTN2.

Dialysis-related carnitine disorder and levocarnitine pharmacology

Among the homeostatic processes controlling the endogenous L-carnitine pool in humans, the kidney has a vital role through extensive and adaptive tubular reabsorption. Kidney disease can lead to disturbances in L-carnitine homeostasis, and long-term hemodialysis therapy can lead to a significant reduction in plasma and tissue L-carnitine levels and an increase in the ratio of acyl-L-carnitine to free L-carnitine. These alterations may interfere with the oxidation of fatty acids and removal from tissues of unwanted short-chain acyl groups. A dialysis-related carnitine disorder (DCD) arises when these biochemical abnormalities exist in association with such clinical symptoms as muscle weakness, cardiomyopathy, intradialytic hypotension, or anemia that is resistant to erythropoietin therapy. Exogenous L-carnitine, administered intravenously, is approved for the treatment of secondary carnitine deficiency caused by long-term hemodialysis. Although intravenous administration of 20-mg/kg doses at the end of each hemodialysis session leads to supraphysiological levels of the compound in plasma, these levels do not appear to be associated with adverse effects. Because more than 99% of the body's carnitine pool is located outside of plasma, supraphysiological plasma levels appear to be required to ensure that depleted muscle stores can be replenished. Although oral L-carnitine has been used for the treatment of DCD, the bioavailability of oral L-carnitine is low (<15%) in healthy subjects and unknown in patients with end-stage renal disease. Moreover, gastrointestinal degradation of L-carnitine to trimethylamine and other compounds might limit the usefulness of long-term oral L-carnitine administration in this patient group.

Impact on carnitine homeostasis of short-term treatment with the pivalate prodrug cefditoren pivoxil

BACKGROUND

Pivalate-generating prodrugs have been suggested to cause clinically significant hypocarnitinemia. To evaluate the effect of pivalate prodrug treatment on carnitine homeostasis, we administered a pivalate prodrug, cefditoren pivoxil, to healthy subjects and performed carnitine balance studies.

METHODS

Cefditoren pivoxil was administered in one of two dosing regimens (200 mg cefditoren twice daily for 10 days or 400 mg cefditoren twice daily for 14 days) to gender-balanced groups of 15 subjects. Plasma and urine concentrations of carnitine, acetylcarnitine, pivaloylcarnitine, and total carnitine were quantified before, during, and after treatment.

RESULTS

Plasma carnitine concentrations fell during cefditoren pivoxil dosing. The nadir in carnitine concentration was dependent on the dose of cefditoren and subject gender (decrease from 44.8 +/- 10.9 micromol/L to 9.2 +/- 1.9 micromol/L in male patients and from 32.5 +/- 5.4 micromol/L to 6.3 +/- 1.7 micromol/L in female patients after 14 days of 400 mg cefditoren twice daily). Urinary elimination of pivaloylcarnitine resulted in a marked increase in total carnitine excretion, as well as net losses of total carnitine of approximately 4.6 mmol with the 200-mg, 10-day regimen and up to 14.9 mmol with the 400-mg, 14-day regimen. Pivaloylcarnitine was the dominant form of excreted pivalate.

DISCUSSION

Short-term administration of cefditoren pivoxil results in hypocarnitinemia and increased net losses of total carnitine. It is estimated that net carnitine losses were only 10% of body stores, even with the highest dose regimen tested. Losses of this magnitude would not be anticipated to result in adverse clinical effects.

Exercise intolerance during post-MI heart failure in rats: prevention with supplemental dietary propionyl-L-carnitine

Exercise capacity in patients with several types of cardiovascular disease can be improved with dietary carnitine, or carnitine derivatives. Mechanisms underlying this improvement remain largely unknown in part due to a lack of animal models of cardiac pathology in which carnitine derivatives improve exercise tolerance. Our goal was to evaluate the ability of propionyl-L-carnitine (PLC) to improve exercise tolerance in a rat model of exercise intolerance. Fischer 344 rats were followed after either a moderate size MI (n = 22) or sham MI surgery (n = 14). Starting 10 days post-surgery 10 of the MI and 7 of the sham rats received 100 mg/kg/day PLC in drinking water, which increased plasma and LV total l-carnitine concentrations 15-23% (p < 0.05). Rats were followed longitudinally until a statistically significant decrease in exercise capacity occurred in one of the groups, at which time all rats were sacrificed for study of the isolated perfused hearts. At 12-weeks post-MI exercise capacity had decreased 16 +/- 7% (p < 0.05) in the MI group, but remained within 3% of baseline in the MI group that received PLC and the sham groups. Both MI groups exhibited the same degree of LV dilation, decrease in fractional shortening, and blunting of the response to isoproterenol. We conclude that supplemental dietary PLC attenuates the exercise intolerance that occurs secondary to post-MI heart failure in rats, but that this beneficial effect is not attributable to altered LV remodeling, an improved response to beta-adrenergic stimulation, or increased skeletal muscle citrate synthase activity.

[Biopharmaceutical studies on molecular mechanisms of membrane transport]

By incorporating the transporter-mediated or receptor-mediated transport process in physiologically based pharmacokinetic models, we succeeded in the quantitative prediction of plasma and tissue concentrations of beta-lactam antibiotics, insulin, pentazocine, quinolone antibacterial agents, and inaperizone and digoxin. The author's research on transporter-mediated pharmacokinetics focuses on the molecular and functional characteristics of drug transporters such as oligopeptide transporter, monocarboxylic acid transporter, anion antiporter, organic anion transporters, organic cation/carnitine transporters (OCTNs), and the ATP-binding cassette transporters P-glycoprotein and MRP2. We have successfully demonstrated that these transporters play important roles in the influxes and/or effluxes of drugs in intestinal and renal epithelial cells, hepatocytes, and brain capillary endothelial cells that form the blood-brain barrier. In the systemic carnitine deficiency (SCD) phenotype mouse model, juvenile visceral steatosis (jvs) mouse, a mutation in the OCTN2 gene was found. Furthermore, several types of mutation in human SCD patients were found, demonstrating that OCTN2 is a physiologically important carnitine transporter. Interestingly, OCTNs transport carnitine in a sodium-dependent manner and various cationic drugs transport it in a sodium-independent manner. OCTNs are thought to be multifunctional transporters for the uptake of carnitine into tissue cells and for the elimination of intracellular organic cationic drugs.

Pivalate-generating prodrugs and carnitine homeostasis in man

Prodrugs that liberate pivalate (trimethylacetic acid) after hydrolysis have been developed to improve the bioavailability of therapeutic candidates. Catabolism of pivalate released by activation of a prodrug is limited in mammalian tissues. Pivalate can be activated to a coenzyme A thioester in cells. In humans, formation and urinary excretion of pivaloylcarnitine generated from pivaloyl-CoA is the major route of pivalate elimination. Because the total body carnitine pool is limited and can only slowly be replenished through normal diet or biosynthesis, treatment with large doses of pivalate prodrugs may deplete tissue carnitine content. Animal models and long-term treatment of patients with pivalate prodrugs have resulted in toxicity consistent with carnitine depletion. However, low plasma carnitine concentrations after pivalate prodrug exposure may not reflect tissue carnitine content and, thus, cannot be used as a surrogate for potential toxicity. The extent of tissue carnitine depletion will be dependent on the dose of pivalate, because carnitine losses may approximate the pivalate exposure on a stoichiometric basis. These concepts, combined with estimates of carnitine dietary intake and biosynthetic rates, can be used to estimate the impact of pivalate exposure on carnitine homeostasis. Thus, even in populations with altered carnitine homeostasis due to underlying conditions, the use of pivalate prodrugs for short periods of time is unlikely to result in clinically significant carnitine depletion. In contrast, long-term treatment with substantial doses of pivalate prodrugs may require administration of carnitine supplementation to avoid carnitine depletion.

Effects of oral L-carnitine supplementation on in vivo long-chain fatty acid oxidation in healthy adults

Despite an abundance of literature describing the basic mechanisms of action of L-carnitine metabolism, there remains some uncertainty regarding the effects of oral L-carnitine supplementation on in vivo fatty acid oxidation in normal subjects under normal conditions. It is well known that L-carnitine normalizes the metabolism of long-chain fatty acids in cases of carnitine deficiency. However, it has not yet been shown that L-carnitine influences the metabolism of long-chain fatty acids in subjects without disturbances in fatty acid metabolism. Therefore, we investigated the effects of oral L-carnitine supplementation on in vivo long-chain fatty acid oxidation by measuring 1-[(13)C] palmitic acid oxidation in healthy subjects before and after L-carnitine supplementation (3 x 1 g/d for 10 days). We observed a significant increase in (13)CO(2) exhalation. This is the first investigation to conclusively demonstrate that oral L-carnitine supplementation results in an increase in long-chain fatty acid oxidation in vivo in subjects without L-carnitine deficiency or without prolonged fatty acid metabolism.