Alpha Lipoic Acid

Alpha-lipoic acid (ALA) is indeed a potent antioxidant that can play a role in various cellular functions. It is a naturally occurring compound found in certain foods and is also synthesized in small amounts by the human body. ALA is known to work with mitochondria, which are the energy-producing organelles in cells, and it has been studied for its potential health benefits.

Some of the reported benefits of ALA include:

1. Antioxidant Properties: ALA can neutralize free radicals, which are unstable molecules that can cause oxidative stress and damage cells. By reducing oxidative stress, ALA may help protect cells from damage and support overall cellular health.

2. Metabolism Support: ALA has been studied for its potential to enhance cellular energy production and improve metabolic function. It may help convert glucose into energy and play a role in carbohydrate metabolism.

3. Anti-inflammatory Effects: ALA has shown some anti-inflammatory properties in studies, which may be beneficial in reducing inflammation in the body and supporting overall immune health.

4. Detoxification Support: Some research suggests that ALA may assist in the detoxification process by promoting the elimination of certain toxins from the body.

5. Skin Health: Due to its antioxidant properties, ALA is sometimes used in skincare products to help protect the skin from free radical damage.

Alpha-Lipoic Acid Alpha-lipoic acid (ALA), also known as thioctic acid, has been studied in the treatment of various medical conditions, including type-2 diabetes, burning mouth syndrome, fibromyalgia, chronic fatigue syndrome, neuropathy, cancer, and atherosclerosis.

Type-2 Diabetes

Type-2 diabetes is associated with high levels of oxidative stress.1 Specifically, diabetes impairs endothelial nitric oxide synthase activity and increases the production of reactive oxygen species, thus resulting in diminished nitric oxide bioavailability and increased oxidative stress.2 Alpha-lipoic acid, a disulfide compound that is produced in small quantities in cells and serves as an antioxidant at pharmacological doses, has been shown to improve insulin sensitivity in type-2 diabetic patients. In addition to its antioxidant properties, it is also beneficial in cases of diabetes because of its anti-inflammatory3 and hypoglycemic4 properties.

In one recent open-label study in which lean and obese individuals with type-2 diabetes were administered 600 mg ALA by mouth, twice per day for four weeks, treatment with ALA was associated with increased glucose effectiveness in both lean and obese diabetics relative to non-diabetic lean and obese controls.4 Lean diabetic patients were also found to have a higher degree of insulin sensitivity and lower fasting glucose. Furthermore, after ALA treatment, lactate and pyruvate before and after glucose loading were approximately 45% lower in both obese and lean diabetics, leading researchers to conclude that treatment with ALA prevents hyperglycemiainduced increments of serum lactate and pyruvate levels and increases glucose sensitivity.

As the result of another study, researchers concluded that oral treatment with 800 mg/day for 4 months may improve cardiac autonomic dysfunction in type-2 diabetics.5

Intravenous administration of ALA has also been shown to be beneficial in type-2 diabetes. In a small, randomized, controlled trial, 13 patients received either 1000 mg ALA or normal saline.6 Both groups were comparable in age, BMI, and duration of diabetes. They also had similar degrees of insulin resistance at baseline. After administration of ALA, patients experienced a significant increase of insulin-stimulated glucose disposal. Metabolic clearance rate for glucose rose by about 50% in the treatment group, while the control group did not experience any significant change. Similar results, specifically a 30% increase in insulin- stimulated glucose disposal, were demonstrated in an uncontrolled, pilot trial that administered 500 mg ALA intravenously per day over a 10-day period.7

In another study, while both oral and intravenous administration of ALA led to improvements in insulin sensitivity, the improvements associated with oral administration were minimal (about 20%) compared to the improvements seen with intravenous administration. The intravenous route of administration remained superior, despite higher doses of oral ALA (up to 1800 mg) and longer treatment time (30 days oral vs. 10 days IV).8-9

Atherosclerosis

 Oxidative stress is considered to be the primary cause in many cardiovascular diseases, including atherosclerosis.42 As we age, oxidative stress increases through an increase in the production of reactive oxygen species and/or a decrease in the body’s antioxidant defenses. This increase in oxidative stress is paralleled by an increase in cardiovascular conditions like atherosclerosis. Research demonstrates that antioxidants help to decrease the incidence of atherosclerosis. ALA exerts potent antioxidant effects on the body and has been studied in experimental models for its ability to prevent and reverse atherosclerosis.

In one study, Watanabe heritable hyperlipidemic rabbits were fed with high cholesterol chow for 6 weeks and then randomized to receive either high cholesterol diet alone or high cholesterol diet combined with 20 mg/kg/day of ALA for 12 weeks.43 At the end of the 12 weeks, researchers found that ALA decreased body weight by 15 ± 5% without alterations in lipid parameters and reduced atherosclerotic plaque in the abdominal aorta with morphological analysis revealing reduced lipid and inflammatory cell content. Furthermore, ALA improved vascular reactivity (as revealed by decreased constriction to angiotensin II and increased relaxation to acetylcholine and insulin), inhibited NF-κB activation, and decreased oxidative stress and expression of key adhesion molecules in the vasculature.

An unrelated study demonstrated the cardioprotective effects of ALA. Eighteen adult male New Zealand White rabbits were randomly assigned to three groups for 10 weeks. One group was fed with normal chow (control group), one was fed with a 1% high cholesterol diet to induce hypercholesterolemia, and the third group was fed a 1% high cholesterol diet plus 4.2 mg/body weight of ALA. At the end of the study, blood total cholesterol (TCHOL) and lowdensity lipoprotein (LDL) levels were found to be significantly lower in the ALA group compared to that of the group that consumed a high cholesterol diet alone. The ALA group also had less atherosclerotic plaque in their aortas than the group that consumed a high cholesterol diet alone, leading researchers to conclude that, apart from its antioxidant activity, ALA may also exert a lipid-lowering effect on TCHOL and LDL levels and may reduce atherosclerosis formation in rabbits fed a high cholesterol diet.

A similarly designed study conducted on streptozotocin-induced diabetic mice models revealed that ALA completely prevented the increase in TCHOL, atherosclerotic lesions, and the general decline in health typically observed with diabetes, suggesting that ALA is a promising protective agent for reducing cardiovascular complications of diabetes.44

Fibromyalgia

Fibromyalgia is a functionally disabling disorder characterized by widespread pain, and frequently accompanied by sleep disturbance, fatigue, depression, and cognitive dysfunction. The commonly prescribed analgesics provide incomplete relief, possibly due to incomplete efficacy and dose-limiting adverse events. Specifically, the side effects of the drugs aggravate some symptoms of the disease they are prescribed to treat, namely fatigue and cognitive dysfunction. These complications have led researchers to search for new treatment options.

While the exact etiology of fibromyalgia is unknown, recent studies have provided evidence that oxidative stress17 and inflammation18 play a role in the pathophysiology of fibromyalgia. Alpha-lipoic acid, which at pharmacologic doses acts as a potent antioxidant, has also been demonstrated to have anti-inflammatory3 effects on the body.

When administered orally, ALA is rarely present in tissues above micromolar levels and is therefore unlikely to function as a primary cellular antioxidant.19 Instead, its potent antioxidant properties appear to be attributable to the fact that ALA increases cellular glutathione levels by regulating glutathione synthesis and ameliorating oxidative stress.20

ALA may exert its anti-inflammatory effects by scavenging free radicals and downregulating pro-inflammatory redox-sensitive signal transduction processes including nuclear factor kappa B translocation, leading to decreased release of other free radicals and cytotoxic cytokines.21-22

While no randomized controlled trials evaluating the efficacy of ALA in the treatment of fibromyalgia have been completed, one is currently underway23 and the research that we do have available suggests that its results will be favorable.

Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS), also referred to as myalgic encephalomyelitis, is an illness characterized by debilitating and relapsing fatigue and often accompanied by neuropsychiatric concerns, such as depression, irritability, sleep disorders, autonomic symptoms and neurocognitive defects, as well as physiosomatic concerns, such as malaise, hyperalgesia, irritable bowel, and muscle pain and tension.

Oxidative stress24-25 and inflammation25 play important roles in the pathogenesis of CFS. In fact, some have suggested that CFS should be renamed in order to better reflect the oxidative and inflammatory nature of the condition.26 Some have also suggested that mitochondrial dysfunction may play a role in the condition.27

Researchers have studied ALA in the treatment of CFS because of its antioxidant and anti-inflammatory properties, as well as its role in mitochondrial function.

When administered orally, ALA is rarely present in tissues above micromolar levels and is therefore unlikely to function as a primary cellular antioxidant.19 Instead, its potent antioxidant properties appear to be attributable to the fact that ALA increases cellular glutathione levels by regulating glutathione synthesis and ameliorating oxidative stress.20

ALA may exert its anti-inflammatory effects by scavenging free radicals and downregulating pro-inflammatory redox-sensitive signal transduction processes including nuclear factor kappa B translocation, leading to decreased release of other free radicals and cytotoxic cytokines.21-22

Evidence implicates mitochondrial dysfunction, impaired oxidative phosphorylation and abnormally high lactate levels in the pathophysiology of CFS.25 ALA acts as a critical cofactor in mitochondrial alpha-ketoacid dehydrogenases, including pyruvate dehydrogenase. As a result, it is important in mitochondrial, oxidative-decarboxylation reactions and plays a critical role in mitochondrial activity and energy metabolism.28 Furthermore, supplementation with ALA has been demonstrated to lead to a decrease in abnormally elevated lactate levels,4 likely as a result of its role in stabilizing and regulating pyruvate dehydrogenase and other mitochondrial 2- ketoacid dehydrogenase complexes.29

Although there are no randomized controlled trials using ALA in the treatment of chronic fatigue syndrome, when we consider its widespread use as a safe nutrient with the ability to reduce oxidative stress, decrease inflammation, and support mitochondrial function, its use in addressing chronic fatigue syndrome appears to be justified.

Neuropathy

Diabetic neuropathy, which is diagnosed in diabetic patients with peripheral nerve dysfunction when other causes of neuropathy have been excluded, is believed to be due to increased flux through the polyol pathway, leading to accumulation of sorbitol, a reduction in myoinositol, and an associated reduced Na+-K+-ATPase activity, as well as nitric oxide inactivation by increased oxygen free radical activity leading to endoneurial microvascular damage and hypoxia.30 As a potent antioxidant, ALA appears to retard or reverse the progression of peripheral diabetic neuropathy.

In a study designed to assess the efficacy of ALA in the improvement of sural nerve conduction velocity and amplitude in patients with diabetic neuropathy, participants were administered 600 mg ALA per day.31 At the conclusion of the study, ALA failed to improve sural nerve conduction velocity and amplitude; however, researchers noted that their study results should be interpreted with caution due to the study’s uncontrolled nature, researchers’ failure to assess patient compliance, small sample size, and short study duration.

Several studies demonstrate beneficial effects of ALA in the management of peripheral neuropathy. In one study that compared results of patients who were administered 600 mg, 1200 mg, and 1800 mg ALA by mouth, patients reported significant improvements in stabbing and burning pain (subset of total symptom score, or TSS), the Neuropathy Symptoms and Change (NSC) score, and the patients' global assessment of efficacy.32 Benefits were not remarkably different between the three groups, suggesting that an oral dosage of 600 mg provides the most favorable cost-benefit ratio.

In another study that administered ALA orally at a dosage of 600 mg per day for 40 days, ALA administration was found to be associated with reductions in neuropathic symptoms [as demonstrated by reduced Neuropathy Symptom Score (NSS), Subjective Peripheral Neuropathy Screen Questionnaire (SPNSQ), and douleur neuropathique (DN4) questionnaire scores at day 40 versus baseline] and in triglycerides.33

One systematic review of the literature concluded that, when administered intravenously at a dosage of 600 mg per day over a period of 3 weeks, ALA leads to a significant and clinically relevant reduction in neuropathic pain (grade of recommendation A). These researchers also studied orally administered ALA and stated that it was unclear whether or not the improvements seen after 3-5 weeks at an oral dosage of 600 mg were clinically relevant.34

Other systematic reviews maintained that oral and intravenous administration may provide similar benefits. For example, one stated that an oral or intravenous ALA dose of at least 600 mg per day resulted in a 50% reduction in the TSS35 and a more recent (2018) systematic review on ALA in the management of diabetic peripheral neuropathy concluded that current data provides evidence for the benefits of ALA in diabetic peripheral neuropathy treatment at a dose of 600 mg per day, either intravenously or orally, for a duration of at least 3 weeks with minimal side effects. 36

Cancer

Most cancer cells utilize aerobic glycolysis, which is the preferential conversion of glucose to lactate for ATP generation, even when oxygen is present. This phenomenon, referred to as the Warburg effect, can be seen in cancer cells of different origin. Because aerobic glycolysis is grossly inefficient, producing only two molecules of ATP per molecule of glucose, cancer cells metabolize large amounts of glucose to keep up with their energy demands. Researchers hypothesized that by shifting cancer cell metabolism toward complete oxidation of glucose and away from aerobic glycolysis, they could effectively reduce proliferation of cancer cells.37

Because ALA is a cofactor of pyruvate dehydrogenase, it was a key consideration in nutrients that can steer energy production away from aerobic glycolysis and toward complete oxidation of glucose, resulting in a decrease in lactate production and an inhibition of glycolysis. Pre-clinical studies designed to investigate ALA’s role in this capacity demonstrated that ALA can reduce cancer cell viability and proliferation, as well as lactate production.37 ALA was also found to induce apoptosis in the following cell lines: neuroblastoma cell lines Kelly, SK-N-SH, Neuro-2a and the breast cancer cell line SkBr3.

ALA also inhibits cancer cell proliferation and induces apoptosis by other mechanisms. The nutrient was found to inhibit cell proliferation and induce apoptosis in MDA-MB-231 breast cancer cell lines38 and to inhibit the colony-forming ability of the highly invasive MDA-MB-231 and 4T1 breast cancer cells. ALA inhibited the migration and invasion of metastatic breast cancer cells at least in part through inhibiting ERK1/2 and AKT signaling.39

Additionally, ALA has been shown to effectively induce apoptosis in human colon cancer cells (HT-29) by a pro-oxidant mechanism that is initiated by an increased uptake of oxidizable substrates into mitochondria,40 and ALA dramatically decreased non-small cell lung cancer (NSCLC) cell proliferation by down-regulating growth factor receptor-bound protein 2 (Grb2).41

Studies evaluating the efficacy of ALA in the inhibition/treatment of cancer are limited to experimental data; however, the research appears to be very promising.

​

Burning Mouth Syndrome

There are no definitive therapies for BMS (50).. According to published data, ALA is reportedly one of the most effective drugs in the management of BMS. However, to date, there is no clear consensus  as many variables such as mood disorders appear to decrease effectiveness when co-existing with BMS (51).

Femiano et al. have published most of the studies that examine the efficacy of ALA in the management of BMS (22-26). They use a dose of 600 mgr/day with a follow up around 30 days in their studies, as our study. Their results have been quite effective for ALA in order to improve symptoms, very similar in general compared with our results. There are some differences to consider that we point below.

In their first study (52), they carried out an open trial of 42 patients to compare ALA treatment (600 mg/day) over placebo. In the study group, none of the patients worsened, similar to our study. 24% presented no changes and 76% reported some level of improvement. However, statistical analysis was not conducted, the sample size was small, and treatment duration was only one month.

Femiano and Scully (53) evaluated ALA at a dose of 600 mg/day in a 60-patient double-blind placebo controlled study. 97% of the patients reported some improvement with ALA, 3% showed no changes in symptomatology, and none of the patients reported worsening of symptoms. These results were statistically significant in favour of ALA. Similarly to our study, not a single patient treated with ALA worsened; but the results obtained with ALA (97% improvement) were higher than our own results. We must also highlight the important placebo effect obtained (40%).

In 2002, Femiano et al. (54) compared ALA with other products (Bethanechol 5mg/8 hours, Lactoperoxidase and 3% Xylitol). Administration of ALA showed statistically significant results.

Femiano et al. (55) in 2003 conducted an open trial of 192 patients divided into four groups: one undergoing cognitive therapy (CT), one treated with ALA (600mg/day), one combining CT and ALA, and one with placebo. The ALA group and the ALA + CT group showed statistically significant improvement compared to CT alone and the placebo group.

In 2004, Femiano et al. (56) studied the efficacy of ALA in patients treated with and without anxiolytics. Although the latter group displayed more significant results, these were not statistically significant. In 2011, López-D’Alessandro and Escovich verified the efficacy of ALA (600 mg/day) in conjunction with gamma-amino butyric acid (GABA) over placebo over a two-month period. The combination ALA + GABA proved to be the most effective according to patients’ perceptions (57).

Other authors have used ALA in higher concentrations. In 2008, Carbone et al. (58) conducted a 60-patient double-blind study to evaluate the efficacy of pure ALA 800 mg/day over ALA 800 mg/day supplemented with a vitamin complex, and in comparison with placebo. The 3 groups showed a reduction in symptoms, but with no statistical significance. López-Jornet et al. (59) used the same concentration of ALA over placebo and equally found that both groups improved, yet with no statistically significant differences.

Finally, Cavalcanti et al. (60), in their crossover trial comparing the efficacy of ALA (600mg/day) over placebo, found a reduction in symptoms in both groups. The rate of this reduction was higher in the first month than in the second month of treatment.

ALA appears to have benefits in the management of BMS, yet the results supporting its efficacy is inconclusive. Further studies, with a higher number of patients, are, therefore, needed.

Variables such as depression, long-term evolution and symptom intensity make it less likely for ALA patients to improve. This fact, together with the importance of the placebo effect, suggests the need to assess the psychological and/or psychiatric implications that may require multidisciplinary treatments.

​

Adverse Effects

While intravenous ALA prevents damage to the membranous structures of cells (including the mitochondria) at typical doses, animal studies suggest that excessively high doses may result in mitochondrial damage. LD50 studies performed on six rhesus monkeys demonstrated that doses of approximately 90 mg/kg to 100 mg/kg of intravenous ALA were lethal to three of the six monkeys.45 Researchers extrapolated this data, stating that this dose would likely be lethal to all primates.

Researchers believe this toxicity may be due to the formation of superoxide anions when ALA comes into contact with diatomic oxygen in the mitochondria.46 These damaging free radicals may then react with the unsaturated double bonds in the lipids of the mitochondrial membrane.

Adverse effects associated with therapeutic doses of ALA include adverse gastrointestinal effects13 such as nausea and vomiting, vertigo,32 and chest distress (however, researchers noted that this may have been due to the velocity of the IV drip, as it improved the same day after the velocity was adjusted).47 There was no laboratory evidence of deficiencies in iron, vitamins, or thyroid function and no hyperglycemia associated with ALA supplementation.11

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