Send Orders for Reprints to reprints@benthamscience.

ae
CNS & Neurological Disorders - Drug Targets, 2018, 17, 000-000 1

RESEARCH ARTICLE

Amyotrophic Lateral Sclerosis and Oxidative Stress: A Double-Blind

Therapeutic Trial After Curcumin Supplementation

Lucia Chico1*, Elena Caldarazzo Ienco1, Costanza Bisordi1, Annalisa Lo Gerfo1, Lucia Petrozzi1,
Antonio Petrucci2, Michelangelo Mancuso1 and Gabriele Siciliano1

1
Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy; 2Center of
Neuromuscular and Neurological Rare Diseases, S. Camillo Forlanini Hospital, Rome, Italy

Abstract: Objective: To investigate the efficacy of curcumin oral supplementation (600 mg/day, Brai-
noil), a natural antioxidant compound, in amyotrophic lateral sclerosis (ALS).
Methods: Patients were randomized into two groups: Group A received placebo for 3 months, then
Brainoil for the following 3 months, Group B took Brainoil for 6 months. The evaluations were con-
ducted at basal (T0), after 3 months of double blinded Brainoil or placebo treatment (T1), and after the
3 month open-label phase (T2). Clinical evaluations and oxidative stress biomarkers, including oxida-
tive protein products (AOPPs), ferric reducing ability (FRAP), total thiols (T-SH) and lactate, were
ARTICLE HISTORY evaluated, compared to a control group, during an incremental forearm exercise test.  

Received: December 22, 2017
Revised: July 09, 2018
Accepted: July 10, 2018
DOI:
10.2174/1871527317666180720162029
Results: Over the entire study Group B showed a stable score of the ALS-FRS-r which decreased in
Group A (p<0.01), in parallel with a reduction of AOPPs (p<0.01) which was not detected into Group
A. Also FRAP exercise values remained stable in Group B, while in Group A they were reduced with-
out treatment at T1 (0.05<p<0.01), for then increase at T2 with introduction of therapy (p<0.05). In
Group B T1>T0 exercise lactate was lower compared to Group A (p<0.01). Compared to controls, the
whole ALS population showed a greater oxidative stress (p<0.001), those treated with curcumin
(Group B) exhibiting decreased exercise AOPPs at T2 with values approaching those of controls.
Conclusion: Although further studies are needed to confirm these data, treatment with curcumin
shows encouraging results indicating a slight slowdown in disease progression, improving aerobic me-
tabolism and oxidative damage, this also contributing to deepen knowledge into the pathogenic
mechanisms of ALS.

Keywords: Amyotrophic lateral sclerosis (ALS), curcumin, oxidative stress, antioxidants, incremental exercise test, lactate

1. INTRODUCTION and defects in RNA metabolism [4], mostly supported by the

Amyotrophic lateral sclerosis (ALS) is a neurodegenera-
tive disease characterized by upper and lower motor neurons
degeneration, resulting in muscle atrophy and weakness with
a median survival of 3-5 years after symptoms onset [1]. To
date, no effective therapy is available and the pathogenesis is
still unknown. Among the hypotheses advanced, the most
important is the glutamate-induced excitotoxicity. It finds a
broad foundation on the evidence of the limited efficacy of
Riluzole, a drug with antiglutammatergic activity [2]. Beside
glutamatergic excitotoxicity, several mechanisms have been
hypothesized in ALS pathogenesis, the most important of
them are mitochondrial dysfunctions [3], oxidative stress,
*Address correspondence to this author at the Department of Clinical and
Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy;
Tel: 0039-050-993191; E-mail: lucia.chico@katamail.com
discovery of ALS-associated genes such as TARDBP [5].
Oxidative stress biomarkers have been widely investi-
gated in several studies and show high protein carbonyl lev-
els, increased lipid peroxidation and DNA/RNA oxidative
modifications, in the nervous and peripheral tissues in both
sporadic and familial ALS patients [6-8].
TARDBP damage may be mediated by oxidative stress, in
fact, an abnormal juxtanuclear aggregation, as well as altered
intracellular trafficking of mitochondria, are demonstrated in
TAR DNA-binding protein 43 (TDP-43) transgenic mice [9,
10]. It is also observed, in human TDP-43 transfected NSC-
34 cells, that TDP-43 causes mitochondrial morphologic
abnormality, a decrease of mitochondrial complex I activity
and mitochondrial transmembrane potential [11].

1871-5273/18 $58.00+.00 © 2018 Bentham Science Publishers

2 CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0
The hypothesis of the oxidative stress in ALS has led to
several experimental trials and although no treatment has
been demonstrated to be effective in slowing the disease,
encouraging results derive by preclinical studies and recent
findings of efficacy of Edaravone, an antioxidant agent [12],
hint the development of antioxidant strategies.
Curcumin, derived from the plant Curcuma longa, is a
yellow-colored spice commonly used in the Indian subconti-
nent, not only for healthcare but also for the preservation of
food and as a yellow dye for textiles [13]. It is a lipophilic
phenolic diferuloylmethane, with a great variety of pharma-
cological functions, such as anti-inflammatory, antioxidant,
antiproliferative, antiviral, antibacterial, antifungal, and neu-
roprotective activities [14].
Curcumin effects are mediated through the regulation of
various transcription factors, growth factors, inflammatory
cytokines, protein kinases, and others, so in this view, it was
used in various diseases including cancer, diabetes, allergies,
arthritis, cardiovascular and neurodegenerative disorders, to
name only a few [15].
In mutated superoxide dismutase 1 (SOD1)-ALS cases,
pathological SOD1 inclusions show amyloid-like properties
and induce inflammation and cytotoxicity. Curcumin acts as
an inhibitor of fibrils aggregation, leading to a smaller and
non-fibrillar aggregate with reduced toxicity. Curcumin
binds to SOD1 amyloidogenic regions removing SOD1 ag-
gregates toxicity occurring in pre-fibrillary and fibrillary
phase [16].
However, the main biological effect of curcumin is its
antioxidant activity since it is capable to bind to metals and
remove free radicals [17], acting as a powerful scavenger of
reactive oxygen species (ROS) and limiting the lipid
peroxidation [18]. In mouse models, when administered
orally, curcumin enhances the activity of antioxidant enzymes
like superoxide dismutase, catalase and glutathione peroxidase
[19]. Dong and colleagues [20] have recently demonstrated
that curcumin can interact with TDP-43 protein by improving
the motoneuron membrane excitability through a positive
effect on oxidative stress and mitochondrial function in mutant
TDP-43 motoneuron-like cell lines [20]. In a study by Lu and
colleagues [11], the use of a curcumin derivative improved
mitochondrial transmembrane potential, increased activity of
mitochondrial complex I and ameliorate mitochondrial
morphology in transgenic neuronal stem cells for TDP-43.
Monocarbonyl dimethoxycurcumin C, a curcumin derivate,
was able to degrade the TDP-43 fragment and strengthen the
antioxidant ability reducing lactate dehydrogenase levels and
malondialdehyde bisdimethyl acetal in neuroblastoma-spinal
cord-34 cells transfected with mutant TDP-43 [11].
Curcumin also acts stimulating mitochondriogenesis by
mechanisms that are partially known, perhaps inducing the
pathway of protein-kinase activated by AMP/PGC-1α and/or
Nfr2, two factors involved in redox homeostasis and in the
production of new mitochondria, also in relation to the
possible involvement of non-neuronal cells such as astrocytes
where oxidative stress stimulates the transcription of genes
induced by Nrf2 [21].
Chico et al.
For these reasons, curcumin can be considered a
promising agent in TDP-43 proteinopathy, and so used in
ALS therapeutic clinical trials.
As previously reviewed [22], only a few studies, re-
stricted to animal models, were conducted in vivo in order to
test the effects of curcumin on neurodegenerative disorders
(predominantly Alzheimer diseases and Mild Cognitive Im-
pairment). Furthermore, focusing on ALS, there are no in
vivo studies and only a few limited in vitro studies have been
performed. Probably, curcumin poor bioavailability and
solubility reduce its ability to reach the central nervous
system in sufficient concentrations to induce benefit explain-
ing the lack of human clinical trials in neurodegenerative
diseases. Moreover, when administered orally, curcumin is
poorly absorbed and it undergoes hepatic conjunction with
the formation of biologically inactive metabolites.
The aim of the study is to investigate the efficacy of oral
supplementation of Brainoil, a nutraceutical curcumin-based
compound, on clinical parameters and biochemical markers
in ALS patients.
2. MATERIALS AND METHOD
2.1. Patients and Healthy Controls
A total of 42 patients (20 males and 22 females) were
recruited in the Neuromuscular Disease Centre of the Neuro-
logical Clinic, University of Pisa.
The age ranged between 39 (RL) and 83 (NM), mean
age: 62.41±11.05 years. Of these patients, 38 were sporadic
cases and 4 were familiar ALS (one of them with G41S
SOD1 mutation, the remaining three cases did want to per-
form the genetic test). The clinical forms at disease onset
were: 7 bulbar onsets, 9 upper limbs onset, 26 lower limbs
onset.
Inclusion criteria were: ALS diagnosis (definite, probable
and possible with laboratory support) according to El Esco-
rial criteria (1998) established by the World Federation of
Neurology (WFN); age between 18 and 85 years; ability of
consent; signing of informed consent. Exclusion criteria
were: tracheotomy; severe psychiatric disorders (Axis 1 or 2
of DSN IV); pregnancy or breastfeeding. Dropout criteria
were: severe adverse effects; consent withdrawal; protocol
scheme deviation. The mean disease duration (until March
2015, when patients recruitment was performed) was
39.76±26.88 months. The mean age at the disease onset was
59.05±11.19 years and the mean age at the diagnosis was
60.36±11.09 years. Demographic, sex, age, disease onset and
duration, as well as disease progression rate, are reported in
Table 1.
During the trial, all patients continued to take their ther-
apy for ALS, basically Riluzole 50 mg twice a day, like any
other therapy, without variations.
Patients were randomized into two groups (Brai-
noil/placebo), matched for sex, age, clinical disability (val-
ued by ALS-FRS-r scale) and clinical phenotype: Group A,
consisting in 24 patients, Group B consisting in 18 patients.
The number disparity between the groups is due to the loss
of patients recruited and randomized 2-4 weeks before the
Effect of Curcumin Supplementation in Amyotrophic Lateral Sclerosis Patients CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0 3

Table 1. General informations of patients recruited (number, sex, age, clinical presentation and disease progression rate) at T0,
T1, T2 evaluation time. Group A = placebo (3 months) + Brainoil (3 months); Group B = only Brainoil (6 months).

Average Upper Lower Onset Aver- Average disease Average Age

n. M F Bulbar
Age Limbs Limbs age Age duration (months) at Diagnosis

Total 42 20 22 62.41 7 9 26 59.05 39.76 60.36

T0 Group A 24 13 11 65.58 3 5 16 62.33 39.5 63.38

Group B 18 6 11 58.17 4 4 10 54.67 40.11 56.33

Total 36 18 18 62.06 6 8 22 58.47 42.19 59.78

T1 Group A 21 12 9 65.62 3 4 14 62.24 40.24 63.24

Group B 15 6 9 57.07 3 4 8 53.2 44.93 54.93

Total 34 18 16 61.15 6 7 21 57.47 43.53 58.79

T2 Group A 20 12 8 64.75 3 4 13 61.25 41.65 62.25

Group B 14 6 8 56 3 3 8 52.07 46.21 53.86

Patients recruitment.

trial beginning (because of death, deviation from inclusion
criteria, consent withdrawal). Anyway, the two groups re-
mained homogeneous (Table 1).
During the former 3 months, 6 patients left the trial be-
cause of adverse effects and consent withdrawal; during the
latter 3 months, other 2 patients went out because of protocol
scheme deviation.
As a control group was analyzed with a single assess-
ment16 healthy subjects (7 males and 9 females), mean age:
42±9.2, without comorbidity for neurological or oxidative
stress-related pathologies.
2.2. Multi-parametric Evaluation Protocol
Clinical parameters and biochemical markers were evalu-
ated.
Clinical evaluation consisted in a neurological examina-
tion, compiling Medical Research Council (MRC) scale,
revised ALS Functional Rating Scale (ALS-FRS-r), estimat-
ing Body Mass Index (BMI) and the Maximum Handgrip
Force (MHF) during an exercise test, in order to estimate
(assess) muscular impairment, clinical disability in everyday
life and the general conditions decline.
For MRC scale were evaluated the following muscles:
upper limbs: deltoid, brachial biceps and triceps, exten-
sor/flexor muscles of wrists and fingers, opposition thumb;
lower limbs muscles: iliopsoas, quadriceps, femoral bicipes,
tibialis anterior, Gemini, extensor and flexor muscles of fin-
gers, and extensor and flexor muscles of the neck.
We analyzed total ALS-FRS-r score and, separately, res-
piratory ALS-FRS-r score (questions 10-11-12).
The following markers were evaluated in plasma samples
basally and during an exercise test.
1) Advanced oxidation protein products (AOPPs) that
estimate the amount of protein oxidized in specific
amino acid sites by ROS;
2) Ferric reducing antioxidant power (FRAP) evaluates
the non-enzymatic antioxidant capacity through fer-
ric ion reduction, included in FRAP reagent, into fer-
rous ion;
3) Total thiols (T-SH), which are organic compounds
with thiolic /sulphydryl (-SH) groups responsible for
their antioxidant action.
4) Lactate, the final product of anaerobic glycolysis; it
is a metabolite involved in maintaining the blood pH,
and it is a source of oxidative stress.
3. EXPERIMENTAL DESIGN
Evaluation session times were established as follows: T-
1, patients were recruited and randomized into the 2 matched
groups; T0, beginning of treatment (Brainoil or placebo); T1,
3 months after Brainoil treatment or placebo assumption; T2,
6 months after the study beginning: 6 months after Brainoil
administration (Group B) and 3 months after the open-label
phase (Group A). At any evaluation time (T0>T1>T2), for
each patient, clinical parameters through neurological ex-
amination and biochemical markers during a standardized
incremental workload exercise test, as detailed below, were
evaluated.
ALS patients, considered both in their totality (Group A
+ Group B) and divided into single groups, were compared
to healthy subjects taking into account biochemical markers.
3.1. Forearm Incremental Workload Exercise Test
(IWET)
Patients were first evaluated for resting MHF at the
strongest side: the average of 3 trials, 5 min apart from each
other, was recorded.
Patients then performed an incremental workload exer-
cise test on forearm muscles with an handgrip connected to a
myometer in order to perform a step-wise contractile per-
4 CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0
formance with sequential 1 min lasting 1 Hz intermittent
exercise bouts, interspersed with 2 min resting intervals,
starting at 30% of MHF and then at 50% and 70% of this
value. Blood samplings from an antecubital vein of the same
limb were made in resting condition, at each one of the 3
contraction levels, immediately after the finishing of hand-
grip exercise, and after 15 minutes of rest. For those patients
(N=8) who could not perform the exercise test because of
hands hyposthenia, an only basal blood sample was obtained.
3.2. Tested Drug
Brainoil is a dietary supplement mainly based on curcumin
(600 mg), containing also 100 mg of Coenzyme Q10 (a potent
antioxidant that acts enhancing mitochondrial activity), 300
mg of Bacopa monnieri, 250 mg of Withania somnifera and
Centella asiatica (250 mg), whose formulation has been
designed and produced to ensure a high bioavailability of the
active principles. The greater bioavailability is obtained partly
with the addition of piperine (1 mg of Piper nigrum), an
alkaloid which, by inhibiting liver enzymes CYP3A4 and P-
glycoprotein, it can increase the curcumin bioavailability of
2000%. Brainoil consists of an exclusive production
technology (with Patent filed by Alveda Laboratories s.r.l),
which consists of moderating heat curcumin with other
cocoa butter herbs and granulating the compound thus
obtained.
3.3. Treatment Randomization
The trial lasted 6 months, consisting in 2 periods, the first
one (T0-T1) 3 months, double-blind, placebo-controlled, the
second one 3 months, open a single branch, all the patients
receiving the drug. Patients were divided into two groups:
the first group (Group A) received placebo for 3 months,
then Brainoil for the following 3 months; the second group
(Group B) was treated with Brainoil for all the 6 months.
3.4. Evaluation of Oxidative Stress Biomarkers
In order to evaluate oxidative stress biomarkers, blood
samples were immediately centrifuged at 3000 rpm, 4°C, for
10 minutes and plasma was stored at -80°C for a maximum
period of three months before the determination.
AOPPs were determined by mixing 30 µl of plasma with
phosphate buffered saline, acetic acid and potassium iodide.
The absorbance was read spectrophotometrically at 340 nm
and compared with a solution of chloramine T dissolved in
the same buffer. The data were expressed as nmol/ml of
chloramine T equivalents [23].
FRAP was assessed by mixing plasma with FRAP rea-
gent, pre-warmed to 37°C, composed by sodium-acetate
buffer (pH 3.6), tripyridyltriazine dissolved in hydrochloric
acid [0.04 M], and ferric chloride dissolved in H2O. The ab-
sorbance was read after 4 minutes at 620 nm, a calibration
curve was established using a solution of iron sulphate in
hydrochloric acid; the data were expressed in mmol/l [24].
For T-SH determination, 200µl of plasma were added to
600µl of Tris-EDTA, 3.16 ml of absolute methanol and 40µl
of 2,2-dithiobis nitrobenzoic acid (DTNB) [10mM]. After
incubation at room temperature for 20 minutes, the samples
were centrifuged at 3000 g for 10 min. The absorbance of the
Chico et al.
supernatant was assessed at 405 nm and by subtracting the
value of a blank consisting of DTNB. The values were ex-
pressed in mmol/l [25].
As previously described [26], the assessment of lactic
acid, conducted in the laboratory of the Department of Clini-
cal Chemistry of the Santa Chiara hospital in Pisa, was car-
ried out by an enzymatic-colorimetric determination using a
commercial kit (Sentinel, Milan-Italy), following the manu-
facturer's instructions. The data were expressed as mg/dl.
3.5. Statistical Analysis
Clinical parameters and biomarker values, at any time
(T0, T1 and T2) and during the exercise test, were expressed
as a mean ± standard deviation and analyzed using one-way
analysis of variance (ANOVA) for repeated measures. Any
difference between groups (Group B versus Group A, total
ALS patients vs. healthy controls, Group B>healthy controls
and Group A> healthy controls), were evaluated using Stu-
dent's t-test. Statistical analysis was performed using the
software SPSS20 and a p-value of < 0.05 was considered to
be statistically significant.
4. RESULTS
4.1. Clinical Data
4.1.1. ALS-FRS-r
Into Group A, as expected, a time-dependent T1 vs T0
decline was observed, at a significant level for respiratory
ALS-FRS-r domains (p<0.01), borderline (p=0.05) for total
ALS-FRS-r. This decrement was not observed anymore at T2
where both parameters were not significantly different com-
pared to T1. On the contrary, in Group B the time-dependent
decrement of both parameters was milder, not reaching statis-
tical significance in inter-time comparison (Fig. 1a).
When comparing the two groups, this was reflected by a
significant difference (p=0.02) in the T1>T0 reduction rate
percentage of the respiratory ALS-FRS-r score: - 14.8% in
Group A vs. -7.7 % in Group B (Fig. 1b).
4.1.2. MRC
As shown in Fig. (2), a time-dependent decline was ob-
served in both groups (significant at p<0.05 for T1>T0 and
T2>T0 in Group A, at T2>T0 in Group B, without signifi-
cant inter-group differences at any time.
4.1.3. Maximum Handgrip Force (MHF)
Neither into Group A nor into Group B significant differ-
ences of MHF values at different times were observed, while
in comparison among groups, MHF values were significantly
lower in Group B at T1 (p<0.05) and at T2 (p<0.01), even if
the groups were comparable at T0 (Fig. 3).
4.1.4. BMI
Considering BMI, this value was reduced at T2 vs T0
(p<0.05) in Group A, while there were no significant differ-
ences over time in Group B. No inter-group differences were
recorded (data not shown).
Effect of Curcumin Supplementation in Amyotrophic Lateral Sclerosis Patients CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0 5

Fig. (1). a) Comparison of total and respiratory ALS-FRS-r score in Group A and Group B in each observational time. b) Inter-groups varia-
tion of ALS -FRS-r score reduction rate (%) between times (T0>T1>T2) in relation to respiratory domain.
*p<0.05; **p<0.01 evaluated by ANOVA for repeated measures (intra-group evaluation); p value not significant for inter-groups evaluation
by Students’ t test.

 

 
Fig. (2). Variation of MRC score in Group A and Group B considering the different times.
*p<0.05 evaluated by ANOVA for repeated measures; p value not significant for inter-group evaluation by Students’ t test.
6 CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0
Fig. (3). MHF values in Group A and Group B.
*p<0.05; evaluated by Students’ t test; p value not significant for intra-group evaluation by ANOVA for repeated measures.
4.2. Biochemical Markers and IWET
4.2.1. AOPPs
In Group A IWET curves were substantially flat and did
not modify over time (Fig. 4a). On the opposite, in Group B,
AOPP levels, while increased (p<0.01) at T1>T0 IWET re-
covery time, 15 min after completing the exercise test, fur-
ther showed a T2 exercise-related decrement, with a p<0.01
significant level (p<0.01) both at T2>T1 50% IWET and at
T2>T0 30% IWET (Fig. 4b). This difference was reflected
in comparison among groups at T2 (AOPPs reduced into
Group B at 50% IWET, although borderline, p=0.05) (Fig.
4c).
When total ALS patients at T0 (Group A + Group B)
were compared to a healthy control group, AOPP levels were
higher in the first than the latter, both in basal conditions
(p<0.001) and during the exercise-test at 50% IWET
(p<0.05), at 70% IWET (p<0.001), and at recovery (p<0.01)
(Fig. 4d). Furthermore, taking into account the single groups
(Group B or Group A), AOPP levels, at T0, were increased
in both groups with respect to healthy controls both in basal
condition (p<0.001) and during the exercise test, with a sta-
tistical difference running from p<0.05 to p<0.001 at the
different exercise bouts (Figs. 4e and 4f).
In Group B, at T2, AOPPs showed nearest values to
healthy controls with a statistical difference that faded at
30% IWET and 50%IWET and decreased in basal condition
(from p<0.001 to p=0.001) and at recovery (from p<0.01 to
p<0.05) (Fig. 4e). Instead, in Group A, were not observed
noticeable differences except at rest, in which AOPP levels,
at T2, decreased in ALS patients with a p-value that change
from p<0.001 to p<0.01 (Fig. 4f).
4.2.2. FRAP
Also, this marker does not seem to show exercise-related
changes during the exercise-test, the relative curve basically
remaining flat. Nonetheless, FRAP values appear confident
in disease progression in Group A showing, as expected, a
Chico et al.
reduction at T1>T0 (p<0.01 at 70% IWET, p<0.05 at post-
exercise recovery), while, after Brainoil supplementation
(T2>T1) they appeared increased (p<0.05 at basal, 70% of
IWET and recovery; Fig. 5a). No significant changes were
observed in Group B (Fig. 5b) and in the comparison be-
tween groups (data not shown).
Considering possible variations in ALS patients vs.
healthy controls, statistical differences were found only in
total ALS population (Groups A+B) at 70% IWET (p<0.05)
(Fig. 5c). No differences were observed after stratification
for groups into Group A and Group B with respect to healthy
controls (data not shown).
4.2.3. T-SH
Both into Group A and Group B at T1 vs T0 comparison,
we observed increased values of T-SH at every time of
IWET (0.05<p<0.01) and at recovery into Group B (p<0.05).
No differences have been observed in T2>T1 comparison,
and again increased values in Group A in T2>T0 basally at
any time of IWET and at recovery (Fig. 6a and 6b).
Decreased T-SH levels were found in ALS patients vs.
healthy controls for the whole exercise-protocol, from basal
(p<0.001) to recovery (p<0.05) (Fig. 6c). When each group
was compared to healthy controls, no statistical differences
were detected in T-SH values (data not shown).
4.2.4. Lactate
Analyzing IWET curve lactate levels increased during
the different exercise bouts with statistical differences at
70% IWET>basal evaluation (p<0.05) for than return to ba-
sal levels at recovery (0.05<p<0.001) for all groups (Fig. 7).
The comparison between times (T0>T1>T2) in both
Group A and Group B did not show significant differences in
lactate absolute values (data not shown); however, when the
relative values for each step were compared to the basal
value (%), only into Group B there was a significant de-
crease at 50% IWET (p<0.01) at T1 vs T0 (Fig. 7a).
Effect of Curcumin Supplementation in Amyotrophic Lateral Sclerosis Patients CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0 7

 
 
Fig. (4). Trend of AOPP levels during exercise test between the different times in Group A (a), in Group B [$$: differences among T1>T0;
**: differences among T2>T1; §§: differences among T2>T0 (b)], between Groups A and B (c), and ALS patients vs. controls (d). AOPP
variations in Group B (e) and Group A (f), at different evaluation times, compared to controls.
From Figure 4a to 4c: **, §§ p<0.01 evaluated by ANOVA for repeated measures;
# borderline p value (p=0.05) for inter-group evaluation by Students’ t test at T2.
Figure 4d : * p<0.05, *** p<0.001 evaluated by Students’ t test
Figure 4e and 4f: § Group B_T0>controls, * Group B_T1>controls, $ Group B_T2>controls evaluated by Students’ t test.

By inter-group comparison (Group A>Group B), consid-
ering times separately, there were no significant differences
in absolute, as well as relative lactate levels, both at T0 and
T2 (data not shown), while at T1 in Group A lactate absolute
values (Fig. 7b) increased with respect to Group B at 50%
IWET (p<0.05) and 70% IWET (p<0.05), the latter one re-
mained significant also considering the relative values
(p<0.05; Fig. 7c).
Compared to healthy controls, ALS patients did not show
statistical differences in the lactate levels both at basal and
during the exercise test (Fig. 7d).
Globally speaking, into Group B we observed a stable
score of the total and respiratory ALS-FRS-r which was re-
duced into Group A. Regarding biochemical markers, al-
though not showing any difference in the trend of the exer-
cise-related curve, we found after 6 months of treatment, into
Group B, a reduction in AOPP levels that were not observed
into Group A. FRAP values remained stable in Group B, for
all treatment period, while into Group A they decreased,
during exercise test, at T1>T0, for then increase at T2. In
Group B we observed the reduced production of lactate dur-
ing IWET compared to Group A after double-blind phase.
8 CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0
Fig. (5). FRAP values during exercise test between the different
times (T0>T1>T2) in Group A (a) [$ and #: differences among
T1>T0; §: differences among T2>T1], in Group B (b), and in ALS
patients vs. controls (c). $, § p<0.05 and $$ p<0.01 evaluated by
ANOVA for repeated measures; # borderline p value (p=0.05) in
comparison between T1>T2 (ANOVA for repeated measures).
* p value significant for inter-groups evaluation (by Students’ t
test) only for 70% of MHF between patients and controls.
ALS patients showed a greater oxidative stress compared to
healthy controls valued by increased AOPP and decreased T-
SH levels. Furthermore, after 6 months of Brainoil admini-
stration, AOPP levels decreased during exercise test with
values approaching those of controls.
4.3. Adverse Events
Eight patients withdrew from the trial, six of them be-
cause of mild scored adverse events: gastralgia (N=3), diar-
rhea (N=1), regressed after Brainoil supplement suspension,
and skin rush (N=1), regressed with corticosteroids and anti-
histamine; the last patient, who was taking a placebo, had
cardiac ischemia.
5. DISCUSSION
In this study, we analyzed the effects of dietary supple-
ment curcumin-based (Brainoil) administration in ALS pa-
tients, for 6 months, in a double-blind trial (for the first three
Chico et al.
Fig. (6). T-SH levels during exercise test between the different times
(T0>T1>T2) in Group A (a), Group B (b), and between ALS patients
and controls for Figures 6a and 6b [*, #: differences among T1>T0].
* p<0.05; ** p<0.01 evaluated by ANOVA for repeated measures; #
borderline p value (p=0.05).
For Figure 6c [*differences among patients and controls, $ differ-
ences among the different steps of IWET].
* p<0.05; *** p<0.001evaluated by Student’s T test.
$$$ p<0.001 evaluated by ANOVA for repeated measures.
months), followed by an open-label phase (for the last three
months). Considering the unfavorable outcome of ASL lead-
ing to death in 3-5 years after the onset, we postulate that 6
months of treatment can be considered suitable to give in-
formation about the possible therapeutic response of curcu-
min supplement.
The comparison between ALS-FRS-r, MRC and BMI
parameters between the groups did not provide any signifi-
cant result at any time, with the exception of a significantly
lower reduction in ALS- FRS-r, relative to the domains in-
vestigating respiratory function, in Group B vs Group A.
Conversely, in the intra-group analysis, encouraging results
were observed during the considered treatment period. By
analyzing the individual clinical parameters, ALS-FRS-r
score does not significantly change in the group treated with
Brainoil for 6 months considering the different evaluations
between T0 and T1 or between T1 and T2, or especially be-
tween T0 and T2 (6 months after the first evaluation). When
analyzing Group A data, in the first phase, the scores were
Effect of Curcumin Supplementation in Amyotrophic Lateral Sclerosis Patients
reduced to the limits of significance for the total value and
statistically significance for the respiratory domains; the val-
ues, on the other hand, appeared to stabilize over the 3
months later, when patients started assuming Brainoil.
  were present.
Fig. (7). Lactate trends during exercise test: (a) comparison among
times (T1 vs. T0) in Group B and between groups at time T1 con-
sidering lactate absolute (b) and relative (%) values (c); comparison
among ALS patients and c controls (d).
*: p value evaluated by t-Student’s test for comparison between
groups, and by ANOVA for repeated measures among times (Fig-
ure 7a).
$, §: p value evaluated by ANOVA for repeated measures for
IWET curve [$: p value for ALS patients curve, §: p value for con-
trols curve];
*,$, § p<0.05; **, §§ p<0.01; ***,$$$, §§§ p<0.001.
In the T2>T0 comparison, a significant deterioration was
observed in Group A for both total score and respiratory do-
mains, possibly explained by the worsening of the first 3
CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0 9
months when patients had taken a placebo. Moreover, the
only significant difference between the two groups was the
percentage of T0-T1 respiratory score reduction, lower in
Group B than in Group A. Overall, ALS-FRS-r score data
appear to suggest a neuroprotective action of Brainol, with
particular attention also to the possible role on respiratory
function, crucial in the disease natural history, similar con-
siderations can be made for the MRC score. Although in the
T2>T0 comparison a significant deterioration was observed
in both groups, into Group A after the first score worsening
at T1>T0 (placebo) follows a score stabilization at T2>T1
then after Brainoil therapy. In Group B three months of ther-
apy were already sufficient to stabilize the score, even if
close to the level of significance (p=0.05), which was even
more noticeable in the T2>T1 comparison. It could, there-
fore, be hypothesized that Brainoil action had less "strength"
or greater latency, in fact, the average MRC score in Group
B stabilizes between 3 and 6 months from enrollment. Again,
the analysis of the inter-group comparison of the raw value
and the percentages of scores at different times did not show
significant differences.
Regarding BMI parameter analysis, although there were
no significant differences between T1>T0 and T2>T1 in ei-
ther of the two groups, the T2>T0 comparison between en-
rollment and end of trial showed a significant reduction in
the group taking placebo for the first three months, but not in
the one who took the supplement since the beginning of the
study, assuming a role of curcumin in protecting muscle
mass.
Park and colleagues [27] demonstrated, in 193 Korean
ALS patients, that nutritional status, as assessed by BMI,
was negatively associated with disease severity evaluated by
ALSFRS-R, this correlation was associated with worse nutri-
tional status, lower intake and a lower score of the bulbary
domains of ALS-FRS-r scale.
Also in the present study, the BMI values appear in line
with ALS-FRS-r scores, significantly worsened between T2
and T0 in Group A, and substantially stable into Group B.
However, unlike of Park et al., the two parameters appeared
to diverge when bulbary domains of ALS-FRS-r was consid-
ered, for which there was no significant worsening variation
both in Group A at T2>T0 nor in Groups A and B at T2>T1
in which comparable number of patients with bulbar onset
Although in this study, no dietary evaluation has been
performed during the 6 months of therapy, an explanation of
BMI stabilization should be sought in a possible protective
effect on the loss of muscle mass; in fact, curcumin was used
yet as adjuvant in treatments for loss of body weight in obe-
sity considering its action in increase lipolysis and the induc-
tion of lipid beta-oxidation, resulting in protein catabolism
reduction [28].
A possible role of curcumin in muscle mass loss has al-
ready been described, notably by blocking the NF-kB path-
way or inhibiting the activity of p38 kinase in catabolism-
enhanced patterns such as sepsis, endotoxemia, or stimulat-
ing muscle fibers regeneration after trauma [29]. This protec-
tive role of curcumin on muscle in hypermetabolism states
10 CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0
could be the explanation of our experimental evidence, as
ALS is a well-known condition of hypermetabolism [30].
Regardless involved mechanisms, which will be clarified
with further studies, our result would ultimately confirm a
therapeutic value of Brainoil in ALS, since BMI is, however,
a negative prognostic factor recognized by many epidemiol-
ogical studies [31].
Again, however, the comparison analysis of raw score
values and percentage of score reduction, at different times,
between groups did not show any significant differences.
Clinical data, as a whole, appear to be promising and
encourage further studies with Brainoil in ALS, although the
comparison between the groups at different times did not
show significant differences.
It is well known that oxidative stress and mitochondrial
dysfunctions may contribute to ALS pathogenesis [32-34],
with elevated ROS production resulting in a vicious circle of
events which can damage biological molecules [4, 35]. Here
we validate this assumption, in fact, elevated AOPP values,
as well as reduced T-SH levels, were found in ALS patients
with respect to healthy controls.
Curcumin is known for its neuroprotective, anti-
inflammatory, and anti-oxidant capacity against different
oxidative stressors, limiting and/or suppressing oxidative
damage [15], suggesting that it could improve pathological
conditions that share oxidative basis, such as ALS. As dem-
onstrated in ALS cell models, curcumin also modulates mi-
tochondrial functions [11, 20-21]; this is in line with our
results suggesting that Brainoil administration can improve
the redox status also in ALS patients. In fact, a significant
reduction in AOPPs was demonstrated in ALS patients be-
longing to Group B that assumed Brainoil for 6 months. This
positive trend was observed also at 30% and at 50% of
IWET in T2>T0 and T2>T1 comparison, respectively. Also,
the analysis inter-group seems to confirm this data; in fact at
T2, the Group B showed, at 50% of MHF, lower AOPP lev-
els than Group A (with a borderline significance). Moreover,
significant decreases of AOPP levels were detected in Group
B vs. healthy controls, after 6 months of Brainoil intake,
showing nearest values to control group especially at 30%
and 50% of IWET. Into Group A, appreciable AOPP de-
creases were observed only in basal condition after the open-
label phase.
Nevertheless, these observations remain uncertain; de-
spite the data were in line with an anti-oxidative and protec-
tive action of Brainoil against oxidative damage after 6
months of Brainoil supplementation, when we considered the
treated patients although in Group B Brainoil acts already
after the first 3 months of treatment, the same was not dem-
onstrated into Group A at T2 (after 3 months of Brainoil
therapy, the same treatment period of the Group B). Moreo-
ver, it remains unclear why the beneficial effect was detected
only in some of the considered exercise steps. Most of the
studies that investigate the effect of curcumin on exercise
performance are focused on animal models finding conflict-
ing results [36, 37] and unfortunately, only limited reports
have been conducted in human. In this regard, Takahashi and
coworkers [38] observed that the concentration of reactive
oxygen metabolites measured immediately after exercise was
Chico et al.
higher than pre-exercise values in the placebo group, but not
after curcumin supplementation.
When we evaluated antioxidant FRAP values, no differ-
ences were observed in ALS patients vs controls, differently
than previously seen [26, 39] except at peak of IWET in
which FRAP was lower in patients. Probably, this simile
FRAP profile between patients and controls, observed also
when ALS subjects were treated with Brainoil, it could be
due to the adoption of a compensatory mechanism to limit
both oxidative damages to proteins and the lower T-SH lev-
els found in ALS patients than the healthy controls. Analyz-
ing Group A and Group B at different times (T2>T1>T0) it
was observed at T1>T0, in Group A, a significant reduction
of FRAP values at 70% of IWET and at recovery, suggesting
that during placebo administration there was a worsening of
FRAP, according to disease progression. Takahashi et al.
[38] found, after curcumin supplementation, an increase of
antioxidant potential concentrations immediately after exer-
cise compared with pre-exercise values, indicating that cur-
cumin supplementation can attenuate exercise-induced oxi-
dative stress by increasing blood antioxidant capacity [38].
These findings are in line with our observations: into Group
A, was observed at T1>T0, a significant reduction of FRAP
values at 70% of IWET and at recovery, suggesting that dur-
ing placebo administration there was a worsening of FRAP,
according to disease progression. When Brainoil was intro-
duced in the dietary of Group A, a FRAP restore, at T2>T1,
was noted, rising FRAP levels at different steps of the
exercise-related curve with values comparable to T0. Differ-
ently, into Group B, in the inter-time evaluation, no differ-
ences were observed in FRAP levels, both at rest and during
the exercise test. So, despite Brainoil supplementation did
not improve the FRAP, it prevented the worsening viewed in
placebo group before the integrator administration; so, in this
case, we could hypothesize a “homeostatic” role of Brainoil.
Its potential "retrieval" and "homeostasis" activity was also
supported by the observation that no difference was detected
from inter-group comparison and when we compared T2
values of Group A and T1 values of Group B with respect to
T1 values of Group A (namely, when a comparison was
made between 3 months of placebo and 3 months of Brai-
noil, regardless of the examined group).
Our observations are in line with another study [38] in
which was found, after curcumin supplementation, an in-
crease of antioxidant potential concentrations immediately
after exercise compared with pre-exercise values, indicating
that curcumin supplementation can attenuate exercise-
induced oxidative stress by increasing blood antioxidant ca-
pacity.
T-SH changes were not consistent with Brainoil/placebo
intake, making data interpretation more difficult. In fact, in
T1-T0 comparison, both in Group A and in Group B, higher
T-SH values were found during the exercise test, with no
difference in basal values. In both groups, the value of thiols
increased at T1 >T0 but not at T2>T1. Assuming that
oxidative stress is implicated in ALS pathogenesis, the
increase in T-SH values in both groups appear contradictory.
This evidence deserves two observations: on the one hand, it
should be noted that in other studies plasma and cerebrospinal
fluid T-SH levels were found unchanged [40] or increased
Effect of Curcumin Supplementation in Amyotrophic Lateral Sclerosis Patients
[41] in line with our study. Secondly, the increase of T-SH
levels, apparently independent of Brainoil assumption,
remains unclear even if it is related to the disease natural
history, suggesting the presence of a further, or even more,
factors.
In ALS patients, it has been shown that mitochondrial
dysfunction occurs both in central nervous system and in
peripheral tissues such as skeletal muscle, therefore the lac-
tate curve analysis during muscle-skeletal exercise can be
considered a valid investigation in ALS patients, as it allows
to assess the aerobic metabolism efficiency and the possible
lactate threshold [42].
Here we found increased lactate levels during the differ-
ent steps of IWET although we did not observe any differ-
ence comparing the curves of ALS patients and healthy sub-
jects (data not shown). When only ALS patients were con-
sidered, the intra-group analysis performed considering the
percent (%) lactate values, showed at 50% of IWET a reduc-
tion into Group B at T1>T0. Interestingly, when we com-
pared the groups at T1, in the double-blind phase, while
there were no differences in basal lactate levels, they pro-
gressively increased during the exercise-test achieving a sta-
tistical significance during the exercise bouts in which the
patient's contract with the highest strength (50% and 70% of
the maximum force). Then, lactate levels returned near to
basal values after the exercise step. Lactate was always
lower in the group of patients treated with Brainoil, suggest-
ing that it reduces lactate production during muscle contrac-
tion, proportionally to the increase of muscular effort. This
action could be hypothetically linked to an optimization of
the mitochondrial function resulting in improved of the oxi-
dative state. Moreover, the lactate evaluation at T0 between
groups, during the exercise test, did not reach statistical sig-
nificance, validating the positive effect of Brainoil. The force
exerted to tighten the myometer, in the patients of both
groups, was comparable; so, differences in lactate production
between Group A and Group B cannot be attributed to a ma-
jor force in patients of the Group B. So, it is possible to con-
clude that Brainoil has a positive effect on the lactate pro-
duction in ALS patients attributable to a mitochondrial
improvement, although it is not clear which of Brainoil's
component may be responsible for this effect. In fact, we
must consider that Brainoil contains curcumin but also which
has a trophic action on mitochondria [43,44]. Coenzyme Q10
also contributes to lactic acid production during exercise, as
demonstrated in another double-blind placebo/drug trial in
which runners treated with coenzyme Q10 showed, after
intense physical exercise, a reduction of lactate levels with
respect to the placebo group [45]. Coenzyme Q10 present in
the Brainoil composition may have contributed to lowering
lactic acid levels in the group that assumed the integrator.
However, the dose of coenzyme Q10 taken in our study (100
mg/day) was lower than that taken in the above study (about
350 mg/day) and therefore a role of curcumin in the
mitochondrial metabolism may be supposed. This is in line
with other studies [46, 47] that demonstrated a curcumin
action in reducing the lactate levels during physical exercise
stimulating the mitochondrial biogenesis in rat skeletal mus-
cle [46], as well as in humans decreasing lactate, ammonia,
and other physical fatigue-associated biomarkers levels in
CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0 11
humans. So, curcumin may improve exercise performance
preventing fatigue [47].
6. STANDARD PROTOCOL ON APPROVALS AND
PATIENT CONSENTS
Diagnosis of ALS was conducted according to the crite-
ria of El Escorial Consensus Criteria. All patients gave their
informed consent. The study protocol was approved by the
Ethics Committee of the Great North West Area of Tuscany.
The study was conducted according to Good Clinical Prac-
tice (GCP).
CONCLUSION
Overall, the comparison between the ALS-FRS-r, MRC
and BMI parameters between groups did not give a signifi-
cant result to any of the times tested, except for the respira-
tory rate reduction of ALS-FRS-r at T1>T0, less in curcumin
Group B than in placebo/curcumin Group A. In intra-group
analysis, comparing different times, encouraging results
were observed indicating a slight slow down in disease pro-
gression in Brainoil patients, also related to therapy length.
As for laboratory parameters, conflicting results have
emerged. Brainoil was able to modify lactate production
profile during muscular exercise suggesting improving in
mitochondrial function and aerobic metabolism. Also with
regard to the trend of FRAP and AOPPs, the results indicate
a positive effect of Brainoil administration, and in particular
considering AOPP because, after 6 months, it was able to
reduce oxidative damage to proteins at comparable values
comparable, or however closer, to controls. Brainoil action
on the T-SH groups, however, is unclear, showing a behavior
apparently independent of the assumption.
In the light of these positive findings, further studies,
increasing the number of subjects and Brainoil administra-
tion time, as well as studies to identify the correct dosage of
curcumin to be used, are needed to confirm a possible thera-
peutic value of this compound. Possible strategies could be
time administration and dose increases as well as enlarge the
cohort, even for better phenotypic stratification and early
compliance, fundamental to increase trial significance.
LIST OF ABBREVIATIONS
ALS-FRS-r = ALS Functional Rating Scale Revised
MRC = Medical Research Council
BMI = Body Mass Index
MHF = Maximum Handgrip Force
IWET = Forearm Incremental Workload Exercise Test
TDP-43 = TAR DNA-Binding Protein 43
AMP = Adenosine Monophosphate
PGC-1α = Peroxisome Proliferator-activated Receptor
Gamma Coactivator 1-alpha
Nrf2 = Nuclear Factor Erythroid-derived 2-like 2
ROS = Reactive Oxygen Species
12 CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0
AOPPs = Advanced Oxidation Protein Products
FRAP = Ferric Reducing Ability Power
T-SH = Total Thiol Groups
ETHICS APPROVAL AND CONSENT TO PARTICI-
PATE
Not applicable.
HUMAN AND ANIMAL RIGHTS
No Animals/Humans were used for studies that are the
basis of this research.
CONSENT FOR PUBLICATION
Not applicable.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or
otherwise.
ACKNOWLEDGEMENTS
The study was supported by ALIVEDA Laboratory s.r.l.
(Fauglia, Pisa) that provided the dietary supplement Brainoil
and placebo.
Lucia Chico, Elena Caldarazzo Ienco and Costanza
Bisordi wrote the manuscript; Lucia Chico, Lucia Petrozzi
and Annalisa Lo Gerfo performed experiments. Annalisa Lo
Gerfo and Elena Caldarazzo Ienco designed the study. Co-
stanza Bisordi, Elena Caldarazzo Ienco, Antonio Petrucci
and Michelangelo Mancuso performed clinical evaluations.
Gabriele Siciliano supervised the study.
REFERENCES
[1] Cleveland DW. From Charcot to SOD1: mechanisms of selective
motor neuron death in ALS. Neuron 1999; 24: 515-20.
[2] Bensimon G, Lacomblez L, Meininger V. A controlled trial of
riluzole in amyotrophic lateral sclerosis. ALS/Riluzole Study
Group. N Engl J Med. 1994; 330(9): 585-91
[3] Shi P, Gal J, Kwinter DM, Liu X, Zhu H. Mitochondrial dysfunc-
tion in amyotrophic lateral sclerosis. Biochim Biophys Acta. 2010;
1802(1): 45-51.
[4] Mitsumoto H, Santella RM, Liu X, et al. Oxidative stress biomark-
ers in sporadic ALS. Amyotroph Lateral Scler. 2008; 9(3): 177-83.
[5] Taylor JP, Brown RH Jr, Cleveland DW. Decoding ALS: from
genes to mechanism. Nature. 2016; 539(7628): 197-206.
[6] Chang Y, Kong Q, Shan X et al. Messenger RNA oxidation occurs
early in disease pathogenesis and promotes motor neuron degenera-
tion in ALS. PLoS One. 2008; 3(8): e2849.
[7] Barber SC, Shaw PJ. Oxidative stress in ALS: key role in motor
neuron injury and therapeutic target. Free Radic Biol Med. 2010;
48(5): 629-41.
[8] Kabuta C, Kono K, Wada K, Kabuta T. 4-Hydroxynonenal induces
persistent insolubilization of TDP-43 and alters its intracellular lo-
calization. Biochem Biophys Res Commun. 2015; 463(1-2): 82-7.
[9] Xu YF, Gendron TF, Zhang YJ, et al. Wild-type human TDP-43
expression causes TDP-43 phosphorylation, mitochondrial aggre-
gation, motor deficits, and early mortality in transgenic mice. J
Neurosci. 2010; 30(32): 10851-9.
[10] Shan X, Chiang PM, Price DL, Wong PC. Altered distributions of
Gemini of coiled bodies and mitochondria in motor neurons of
Chico et al.
TDP-43 transgenic mice. Proc Natl Acad Sci USA. 2010; 107(37):
16325-30.
[11] Lu J, Duan W, Guo Y, et al. Mitochondrial dysfunction in human
TDP-43 transfected NSC34 cell lines and the protective effect of
dimethoxy curcumin. Brain Res Bull. 201; 89(5-6): 185-90.
[12] Edaravone (MCI-186) ALS 19 Study Group. Safety and efficacy of
edaravone in well defined patients with amyotrophic lateral sclero-
sis: a randomised, double-blind, placebo-controlled trial. Lancet
Neurol. 2017; 16(7): 505-512.
[13] Aggarwal BB, Sundaram C, Malani N, Ichikawa H. Curcumin: the
Indian solid gold. Adv Exp Med Biol. 2007; 595: 1-75.
[14] Aggarwal BB, Sung B. Pharmacological basis for the role of cur-
cumin in chronic diseases: an age-old spice with modern targets.
Trends Pharmacol Sci. 2009; 30(2): 85-94.
[15] Aggarwal BB, Harikumar KB. Potential therapeutic effects of
curcumin, the anti-inflammatory agent, against neurodegenerative,
cardiovascular, pulmonary, metabolic, autoimmune and neoplastic
diseases. Int J Biochem Cell Biol. 2009; 4(1): 40-59.
[16] Bhatia NK, Srivastava A, Katyal N, et al. Curcumin binds to the
pre-fibrillar aggregates of Cu/Zn superoxide dismutase (SOD1) and
alters its amyloidogenic pathway resulting in reduced cytotoxicity.
Biochim Biophys Acta. 2015; 185(5): 426-36.
[17] Ciftci G, Aksoy A, Cenesiz S, et al. Therapeutic role of curcumin
in oxidative DNA damage caused by formaldehyde. Microsc Res
Tech. 2015; 78(5): 391-5.
[18] Lee HY, Kim SW, Lee GH, et al. Curcumin and Curcuma longa L.
extract ameliorate lipid accumulation through the regulation of the
endoplasmic reticulum redox and ER stress. Sci Rep. 2017; 7(1):
6513.
[19] Akbik D, Ghadiri M, Chrzanowski W, Rohanizadeh R. Curcumin
as a wound healing agent. Life Sci. 2014; 116(1): 1-7.
[20] Dong H, Xu L, Wu L, et al. Curcumin abolishes mutant TDP-43
induced excitability in a motoneuron-like cellular model of ALS.
Neuroscience. 2014; 272: 141-53.
[21] Negrette-Guzmán M, García-Niño WR, Tapia E et al. Curcumin
Attenuates Gentamicin-Induced Kidney Mitochondrial Alterations:
Possible Role of a Mitochondrial Biogenesis Mechanism. Evid
Based Complement Alternat Med. 2015; 2015: 917435.
[22] Chico L, Caldarazzo Ienco E, Bisordi C. et al. Curcumin as an ROS
Scavenger in Amyotrophic Lateral Sclerosis. Reactive Oxygen
Species. 2016; 2(5): 339–354.
[23] Witko-Sarsat V, Nguyen Khoa T, Jungers P, Drüeke T, Descamps-
Latscha B. Advanced oxidation protein products: oxidative stress
markers and mediators of inflammation in uremia. Adv Nephrol
Necker Hosp. 1998; 28: 321-41.
[24] Benzie IF, Strain JJ. The ferric reducing ability of plasma (FRAP)
as a measure of "antioxidant power": the FRAP assay. Anal Bio-
chem. 1996; 239(1): 70-6.
[25] Hu ML. Measurement of protein thiol groups and glutathione in
plasma. Methods Enzymol. 1994; 233: 380-5.
[26] Pasquinelli A, Chico L, Pasquali L, et al. Gly482Ser PGC-1α Gene
Polymorphism and Exercise-Related Oxidative Stress in Amyotro-
phic Lateral Sclerosis Patients. Front Cell Neurosci. 2016; 10: 102.
[27] Park Y, Park J, Kim Y, Baek H, Kim SH. Association between
nutritional status and disease severity using the amyotrophic lateral
sclerosis (ALS) functional rating scale in ALS patients. Nutrition.
2015; 31(11-12): 1362-7.
[28] Rupasinghe HP, Sekhon-Loodu S, Mantso T, Panayiotidis MI.
Phytochemicals in regulating fatty acid β-oxidation: Potential un-
derlying mechanisms and their involvement in obesity and weight
loss. Pharmacol Ther. 2016; 165: 153-63.
[29] Alamdari N, O'Neal P, Hasselgren PO. Curcumin and muscle wast-
ing: a new role for an old drug? Nutrition. 2009; 25(2): 125-9.
[30] Bouteloup C, Desport JC, Clavelou P, et al. Hypermetabolism in
ALS patients: an early and persistent phenomenon. J Neurol. 2009;
256(8): 1236-42.
[31] Moura MC, Novaes MR, Eduardo EJ, Zago YS, Freitas Rdel N,
Casulari LA. Prognostic Factors in Amyotrophic Lateral Sclerosis:
A Population-Based Study. PLoS One. 2015; 10(10): e0141500.
[32] Xu Z, Jung C, Higgins C, Levine J, Kong J. Mitochondrial degen-
eration in amyotrophic lateral sclerosis. J Bioenerg Biomembr.
2004; 36(4): 395-9.
[33] Duan W, Li X, Shi J, Guo Y, Li Z, Li C. Mutant TAR DNA-
binding protein-43 induces oxidative injury in motor neuron-like
cell. Neuroscience. 2010; 169(4): 1621-9.
Effect of Curcumin Supplementation in Amyotrophic Lateral Sclerosis Patients CNS & Neurological Disorders - Drug Targets, 2018, Vol. 17, No. 0 13

[34] Onesto E, Colombrita C, Gumina V, et al. Gene-specific mito-
chondria dysfunctions in human TARDBP and C9ORF72 fibro-
blasts. Acta Neuropathol Commun. 2016; 4(1): 47.
[35] D'Amico E, Factor-Litvak P, Santella RM, Mitsumoto H. Clinical
perspective on oxidative stress in sporadic amyotrophic lateral scle-
rosis. Free Radic Biol Med. 2013; 65: 509-27.
[36] Boz I, Belviranli M, Okudan N. Curcumin Modulates Muscle
Damage but not Oxidative Stress and Antioxidant Defense Follow-
ing Eccentric Exercise in Rats. Int J Vitam Nutr Res. 2014; 84(3-
4): 163-72.
[37] Kawanishi N, Kato K, Takahashi M, et al. Curcumin attenuates
oxidative stress following downhill running-induced muscle dam-
age. Biochem Biophys Res Commun. 2013; 441(3): 573-8.
[38] Takahashi M, Suzuki K, Kim HK, et al. Effects of curcumin sup-
plementation on exercise-induced oxidative stress in humans. Int J
Sports Med. 2014; 35(6): 469-75.
[39] LoGerfo A, Chico L, Borgia L, et al. Lack of association between
nuclear factor erythroid-derived 2-like 2 promoter gene polymor-
phisms and oxidative stress biomarkers in amyotrophic lateral scle-
rosis patients. Oxid Med Cell Longev. 2014; 2014: 432626.
[40] Oteiza PI, Uchitel OD, Carrasquedo F, et al. Evaluation of antioxi-
dants, protein, and lipid oxidation products in blood from sporadic
amyotrophic lateral sclerosis patients. Neurochem Res. 1997;
22(4): 535-9.
[41] Kokić AN, Stević Z, Stojanović S, et al. Biotransformation of nitric
oxide in the cerebrospinal fluid of amyotrophic lateral sclerosis pa-
tients. Redox Rep. 2005; 10(5): 265-70.
[42] Siciliano G, Pastorini E, Pasquali L, Manca ML, Iudice A, Murri L.
Impaired oxidative metabolism in exercising muscle from ALS pa-
tients. J Neurol Sci. 2001; 191(1-2): 61-5.
[43] Matthews RT, Yang L, Browne S, Baik M, et al. Coenzyme Q10
administration increases brain mitochondrial concentrations and
exerts neuroprotective effects. Proc Natl Acad Sci U S A. 1998;
95(15): 8892-7.
[44] Hargreaves IP. Coenzyme Q10 as a therapy for mitochondrial
disease. Int J Biochem Cell Biol. 2014; 49: 105-11.
[45] Armanfar M, Jafari A, Dehghan GR, Abdizadeh L. Effect of coen-
zyme Q10 supplementation on exercise-induced response of in-
flammatory indicators and blood lactate in male runners. Med J Is-
lam Repub Iran. 2015; 29: 202.
[46] Huang WC, Chiu WC, Chuang HL, et al. Effect of curcumin sup-
plementation on physiological fatigue and physical performance in
mice. Nutrients. 2015 Jan 30; 7(2): 905-21.
[47] Ray Hamidie RD, Yamada T, Ishizawa R, Saito Y, Masuda K.
Curcumin treatment enhances the effect of exercise on mitochon-
drial biogenesis in skeletal muscle by increasing cAMP levels. Me-
tabolism. 2015; 64(10): 1334-47.

DISCLAIMER: The above article has been published in Epub (ahead of print) on the basis of the materials provided by the author. The Edito-
rial Department reserves the right to make minor modifications for further improvement of the manuscript.

PMID: 30033879