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Archive for the ‘Melatonin & Circadian Regulation’ Category


Novel delivery system in REMfresh mimics the way the body naturally releases and maintains melatonin over a 7-hour period

Real-world evidence confirms previous clinical data on improved sleep duration and sleep quality with REMfresh

Reporter: Gail S. Thornton, M.A.

Chronic disorders of sleep and wakefulness affect an estimated 50-70 million adults in the United States.[i] The cumulative long term effects of sleep loss have been associated with a wide range of damaging health consequences, including obesity, diabetes, impaired glucose tolerance, cardiovascular disease, hypertension, anxiety and depression.[ii]In terms of preventing health consequences, sleeping 6-8 hours per night consistently may provide optimal health outcomes.[iii]

This month, real-world evidence from two recently completed patient-reported outcomes (PRO) studies presented at SLEEP 2019 in San Antonio, Texas, confirms previous clinical data demonstrating statistically significant improvements in sleep onset, sleep duration, sleep maintenance and sleep quality with REMfresh®, the first and only continuous release and absorption melatonin (CRA-Melatonin™). This data supports and reinforces the benefits of REMfresh, which is designed to give patients up to 7 hours of sleep support. PRO studies of this kind, which more closely address real-world patient experience, are increasingly being recognized by regulatory authorities and academia in evaluating new therapies.

The REMfresh Duration Validation (REMVAL) study provides further evidence of a correlative relationship between the 7-hour pharmacokinetic profile observed in the earlier clinical study, REM Absorption Kinetics Trial (REMAKT), and the hypnotic effects of REMfresh, observed in subsequent studies, as demonstrated by improvements in sleep onset, sleep duration, sleep maintenance, sleep quality and patient satisfaction. This latest study further validates the findings of past studies that have been presented and undergone peer review at major sleep conferences:  

  • REMfresh Patient Reported Outcomes DURation (REMDUR), the first, 500-patient, PRO study of this sleep brand, presented at the annual meeting for sleep specialists, SLEEP 2018, which demonstrated that more than 77 percent of patients achieved 6 or more hours of sleep compared to 23.6 percent who slept that duration prior to taking REMfresh (p<.0001)[iv], and
  • REM Absorption Kinetics Trial (REMAKT), a pharmacokinetic study presented at SLEEP 2017 and 2018, which demonstrated that REMfresh mimics the body’s own seven-hour Mesa-Wave® release profile, a natural pattern of melatonin blood levels during a normal night’s sleep cycle.[v] 

An additional PRO subset study, part of REMVAL, called the REMfresh Short Sleep Cohort Assessment (REMSS), assessed improvements in sleep duration and sleep maintenance among 311 patients with morbid or extreme short sleep duration of 4 hours or less.

These two PRO studies (REMVAL and REMSS) were presented at SLEEP 2019, the 33rd Annual Meeting of the Associated Professional Sleep Societies (APSS), which is a joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society, held in San Antonio, Texas, from June 8-12.

“These latest findings provide further confirmation of the potential for nonprescription REMfresh to help address the public health issue of  the cumulative effects of sleep loss,” said David C. Brodner, M.D., a leading sleep specialist who is Double Board-Certified in Otolaryngology — Head and Neck Surgery as well as Sleep Medicine, Founder and Principle Physician at the Center for Sinus, Allergy, and Sleep Wellness, in Palm Beach County, Florida, and Senior Medical Advisor for Physician’s Seal, LLC. “Based on a novel Ion Powered Pump® (IPP®) delivery system that provides a pharmacokinetic (PK) profile that more closely aligns with the body’s own natural sleep pattern, REMfresh has demonstrated once again promising results and high levels of satisfaction in a real-world population of patients who have had chronic difficulties sleeping, providing up to seven hours of sleep support,” said Dr. Brodner.

Topline findings of these studies are as follows:

  • The 1,116 patient-reported outcomes (PRO) study, REMfresh Duration Validation (REMVAL), found that after taking 99 percent ultra-pure, continuous release and absorption melatonin (REMfresh®, CRA-melatonin™), the majority (78.8 percent) of patients involved achieved a sleep duration of greater than or equal to 6 hours (p<.0001), while more than 91 percent of patients reported a major/moderate improvement in sleep onset, sleep maintenance and sleep quality (p<.0001).  Of the 30.7 percent of patients (342 in total), who reported never having taken other brands of melatonin, 99.4 percent indicated they were likely or very likely to continue taking CRA-melatonin for their sleep issues (p<.0001).
  • REMVAL provides further real-world evidence of a correlative relationship between the originally observed 7-hour pharmacokinetic profile in the REM Absorption Kinetics Trial (REMAKT) and the strong observed hypnotic effects of CRA-melatonin, as demonstrated by improvements in sleep onset, sleep duration, sleep maintenance and sleep quality.
  • A second PRO subset study, REMfresh Short Sleep Cohort Assessment (REMSS), involving 311 patients who reported sleeping four hours or less nightly from the REMVAL study, found that 95.8 percent of patients who previously experienced daily, morbid short sleep duration of less than or equal to 4 hours reported an improvement in sleep duration (p<.0001), including more than 46 percent who achieved a sleep duration of greater than or equal to 6 hours (p<.0001). More than 93 percent of patients reported a major/moderate improvement in sleep onset, sleep maintenance and sleep quality (p<.0001).
  • REMVAL and REMSS also provides validation of the results from the previously peer-reviewed and presented clinical study, REMAKT, which demonstrated that REMfresh mimics the body’s own 7-hour Mesa Wave®, a natural pattern of melatonin blood levels during a normal night’s sleep cycle and the 500-patient, peer-reviewed and presented  REMfresh® Patient Reported Outcomes DURation (REMDUR) study, that demonstrated statistically significant improvements in sleep onset, sleep maintenance and sleep quality.

REMVAL Study Describes Improvements in Sleep Duration and Sleep Quality

The poster entitled, “Observed Hypnotic Effects with a Continuous-Release Ion Powered Pump Melatonin Delivery System: Self-Reported Patient Outcomes Study Results Demonstrating Improvement in Sleep Duration and Quality,” reported findings provides further real-world evidence of a correlative relationship between the originally observed 7-hour pharmacokinetic profile in the REM Absorption Kinetics Trial (REMAKT) and the strong hypnotic effects of CRA-melatonin observed in subsequent studies and may offer a new low-dose, drug-free alternative to prescription hypnotics to treat chronic sleep disturbances.

The 1,116-patient REMVAL study was designed to obtain clinically relevant information about patients’ past usage of melatonin and non-melatonin sleep aids, sleep patterns prior to taking CRA-melatonin, sleep duration before and after taking CRA-melatonin, frequency of CRA-melatonin usage, improvement in sleep onset, sleep maintenance and sleep quality after taking CRA-melatonin, and overall satisfaction with CRA-melatonin.

In the study, patients with sleep disturbances in the general population received a sample of REMfresh from their physicians and were invited to complete a 13-question online survey. After taking REMfresh, the majority (78.8 percent) of patients achieved a sleep duration of greater than or equal to 6 hours (p<.0001). More than 91 percent of patients reported a major/moderate improvement in sleep onset, sleep maintenance and sleep quality (p<.0001). Of the 30.7 percent of patients (342 in total), who reported never having taken other brands of melatonin, 99.4 percent indicated they were likely or very likely to continue taking REMfresh for their sleep issues (p<.0001).

REMSS Study Shows Improvement in Patients with Chronic, Extreme Short Sleep

The poster entitled, “Improvement in Sleep Duration and Maintenance with Ion Powered Continuous Release and Absorption Melatonin in a Cohort of Patients with Chronic Short Sleep Duration: Results from a Patient-Reported Outcomes Study,” highlighted findings from the REMfresh Short Sleep Cohort Assessment (REMSS), involving a cohort of 311 patients from the REMVAL study who reported sleeping four hours or less nightly. This cohort analysis was designed to obtain clinically relevant information from these patients experiencing morbid short sleep disturbances, including sleep patterns and melatonin usage before taking REMfresh, sleep duration before and after taking REMfresh, improvement in sleep onset, sleep maintenance and sleep quality after taking REMfresh, and overall product satisfaction.

Data from this cohort show that 95.8 percent of patients who previously experienced daily, morbid short sleep duration of less than or equal to 4 hours reported an improvement in sleep duration (p<.0001), including more than 46 percent who achieved a sleep duration of greater than or equal to 6 hours (p<.0001). This increase from less than or equal to 4 hours to greater than or equal to 6 hours represents a major sleep duration upgrade in this group facing morbid sleep disturbances. More than 93 percent of patients reported a major/moderate improvement in sleep onset, sleep maintenance and sleep quality (p<.0001). Ninety-nine percent of the patients suffering with morbid short sleep (27.2 percent of whom had never previously tried a melatonin brand) reported that they were very likely or likely to continue using CRA-melatonin. These results provide real-world evidence that CRA-melatonin with its extended 7-hour pharmacokinetic  plateau time and benign safety-profile may be a practical baseline therapy to improve sleep duration and other key sleep parameters, including, sleep maintenance and sleep quality in this group of patients who have a higher risk of all-cause mortality.[vi]˒[vii]˒[viii]˒[ix]

Statistics & Data Corporation (SDC), a top-tier clinical data services provider, has independently determined that the number of participants in the study provides adequate power (>90%) to detect even small improvements in sleep outcomes. This high power, or probability of seeing statistically significant results if CRA-melatonin is truly working to improve sleep outcomes, applies to the overall study population (REMVAL) as well as the cohort of short sleepers (REMSS). SDC has subsequently independently validated the statistical results achieved, (e.g., p-values and statistical language).

The Increasing Appreciation of PRO Studies to Include Patient Experience 
Increasingly, there is an appreciation by the U.S. Congress, regulatory authorities and academia, of the substantive value that real-world patient experience brings to assessing new therapies. In addition to the traditional randomized, placebo-controlled trial studies, regulatory authorities are now incorporating the patient perspective in their decision making, including PRO studies. A PRO study is a measurement based on a report that comes directly from the patient about the status or change in their health condition and without amendment or interpretation of the patient’s response by health-care intermediaries. PRO measures can be used to capture a patient’s everyday experience outside of the clinician’s office, and the effects of a treatment on the patient’s activities of daily living.[x]˒[xi]Together, clinical measures and PRO measures can provide a fuller picture of patient benefit.

REMAKT Clinical Study Presented at Past Medical Meetings 
Pharmacokinetic data on REMfresh® was peer-reviewed and then presented in 2017 and 2018 at SLEEP, the Annual Meeting of the Associated Professional Sleep Societies LLC (APSS), and a joint meeting of the American Academy of Sleep Medicine (AASM) and the Sleep Research Society (SRS). 

The study, REM Absorption Kinetics Trial (REMAKT), was a U.S.-based randomized, crossover pharmacokinetic (PK) evaluation study in healthy, non-smoking adults that compared REMfresh (CRA-melatonin) with a market-leading, immediate-release melatonin (IR-melatonin). The study found that melatonin levels with REMfresh exceeded the targeted sleep maintenance threshold for a median of 6.7 hours, compared with 3.7 hours with the leading IR-melatonin. Conversely, the levels of the market-leading IR-melatonin formulation dramatically increased 23 times greater than the targeted levels of exogenous melatonin for sleep maintenance and then had a rapid decline in serum levels that did not allow melatonin levels to be maintained beyond 4 hours. 

Analysis presented at SLEEP 2017 and 2018 showed that REMfresh builds upon the body of evidence from prolonged-release melatonin (PR-M), approved by the European Medicines Agency (EMA) in 2007 as a prescription drug for insomnia, which demonstrated in well-conducted, placebo-controlled studies, statistically significant improvement in sleep quality, morning alertness, sleep onset and quality of life in patients aged 55 years and older compared with placebo.[xv] REMfresh was designed to overcome the challenges of continuous release and absorption in the intestines, thereby extending the continual and gradual release pattern of melatonin through the night (known as the Mesa Wave®, a flat-topped hill with steep sides).[xvi] There was the desirable fast time to reach the sleep threshold level, which is anticipated to result in improved sleep onset, while the extended median plateau time to 6.7 hours and rapid fall-off in plasma levels at the end of the Mesa Wave may help to improve sleep maintenance and morning alertness. 

Over 5,000 healthcare practitioners are estimated to have used REMfresh for their patients and about 320,000 patients are estimated to have purchased and used REMfresh. The continuing, rapid acceptance of REMfresh by patients is observable by several markers, including rapid sales growth and availability among major drug retailers.

###

Data Presented at SLEEP 2019 Poster Sessions:

Monday, June 10, 2019, 5:15-7:15pm

  • (Abstract 0398, Poster Board #135) Improvement in Sleep Duration and Maintenance with Ion Powered Continuous Release and Absorption Melatonin in a Cohort of Patients with Chronic Short Sleep Duration: Results from a Patient-Reported Outcomes Study
    • David J. Seiden, M.D., FAASM,  David Brodner, M.D., Syed M. Shah, Ph.D.
  • (Abstract 0399, Poster Board #136) Observed Hypnotic Effects with a Continuous-Release Ion Powered Pump Melatonin Delivery System: Self-Reported Patient Outcomes Study Results Demonstrating Improvement in Sleep Duration and Quality
    • David J. Brodner, M.D., David J. Seiden, M.D. FAASM, Syed M. Shah, Ph.D.

The abstracts are published in an online supplement of the journal, Sleep, which is available at https://sleepmeeting.org/wp-content/uploads/2019/04/SLEEP_42_S1-Website-Final.pdf.

REFERENCES:


[i] Colten, H.R., & Altevogt, B.M. (Eds). (2006). Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem.  Institute of Medicine (US) Committee on Sleep Medicine and Research. Washington, DC: National Academies Press (US). doi: https://doi.org/10.17226/11617

[ii] Cappuccio, F.P., D’Elia, L., Strazzullo, P., & Miller, M.A. (2010). Sleep duration and all-cause mortality: A systemic review and meta-analysis of prospective studies. Sleep, 33(5):585-592.

[iii] Watson, N.F., Badr, M.S., Belenky, G., et al. (2015). Joint Consensus Statement of the American Academy of Sleep  Medicine and Sleep Research Society on the Recommended Amount of Sleep for the Healthy Adult, Methodology and Discussion. Journal of Clinical Sleep Medicine, 11(6); 591-592.

[iv] Seiden,D.J., Brodner, D.C., & Shah, S.M. (2018, June 2-6). Improvement in Sleep Maintenance and Sleep Quality with Ion-Powered Pump Continuous Release and Absorption Melatonin: Results from a Self-Reported Patient Outcomes Study (Abstract #0419). Poster presented at SLEEP 2018, Baltimore, Maryland.

[v] Brodner, D.C., Shah, S.M. (2017, June 3-7). REM Absorption Kinetics Trial: A Randomized, Crossover, Pharmacokinetics Evaluation of a Novel Continuous Release and Absorption Melatonin Formulation versus a Same Strength Immediate-Release Formulation in Healthy Adults (Abstract #0396). Poster presented at: SLEEP 2017, Boston, Massachusetts.

[vi] Knutsen, K.L., Turek,, F.W., Patel, S.R., et al (2006). The u-shaped association between sleep and health: the 2 peaks do not mean the same thing.  Comment on Patel, SR, et al. Sleep, 29(7): 878-879.

[vii] Lubetkin,, E.I., & Haomiao, J. (2018). Burden of disease due to sleep duration and sleep problems in the elderly. Sleep Health, 4; 182-187.

[viii] Hafner M, et al. (2017). Why sleep matters-the economic costs of insufficient sleep: A cross-country comparative analysis, Rand Quarterly.

[ix] Ikehara, S, et al. (2009). Association of Sleep Duration with Mortality  from Cardiovascular Disease and other Causes for Japanese Men and Women: the JACC Study. Sleep, 32(3); 295-301.

[x] U.S. Food and Drug Administration. Real World Evidence. Retrieved from https://www.fda.gov/scienceresearch/specialtopics/realworldevidence/default.htm

[xi] U.S. Food and Drug Administration. 21st Century Cures Act. Retrieved from https://www.fda.gov/regulatoryinformation/lawsenforcedbyfda/significantamendmentstothefdcact/21stcenturycuresact/default.htm.

[xii] Colten, H.R., & Altevogt, B.M. (Eds). (2006). Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem.  Institute of Medicine (US) Committee on Sleep Medicine and Research. Washington, DC: National Academies Press (US). doi: https://doi.org/10.17226/11617

[xiii] Cappuccio, F.P., D’Elia, L., Strazzullo, P., & Miller, M.A. (2010). Sleep duration and all-cause mortality: A systemic review and meta-analysis of prospective studies. Sleep, 33(5):585-592.

[xiv] Watson, N.F., Badr, M.S., Belenky, G., et al. (2015). Joint Consensus Statement of the American Academy of Sleep  Medicine and Sleep Research Society on the Recommended Amount of Sleep for the Healthy Adult, Methodology and Discussion. Journal of Clinical Sleep Medicine, 11(6); 591-592.

[xv] European Medicines Agency.(2007). Assessment Report for CIRCADIN.

[xvi] Brodner, D.C. & Shah, S.M. (2017, June 3-7). A Continuous Release Ion Powered Pump Melatonin Delivery System that Overcomes Challenges of Release and Absorption in the Intestines (Abstract #0385). Poster presented at: SLEEP 2017,  Boston, Massachusetts.

SOURCES:

https://finance.yahoo.com/news/significant-real-world-evidence-confirms-123000247.html

Dr. David C. Brodner, Center for Sinus, Allergy, and Sleep Wellness (http://www.brodnermd.com/sleep-hygiene.html)

Other related articles published in this Open Access Online Scientific Journal include the following:

2018

https://pharmaceuticalintelligence.com/2018/06/10/patient-reported-outcomes-study-presented-at-sleep-2018-provides-confirmatory-real-world-evidence-of-the-previously-presented-7-hour-action-of-remfresh-the-first-continuous-release-and-absorp/

2017

https://pharmaceuticalintelligence.com/2017/10/02/2017-nobel-prize-in-physiology-or-medicine-jointly-to-jeffrey-c-hall-michael-rosbash-and-michael-w-young-for-their-discoveries-of-molecular-mechanisms-controlling-the-circadian-rhythm/

https://pharmaceuticalintelligence.com/2017/06/11/ultra-pure-melatonin-product-helps-maintain-sleep-for-up-to-7-hours/

2016

https://pharmaceuticalintelligence.com/2016/03/16/sleep-science/

2013

https://pharmaceuticalintelligence.com/2013/03/09/melatonin-and-its-effect-on-acetylcholinesterase-activity-in-erythrocytes/

Read Full Post »


  • More than 77 percent of patients in the REMfresh® Patient Reported Outcomes DURation (REMDUR) study reported achieving 6 or more hours of sleep after taking REMfresh®, the first continuous release and absorption melatonin (CRA-melatonin)
  • More than 91 percent experienced improvements in sleep onset, sleep maintenance and total sleep quality, after taking REMfresh® (CRA-melatonin)
  • Post-marketing, patient-reported outcomes data reinforces clinical trial evidence demonstrating the potential of non-prescription REMfresh®, as a new, non-prescription, drug-free hypnotic (sleep) product designed to achieve 7-hour sleep
  • New data confirms previously presented SLEEP 2017 study showing the patented Ion Powered Pump (IPP) technology in REMfresh® helps extend melatonin-targeted sleep maintenance levels in the body from 3.7 hours (with marketed immediate-release melatonin) to 6.7 hours, while mimicking the pattern of the body’s natural melatonin blood levels during the nightly sleep cycle

Real Time Coverage at SLEEP 2018 meeting, Baltimore.

Reporters: Aviva Lev-Ari, PhD, RN, and Gail S. Thornton, MA

BALTIMORE – (June 6, 2018) – A patient-reported outcomes study presented at SLEEP 2018 provides confirmatory real-world evidence of the previously peer-reviewed and presented data showing the 7-hour action of REMfresh®, a new product for sleep. REMfresh® Ion-Powered Melatoninis the first and only, continuous release and absorption melatonin (CRA-melatonin) to mimic the body’s own 7-hour Mesa Wave, the natural pattern of melatonin blood levels during a normal night’s sleep cycle. This induces sleep onset and provides lasting and restorative sleep for up to 7 hours.

This new data shows a correlative relationship between a 7-hour Mesa Wave pharmacokinetic (PK) profile and real-world evidence of improvements in sleep duration, onset, maintenance and sleep quality after taking REMfresh® (CRA-melatonin).

The post-marketing REMfresh® Patient Reported Outcomes DURation (REMDUR) study was presented at SLEEP 2018, the 32nd Annual Meeting of the Associated Professional Sleep Societies (APSS), LLC, a joint partnership of the American Academy of Sleep Medicine (AASM) and the Sleep Research Society (SRS).

 

Brodner and Seiden

Pictured here is David C. Brodner, M.D., and David J. Seiden, M.D., FAASM, after presenting the latest study data which found REMfresh is the first and only continuous release and absorption melatonin™ to mimic the body’s own 7-hour Mesa Wave™.

 

In a sample of 500 patients on REMfresh® (CRA-melatonin) responding to an online survey, 77.6 percent achieved 6 or more hours of sleep compared to 23.6 percent who slept that duration prior to taking REMfresh® (p<.0001). A vast majority of respondents also reported a major or moderate improvement in sleep onset (91.6 percent, p<.0001), sleep maintenance (94.8 percent, p<.0001) and total sleep quality (97.2 percent, p<.0001). More than three-quarters (76.6 percent) of patients indicated they take REMfresh® (CRA-melatonin) nightly. The proportion of patients reporting nightly CRA-melatonin use was significantly greater than the proportion of patients with less than nightly use (p<.0001). Most importantly, over 98 percent of patients reported they were very likely or likely to continue taking REMfresh® (CRA-melatonin) to treat their sleep complaints.

“The real-world evidence reported today in REMDUR provides further confirmation that REMfresh® represents a significant advance in the use of melatonin as a baseline therapy for treating sleep complaints,” said David C. Brodner, M.D., a leading sleep specialist who is Double Board-Certified in Otolaryngology — Head and Neck Surgery and Sleep Medicine, founder and principle Physician at the Center for Sinus, Allergy, and Sleep Wellness, in Palm Beach County, Florida, and Senior Medical Advisor for Physician’s Seal, LLC®.

“REMfresh® Ion-Powered Melatoninhas been shown to be an effective drug-free solution that is now available to the millions of Americans in need of a good night’s sleep, many of whom seek new therapies that will induce sleep and keep them asleep until the morning, without causing residual effects they’ll feel the next day. With its unique delivery system that imitates the body’s own natural sleep pattern, REMfresh® has revolutionized the role of melatonin, when delivered in the CRA form. It is no longer just a treatment for jet lag, but the CRA-melatonin found in REMfresh® has been shown to provide substantial relief to individuals having nightly sleep challenges,” said Dr. Brodner.

The scientifically advanced, patented delivery system in REMfresh® (CRA-melatonin), called Ion Powered Pump (IPP™) technology, replicates the way in which the body naturally releases and absorbs melatonin, unlike conventional melatonin sleep products. Since REMfresh® is not a drug, there is no drug hangover.

Nearly one-third of U.S. adults sleep less than the recommended seven hours daily.[1],[2] Increasing evidence suggests an association between sub-optimal sleep duration and adverse health outcomes including a higher risk of diabetes, hypertension, heart attack, stroke, obesity and depression.[3] A pooled analysis of 16 studies and over one million patients found short sleep duration corresponded with greater risk of morbidity and mortality.[4]

 REMDUR Study Design

The post-marketing REMfresh® Patient Reported Outcomes DURation (REMDUR) study was designed to obtain real-world evidence about patients’ sleep patterns, duration of sleep before and after REMfresh® (CRA-melatonin), daily REMfresh® (CRA-melatonin) use, onset of action, sleep maintenance, quality of sleep, and overall satisfaction with REMfresh® (CRA-melatonin).

Patients with sleep disturbances in the general population who received a sample of CRA-melatonin (REMfresh®) from their physicians were invited to complete a 12-question survey. Survey responses were received from 500 patients.

Confirmation of the REMAKT Clinical Study

REMDUR confirmed clinical trial findings from REMAKT (REM Absorption Kinetics Trial), a U.S.-based randomized, crossover pharmacokinetic (PK) evaluation study in healthy, non-smoking adults that compared REMfresh® (CRA-melatonin) with a market-leading, immediate-release melatonin (IR-melatonin).[5]

The study results, peer-reviewed and presented last year at SLEEP 2017, showed that melatonin levels with REMfresh® (CRA-melatonin) exceeded the targeted sleep maintenance threshold for a median of 6.7 hours, compared with 3.7 hours with the leading IR-melatonin. Conversely, the levels of the market-leading IR-melatonin formulation dramatically increased 23 times greater than the targeted levels of exogenous melatonin for sleep maintenance and had a rapid decline in serum levels that did not allow melatonin levels to be maintained beyond 4 hours.

The REMfresh® (CRA-melatonin) studies build upon the body of evidence from prolonged-release melatonin (PR-M), marketed in Europe, which demonstrated in well-conducted, placebo-controlled studies, statistically significant improvement in sleep quality, morning alertness, sleep latency and quality of life in patients aged 55 years and older compared with placebo. REMfresh® (CRA-melatonin) was designed to overcome the challenges of absorption in the intestines, thereby extending the continual and gradual release pattern of melatonin through the night (known as the Mesa Wave, a flat-topped hill with steep sides). There was a fast time to Cmax, which is anticipated to result in improved sleep onset, while the extended median plateau time to 6.7 hours and rapid fall-off in plasma levels at the end of the Mesa Wave, may help to improve sleep maintenance and morning alertness.

Conventional melatonin products have had challenges at mimicking the profile of a Mesa Wave™. The scientific work behind REMfresh® (CRA-melatonin) sought to overcome these challenges by having the melatonin formulation in a matrix that maintains a patented, solubility-enhancing pH environment to help with the transport to the brush border of the gut and its subsequent absorption.

Designed as a hydrogel matrix tablet, REMfresh® (CRA-melatonin) provides rapid release of the melatonin from the surface of the tablet, as the hydrogel release-controlling matrix is setting up in the acidic environment (pH of 1 to 3.5) in the stomach. As the tablet moves into the higher pH (5.5 to 6.5) environment of the small-intestine, which is above the pKa of melatonin (~4.0), the acidic moiety in the tablet is designed to maintain the pH within the tablet below 4.0 for 7+ hours. The hydrogel matrix, after proper hydration, allows continuous release of the active melatonin and acidic moiety into the lumen of the intestines.

Melatonin: The Body’s Natural Sleep Ingredient

Melatonin is produced by the pineal gland in the brain and is the body’s natural sleep ingredient. Melatonin levels normally begin to rise in the mid-to late evening and remain high for the majority of the night. Levels begin to decline towards early morning, as the body’s wake cycle is triggered. As people age, melatonin levels can drop by as much as 70 percent[6] and their bodies may no longer produce enough melatonin to ensure adequate sleep.

Other available products, such as immediate-release melatonin, help initiate the onset of sleep but are usually unable to sustain prolonged sleep maintenance due to an immediate burst of melatonin, which is quickly degraded due to its relatively short half-life (60 minutes). Absorption in the lower digestive tract is limited by melatonin’s limited ability to be absorbed in a low acidity or neutral pH environment.

Importance of Sleep

Sleep is an essential part of every person’s life. The body requires a certain amount of sleep in order to properly rest, repair and renew itself. Sleep is customarily divided in four different stages, with each stage having a different effect. These four stages are:

N1, N2, deep sleep and REM sleep. The body moves among these four stages several times while asleep. If sleep is disrupted for any reason, a person’s body may not have a chance to properly restore itself, especially if it is struggling to get to the later stages, called deep sleep and REM sleep. Studies have shown that sound and sufficient sleep is important for learning, memory and a healthy immune system. A regular pattern of deep sleep and REM sleep will help a person begin the next day feeling refreshed and ready to go.

About Non-Prescription REMfresh®

REMfresh® (CRA-melatonin) is the first and only, continuous release and absorption formulation of UltraMel® melatonin (available as 2 mg and 5 mg and with a 0.5 mg anticipated in the second half of 2018). UltraMel® melatonin is a high-quality, 99 percent ultra-pure melatonin sourced from Western Europe exclusively for Physician’s Seal®.

REMfresh® (CRA-melatonin) is a dietary supplement and is regulated under the Federal Dietary Supplement Health and Education Act, which does not require pre-approval. Melatonin has been in common use for over two decades and has a well-established profile of safe use by millions of people around the world. As with all supplements, individual results may vary.

REMfresh® (CRA-melatonin) is non-habit forming and does not contain narcotics, hypnotics, barbiturates, sedatives, antihistamines, alcohol or other harsh or additive chemicals. The usual adult recommended dose is 1-2 tablets 30-60 minutes before bedtime. Follow specific dosing instructions found on the back of the box for proper use of supplements.

REMfresh® (CRA-melatonin) is available at Walmart, Rite Aid and CVS/pharmacy. In 2017 REMfresh® was ranked as  the #1 recommended brand for sleep management by sleep doctors[7].

About Physician’s Seal®

Physician’s Seal® is the innovator of REMfresh®, the first and only continuous release and absorption, 99 percent ultra-pure melatonin (CRA-melatonin) that mimics the way the body naturally releases and maintains melatonin over a 7-hour period. Physician’s Seal®, founded in 2015, is a privately held company based in Boca Raton, Florida. It is committed to bringing cutting-edge life science applications to doctors and their patients. For more information, visit www.remfresh.com and connect with us on Facebook and You Tube.

Its sister subsidiary, IM HealthScience® (IMH) is the innovator of IBgard® and FDgard® for the dietary management of Irritable Bowel Syndrome (IBS) and Functional Dyspepsia (FD), respectively. In 2017, IMH added Fiber Choice®, a line of prebiotic fibers, to its product line via an acquisition. IMH® is a privately held company based in Boca Raton, Florida. It was founded in 2010 by a team of highly experienced pharmaceutical research and development and management executives. The company is dedicated to developing products to address overall health and wellness, including conditions with a high unmet medical need, such as digestive health. The IM HealthScience® advantage comes from developing products based on its patented, targeted-delivery technologies called Site Specific Targeting® (SST®). For more information, visit www.imhealthscience.com to learn about the company, or www.IBgard.com,  www.FDgard.com,and www.FiberChoice.com.

This information is for educational purposes only and is not meant to be a substitute for the advice of a physician or other health care professional. You should not use this information for diagnosing a health problem or disease. The company will strive to keep information current and consistent but may not be able to do so at any specific time. Generally, the most current information can be found on www.remfresh.com. Individual results may vary.

Data Presented at SLEEP 2018 Poster Session on Sleep Maintenance/Sleep Quality

Tuesday, June 5, 2018, 5-7pm

  • (Abstract 0419, Poster Board #104) Improvement in Sleep Maintenance and Sleep Quality with Ion Powered Pump Continuous Release and Absorption Melatonin: Results from a Self-Reported Patient Outcomes Study
    • David J. Seiden, M.D., FAASM, David C. Brodner, M.D., Syed M. Shah, Ph.D.

Visit Physician’s Seal® at booth 220 to learn more about REMfresh®.

The abstract is published in an online supplement of the journal, Sleep, which is available at http://www.sleepmeeting.org/docs/default-source/default-document-library/abstractbook2018.pdf?sfvrsn=2

[1] Ford, E.S., Cunningham, T.J., & Croft, J.B. (2015, May 1). Trends in Self-Reported Sleep Duration among US Adults from 1985 to 2012. Sleep, 38(5):829-832. doi: 10.5665/sleep.4684.

[2] Watson, N.F., Badr, M.S., Belenky, G., Bliwise, D.L., Buxton, G.M., Buysse, D.,…Tasali, E. (2015). Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. Journal of Clinical Sleep Medicine, 11(8):931-952. doi:10.1176/appi.ajp.158.11.1856.

[3] Colten, H.R., & Altevogt, B.M. (Eds). (2006). Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem.  Institute of Medicine (US) Committee on Sleep Medicine and Research. Washington, DC: National Academies Press (US). doi: https://doi.org/10.17226/11617.

[4] Cappuccio, F.P., D’Elia, L., Strazzullo, P.,&  Miller, M.A. (2010). Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep, 33(5):585-592

[5] For this clinical trial, the head-to-head comparison was with the 5 mg form; a 2 mg form of the comparator was not available.

[6] Zisapel, N. (2010). Melatonin and sleep. The Open Neuroendocrinology Journal, 3: 85-95.

[7] Among primary care physicians with a certification in sleep disorders who recommended a brand of modified-release melatonin. Quintiles IMS ProVoice July-September 2017 survey.

REFERENCE/SOURCE

Physician’s Seal® and REMfresh® (www.remfresh.com)

Dr. David C. Brodner, Center for Sinus, Allergy, and Sleep Wellness (http://www.brodnermd.com/sleep-hygiene.html)

Other related articles published in this Open Access Online Scientific Journal include the following:

2017

Ultra-Pure Melatonin Product Helps Maintain Sleep for Up to 7 Hours

https://pharmaceuticalintelligence.com/2017/06/11/ultra-pure-melatonin-product-helps-maintain-sleep-for-up-to-7-hours/

2016

Sleep Science

Genetic link to sleep and mood disorders

https://pharmaceuticalintelligence.com/2016/02/27/genetic-link-to-sleep-and-mood-disorders/

2015

Sleep quality, amyloid and cognitive decline

https://pharmaceuticalintelligence.com/2015/10/31/sleep-quality-amyloid-and-cognitive-decline/

2013

Day and Night Variation in Melatonin Level affects Plasma Membrane Redox System in Red Blood Cells

https://pharmaceuticalintelligence.com/2013/02/23/httpwww-ncbi-nlm-nih-govpubmed22561555/

 

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Ultra-Pure Melatonin Product Helps Maintain Sleep for Up to 7 Hours

Curator: Gail S. Thornton, M.A.

Co-Editor: The VOICES of Patients, Hospital CEOs, HealthCare Providers, Caregivers and Families: Personal Experience with Critical Care and Invasive Medical Procedures

 

The role of melatonin is important in regulating natural sleep and wake cycles. Typically, melatonin levels decline with age, significantly decreasing after age 40. An estimated 50 to 70 million Americans are affected by sleep difficulties – a process regulated by melatonin — and long-term sleep deprivation has been associated with negative health consequences, including an increased risk of diabetes, hypertension, heart attack, stroke, obesity, and depression.

Clinical data from a new pharmacokinetic study suggests that REMfresh®, the first and only continuous release and absorption melatonin (CRA-melatonin), helps maintain sleep for up to 7 hours. REMfresh® contains 99 percent ultra-pure melatonin and is sourced in Western Europe, a factor that is significant and important to many sleep specialists.

Three research abstracts on the REMfresh® data were published in an online supplement in the journal, Sleep, and were presented recently at the 31st Annual Meeting of the Associated Professional Sleep Societies LLC (APSS).

REMfresh Photo

Image SOURCE: Photograph courtesy of Physician’s Seal®

How REMfresh® Works

REMfresh® (CRA-melatonin) mimics the body’s own 7-hour Mesa Wave™, a natural pattern of melatonin blood levels during a normal night’s sleep cycle.

The study demonstrated the continuous release and absorption of 99 percent ultra-pure melatonin in REMfresh® (CRA-melatonin) was designed to induce sleep onset and provide continuous, lasting restorative sleep over 7 hours.

The scientifically advanced, patented formulation, called Ion Powered Pump (IPP™) technology, replicates the way in which the body naturally releases and absorbs melatonin, unlike conventional melatonin sleep products.

Since REMfresh® (CRA-melatonin) is not a drug, there is no drug hangover.

REMfresh MesaCurveNew-1

Image SOURCE: Diagram courtesy of Physician’s Seal®

 

Data Based on Scientifically Advanced Delivery Technology

According to the primary study author, David C. Brodner, M.D., “These study results represent an unparalleled breakthrough in drug-free, sleep maintenance that physicians and patients have been waiting for in a sleep product.” Dr. Brodner is a sleep specialist who is double board-certified in Otolaryngology – Head and Neck Surgery and Sleep Medicine and is the founder and principle physician at the Center for Sinus, Allergy, and Sleep Wellness in Palm Beach County, Florida.

Dr. Brodner said, “Melatonin products have been used primarily as a chronobiotic to address sleep disorders, such as jet lag and shift work. The patented delivery system in REMfresh mimics the body’s own natural sleep pattern, so individuals may experience consistent, restorative sleep and have an improved quality of life with this drug-free product.”

Study Findings With REMAKT

The study findings are based on REMAKT™ (REM Absorption Kinetics Trial), a U.S.-based randomized, crossover pharmacokinetic (PK) evaluation study in healthy, non-smoking adults that compared REMfresh® (CRA-melatonin) with a market-leading, immediate-release melatonin (IR-melatonin).

The study found that melatonin levels with REMfresh® exceeded the targeted sleep maintenance threshold for a median of 6.7 hours, compared with 3.7 hours with the leading IR-melatonin. Conversely, the levels of the market-leading IR-melatonin formulation dramatically increased 23 times greater than the targeted levels of exogenous melatonin for sleep maintenance and had a rapid decline in serum levels that did not allow melatonin levels to be maintained beyond 4 hours.

Additional analysis presented showed that REMfresh® (CRA-melatonin) builds upon the body of evidence from prolonged-release melatonin (PR-M), which demonstrated in well-conducted, placebo-controlled studies, statistically significant improvement in sleep quality, morning alertness, sleep latency and quality of life in patients aged 55 years and older compared with placebo.

REMfresh® (CRA-melatonin) was designed to overcome the challenges of absorption in the intestines, thereby extending the continual and gradual release pattern of melatonin through the night (known as the Mesa Wave™, a flat-topped hill with steep sides). There was a faster time to Cmax, which is anticipated to result in improved sleep onset, while the extended median plateau time to 6.7 hours and rapid fall-off in plasma levels at the end of the Mesa Wave™ may help to improve sleep maintenance and morning alertness.

REFERENCE/SOURCE

Physician’s Seal® and REMfresh® (www.remfresh.com)

REMfresh® press release, June 5, 2017 (http://www.prnewswire.com/news-releases/scientifically-advanced-delivery-technology-in-sleep-management-debuts-at-sleep-2017-with-clinical-data-showing-remfresh-the-first-and-only-continuous-release-and-absorption-melatonin-helps-maintain-sleep-for-up-to-7-hours-300468218.html)

Dr. David C. Brodner, Center for Sinus, Allergy, and Sleep Wellness  (http://www.brodnermd.com/sleep-hygiene.html)

Other related articles published in this Open Access Online Scientific Journal include the following:

2017

Sleep Research Society announces 2017 award recipients including Thomas S. Kilduff, PhD, Director, Center for Neuroscience at SRI International in Menlo Park, California

https://pharmaceuticalintelligence.com/2017/04/28/sleep-research-society-announces-2017-award-recipients-including-thomas-s-kilduff-phd-director-center-for-neuroscience-at-sri-international-in-menlo-park-california/

2016

Sleep Science

Genetic link to sleep and mood disorders

https://pharmaceuticalintelligence.com/2016/02/27/genetic-link-to-sleep-and-mood-disorders/

2015

Sleep quality, amyloid and cognitive decline

https://pharmaceuticalintelligence.com/2015/10/31/sleep-quality-amyloid-and-cognitive-decline/

2013

Day and Night Variation in Melatonin Level affects Plasma Membrane Redox System in Red Blood Cells

https://pharmaceuticalintelligence.com/2013/02/23/httpwww-ncbi-nlm-nih-govpubmed22561555/

Read Full Post »

Why should Quality Assurance be difficult and awkward? Take a strategic view on achieving compliance (focus on ISO 13485)


Why should Quality Assurance be difficult and awkward? Take a strategic view on achieving compliance (focus on ISO 13485)

 Reporter: Dror Nir, PhD

Converting life-science innovations into useful products involves allocation of significant resources to handling of regulatory processes. A typical approach that makes the management of these processes difficult and awkward is starting your project and later patching it with a QA system. It then becomes a source of sever headaches to many people who need to live and operate according to such patch.
I hope that the following post by Rina will inspire you all.
It is all too easy to dive into the list of requirements contained within the ISO 13485 and achieve compliance by just ticking the boxes: looking at one requirement or one area at a time and making sure you have put in place something to address that requirement. This may easily result in a quality system that feels like a patchwork. Compliant, perhaps, but most certainly awkward and difficult to sustain.
The second most common mistake is to not ask yourself how software tools can help in setting up the quality system. “We already have MS Word, MS Excel, email, and we can always print a document and have it signed.” This is only a solution if you think that the quality system is a one-off activity. In the longer run, the system turns out to be a constant struggle with non-integrated elements that have no cohesion.
A better way to address compliance is to:
  1. Accept the fact that the quality system is a long term commitment and that it is very demanding.
  2. Assume that the right software tools do help.
  3. Think strategically, reviewing the whole standard, and try to identify the different areas, in respect to what type of software would help address those.

Real life example: A company maintains an Excel list of all corrective actions. The date of effectiveness check is filled in manually. A QA engineer needs to review the Excel spreadsheet once a week to identify which effectiveness checks are due. Last audit revealed that in most cases, effectiveness checks were not followed up.
Real life question: Meetings and other events are registered in a calendar and you are reminded when they are due. Wouldn’t it be easier if effectiveness checks due dates were also linked to a calendar? Putting those dates in Excel does not make more sense than putting your meetings in Excel…..

What follows is how we can divide the ISO-13485:2003 in regard to the type of software features which can help us. You do not need to be an IT expert to follow the logic or the explanation – if you know the standard and see my examples hopefully you will get the idea.
In any case, I put here the complete mapping of the ISO into the different categories I describe. I also mention the main Atlassian tools we use to address each area. In future posts we will dive deeper into each of those categories and provide more details on exactly how we achieve easy and sustainable, compliance.
So, as promised, these are the various categories that appear in the ISO 13485:2003:
  1. Document management: These are the various requirements relating to the procedures, manuals, and device related documents you need to have, and how they should be handled within the organization. The ISO elaborates in quite a detailed manner about how the controlled documents needs to be approved, who should access them, etc. Confluence is the key tool we use to handle all these requirements.
  2. Procedures and records are the evidence that the organization lives up to its quality system: The various procedures and work instructions should be followed consistently on a daily basis, forms or other records should be collected as evidence. Some examples (with reference to the standard section):
    • Training( 6.2.2).
    • Customer complaints: (8.5.1).
    • Corrective and preventive actions: (8.5.2, 8.5.3)
    • Subcontractor approvals( 7.4.1)
    • Purchasing forms( 7.4.1).

Those records may be created as electronic or physical paper forms which need to be completed by the authorized person. However, a much better way is to implement an automatic workflow that makes it easier for the team to create, follow, and document all the various tasks they need to do. Such a workflow can automatically schedule tasks, remind and alert, thus triggering better compliance to the quality system and at the same time automatically creating the required records. This is a double win. JIRA® is our tool of choice and it provides a state-of-the-art solution to everything related to forms and workflows.

  1. Design control: Some of the issues covered by section 7 of the ISO 13485 require quite advanced control along several phases of design and development. The risk mitigation measures and the product requirements should be, for example, verified in the product verification stage. This verification, or the test file, could be written as a simple Word or Excel document, but a far better implementation is to create it within JIRA. The advantage of JIRA here is the various reporting that it allows once the data is in and the fact that it can connect directly into the work scheduling of the various team members. JIRA is the principal tool we use for design control. Confluence can be used in some advanced implementations. If the medical device involves software, then the development suite from Atlassian can be implemented to provide a complete software life cycle management suite.
  2. Manufacturing and product traceability: Some requirements relate to your manufacturing setup. Depending on the scale and type of manufacturing, specialized ERP may be the best option. When manufacturing is more basic and does not call for a full blown manufacturing facility, JIRA can handle the requirements of the standard.
  3. Monitoring and improving: A key theme of the standard is the need of the organization to measure and improve (for example, section 8.2.3). The nice thing is that the framework we have put in place to support the other categories, if done correctly, should provide us with the reports, alerts, and statistics we need. Indeed, all the processes we have implemented in JIRA, as well as the various elements we have implemented in Confluence, may easily be collected and displayed in practically endless variations of reports and dashboards.
Requirement (Article) Requirement type
4.Quality management system – 1.General requirements Non specific
4.Quality management system – 2.Documentation requirements – 1.General Document management
4.Quality management system – 2.Documentation requirements – 2.Quality manual Document management
4.Quality management system – 2.Documentation requirements – 3.Control of documents Document management
4.Quality management system – 2.Documentation requirements – 4.Control of records Procedures and records
5.Management responsibility – 1.Management commitment Document management
5.Management responsibility – 2.Customer focus Non specific
5.Management responsibility – 3.Quality policy Monitoring and ongoing improvement
5.Management responsibility – 4.Planning – 1.Quality objectives Monitoring and ongoing improvement
5.Management responsibility – 4.Planning – 2.Quality management system planning Monitoring and ongoing improvement
5.Management responsibility – 5.Responsibility, authority and communication – 1.Responsibility and authority Document management
5.Management responsibility – 5.Responsibility, authority and communication – 2.Management representative Monitoring and ongoing improvement
5.Management responsibility – 5.Responsibility, authority and communication – 3.Internal communication Monitoring and ongoing improvement
5.Management responsibility – 6.Management review – 1.General Monitoring and ongoing improvement
5.Management responsibility – 6.Management review – 2.Review input Monitoring and ongoing improvement
5.Management responsibility – 6.Management review – 3.Review output Monitoring and ongoing improvement
6.Resource management – 1.Provision of resources Non specific
6.Resource management – 2.Human resources – 1.General Procedures and records
6.Resource management – 2.Human resources – 2.Competence, awareness and training Procedures and records
6.Resource management – 3.Infrastructure Manufacturing and product traceability
6.Resource management – 4.Work environment Non specific
7.Product realization – 1.Planning of product realization Design control
7.Product realization – 2.Customer-related processes – 1.Determination of requirements related to the product Design control
7.Product realization – 2.Customer-related processes – 2.Review of requirements related to the product Design control
7.Product realization – 2.Customer-related processes – 3.Customer communication Design control
7.Product realization – 3.Design and development – 1.Design and development planning Design control
7.Product realization – 3.Design and development – 1.Design and development input Design control
7.Product realization – 3.Design and development – 3.Design and development outputs Design control
7.Product realization – 3.Design and development – 4.Design and development review Design control
7.Product realization – 3.Design and development – 5.Design and development verification Design control
7.Product realization – 3.Design and development – 6.Design and development validation Design control
7.Product realization – 3.Design and development – 7.Control of design and development changes Design control
7.Product realization – 4.Purchasing – 1.Purchasing process Procedures and records
7.Product realization – 4.Purchasing – 2.Purchasing information Procedures and records
7.Product realization – 4.Purchasing – 3.Verification of purchased product Procedures and records
7.Product realization – 5.Production and service provision – 1.Control of production and service provision – 1.General requirements Procedures and records
7.Product realization – 5.Production and service provision – 1.Control of production and service provision – 2.Control of production and service provision: Specific requirements – 1.Cleanliness of product and contamination control Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 1.Control of production and service provision – 2.Control of production and service provision: Specific requirements – 2.Installation ativities Procedures and records
7.Product realization – 5.Production and service provision – 1.Control of production and service provision – 2. – 3.Servicing activities Procedures and records
7.Product realization – 5.Production and service provision – 1.Control of production and service provision – 3.Particular requirements for sterile medical devices Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 2.Validation of processes for production and service provision – 1.General requirements Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 2.Validation of processes for production and service provision – 2.Particular requirements for sterile medical devices Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 3. Identification and traceability – 1.Identification Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 3. Identification and traceability – 2.Traceability – 1.General Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 3. Identification and traceability – 2.Particular requirements for active implantable medical devices and implantable medical devices Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 3. Identification and traceability – 3.Status identification Manufacturing and product traceability
7.Product realization – 5.Production and service provision – 4.Customer property Non specific
7.Product realization – 5.Production and service provision – 5.Preservation of product Procedures and records
7.Product realization – 6.Control of monitoring and measuring devices Manufacturing and product traceability
8.Measurement, analysis and improvement – 1.General Monitoring and ongoing improvement
8.Measurement, analysis and improvement – 2.Monitoring and measurement – 1.Feedback Monitoring and ongoing improvement
8.Measurement, analysis and improvement – 2.Monitoring and measurement – 2.Internal audit Procedures and records
8.Measurement, analysis and improvement – 2.Monitoring and measurement – 3.Monitoring and measurement of processes Monitoring and ongoing improvement
8.Measurement, analysis and improvement – 2.Monitoring and measurement – 4.Monitoring and measurement of product – 1. General requirements Design control
8.Measurement, analysis and improvement – 2.Monitoring and measurement – 4.Monitoring and measurement of product – 2.Particular requirement for active implantable medical devices and implantable medical devices Procedures and records
8.Measurement, analysis and improvement – 3.Control of nonconforming product Procedures and records
8.Measurement, analysis and improvement – 4.Aalysis of data Monitoring and ongoing improvement
8.Measurement, analysis and improvement – 5.Improvement – 1.General Monitoring and ongoing improvement
8.Measurement, analysis and improvement – 5.Improvement – 2.Corrective action Procedures and records
8.Measurement, analysis and improvement – 5.Improvement – 3.Preventive action Procedures and records

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Alteration in Reduced Glutathione level in Red Blood Cells: Role of Melatonin

Author: Shilpa Chakrabarti, PhD

List of abbreviation:
DTNB- 5,5- dithiobis,2-nitrobenzoic acid
t-BHP- Tertiary butyl hydroperoxide
GSH-Reduced glutathione
GSSG- Oxidised glutathione

Objective: The study was taken up to see the effect of melatonin on the alteration of reduced glutathione level in red blood cells.

Pineal melatonin is involved in many physiological functions, the most important among them being sleep promotion and circadian regulation. This pineal product exhibits characteristic diurnal rhythm of synthesis and secretion, which attains its peak at night followed by a gradual decrease during the daytime. Melatonin detoxifies highly toxic hydroxyl and peroxyl radicals in vitro, scavenges hydrochlorous acid, as well as peroxynitrite. It has also been reported to increase the synthesis of glutathione and of several antioxidant enzymes [1].

Method: The present study was undertaken to understand the modulation of intracellular reduced glutathione (GSH) by melatonin in human red blood cells according to the oscillatory circadian changes in levels of this hormone.We have also studied the dose-dependent effect of melatonin on GSH in erythrocytes obtained from blood at two different times, subjected to oxidative stress by incubating with tert-butyl hydroperoxide (t-BHP) [2]. We used t-BHP as pro-oxidant [3]. Erythrocyte GSH was measured following the method of Beutler [4]. The method was based on the ability of the –SH group to reduce 5,5- dithiobis,2-nitrobenzoic acid (DTNB) and form a yellow coloured anionic product whose OD is measured at 412 nm.

A suspension of packed red blood cells in phosphate-buffered saline (PBS) containing glucose was treated with melatonin taken at different concentrations. A stock solution (10mM) of melatonin was prepared in absolute ethanol; further dilutions (100 uM–10 nM) were done with PBS. The concentration of ethanol was alwaysThe in vitro effect of melatonin was evaluated by incubating erythrocytes with melatonin at different doses (10 uM –1 nM final concentration) of melatonin for 30 minutes at 37°C. After washing the erythrocytes with the buffer, to remove any amount of the compound, and finally, packed erythrocytes were used for the assay of GSH. In parallel control experiments, blood was incubated with ethanol (final concentration not more than 0.01% (v/v)) but without melatonin.Oxidative stress was induced in vitro by using tert-butyl hydroperoxide both in presence and absence of melatonin. Use of TBHP is in accordance with the published reports [5].

Results and Discussion: The experiment demonstrated that erythrocyte GSH level increased in nocturnal samples which highlights the role of endogenous melatonin in the circadian changes in cellular glutathione level. Exogenous melatonin demonstrated a protective effect against t-BHP-induced peroxidative damage in both diurnal and nocturnal samples, the effect being more pronounced in aliquots containing very low concentration of melatonin (10 nM – 1 nM) [6]. Melatonin was found to inhibit GSH oxidation in a dose-dependent manner.

Melatonin has been found to upregulate cellular glutathione level to check lipid peroxidation in brain cells [7]. We may say that the incubation of the red cells with melatonin for an extended period (more than 30 minutes) may not have the same effects on the level of glutathione in these cells [12]. Melatonin may act as pro-oxidant in the cells exposed to the indoleamine for longer time. Also, the half-life period of pineal melatonin is for 30 to 60 minutes, as reviewed by Karasek and Winczyk [11].The recycling of glutathione in the cells depends on an NADPH-dependent glutathione enzyme system which includes glutathione peroxidise, glutathione reductase, and γ-glutamyl-cysteine synthase forming a meshwork of an antioxidative system. The stimulatory effect of melatonin on the regulation of the antioxidant enzymes has been reported [8].Since melatonin has an amphiphilic nature, its antioxidative efficiency crosses the cellular membrane barriers in a non-receptor-mediated mechanism. Another explanation of melatonin’s antioxidative activity may be based on its role in the upregulation of some antioxidant enzymes directly. Blanco et al had reported that glutathione reductase and glutathione peroxidase, the major constituents of the glutathione-redox system being stimulated by melatonin [9]. The plasma GSH/GSSG redox state is controlled by multiple processes, which includes synthesis of GSH from its constitutive amino acids, cyclic oxidation and reduction involving GSH peroxidase and GSSG reductase, transport of GSH into the plasma, and the degradation of GSH and GSSG by γ-glutamyltranspeptidase. The increase in erythrocyte GSH concentration after melatonin administration can be related Blanco et al’s report on the known stimulation of γ-glutamylcysteine synthase,a rate-limiting enzyme in reduced glutathione synthesis, by melatonin [10].

Conclusion: On the basis of our study, we may conclude that melatonin affects the glutathione level in red blood cells in a circadian manner. The rhythmic pattern of glutathione level confirms the relationship between physiological melatonin and erythrocyte GSH level and pharmacological dosage of the drug. The role of melatonin as an antioxidant and its activity in relation to these biomarkers has been studied in the above experiments.

Key words: Glutathione, circadian rhythm,, melatonin, biomarkers, oxidative stress

REFERENCES


1. D. Bonnefont-Rousselot and F. Collin, “Melatonin: action as antioxidant and potential applications in human disease and aging,” Toxicology, vol. 278, no. 1, pp. 55–67, 2010. http://www.drvitaminsolutions.com/images/products/Melatonin%20as%20antioxidant%20and%20potential%20applications%20in%20human%20disease%20and%20aging.pdf
2. A. V.Domanski, E. A. Lapshina, and I. B. Zavodnik, “Oxidative processes induced by tert-butyl hydroperoxide in human red blood cells: chemiluminescence studies,” Biochemistry (Moscow), vol. 70, no. 7, pp. 761–769, 2005. http://link.springer.com/article/10.1007%2Fs10541-005-0181-5
3. Z. Cˇervinkova´, P. Krˇiva´kova´, A. La´bajova´ et al., “Mechanisms participating in oxidative damage of isolated rat hepatocytes,” Archives of Toxicology, vol. 83, no. 4, pp. 363–372, 2009. http://www.ncbi.nlm.nih.gov/pubmed/16097939
4. E. Beutler, A Manual of Biochemical Methods, Grunne and Stratton, New York, NY, USA, 1984.
5. P. Di Simplicio, M. G. Cacace, L. Lusini, F. Giannerini, D. Giustarini, and R. Rossi, “Role of protein -SH groups in redox homeostasis—the erythrocyte as a model system,” Archives of Biochemistry and Biophysics, vol. 355, no. 2, pp. 145–152, 1998.
6. S. Chakravarty and S. I. Rizvi., “Day and Night GSH andMDA Levels in Healthy Adults and Effects of Different Doses ofMelatonin on These Parameters” International Journal of Cell Biology, vol. 2011, pp. Article ID 404591.http://www.hindawi.com/journals/ijcb/2011/404591/9CDay+and+Night+GSH+andMDA+Levels+in+Healthy+Adults+and+Effects+of+Different+Doses+ofMelatonin+on+These+Parameters”&gt;
7. S. R. Pandi-Perumal, V. Srinivasan, G. J. M. Maestroni, D. P. Cardinali, B. Poeggeler, and R. Hardeland, “Melatonin: nature’s most versatile biological signal?” FEBS Journal, vol. 273, no. 13, pp. 2813–2838, 2006.http://onlinelibrary.wiley.com/doi/10.1111/j.1742-4658.2006.05322.x/full
8. R. J. Reiter, R. C. Carneiro, and C. S. Oh, “Melatonin in relation to cellular antioxidative defense mechanisms,” Hormone and Metabolic Research, vol. 29, no. 8, pp. 363–372, 1997.http://www.ncbi.nlm.nih.gov/pubmed/9288572
9. Y.Urata, S.Honma, S. Goto et al., “Melatonin induces gammaglutamylcysteine synthetase mediated by activator protein-1in human vascular endothelial cells,” Free Radical Biology and Medicine, vol. 27, no. 1-2, pp. 838–847, 1997.http://www.ncbi.nlm.nih.gov/pubmed/10515588
10. R. A. Blanco, T. R. Ziegler, B. A. Carlson et al., “Diurnal variation in glutathione and cysteine redox states in human plasma,” American Journal of Clinical Nutrition, vol. 86, no. 4, pp. 1016–1023, 2007. http://www.ncbi.nlm.nih.gov/pubmed/17921379
11. M. Karasek, K. Winczyk, “Melatonin in humans,” Journal of Phsiology and Pharmacology, vol. 57, no. 5, pp. 19-39, 2006. http://www.jpp.krakow.pl/journal/archive/11_06_s5/articles/02_article.html
12. A. Krokosz ,J. Grebowski, Z. Szweda-Lewandowska et al., ” Can melatonin delay oxidative damage of human
erythrocytes during prolonged incubation?” Advances in Medical Sciences, vol. 58, no. 1, 2013.http://www.researchgate.net/publication/236614971_Can_melatonin_delay_oxidative_damage_of_human_erythrocytes_during_prolonged_incubation

 

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Melatonin and its effect on acetylcholinesterase activity in erythrocytes

Author: S. Chakravarty, PhD

 

Objective: The study was conducted to see the effect of melatonin on the activity of acetylcholinesterase in red blood cells.

Mammalian red blood cells contain membrane-bound acetylcholinesterase which acts as biomarkers of oxidative imbalance. Melatonin is a powerful free radical scavenger and upregulates several antioxidant enzymes to reduce oxidative stress. Being an effective antioxidant, it may initiate variation in erythrocyte acetylcholinesterase activity.

The study was carried out on twenty-nine subjects of both sexes who gave their informed consent for the use of their blood samples for the study (Chakravarty and Rizvi, 2011a). The red cells isolated from blood collected at two different timings of the day, viz., 10:00 a.m. and 10:00 p.m.,were subjected to in vitro treatment with melatonin in a dose-dependant manner followed by the assay of enzyme activity (Ellman et al., 1961).

Acetylcholinesterase (AChE) is also found on the red blood cell membranes, where it constitutes the Yt blood group of antigen, which is a blood-group determining protein. AChE has the features of a secreted rather than a transmembrane protein because it lacks long hydrophobic stretches, other than that which forms the signal peptide (Li et al., 1991). Besides, acetylcholinesterase activity in erythrocytes may be considered as a marker of central cholinergic status (Kaizer et al., 2008). AChE shows highest activity in the immature rat brain is at 6.00 a.m. and lowest after midnight, which undergoes a reversal after attaining maturity (Moudgil and Kanungo, 1973). The enzyme also exhibits annual changes in its activity (Lewandowski, 2008). Acetylcholinesterase activity has been used to for studying the activity pattern of human erythrocytes (Prall et al., 1998). Free radicals and increased oxidative stress have been found to reduce AChE activity (Molochkina et al., 2005). This indicates that melatonin may have some relation with the circadian rhythmicity of acetylcholinesterase activity.

The concentration-dependant assay of AChE activity in red cells bear close relation with the circadian rhythm in humans thus sharing a similar conclusion with that mentioned by Moudgil and Kanungo (Moudgil and Kanungo, 1973). The effect of melatonin on enzyme functions in erythrocytes follows rhythmic modulation with day/night cycle. The samples obtained in the morning exhibit significantly higher activity of acetylcholinesterase than those obtained during the night-time. The samples collected at two different timings of the day show different response to in vitro melatonin treatment. The rise in AChE activity is more pronounced at low doses of melatonin. Our results indicate significant increase in acetylcholinesterase activity in diurnal as well as nocturnal blood samples at different concentrations of exogenous melatonin (Rizvi and Chakravarty, 2011). At supraphysiological doses, the enzyme activity exhibits no significant change, owing to the prooxidative influence exerted by melatonin (Marchiafava and Longoni, 1999).

Acetylcholinesterase activity is affected by the hydrophobic environment of the cell membrane and depends on the plasma membrane fluidity and surface charge of the cell (Klajnert et al., 2004).  The activity of AChE depends largely on the biophysical features of membrane. Oxidative stress decreases the fluidity of membrane lipid bilayer, thus affecting its normal functions (Goi et al., 2005).  Such are the ill-effects of oxidative radicals that tend to increase with aging. The decrease in AChE correlates significantly with age-induced oxidative stress (Jha and Rizvi, 2009).  On the basis of our study we conclude that melatonin modulates acetylcholinesterase activity in erythrocytes. The rhythmicity observed in the activity of acetylcholinesterase in response to the melatonin confirms our opinion on the relationship between the enzyme function, pineal secretion and pharmacological dosage of the indole antioxidant.

References:

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Day and Night Variation in Melatonin Level affects Plasma Membrane Redox System in Red Blood Cells

Author: Shilpa Chakravarty, PhD

Melatonin is a well-established antioxidant and sleep-regulating hormone. Over the past fifty years, its efficiency as a regulator of circadian rhythm and several other physiological functions has been studied extensively in different species. As a free-radical scavenger, melatonin has shown its activity in coordination with its circadian nature. One of the most important biomarkers of oxidative stress studied in red blood cells is the plasma membrane redox system (PMRS).

As a part of the research activity, PMRS activity has been summarised in this article. The experiments with PMRS and ascorbate free-radical reductase (AFR reductase) have been conducted in vitro.

The study was carried out on 61 healthy individuals of both sexes (aged 20-30) having no acute or chronic diseases (such as diabetes mellitus, asthma, or tuberculosis) or any organ dysfunction and had not taken any medication. Blood samples were collected at two different timings at 10:00AM and 10:00PM.  Red blood cell-membrane, was in retrospect a good experimental system to try to extract and isolate membrane proteins for biochemical assays. Two factors that have favoured it for experimental use are availability and simplicity. Results from its study have been replicated in every other mammalian cell type, and in some crucial points, the patterns shown by RBC
proteins have led the way to such interpretations of extensive physiological studies.

PMRS transfers electrons from extracellular substates to intracellular electron acceptors incorporating AFR reductase. An increase in PMRS activity indicates the ability of the cell to combat oxidative damage.The aging of human red cells may well be attributed to free radical induced oxidative damage. Maintenance of redox state of sulphydryl residues and reduction of lipid hydroperoxides at the expense of electron donors, such as ascorbate and NADH, is essential for normal energy metabolism in the cell. The neutralisation of oxidants also involves some membrane proteins that comprise the PMRS. The rise in PMRS activity is required to maintain a balanced NAD+/NADH ratio that is essential for normal energy metabolism. It leads to cell survival and membrane homeostasis under stress conditions and during calorie restriction in eukaryotes. The day and night variation in PMRS activity shows that the antioxidative behaviour of melatonin is also influenced by its circadian mode of action. While melatonin is an effective antioxidant against cellular toxicity, it also increases the PMRS activity in red blood cells at night. During the day, when the pineal secretion is low, the PMRS activity is also suppressed.

However, if subjected to in vitro treatment with melatonin, at such a concentration that lies close to the maximal melatonin level in the plasma (maximal secretion of melatonin occurs during the scotopic phase of the day), PMRS increases in red blood cells. This shows that the circadian nature of the hormone not only pertains to its pineal production but also to exogenous administration of the drug.

REFERENCES

  1. Chakravarty S,  Rizvi SI (2012) Modulation of human erythrocyte redox status by melatonin: A protective mechanism against oxidative damage. Neurosci Lett. 518:32-35.
  2. Karasek M,  Winczyk K (2006) Melatonin in humans. Neurosci Lett518:32-35.
  3. Hardeland R, Pandi-Perumal SR (2005) Melatonin, a potent agent in antioxidative defense: Actions as a natural food constituent, gastrointestinal factor, drug and prodrug. Nutr Metab. (Lond) 2:22.
  4. Hardeland R,  Coto-Montes A, Poeggeler B (2003)  Circadian rhythms, oxidative stress and antioxidative defense mechanisms. Chronobiol Int. 20:921-962.
  5. Hyun D.H., Hernandez J.O., Mattson M.P., de Cabo R., (2006)  The plasma membrane redox system in aging, Ageing Res. Rev. 209–220.
  6. Hyun D.H., Emerson S.S., Jo D.G., Mattson M.P., de Cabo R., (2006) Calorie restriction up-regulates the plasma membrane redox system in brain cells and suppresses oxidative stress during aging, Proceedings of the National Academy of Sciences of the United States of  America 103: 19908–19912.
  7. Rizvi S.I., Jha R., Maurya P.K., (2006)  Erythrocyte plasma membrane redox system in human aging, Rejuvenation Research 9: 470–474.

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