sodium selenite for stroke - amazon s3sodium selenite for stroke day 1 treatment ideally begins...

Sodium selenite for stroke

selenase®

• improves selenium status

• eliminatesseleniumdeficiency

• areducedSelenoproteinPstatusissignificantlyassociated withahigherriskofastroke

we are research

[1]ZimmermannC,WinnefeldK,StreckS,RoskosM,HaberlRL.EurNeurol.2004;51(3):157-61.Antioxidantstatusinacutestrokepatientsandpatientsatstrokerisk.http://www.ncbi.nlm.nih.gov/pubmed/15073440

[2]KoyamaH,AbdulahR,OhkuboT,ImaiY,SatohH,NagaiK.NutrRes.2009Feb;29(2):94-9.doi:10.1016/j.nut-res.2009.01.002.DepressedserumselenoproteinP:possiblenewpredicatorofincreasedriskforcerebrovascularevents. http://www.ncbi.nlm.nih.gov/pubmed/19285599


Day1

Treatmentideallybeginswithin6hoursafteradmission totheICU

BolusdirectlyafteradmissiontoICU

1,0001µgSe

thenascontinuousinfusion

5001µgSe

Fromday2 of the ICUstay

maintenancetherapy 5001µgSe/day

Literature 1ReisingerJetal.2009,AmJEmergMed27:176-181

Sodium selenite for stroke• Strokepatientsshowsignificantlyreducedseleniumvalues[1]

• Highglutathioneperoxidaseconcentrationcorrelateswithlowneurological deficiencyandapositiveoutcomeafterastroke [1]

• SignificantlyreducedSelenoproteinPconcentrationinpatientsafter anacutestroke[2]

• ReducedSelenoproteinPstatusisassociatedwithasignificantlyhigherrisk for stroke [2]

Bynowarandomized,double-blinded,placebocontrolledtrialwiththetitle„Seleniumandische-micstrokeoutcome“(NCT02505295)isunderway,whichinvestigates,if2,000µgselenium

in form of selenase®directlyafterpatientadmis-sionplus1,000µgseleniumperday(selenase®)forfivedaysreducesmortalityandneurologicaldamage.

Summary2

http://www.ncbi.nlm.nih.gov/pubmed/15073440



Miscibility

Yes No

• 5%glucosesolution

• Ringersolution

• Carbohydratesolutions (stability72hours(3days))

• Colloidalvolumeexpandersolutions(stability72hours(3days))

• Electrolytesolutionswithincreased potassiumconcentration(stability 48hours(2days))

• Crystalloidelectrolytesolutions (stability48hours(2days))

• Aminoacidsolutionswithoutcysteine(stability36hours(1.5days))

• Fatemulsions (stability24hours(1day))

• Vitaminsolutions(withoutvitaminC)

• Cytostaticagentsolutions[1]

• Aminoacidsolutions thatcontaincysteine[2]

• Solutions thatcontainglutathione(GSH)[3]

• Vitamin solutions thatcontainvitaminC[4]

[1] selenase®shouldgenerallybeadministered1hour beforecytostaticagentapplicationfortimelyincorporationintheendogenousprotectivesystems.

[2,3]SHgroupsreacttoNa-selenite;Na-selenitecan nolongersatisfyitstaskasaradicalscavenger

[4]Selenium(Se+IV)insodiumseleniteisreducedbyvitaminCtotheelementaryselenium(Se0)andistherebyineffective.

Literature: RobinsonMF,ThomsonCD,HuemmerPK.NZMedJ.1985Aug14;98(784):627-9.Effectofamegadoseof ascorbicacid,amealandorangejuiceontheabsorption ofseleniumassodiumselenite. http://www.ncbi.nlm.nih.gov/pubmed/3861972

IpC.JNatlCancerInst.1986Jul;77(1):299-303.InteractionofvitaminCandseleniumsupplementationinthemodifica-tionofmammarycarcinogenesisinrats. http://www.ncbi.nlm.nih.gov/pubmed/3088312

Summary 3



Productsforinjectiontherapy

Prescriptiononly

selenase® 100µg proinjectione

selenase® T proinjectione

100 µg Selenium/ampoule

500 µg Selenium /injectionvial

10(N2)and50ampoules with2mlsolutionforinjection

2,10(N2),30(3×10)and50 (5×10)glassvialswith10mlsolution forinjection

selenase® 100 µg / T: Active substance: Sodium selenite pentahydrate, 50 µg selenium per ml. Indications: Clinically proven selenium deficiency that cannot be compensated by nutritional sour-ces. Selenium deficiencies may occur as a result of states of maldigestion and malabsorption, as well as in malnutrition (e.g. due to complete parenteral nutrition). Composition: selenase® 100 µg pro injectione: 1 ampoule of 2 ml solution for injection contains: 0.333 mg sodium selenite pentahydrate, corresponding to 100 µg (micrograms) selenium. selenase® T pro injectione: 1 injection vial of 10 ml / 20 ml solution for injection contains: 1.67 mg / 3.33 mg sodium selenite pentahydrate, corresponding to 500 µg / 1000 µg selenium. selenase® 100 µg peroral: 1 drinking ampoule of 2 ml oral solution contains: 0.333 mg sodium selenite pentahydrate, corresponding to 100 µg selenium. selenase® T peroral: 1 ml oral solution contains: 0.167 mg sodium selenite pentahydrate, corresponding to 50 µg selenium. Excipients: Sodium chloride, hydrochloric acid, water for injections. Contra-indications: Selenium poisoning. Undesirable effects: None known to date if the medicinal product is administered according to prescription. selenase® 100 µg / T pro injectione: General disorders and administration site conditions: Frequency not known (cannot be estimated from the available data): After intramuscular administration local pain at the site of administration has been reported. Form of administration, size of packages: selenase® 100 µg pro injectione: 10 or 50 ampoules of 2 ml solution for injection. selenase® T pro injectione: 2 or 10 injection vials of 10 ml solution for injection, hospital-size pack 30 (3 x 10) or 50 (5 x 10) injection vials of 10 ml solution for injection, 2 or 10 injection vials of 20 ml solution for injection, hospital-size pack 30 (3 x 10) or 50 (5 x 10) injection vials of 20 ml solution for injection. selenase® 100 µg peroral: 20, 60, 90 or 100 ampoules of 2 ml oral solution. selenase® T peroral: 10 drinking bottles of 10 ml oral solution plus one measuring cup. 10/14 e

8 Seleniuminthebrain8 Seleniumisessentialforthebrain

10 Glutathioneperoxidase1influencestheinfarctvolumes

12Glutathioneperoxidase4:essentialforbraindevelopmentandneuropathologicaldiseases

14 SelenoproteinPknock-outcausessevereneurologicaldysfunction

16 Sodium selenite for stroke

16 Sodiumseleniteactsneuroprotectivelyevenhoursafterinductionofthedamage

20Seleniumdeficitmassivelyincreasessusceptibilitytoexcitotoxicity andincreasedneuronalcellloss

22 Principleofactionofneuronalprotectionbysodiumselenite

29 Impactofaseleniumdeficitonthebrainaffectedbystroke

30 Seleniumstatusandselenoproteinactivity in the event of a stroke

30 Strokepatientsshowsiginficantlydecreasedseleniumvalues

32Correlationbetweenglutathionperoxidaseconcentration,neurologicaldeficit, andoutcome

34 SignificantlyreducedSelenoproteinPconcentrationinpatientswithanacutestroke

36 Additionalinformation

36 Seleniuminguidelines

38 biosynArzneimittelGmbH

5Content

Ischaemia/reperfusion

Selenium inthebrain

Seleniumisessentialforthebrain

Glutathioneperoxidase-1influencestheinfarctvolume

Glutathioneperoxidase4isessentialinbraindevelopmentand neuropathologicaldiseases

ThelackoftheseleniumtransportproteinsSelenoproteinPcauses severeneurologicaldysfunction,whichcanbeattenuatedbysodium selenite supplementation


Sodiumseleniteactsneuroprotectivelyevenhoursafterinduction ofthedamage

Seleniumdeficitresultsinamassiveincreaseinsusceptibility forexcitotoxicityandincreasedneuronalcellloss

Theneuroprotectiveeffectofsodiumseleniteisbasedon:

• thereductionoftheoxidativestressinneurons

• thepreservationofthemitochondrialrespiratorychain

• theinhibitionofNFκBandAF1activation

• theinhibitionofischaemia-inducedDNAoxidation

• thenormalizationofischaemia-activatedautophagy

Selenium sta-tus and seleno-proteinactivityin the event of a stroke

Strokepatientsshowsignificantlyreducedseleniumvalues

Highglutathioneperoxidaseconcentrationcorrelateswithalow neurologicaldeficitandafavorableoutcomeforstrokes

SignificantlyreducedSelenoproteinPconcentration inpatientswithanacutestroke

AreducedSelenoproteinPlevelisaccompanied byanassociatedsignificantlyhigherriskofstroke

Summary

Summary6

Summary 7

Seleniuminthebrain

Generalinformation

• Seleniumplaysanimportantroleinthebrain

• Glutathioneperoxidase-1influencestheinfarctvolume

• Glutathioneperoxidase4isessentialinbraindevelopment andinneuropathologicaldiseases

• ThelackoftheseleniumtransportproteinSelenoproteinPcausessevereneurologicaldysfunction,whichcanbeattenuatedbysodiumselenite supplementation

Selenium is essential forthebrainThetotalamountofseleniuminthe brainiscomparativelylow.Inthebrain, aconcentrationof110±21ngsele-nium/gwetweightwasdeterminedinGermanadults.Incontrast,thereis771±169ngselenium/ginthekidneyand291±78ngselenium/gintheliver.Thebrainthuscontainsonly2.3%oftheentireseleniuminahumanbody[1].Withalong-termlow-seleniumdiet,theavailableseleniumispreferablytranspor-tedtothebrainattheexpenseofotherorgans,suchastheliver[2].Approxima-tely20%oftheentireseleniumamountinthebrainisincorporatedinglutathioneperoxidase[2].Withasufficientseleniumsupply,theglutathioneperoxidase activityintheliveris13timesgreaterthaninthebrain.Afteraselenium-deficitdietofabout6months,theactivityof

theglutathioneperoxidasewasreducedby92%,whileinthebrainitonlydeclinednegligibly[3].Seleniumplaysadecisiveroleforvariousdiseasesofthecentralnervoussystem(CNS),amongothersstroke,braintumors,braindevelopmentandaffectivedisorders.Firstindicationsdeliveredreportsaboutneurologicaldiseases in patients with low seleni-umstatusorrestrictedselenoproteinbiosynthesis.Overalongtimeperiod,parenterallynourishedpatientswithinadequateseleniumcontentdevelopedprogressiveencepalopathy[4].TworaremutationsofthehumanSEPSECSgenethatcodestheselenocysteinesynthaseleadtoprogressivecerebellarandcereb-ralatrophy[5].

Ischaemia/ reperfusion8 Seleniuminthebrain

Literature

1 OsterO,SchmiedelG,PrellwitzW.BiolTraceElemRes.1988Jan-Apr;15:23-45.Theorgandistributionofseleni-uminGermanadults.

2 SteinbrennerH,SiesH.ArchBiochemBiophys.2013Aug15;536(2):152-7.doi:10.1016/j.abb.2013.02.021.Seleni-umhomeostasisandantioxidantselenoproteinsinbrain:implicationsfordisordersinthecentralnervoussystem.

3 BuckmanTD,SutphinMS,EckhertCD.BiochimBiophysActa.1993May13;1163(2):176-84.Acomparisonoftheeffectsofdietaryseleniumonselenoproteinexpressioninratbrainandliver.

4HiratoJ,NakazatoY,KoyamaH,YamadaA,SuzukiN,KuroiwaM,TakahashiA,MatsuyamaS,AsayamaK.ActaNeuropathol.2003Sep;106(3):234-42.Encephalopathyinmegacystis-microcolon-intestinalhypoperistalsissyndro-mepatientsonlong-termtotalparenteralnutritionpossiblyduetoseleniumdeficiency.

5AgamyO,BenZeevB,LevD,MarcusB,FineD,SuD,NarkisG,OfirR,HoffmannC,Leshinsky-SilverE,FlusserH,SivanS,SöllD,Lerman-SagieT,BirkOS.AmJHumGenet.2010Oct8;87(4):538-44.Mutationsdisruptingselenocysteineformationcauseprogressivecerebello-cerebralatrophy.

6CrackPJ,TaylorJM,FlentjarNJ,deHaanJ,HertzogP,IannelloRC,KolaI.JNeurochem.2001Sep;78(6):1389-99.Increasedinfarctsizeandexacerbatedapoptosisintheglutathioneperoxidase-1(Gpx-1)knockoutmousebraininresponsetoischemia/reperfusioninjury.

7 IshibashiN,ProkopenkoO,Weisbrot-LefkowitzM,ReuhlKR,MirochnitchenkoO.BrainResMolBrainRes.2002Dec30;109(1-2):34-44.Glutathioneperoxidaseinhibitscelldeathandglialactivationfollowingexperimentalstroke.

8YantLJ,RanQ,RaoL,VanRemmenH,ShibataniT,BelterJG,MottaL,RichardsonA,ProllaTA.FreeRadicBiolMed.2003Feb15;34(4):496-502.TheselenoproteinGPX4isessentialformousedevelopmentandprotectsfromradiationandoxidativedamageinsults.

9 SavaskanNE,UferC,KühnH,BorchertA.BiolChem.2007Oct;388(10):1007-17.Molecularbiologyofglutathioneperoxidase4:fromgenomicstructuretodevelopmentalexpressionandneuralfunction.

10BellingerFP,BellingerMT,SealeLA,TakemotoAS,RamanAV,MikiT,Manning-BoğAB,BerryMJ,WhiteLR,RossGW.MolNeurodegener.2011Jan21;6(1):8.doi:10.1186/1750-1326-6-8.GlutathionePeroxidase4isassoci-atedwithNeuromelanininSubstantiaNigraandDystrophicAxonsinPutamenofParkinson'sbrain.

11WirthEK,ConradM,WintererJ,WoznyC,CarlsonBA,RothS,SchmitzD,BornkammGW,CoppolaV,Tessa-rolloL,SchomburgL,KöhrleJ,HatfieldDL,SchweizerU.FASEBJ.2010Mar;24(3):844-52.doi:10.1096/fj.09-143974.Neuronalselenoproteinexpressionisrequiredforinterneurondevelopmentandpreventsseizuresandneurodegeneration.

12 DringenR,PawlowskiPG,HirrlingerJ.JNeurosciRes.2005Jan1-15;79(1-2):157-65.Peroxidedetoxificationbybraincells.

13BennerMJ,SettlesML,MurdochGK,HardyRW,RobisonBD.PhysiolGenomics.2013Aug1;45(15):653-66.doi:10.1152/physiolgenomics.00030.2013.Sex-specifictranscriptionalresponsesofthezebrafish(Daniorerio)brainselenoproteometoacutesodiumselenitesupplementation.

14 JeeMK,JungJS,ChoiJI,JangJA,KangKS,ImYB,KangSK.Brain.2012Apr;135(Pt4):1237-52.doi:10.1093/brain/aws047.MicroRNA486isapotentiallynoveltargetforthetreatmentofspinalcordinjury.

15 BurkRF,HillKE,ReadR,BellewT.AmJPhysiol.1991Jul;261(1Pt1):E26-30.ResponseofratselenoproteinPtoseleniumadministrationandfateofitsselenium.

16 SchomburgL,SchweizerU,HoltmannB,FlohéL,SendtnerM,KöhrleJ.BiochemJ.2003Mar1;370(Pt2):397-402.GenedisruptiondisclosesroleofselenoproteinPinseleniumdeliverytotargettissues.

17 HillKE,ZhouJ,McMahanWJ,MotleyAK,AtkinsJF,GestelandRF,BurkRF.JBiolChem.2003Apr18;278(16):13640-6.DeletionofselenoproteinPaltersdistributionofseleniuminthemouse.

18 HillKE,ZhouJ,McMahanWJ,MotleyAK,BurkRF.JNutr.2004Jan;134(1):157-61.NeurologicaldysfunctionoccursinmicewithtargeteddeletionoftheselenoproteinPgene.

19RamanAV,PittsMW,SeyedaliA,HashimotoAC,SealeLA,BellingerFP,BerryMJ.GenesBrainBehav.2012Jul;11(5):601-13.doi:10.1111/j.1601-183X.2012.00794.x.AbsenceofselenoproteinPbutnotselenocysteinelyaseresultsinsevereneurologicaldysfunction.

Ischaemia/ reperfusion 9Seleniuminthebrain



























Fig.

13-foldincreasedinfarctvolumeforglutathioneperoxidase1(GPx1)knock-outmice.[6]

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p < 0.01

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Glutathioneperoxidase1influences theinfarctvolumeAsalreadylongknown,glutathioneperoxidase1(GPx1)inknock-outmiceshowa3-foldincreaseofinfarctvolumecomparedwithwild-typemice(p<0.01)(Fig.1)[6].Thisisalsoreflectedintheincreasednumberofnecroticandapop-toticcells(Fig.2).Anearlieractivationofcaspase3inGPx1knock-outmicemoreoverindicatesincreasedsuscep-tibilitycomparedtoapoptosisinGPx1knock-outmice.

Furthermore,aninvestigationwithtransgenicmice,whichoverexpressedglutathioneperoxidase,revealedasigni-ficantreductionintheinfarctvolume

inconsequenceofI/Rdamagecomparedwithnon-transgenicmice[7].Anoverex-pressionofglutathioneperoxidasesigni-ficantlyreducedbothnecroticaswellasapoptoticcelldeathinendangeredbrainregions(p<0.05).Intheseanimals,theactivationofastrocytomaandmicrogliaintheischemicbrainwasreduced.Incontrasttowildtype-mice,glutathioneperoxidaseoverexpressedmiceshowedasignificantlybetterpreservedtissuestructureandareducedinfiltrationofacuteinflammatorycells(p<0.05).


Fig.

2Significantlyincreasednumberofnecrotic andapoptoticcellsinGPx1knock-outmice[6]

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Glutathioneperoxidase4: essentialforbraindevelopment andneuropathologicaldiseasesGlutathioneperoxidase4(GPx4)isessentialforsurvival.HomozygousGPx4knock-outmiceinthesecondtrimesterofpregnancydieinuterobecauseofin-creasedapoptosisandcelldeath,whichresultinthemalformationoftheembryo[8].GPx4isexpressedinneurons,aboveallinthehippocampus[9].Justrecentlyit was demonstrated that the neuronal GPx4expressionplaysanessentialneu-roprotectiveroleinMorbusParkinson[10].GPx4moreovermodulatestheinter- neuronalfunctionaswellastheexpres-sionofparvalbumin[11].Furthermore,GPx4preventsseizuresandneuro- degeneration[11].

GPx4isamultifunctionalantioxidativeproteinwithanti-apoptoticcharacter- istics[9].Thisisparticularlyrelevantbecauseneurons,incontrasttoglialcells,essentiallydependontheirGPxactivitytodetoxifyfreeoxygenradicals(ROS)andlipidperoxides[12].IncreasedROSlevelsoccurinneuropathologicaldisorderssuchastrauma,seizureandischaemia.Furthermore,ithasbeenshownthatthecytosolicvariantsofGPx4areup-regulatedafterbraininjuries[9].

Howevernotinneurons,butratherinreactiveastrocytes,aglialcelltypethatundernormalconditionsexpressesnoGPX4.Afterbraininjuries,astrocyteschangetheircytoskeletonandmigrateinthedirectionofthelesion,wheretheyareinvolvedintherepairofoligodendrocytesandmyelination,aswellasinthere-es-tablishmentoftheblood-brainbarrierinordertopreventneuroinflammation[9].TheexpressionofGPx4intheastrocy-tes is therefore a response to stress that servesforneuro-protectiontopreventadditionaldamage.Asodiumselenitesupplementationinthephysiologicalrangewithzebrafishsignificantlyincrea-sedtheGPx4expressioninthebraincomparedtoselenium-deficitzebrafish(p=0.048)(Fig.3)[13].ApartfromGPx4,theexpressionofGPx3alsoincreased,whichalsoplaysanactiveantioxidativeroleintheCNS[14].Overall,theseresultssuggestthatasodiumselenitesupple-mentationincreasestheantioxidativecapacityofthebrain[13].


Fig.

3

Sodium selenite supplementation in the physiologicalrangesignificantlyincreases theGPx4expressioninthebrain.[13]

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Fig.

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SignificantimprovementofbrainfunctiondisordersforSEPP1knock-outmicewithasodiumselenitesupplementationabove thedailynormalseleniumrequirement.[18]

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SelenoproteinPknock-outcauses severeneurologicaldysfunctionAlmostallknownselenoproteinsoccur inthebrain,wherebythetransportprotein for selenium, the selenoprotein P(SEPP1),makesseleniumavailableintheformofselenocysteinefortheexpressionofselenoprotein.UnderseleniumdeficitconditionsseleniumfromSEPP1isdetectedinthebrainaftertwo hours 15].The“knock-out”ofSEPP1leadstodecreasedseleniumconcen-trationandselenoproteinactivitiesinthebrain[16,17].SEPP1knock-outmicedevelopedbrainfunctiondisordersandshowedlimitedmotorcoordinationwithan adequate selenium diet with sodium selenite [16,17].However,theneurologicaldisorders with an adequate selenium diet

with selenomethionine were so massive thathalfoftheSEPP1knock-outmicehadtobeeuthanized.Asodiumselenitesupplementationabovethedailynormalseleniumrequirementcouldpreventbrainfunctiondisorders(Fig.4)[18].

Moreover,significantlygreaterneuro-logicaldysfunctionoccurredwithmaleanimalsinSEPP1knock-outmice(p<0.001)(Fig.5)[19].Asupplementation with sodium selenite attentuated the mo-toricdeficitsofmaleanimalstoagreaterdegree(p<0.001)(Fig.6).


Fig.

5ReducedmotorcoordinationinSEPP1knock-outmiceismorepronounced inmaleanimals.[19]

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General information

• Sodiumseleniteactsneuroprotectivelyevenhoursafterinduction ofthedamage

• Seleniumdeficitresultsinmassivelyincreasedsusceptibility toexcitotoxicityandgreaterneuronalcellloss

• Theneuroprotectiveeffectofsodiumseleniteisbasedon:

• thereductionofoxidativestressinneurons

• thepreservationofthemitochondrialrespiratorychain

• theinhibitionofNFκB-andAF1activation

• theinhibitionoftheischaemia-inducedDNAoxidation

• thenormalizationofischaemia-activatedautophagy

Sodiumseleniteactsneuroprotectively evenhoursafterinductionofthedamageSavaskanetal.investigatedtheroleofselenium for stroke in vitro and in animal experiments.Glutamatewasemployedfor the simulation of a stroke [1].Itisthepredominantstimulatingneurotrans-mitterinthebrain.Underpathologicalconditionssuchasstroke,epilepsyandtraumaticbraindamage,glutamatecanbetoxicforneurons.Experimentshaveshowed that simultaneous administrati-onofsodiumseleniteinaconcentrationdependentmannerpreventedglutamateinducedcelldeath(p<0.01)(Fig.1),wherebythegreatesteffect(98%protec-tion)wasdeterminedforaconcentrationof100nMsodiumselenite,aconcentra-

tionthatliesinthehumanphysiologicalrange.Glutamate-inducedcelldeathcouldnotonlybepreventedwiththesimultaneous administration of sodium selenite,butalsowithasodiumsele-nite administration two hours after the glutamate-induceddamage(p<0.001)(Fig.2).TheseresultswereconfirmedinanadditionalstudybyMehtaetal.[2].Bothasignificantneuroprotectiveeffectofsodiumselenitewithglutamatetoxicityaswellaswithhypoxia(p<0.001or P<0.05)wasdemonstrated(Fig.3)

Ischaemia/ reperfusion16 Sodium selenite for stroke

Fig.

1Concentration-dependentneuronalprotection ofsodiumselenite.[1]

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Asodiumseleniteadministration inthephysiologicalrangeaftertwohourspreventsneurondeath.[1]

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Neuroprotectiveeffectofsodiumseleniteagainstglutamatetoxicityandhypoxia.[2]

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Ischaemia/ reperfusion 17Sodium selenite for stroke

Fig.

4Significantimprovementoftheneurologicaloutcome insodiumselenitesupplementedischaemiagroup.[3]

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Thecomparisonofneurologicaldamagewithischaemiawithandwithoutsodiumselenitesupplementsrevealedsignifi-cantlylessneurologicaldeficitswithaninterventionofsodiumselenite(p<0.05orp<0.01)(Fig.4)[3].Alsothedeathofbraincellswithischaemiawassig-nificantlyreducedby38%withsodiumselenitesupplementation(p<0.05) (Fig.5)[3].

Aseven-daysodiumselenitesupplemen-tationbeforeischaemiainvivoresultedinasignificantreductionofbraindamage(p<0.01)(Fig.6)[2].Theinfarctvolumewastherebyreducedfrom36.4±24.5%to11.6±5.0%comparedtothecontrolgroup24hoursafterre-establishmentofthecirculation.Thisinvivoresultclearlyshowstheneuroprotectiveeffectofsodi-umseleniteforstrokes.


Fig.

5Significantlylowerinductionofapoptosisinthesodiumselenitesupplementedischaemiagroup.[3]

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Sodium selenite supplementation significantlyreducesischaemiainducedbraindamage.[2]

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Sodium selenite


Seleniumdeficitmassivelyincreases susceptibilitytoexcitotoxicity andincreasedneuronalcelllossInordertoconfirmthisinvitroresult,ratswere administered a selenium adequate ordeficientdiet[1].Theresultconfirmedthehierarchyofseleniumdistributionunderselenium-deficitconditions. Aselenium-poordietinratsresulted inadramaticreductionoftheseleniumconcentrationintheliver(p<0.001),whileinthebrain,theseleniumlevel wassignificantlyreducedby10% (p<0.01)(Fig.7)[1].

InaKainatmodelforexcitotoxicityitwashowevershownthatthis10%reductionoftheseleniumlevelinthebrainsufficedtoproducesignificantlyhigherseizurerates(p<0.01)(Fig.8)[1].Moreover,selenium-deficitratsshowedsignificantlymoreapoptoticneuronsandtheneuronalcelllossinthehippocampuswassignifi-cantlyhigherthaninratsfedaseleniumadequatediet(p<0.01)(Fig.9).

Fig.

7

Differentimpactofaseleniumdeficitontheseleniumconcentrationintheliverandinthebraincomparedwith anadequateseleniumintake.[1]

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Sel

eniu

m c

once

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tion

[mg/

kg]

Sel

eniu

m c

once

ntra

tion

[mg/

kg]

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80

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160

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Adequate selenium diet

Liver Brain

Deficit selenium diet

Adequate selenium diet

Deficit selenium diet

p < 0.001 p < 0.01


Fig.

9

Aselenium-poordietleadstosignificantlygreaterneural celllossinthehippocampuscomparedtoadietwithadequateselenium.[1]

0-30 0 30 60 90 120 150 180

0.5

1

1.5

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3.5

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4.5

5

Sei

zure

act

ivity

Time after kainate injection [min]

Deficit selenium diet + kainate

Adequate selenium diet + kainate

Control

Fig.

8Seleniumdeficitleadstosignificanthigherseizurerates inthebrain.[1]

0

50

75

125

25

100

num

ber o

f CA

1 ne

uron

s

Deficit selenium diet + control

Deficit selenium diet+ kainate

Adequate selenium diet+ kainate

p < 0.01

p < 0.001


Principleofactionofneuronalprotection bysodiumselenite

Sodiumselenitereducesoxidativestressinneurons

Asurplusofglutamateinduceshighlevelsofreactiveoxygenspecies(ROS)inneuronsandtherebystronglyincrea-sesoxidativestress.SodiumseleniteadministrationpreventstheproductionofROS(p<0.01)(Fig.10),whilehavingnoinfluenceontheglutathionelevel[1].AlsointhestudybyMehtaetal,sodiumselenitesignificantlyreducedtheproduc-

tionofROSinducedbyglutamatetoxicityandhypoxia(p<0.001)orp<0.05) (Fig.11)[2].Oneofthebasicmechanismsofsodiumselenite-mediatedneuronalprotectionliesinthesignificantattenuati-onofoxidativestress.

Fig.

10SodiumselenitereducesthenumberofROS instroke.[1]

0

20

40

60

80

100

120

140

160

180

200

Per

oxid

e le

vel (

RO

S)

Control Sodium selenite+ Glutamate

p < 0.01

Glutamate


Fig.

11SodiumselenitesignificantlyattenuatesROSformationinducedbyglutamate(A)andhypoxia(B).[2]

0

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250

RO

S fo

rmat

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tive

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ihyd

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um) [

%]

ControlControl Glutamate Control Glutamate

Sodium selenite

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%]

ControlControl Hypoxia Control Hypoxia

Sodium selenite

p < 0.001 p < 0.001

p < 0.01 p < 0.05

A

B


SodiumselenitepreservesthemitochondrialrespiratorychainafterhypoxiaHypoxiasignificantlyreducestheactivityofthecomplexI–IVoftherespiratorychain(p<0.01)(Fig.12)[2].Apretre-atmentwithsodiumseleniteincreasestheactivityoftheindividualcomplexesonthebasallevelandalsosignificantlyreducestheinhibitoryeffectofhypoxiaontherespiratorychain(Table1).

Therefore,asodiumselenitesupplemen-tationmitigatesthenegativeeffectofhypoxiaonthemitochondrialrespiratorychain,wherebytheactivityofthecom-plexeitherremainedatanormallevelorsignificantlyimprovedcompared tonosodiumseleniteadministration.

SodiumseleniteinhibitsNFκB- andAF-1activationGlutamatetreatmentresultedinincrea-sednuclearNFκBandAP-1level.Thisincreasewasinhibitedbysodiumsele-nite [1].Thegel-shiftassaysignificantlyshowedthattheglutamate-inducedacti-vationandbondingofNFκBandAP-1ontheir“nuclearresponseelements”was

reducedbysodiumselenite.ThemissingactivationofNFκBandAP-1preventsneuronalcelldeathandreducestheactivationofglialcells.Theglialactiva-tionraisesstresssignalsandneuronaldamagetoahigherpower,whichleadstosecondarycelldeath(“secondhit”).

Tab.

1Sodiumselenitesignificantlypreventsorreducesthenegativeeffectofhypoxiaonthecomplexoftherespiratorychain.[2]

Hypoxia Hypoxia+ sodium selenite

P-value

ComplexI -37% -5% p<0.01

ComplexII+III -65% -45%

ComplexIV -24% -3% p<0.001


Fig.

12Sodiumselenitepreservestheactivityoftherespiratory chainofmitochondriaafterhypoxia.[2]

0

50

100

150

Com

plex

I ac

tivity

[%]


Sodium selenite

0

50

100

150

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plex

II +

III a

ctiv

ity [%

]


Sodium selenite

0

50

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150

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plex

IV a

ctiv

ity [%

]


Sodium selenite

p < 0.01

p < 0.001 p < 0.01

p < 0.01

p < 0.001 p < 0.001


Effectofsodiumseleniteisdependent onthebiosynthesisofselenoproteinsIncontrasttosodiumselenite,sodiumselenatehasnodirectantioxidativecharacteristics,butratherisincorporatedinselenoproteins.Aftersodiumselenitewasreplacedbysodiumselenate,mostoftheneuroprotectiveprotection(70%)remained preserved [1].Thissuggests

thattheneuroprotectiveeffectofsodiumselenitedependsonthebiosynthesisofselenoprotein.Theadditionofcyclohe-ximide,whichinhibitsproteinbiosynthe-sis,cancelstheneuroprotectiveeffectofsodiumselenitetherebysupportsthehypothesis(Fig.13).

Sodiumselenitereducedischaemia inducedDNAoxidationInaddition,Mehtaetal.investigatedwhethercerebralischaemiainduces oxidativeDNAdamage[2].Theevidence of8-OHdGrevealedasignificantincrea-seintheoxidativedamage24hoursafterre-establishmentofcirculation. Incomparisontothis,apre-treatmentwithsodiumselenitesignificantlyre-

ducedtheoxidativeDNAdamage(p<0.05)(Fig.14).Thus,theantioxidativeimpactofsodiumseleniteconsistsinavoidingtheoxidationofDNAandthere-byitsbeingdamaged.

Literature

1 SavaskanNE,BräuerAU,KühbacherM,EyüpogluIY,KyriakopoulosA,NinnemannO,BehneD,NitschR.FASEBJ.2003Jan;17(1):112-4.Seleniumdeficiencyincreasessusceptibilitytoglutamate-inducedexcitotoxicity.

2MehtaSL,KumariS,MendelevN,LiPA.BMCNeurosci.2012Jul9;13:79.doi:10.1186/1471-2202-13-79.Seleni-umpreservesmitochondrialfunction,stimulatesmitochondrialbiogenesis,andreducesinfarctvolumeafterfocalcerebralischemia.

3 YousufS,AtifF,AhmadM,HodaMN,KhanMB,IshratT,IslamF.BrainRes.2007May25;1147:218-25.Seleniumplaysamodulatoryroleagainstcerebralischemia-inducedneuronaldamageinrathippocampus.






Fig.

13Theadditionoftheproteinsynthesisinhibitorcycloheximidecancelstheneuroprotectiveeffectofsodiumselenite.[1]

0

50

75

125

25

175

100

150

Cel

l via

bilit

y [%

]

Control Sodium selenite+ Glutamate

Sodium selenite+ Glutamate

+ Cycloheximid

Glutamate

p < 0.01 p < 0.001

Fig.

14SodiumselenitereducesDNAoxidationinduced byischaemia.[2]

0

20

30

50

60

10

40

8-O

HdG

pos

itive

cel

ls

Control Sodium selenite

p < 0.01


Sodiumselenitenormalizes ischaemia-activatedautophagyInordertoremovedamagedorganellesandcelldebrisafteracerebralischae-mia,autophagyisactivated.LC3-IIisamarkerofautophagy.ThemeasurementofLC3-IIinvivoafteraninducedischae-miarevealedasignificantincreaseafterfivehours(p<0.001)andadeclinetotheoriginallevelafter24hours(Fig.15)[2].Inrats,thatreceivedsodiumseleniteforsevendays,theincrease

ofLC3-IIafterfivehourswassignificantlylower(p<0.01).After24hoursthe LC3-IIlevelreductionwashighlysignifi-cantcomparedtothecontrolgroup (p<0.001).Asodiumselenitepre-treat-mentpreventsbraindamagebyischae-mia.Thereforetheactivationofautopha-gyisreduced.

Fig.

15Sodiumseleniteinhibitstheactivationofautophagy aftercerebralischaemia.[2]

0

50

100

150

Cel

l via

bilit

y [%

]

Control

Control Sodium selenite Control Sodium selenite Control Sodium selenite

Glutamate Hypoxia

p < 0.05

p < 0.001 p < 0.001 p < 0.05


Fig.

16Effectofaseleniumdeficit(rightside)onthebrain affectedbystroke,ischaemiaandbraintrauma.[1]

Glutamate release calcium influx

Glutamate-induced seizure

Glutamate release calcium influx

NF-κB NF-κB

Oxidative stress Oxidative stress

Neuron cell death

Neuron cell death

Glia activation

Glia activation

Tissue damage

Seizures

Tissue damage

Seizures

withsodiumselenitepre-treatment Controlgroup

Impactofaseleniumdeficit onthebrainaffectedbystroke


Selenium status and selenoprotein activityintheeventofastroke

General information

• Strokepatientsshowsignificantlydecreasedseleniumvalues

• Correlationbetweenglutathionperoxidaseconcentration, neurologicaldeficit,andoutcome

• SignificantlyreducedSelenoproteinPforpatientswithan acutestroke

• AreducedSelenoproteinPstatusissignificantlyassociated withahigherriskofastroke

Strokepatientsshowsiginficantly decreasedseleniumvaluesAtrialbyZimmermannetal.hascompa-redtheantioxidantstatusofpatients withacutestroke(n=11)withpatientswho suffered a stroke in the previous 12months(n=17)[1].Inpatientswithastrokeanamnesis,theaveragese-rumseleniumconcentrationof73.4±11.1µg/lwasbelowthereferencevalue

of80µg/lseleniuminserum.Valuesbe-low80µg/lseleniuminserumareconsi-deredasseleniumdeficit.Incomparison,the serum selenium level in patients with anacutestrokeshowedsignificantlylowerseleniumvalues(61.6±9.5µg/l; p<0.01)atadmission(Fig.1).


Fig.

1Significantlyreducedserumseleniumconcentration inpatientswithanacutestroke.[1]

p < 0.01 Reference range

Patients with stroke within

last 12 months

Patients with acute stroke

Admission to ICU


Day 1


Day 2


Day 7

0

10

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30

40

50

60

70

80

90

Ser

um s

elen

ium

con

cent

ratio

n [µ

g/l]


Correlationbetweenglutathionperoxidaseconcentration,neurologicaldeficit, andoutcomeMeasurementoftheselenium-depen-dent,antioxidantglutathioneperoxi-dasedisplayedasignificantincreaseoftheglutathioneperoxidaselevelinacutestrokepatientsondayone(p<0.05)(Fig.2).Inhalfofthepatients,who suffered a stroke in the previous 12months,theglutathionelevelswerebelowthenormalrange.However,theglutathioneconcentrationinpatientswithanacutestrokewassignificantlyincrea-sed(p<0.01)(Fig.3).Moreover,therewasanegativecorrelationbetweentheglutathioneperoxidaseconcentrationandtheNIHSS(NationalInstituteofHealth

StrokeScale)atadmission(r=−0.84;p<0.001)andaftersevendays(r=−0.63;p<0.05).Highglutathionepero-xidaseconcentrationscorrelatedwithalowneurologicaldeficit(lowerNIHSSvalueatadmission)andwithafavorab-leoutcome(lowerNIHSSvalueondayseven).Theseresultsconfirmedfindingsacquiredinanimalexperiments,i.e.thatglutathioneperoxidasehasaprotectiveeffectagainstbraindamageandthatareducedglutathioneperoxidaselevelisassociatedwithincreasedstrokerisk[2,3].


Fig.

2Significantincreaseofglutathioneperoxidaseconcentration inpatientswithacutestroke.[1]


Day 1


Day 3

Patients with acute stroke,

admission to ICU


Day 7


last 12 months

0

100

50

150

200

Glu

tath

ione

per

oxid

ase

in s

erum

[U/l]

p < 0.05

Fig.

3Significantlyincreasedglutathioneconcentrationinpatientswithacutestroke.[1]


Day 1


Day 3

Patients with acute stroke,

admission to ICU


Day 7


last 12 months

0

40

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80

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120

Glu

tath

ione

con

cent

ratio

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mol

/l]

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SignificantlyreducedSelenoproteinP concentrationinpatientswithanacutestrokeInapopulation-basedembeddedca-se-controltrialwith1,632participants,Koyamaetal.comparedtheserumsele-niumandSelenoproteinPconcentrationsof30strokepatientswith30controls[2].Theserumseleniumconcentrationwaslower(105.2vs.116.5µg/l;p=0.054) instrokepatients.Theresultfortheser-umseleniumvaluesiscomparableto theZimmermanntrial.Acomparison of the two studies, however, also shows thatlocalizationplaysamajorrolein aseleniumtrial.InstudiesfromEurope,theseleniumlevelsaresignificantly lowerincomparisonwithJapan,forinstance,suchasthetrialbyKoyama.Apartfromtheserumseleniumconcent-ration,theSelenoproteinPconcentration

withstrokepatientswassignificantlylower(54.5vs.63.9µg/l;p=0.006)(Ta-ble1).Amultivariateregressionanalysisshowed,thatareducedSelenoproteinPlevelisassociatedwithhigherstrokerisk(OR0.28;95%CI0.1-0.85).SincetheSelenoproteinPconcentrationdependsontheseleniumstatus,itcanbecon-cludedthatthesignificantlylowerserumseleniumconcentrationsinEuroperesultinlowerSelenoproteinPlevels.Therefo-rethequestionmustbeposedwhetheraseleniumdeficientdietpresentsanadditionalriskfactorapartfromhyperten-sion,smokingandhypercholesterolemiaforstroke.

Literature

1 ZimmermannC,WinnefeldK,StreckS,RoskosM,HaberlRL.EurNeurol.2004;51(3):157-61.Antioxidantstatusinacutestrokepatientsandpatientsatstrokerisk.

2KoyamaH,AbdulahR,OhkuboT,ImaiY,SatohH,NagaiK.NutrRes.2009Feb;29(2):94-9.doi:10.1016/j.nut-res.2009.01.002.DepressedserumselenoproteinP:possiblenewpredicatorofincreasedriskforcerebrovascularevents.




Tab.

1SignificantlylowerserumseleniumandSelenoproteinP concentrationsinstrokepatients.[2]

Stroke Control P-value

seleniuminserum[µg/l] 105.2±19.6 116.5±16.6 0.054

SelenoproteinP[µg/l] 54.5±8.69 63.0±9.18 0.006


Day1

Treatmentideallybeginswithin6hoursafteradmission totheICU

BolusdirectlyafteradmissiontoICU

1,0001µgSe

thenascontinuousinfusion

5001µgSe

Fromday2 of the ICUstay

maintenancetherapy 5001µgSe/day

Literature 1ReisingerJetal.2009,AmJEmergMed27:176-181



Seleniuminguidelines

Adults Infantswithlowbirthweight

Children (prematureand term infants)

Burn patients

Sepsis patients

ICUpatientsingeneral

GuidelineParenteralNutrition ofDGEM2007

BiesalskiHKetal.:Wasser,Elektroly-te,VitamineundSpurenelemente.AktErnMed2007;32,Sup1:S30–S34.

× × × × ×ESPENGuidelinesonParenteralNutrition

ClinicalNutrition(2009)28,387–400.× × × ×

DeutscheSepsis-Leitlinien

Prävention,Diagnose,Therapie undNachsorgederSepsis

ReinhartK,BrunkhorstFM,AWMFonline2010.

×CanadianClinicalPractice Guidelines2013

www.criticalcarenutrition.com× ×

GuidelinesfortheProvisionandAssessmentofNutritionSupportTherapyintheAdultCriticallyIIIPatient:SCCMandA.S.P.E.N.

McClaveetal.,Jpen33(2009)3,277–316.

× ×GuidelinesonPediatric ParenteralNutrition

JofPediatrGastroenterolNutr. 41:S39–S46,November2005ESPG-HAN

×NutritionSupportforAdults: OralNutritionSupport,EnteralTubeFeedingandParenteralNutrition

NationalInstituteforClinicalExcellen-ceFeb2006,UK

×

Summary36 Guidelines

http://www.dgem.de/material/pdfs/7%20Wasser,%20Elektrolyte,%20Vitamine,%20Spurenelementes-2006-951867.pdf

http://www.dgem.de/material/pdfs/7%20Wasser,%20Elektrolyte,%20Vitamine,%20Spurenelementes-2006-951867.pdf


http://www.awmf.org/leitlinien/detail/ll/079-001.html

http://www.awmf.org/leitlinien/detail/ll/079-001.html

http://www.criticalcarenutrition.com








37Guidelines

Thishiddenchampionsuppliesitshigh-revenue blockbusterselenase®to22countries, primarilyforoncologyandintensivecaremedicine.

Foundedin1984,biosynArzneimittelGmbHwasoneofthefirstGermanbiotechnologycompanies.Nowithasaround70employeesinGermanyandsubsidiariesinLiechtenstein,AustriaandtheUSA.

Itsportfolioencompassessome30pro-ductsrangingfrombiotechnologicallyengineeredmedicinesthroughchemo-therapeuticstocomplementarydrugsandfoodsupplementsforitsmainfields

ofintensivecaremedicineandoncology.Thecompany’smajorconcernistreatingpatientsasawhole.biosyn,arese-arch-focusedpharmaceuticalcompany,putsupto25percentofrevenuesbackintoitspipeline.

Itsmissionistoexplore,evolveandmar-kethighlyefficaciousdrugswithlowsideeffectsbasedonthemostup-to-dateevidencemolecularbiologyhastooffer.

High-qualityproductsfromtheworld’sfirst GMP-compliantproductionofsodiumselenite

In2009,biosynArzneimittelGmbHwas,andpresumablystillis,thefirstandonlycompanyintheworldabletomanufac-turetheactiveingredientsodiumselenitepentahydrateininternationallyprescribedGMPquality–thankstobiosyn’sprop-rietaryandpatentedproductionmethod.Itspurificationandcrystallizationtechno-logiesallowmicrobe-freeproductionofhigh-qualitytraceelementcompoundsundercleanroomconditions.

Thisenablestheproductionofinjecta-bleliquidpharmaceuticalstomeettheparticularlystringentdemandsonquality.

biosyncurrentlymanufacturesanhyd-rous sodium selenite and sodium seleni-tepentahydratefororalandparenteralformulations.

Thebiosynmotto“weareresearch”notonlysymbolizesourdedicationtome-dicalandpharmaceuticalprogressbutalso for our drive to develop innovative manufacturingprocesses.

Thecompanymarketsitsseleniumdrugsunderthebrandnameselenase® world-wide.

biosynArzneimittelGmbHbiosynistheglobalmarketleader inhigh-doseseleniumpharmaceuticals

GMP-compliantproductionofsodiumseleniteatbiosyn: Vacuumdryingsystemfortargetedcrystallizationofmetallicsaltswithdefinedportionsofhydratedingredients

Summary38 Company

Summary 39Company


we are research

01D01753/A•Export•02/16•DD0,25

ContactandInformationwww.biosyn.de www.biosyncorp.com biosynArzneimittelGmbH SchorndorferStraße32 70734Fellbach [email protected]

ManagingDirector:Dr.ThomasStiefelandOrtwinKottwitz CommercialRegister:CountyCourtStuttgartHRB262712 Placeofperformance:Fellbach,LegalvenueStuttgart

http://www.biosyn.de

http://www.biosyncorp.com

mailto:[email protected]

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