OZONE THERAPY IN PATIENTS WITH VIRAL HEPATITIS

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OZONE THERAPY IN PATIENTS WITH VIRAL HEPATITIS
CA CLINICAL STUDY

• BY
• PROF. M. N. MAWSOUF,, DR. T. T. TANBOULI ,
  DR. W. I. EL-TAYAR,
• DR. N. EL-MASRY
• DR. W. ANAS
• Cancer Institute, Cairo University
• Cairo Medical Center

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Aim of the Study

• To evaluate the effectiveness of ozone therapy in
  hepatitis C genotype 4 infection.
• To update, modulate and add to a previous study
  made to evaluate a proposed ozone therapy
  protocol in HCV genotype 4 treatment.

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Why HCV?

• Worldwide medical problem (estimated that more
  than 300 millions suffering from HCV)
• Major medical problem in EGYPT (postulated that
  more than 15 i.e. more than 10 millions of the
  population are suffering from HCV)
• Slowly progressing, detected mainly accidentally,
  devitalizing and difficult to treat

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Why HCV? (cont.)

• In most cases it leads to complications e.g.
  liver cirrhosis, ascitis, liver carcinoma and
  ultimately liver cell failure
• Not only a medical problem, but also an economic
  problem (less work, less production and very high
  costs of usual treatment)

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Hepatitis C

• There is a worldwide prevalence of genotypes 1,2
  3.
• In Africa genotype 4 and 5 are more dominant.
• In Asia genotype 6 is more dominant
• Genotype differences have shown varying
  susceptibility to antiviral therapy.

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Hepatitis C (cont.)

• Liver Cirrhosis is estimated to develop in 20 -25
  of patients with HCV within 20 years.
• Hepato-cellular carcinoma (5 of patients )
• Hepatic decompensation and liver cell failure
  with ascitis

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Hepatitis C (cont.)

• The main line of treatment nowadays for hepatitis
  C include interferon and ribavirin.
• Ribavirin and interferon have significant
  organic and psychiatric side effects.

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Why Ozone?

• Known Anti-viral action
• Safe if used by experts
• Can de used even in presence of complications
• Less costs
• Classic method of treatment very expensive with
  major side effects and minimal cure results

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Ozone and HCV

• Lipid and protein peroxides, produced in small
  amounts by ozonation, have demonstrable antiviral
  properties.
• Ozone tends to stimulate leucocyte function and
  cytokine production.
• Ozone increases the oxygen saturation (P02) in
  erythrocytes and enhances their pliability so
  that capillary circulation is facilitated (Gérard
  Sunnen 2001).

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Ozone and HCV (cont.)

• In HCV, viral load appears to be a major factor
  in the invasiveness and virulence of the disease
  process.
• Preliminary research has shown that reduction of
  viral load in Hepatitis C by means of ozone
  therapy can significantly normalize hepatic
  enzymes and improve measures of global patient
  health (Gérard Sunnen 2001).

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Ozone and HCV (cont.)

• Ozone proper, and the peroxide compounds it
  creates, may directly alter structures on the
  viral envelope which are necessary for attachment
  to host cells. Peplomers, the viral glycoproteins
  protuberances which connect to host cell
  receptors are likely sites of ozone action.

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Mode of Action of Ozone in HCV
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Mode of Action of Ozone in HCV
There are two Mechanisms 1- Antiviral Effect 2-
Immuno-activating Effect
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Antiviral Effects of Ozone

• It is known that, a normal body cell has a wall,
  which contains antioxidant enzymes (glutathione,
  catalase, super oxide dismutase).
• These enzymes are absent or deficient in
  bacteria, fungi and viruses (viruses have no cell
  wall). So they cannot withstand this oxidative
  stress caused by the single oxygen and the free
  radicals, which are already, present in the
  body.(Balkanyi, 1989)

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Antiviral Effects of Ozone (cont.)

• The virus with its spikes of the free virion
  react via condensation with the corresponding
  receiver substance of the cell (Nacetylglucosamini
  c acid), thus enabling the virus to penetrate the
  host cell.
• The free pair of electrons on the nitrogen of
  the N-acetylglucosamine represents the point of
  attack for the electrophilic ozone molecule or
  its peroxides, so that further reaction is
  blocked for the virus, making it inactive
  (Gerard, 1994).

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Antiviral Effects of Ozone (cont.)

• The electrophilic reaction of ozone can also take
  place with the unsaturated fatty acids as a
  membrane constituent of the virally infected cell
  body and inject peroxides into the cell. The
  infected cell, already produces hydrogen
  peroxides (H2O2) as a defense mechanism, so that
  further peroxides are no longer tolerated and the
  cell bursts before reproduction of the viruses
  has been completed.
• The peroxides introduced into the cell act
  synergistically with those already present inside
  it thus destroying any microorganisms which had
  penetrated.(Konrad, 1995)

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Antiviral Effects of Ozone (cont.)

• Denaturation of virions through direct contact
  with ozone. Ozone disrupts viral envelope
  proteins, lipoproteins, lipids, and
  glycoproteins.
• The presence of numerous double bonds in these
  unsaturated molecules makes them vulnerable to
  the oxidizing effects of ozone.

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Antiviral effect of Ozone (cont.)

• Molecular architecture is disrupted and
  widespread breakage of the envelope ensues.
• Deprived of an envelope, virions cannot sustain
  nor replicate themselves.

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Immune Activating effect of Ozone

• It is known that, ozone has the ability to assume
  the activation of immuno-competent cells
  directly, i.e. it can produce a specific
  immuno-activation.(Viebahn, 2002).
• Many researches has proved that ozonized blood
  releases interferons (IFN-?, IFN-?, and IFN-?),
  Interleukins (interleukins of the types IL-1b, 2,
  4, 6, 8, 10), tumor necrosis factor (TNF - ?),
  granulocyte macrophage colony-stimulating factor
  (GM-CSF) and the transforming growth factor
  TGF-ß1.(Bocci et al 1990 1993, Paulesu et al
  1991, Larini et al 2001)

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Immune Activating effect of Ozone (cont.)

• The first step in the ozone activation of
  immuno-competent cells takes place via the
  ozonolysis of unsaturated fatty acids as
  components of the cell membrane. Short-chained
  hydroxy-hydroperoxides enter the intracellular
  space and activate nuclear factor NF-kB (Haddad
  et al 1996).
• Via the activation of cell nucleus mRNA,
  translation, the corresponding protein synthesis,
  cell-specific cytokines are finally released (
  Dee Forge et al 1992, Andreson et al 1994, Schenk
  et al 1996, Sen and Packer 1996, Bocci 1996,
  Flohe et al 1997, Ginn-Pease and Whisler 1998,
  Hack et al 1998, Arrigo 1999, Tatla et al 1999,
  Allen and Tresini 2000).

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Immune Activating effect of Ozone (cont.)

• Interleukin-6 accelerates antibody synthesis
  GM-CSF factor produces leucocytosis
• Interferons with their antiviral activity prevent
  viral replication, additionally activating basic
  immuno-modualtory functions together with
  interleukin-2 and TNF-?.

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Immune Activating effect of Ozone (cont.)

• These produce an activation of the cytotoxic
  T-cells (CD8), macrophages, neutrophils,
  eosinophils, natural killer cells, and activation
  of antibody-dependent cell-mediated cytotoxicity,
• This is finally responsible for killing off virus
  infected cells or neoplastic cells and
  responsible for eliminating bacteria.
• The release of interleukine-10 and TGF-ß1 is able
  to suppress excess immuno-stimulation, thus
  resulting in an orderly programming of immune
  response. (Bocci, 1995)

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Immune Activating effect of Ozone (cont.)

• Among the immuno-competent cells, the T4
  lymphocytes (TH1) occupy a key position.
  Activated by the macrophages, they produce
  cytokines, which initiate intercellular
  communication in their function as messengers.
• Interleukin-2, is responsible for activation of
  more T4 lymphocytes to become cytotoxic killer
  cells, and the activation of B lymphocytes to
  produce specific antibodies.
• Activated helper cells set off a whole cascade of
  immune reactions.

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PATIENTS and METHODS
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Patients and Methods

• Fifty patients type 4 HCV
• Forty four males
• Six females
• Age range 23 to 58 years
• Randomly selected

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Patients and Methods (cont.)

• Investigations
• C.B.C, Liver function tests, AFP
• Prothrombin time and concentration
• Antibodies for Bilharziasis
• PCR quantitative for HCV
• Abdominal ultrasonography

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Patients and Methods (cont.)

• Ozone Treatment Protocol
• MAH RI three times per week for twelve weeks
  followed by two times per week for twelve weeks
• The rationale of start low and go slow was
  respected

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Patients and Methods (cont.)

• MAH 20µ/ml ozone ? 20 ? 25 ?25 ?30 ? 30 ? 35 ? 40
  ? 45 ? 45 ? 50 ? 50 ?55 ? 55 ? 60 .. The volume
  was constant 140 ml
• Rectal Insufflations 15µ/ml ozone x 250 ml ?
  15µ/ml x 250 ml ? 20µ/ml x 250 ml ? 20µ/ml x 250
  ml ?25µ/ml x 250 ml ? 25µ/ml x 250 ml ? 30µ/ml x
  250 ml ? 30µ/ml x 250 ml ? 30µ/ml x 300 ml ?
  35µ/ml x 300 ml ? 35µ/ml x 300 ml ? 40µ/ml x 300
  ml ..

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Patients and Methods (cont.)

• Investigations were repeated after 8 and 24 weeks
  of treatment
• General health and daily activity were observed

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RESULTS
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63.85
71.84
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NE VL L M H PCR
0 1 3 13 33 start
12 2 9 15 12 after 2 months
18 1 18 7 6 after 6 months
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DISCUSSIONand CONCLUSION
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Following this Second Study Ozone therapy was
found again to be an effective, safe and less
expensive method in Hepatitis "C" patients.A
Third Comprehensive Study will Start on October
2004 with the Co-operation of the Ministry of
Health
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Pilot Studies

• MAH twice/week for 2 months
• MAH three times/week for 2 months
• RI twice/week for 2 months
• RI three times /week for 2 months
• Following rationale of start low and go slow Good
  results but not as good as the mentioned protocol

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Pilot Studies (cont.)

• Combined MAH RI once /week following 2 months
  of mentioned protocol was not satisfactory from
  the general condition point of view
• but if we shift to twice / week the general
  condition is better.

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Comments

• Why Combined MAH RI ?
• pilot studies
• hyper-oxygenation of portal circulation
  (Knoch et al 1987)
• Why the enzymes are normal in some patients
  before ozone therapy ?
• Medications affecting the enzymes level

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Important Postulated Reasons for Less
Effectiveness

• Diet
• Over Exertion
• Anxiety, Stress, Insomnia.
• Hepatotoxic Drugs

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Remarks on Modulating the Concentrations

• Reduce the concentration and/or the volume if
• Headache (as a new complaint)
• Chest oppression
• Prolonged lassitude (more than one day)
• Constipation (as a new complaint)
• N.B. You may give Vit. C

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Important Observation

• In five cases of the study it was observed that
  the state of Liver Cirrhosis REGRESSED after six
  months or more of Ozone Therapy by
  Ultrasonography
• This should be evaluated by further studies by
  using liver biopsy.

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Parameters for the Third Study

• Randomized Placebo Controlled Study
• Selection of Patients
• No complications (Cirrhosis, Ascitis, Liver cell
  failure, etc..)
• No associated chronic disease (Diabetes,
  Bilharziasis, etc..)

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Parameters for the Third Study (cont.)

• Evaluation should be based on many parameters
• General condition
• Liver Function tests (synthesis,excretions,integri
  ty)
• Complete Blood Count
• Liver biopsy

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Parameters for the Third Study (cont.)

• Quantitative PCR as one only parameter for
  evaluation can be considered as a guide for
  evaluation but is not conclusive
• sharp fluctuations of viral load (virus is in
  liver cells)
• so far there is no precise and accurate method
  for quantitative estimation of viral load
• different methods, different units and wide
  variation from one laboratory to another must be
  put in consideration

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Thank You