Targeted Plasmalogen Supplementation: Effects on Blood Plasmalogens, Oxidative Stress Biomarkers, Cognition, and Mobility in Cognitively Impaired Persons.

Plasmalogens are a specific type of glycerophospholipid found in especially high levels in neuronal membranes. Decreased blood and brain levels of docosahexaenoic acid (DHA) containing plasmalogens are associated with decreased cognition and neuromuscular function in humans. Administration of 1-O-alkyl-2-acylglycerol (AAG) plasmalogen precursors containing DHA at the sn-2 position dose-dependently increase blood DHA plasmalogens and are neuroprotective in animal models of neurodegeneration at doses between 10 and 50 mg/kg. We conducted an investigational clinical trial in 22 cognitively impaired persons to evaluate the effects of an escalating oral dosing regimen of DHA-AAG from 900 to 3,600 mg/day over a 4-month period on blood serum plasmalogen and non-plasmalogen phospholipids and oxidative stress biomarkers. Safety, tolerability and therapeutic effects on cognition and mobility were also evaluated. DHA plasmalogen levels increased with increasing dose and remained significantly elevated at all treatment doses and durations. DHA plasmalogen levels were positively associated with catalase activity and negatively associated with malondialdehyde (MDA) levels. DHA-AAG supplementation normalized catalase activity in persons with low baseline catalase activity, normalized MDA levels in persons with high baseline MDA levels, and normalized superoxide dismutase activity in persons with high baseline SOD activity. Cognition improved in nine participants, was unchanged in nine, and declined in four. Mobility improved in twelve, was unchanged in five and declined in four participants. Changes in cognition and mobility were statistically significant versus a random outcome. Baseline DHA-plasmalogen levels were not predictive of clinical response. DHA-AAG was well tolerated at all dosages and no adverse reactions were observed.

Introduction

A 2021 survey of 1,221 adults in the US revealed that cognitive decline and the loss of mobility were the two most feared health outcomes (Author Anonymous, 2021). The prevalence of dementia in persons with sarcopenia is approximately three times higher than in persons without sarcopenia (Pacifico et al., 2020) and reduced muscle function is associated with increased risk of incident dementia and a faster rate of cognitive decline (Beeri et al., 2021). Reduced cognition and reduced mobility are comorbid. Reduced cognition and reduced mobility are also associated with plasmalogen deficiency. In humans, the association between low blood and brain plasmalogen levels and reduced cognition is robust and reproducible (Ginsberg et al., 1995; Ginsberg et al., 1998; Guan et al., 1999; Han et al., 2001; Han, 2005; Goodenowe et al., 2007; Wood et al., 2010; Wood et al., 2011a; Goodenowe and Senanayake, 2019; Senanayake and Goodenowe, 2019; Kling et al., 2020; Lim et al., 2020; Goodenowe, 2021). In animal models of plasmalogen deficiency, neuromuscular junction defects (Dorninger et al., 2017a; Dorninger et al., 2017b) have been reported and the selective knockout of oligodendrocyte peroxisomes cause white matter plasmalogen defects, morphology and symptomology similar to multiple sclerosis (Kassmann et al., 2007). These observations imply that impaired or insufficient plasmalogen related functions may represent a putative common link between dementia and sarcopenia.

A core component of human physiology is the compartmentalization of specific and distinct functions at both the intra- and intercellular level. The integrity and maintenance of function of these compartments are dependent upon efficient communication and transport of materials between compartments. This biochemical compartmentalization of function is dependent upon the physical and operational integrity of the biological membranes that separate cells from one another and divide intracellular space into various organelles and cytoplasm. These membranes are mostly comprised of glycerol phospholipids and cholesterol. The ability of cells and subcellular organelles to maintain optimal membrane functionality is dependent upon the cell’s ability to regulate its membrane composition. Membrane composition regulation, in turn, is dependent upon a complex interdependent mix of genetics, environment, and nutrition.

The backbone of most phospholipids is glycerol—a simple three carbon molecule with a single free alcohol on each carbon. The three carbons are commonly referred to as sn-1, -2, or -3. Glycerol phospholipids contain a polar phosphate-linked head group at sn-3. Phospho-ethanolamine or phospho-choline are the most abundant and ubiquitous phospholipid head groups in the human body. The sn-1 position is comprised of either a fatty alcohol (plasmalogen) or fatty acid (phosphatidyl). The sn-1 bond type and the type of fatty acid at sn-2 are the key determiners of the effect of membrane phospholipid composition on membrane structure and cellular function (Mankidy et al., 2010; Wood et al., 2011a). When alkyl-acylglycerols (AAG) are converted to ethanolamine plasmalogens (PL) the PL species retains the sn-2 fatty acid of the AAG. In vitro studies have shown that increasing membrane levels of DHA-plasmalogens using DHA-AAG dose-dependently increases the non-amyloidogenic processing of amyloid precursor protein (APP) via an upregulation of the alpha-secretase pathway resulting in an equally dose dependent increase in secreted APP-alpha and a dose-dependent decrease in Aβ1-42 (Wood et al., 2011a). In addition, increasing membrane DHA plasmalogen levels increases HDL-mediated cholesterol transport by dose-dependently increasing cholesterol esterification via acetyl-CoA acetyltransferase (ACAT) and dose-dependently decreases the level of free cholesterol in membranes (Mankidy et al., 2010). DHA-AAG plasmalogen precursor also blocks the increase in Aβ1-42 caused by cholesterol loading (Wood et al., 2011a).

There has been an increasing interest in plasmalogens as a potential therapeutic agent for age-related cognitive decline and neurodegenerative conditions, given the growing understanding of their involvement in key cellular functions as well as the clinical trends observed when plasmalogen levels are depleted. In addition to supporting the structural integrity of membranes, plasmalogens are also involved in a variety of critically important cell functions: membrane fusion, ion transport, vesicle formation, cholesterol and amyloid regulation, and oxidation-reduction (Glaser and Gross, 1994; Glaser and Gross, 1995; Sindelar et al., 1999; Zoeller et al., 1999; Farooqui et al., 2000; Munn et al., 2003; Mankidy et al., 2010; Wood et al., 2011b; Wood et al., 2011c; Stables and Gilroy, 2011; Messias et al., 2018). In addition, recent research has shown that oral, DHA-enriched plasmalogen supplementation in mice increased hippocampal plasmalogen levels, improved learning and memory, and modulated various cell signaling pathways. In particular, research results suggested that the observed effect of oral plasmalogens on memory and learning were due, in part, to enhanced brain derived neurotrophic factor (BDNF) expression (Hossain et al., 2022). These observations are consistent with the detailed post-mortem examination of plasmalogen and phosphatidyl ethanolamine species, neuropathology and premortem cognition in human (Goodenowe and Senanayake, in press). Epidemiologically, it has been demonstrated that plasmalogen levels in the brain increase up to 30–40 years of age, and then significantly decrease by around 70 years of age (Rouser and Yamamoto, 1968; Goodenowe, 2021) and plasmalogen supplementation has been reported to improve cognition in humans (Fujino et al., 2017; Fujino et al., 2018).

Aging-related neurological and muscular degeneration lack accessible and effective therapeutic interventions. A possible treatment approach would involve a supplementation regimen of a plasmalogen precursor, such as the DHA-AAG plasmalogen precursor investigated in this study.

Materials and Methods

Study Participants

Twenty-two persons diagnosed with cognitive impairment were enrolled. Eleven were male and eleven were female and their ages ranged from 37 to 84 (average = 67). Cognitive impairment ranged from mild/questionable cognitive impairment (n = 14), to mild dementia (n = 4), to moderate dementia (n = 4) according to the Clinical Dementia Rating Scale (CDR). No biomarker analyses were performed prior to enrollment and no pre-selection occurred. 29 persons were screened, four were excluded due to non-compliance, and three dropped out due to non-trial related reasons. All participants signed informed consent forms and the trial registration number was NCT04484454.

Study Materials

The DHA-AAG (Prodrome Sciences United States LLC) used was a synthetic alkyl-acylglycerol comprised of C16 and C18 alkylglycerol backbone (chimyl and batyl alcohol) with DHA covalently bound to the sn-2 and sn-3 positions. The relative proportion of C16 and C18 plasmalogen backbone was 1:1 and the relative proportion of the fatty acids at sn-2 and sn-3 were >95% DHA, 2–5% docosapentaenoic acid (DPA) and <2% eicosapentaenoic acid (EPA). The DHA was purified from an algae source. The average density of the final product was 0.9 g/ml which corresponded to 900 mg of active product per ml. Product purity was >98%. A 1-month supply of DHA-AAG was provided to participants after each visit. Participants were instructed to take DHA-AAG each morning at the following dosages: 1.0 ml/day (Month 1, M1); 2.0 ml/day (Months 2 + 3, M2, M3); 4.0 ml/day (Month 4, M4); 0 mg/day (Month 5, M5).

Clinical Assessments

Cognition and mobility assessments were administered at baseline and the end of each month of the study. The primary outcome for cognitive status was change in Clinical Dementia Rating level (CDR) derived using the Quick Dementia Rating System (QDRS). The QDRS is a 10-item questionnaire completed by an informed third party to the participant (caregiver, spouse, etc.,). Scores range from 0 to 30 with higher scores representing greater cognitive impairment in a corresponding CDR level. The CDR rates cognitive function in six categories (memory, orientation, judgment and problem solving, and performance in community affairs, home and hobbies, and personal care). A CDR level of 0 indicates no dementia; CDR 0.5 represents MCI or very mild dementia; CDR 1, 2, or three corresponds to mild, moderate, or severe dementia respectively (Galvin, 2015).

The primary mobility outcome was the 30-s Sit/Stand test. Participants were given 30 s to fully stand and sit for as many repetitions as possible within the time window. The Sit/Stand test has been found to be both reliable and valid in assessing the functional mobility in older adults, and has also been shown to be sensitive to change (McAllister and Palombaro, 2020).

A clinically relevant change in cognition or mobility was defined as a change in CDR of one or more units or a change in two or more sit/stands, respectively. The monthly CDR and sit/stand performance of each participant were evaluated to determine the relative cognitive and mobility status of each participant at the end of months four and five relative to their baseline assessment. Each participant was rated as either exhibiting functional improvement, no change, or decline.

At the end of the study, each participant was asked to evaluate the treatment regimen using an 11-point Global Rating of Change scale from −5 to +5 in which the participant rates the overall change in their health. No change is rated as “0”, improved health from minor “+1” to significant “+5”, and reduced health from minor “−1” to significant “−5” (Kamper et al., 2009). The individual participant results are presented in Table 4.

TABLE 4

Individual participant demographics and clinical responses.

Id	Age	Sex	CDR		S/S		CDR	S/S	DHA-PL/(LA + AA)-PE			GRC
			(BL)	(M4)	(BL)	(M4)	(+/-)	(+/-)	(BL)	(M4)	Max (month)	GRC
Group 1—Moderate Dementia (CDR = 2)
16	78	F	2	3	16	14	-	-	0.29	0.48	0.90 (M3)	0
19	58	F	2	1	11	16	+	+	0.88	2.15	2.15 (M4)	0
1	81	M	2	1	11	15	+	+	0.90	1.65	1.65 (M4)	+5
29	63	F	2	0.5	30	34	+	+	1.26	2.56	2.69 (M5)	+2
Group 2—Mild Dementia (CDR = 1)
12	75	M	1	1	15	21	0	+	2.72	3.03	3.03 (M4)	+2
18	80	M	1	1	21	16	0	-	0.69	0.90	1.35 (M2)	0
8	84	M	1	0.5	12	15	+	+	0.57	0.64	0.74 (M3)	NA
21	48	M	1	0.5	14	14	+	0	1.04	1.78	2.38 (M2)	+1
Group 3—Mild Cognitive Impairment (CDR = 0.5)
11	69	F	0.5	2	NA	NA	-	NA	1.03	2.44	2.44 (M4)	+1
24	66	F	0.5	2	13	16	-	+	0.36	1.96	1.96 (M4)	NA
7	81	F	0.5	1	15	16	-	0	0.87	1.57	1.57 (M4)	0
3	74	F	0.5	0.5	13	17	0	+	0.41	1.33	1.33 (M4)	0
6	74	M	0.5	0.5	12	14	0	+	0.91	2.69	2.69 (M4)	+1
10	81	M	0.5	0.5	19	22	0	+	0.87	0.87	1.17 (M2)	+2
20	78	M	0.5	0.5	11	8	0	-	0.44	0.62	1.10 (M3)	0
22	63	F	0.5	0.5	13	12	0	0	2.27	3.88	4.04 (M3)	NA
23	64	F	0.5	0.5	10	12	0	+	0.40	1.79	1.79 (M4)	+4
28	67	F	0.5	0.5	12	14	0	+	2.38	3.94	3.94 (M4)	NA
2	37	M	0.5	0	13	14	+	0	0.79	1.54	1.54 (M4)	+1
14	59	M	0.5	0	14	12	+	-	1.24	2.92	2.92 (M4)	+1
15	64	M	0.5	0	21	22	+	0	1.33	1.36	2.73 (M5)	+1
17	77	F	0.5	0	11	14	+	+	0.34	0.51	1.16 (M3)	+4

BL-baseline, M4—Month 4, S/S—Sit/Stand, GRC, Global Rating of Change, NA-Not Available.

Blood Serum Collection

Blood was drawn by trained nurses in an on-site surgical center. Venous blood was collected in a 10 ml redtop vacutainer tube and allowed to clot for 45–120 min. Serum was separated from the whole blood sample via centrifugation and stored at −80°C until processing.

Plasmalogen Extraction and Analysis

Serum samples were extracted using a modified version of the protocol described by Goodenowe et al. (Goodenowe et al., 2007). Briefly, 10 µL of serum was diluted with 50 µL of 0.1% formic acid and subjected to extraction three times with 1.0 ml of acidified ethyl acetate (98:2 ethyl acetate: 0.1% formic acid). Extracts were directly injected into a Thermo Fisher Scientific LTQ Orbitrap mass spectrometer (Thermo Fisher Scientific, MA, United States) in both positive and negative ionization electrospray modes at a flow rate of 200 μL/min. Full scan mass spectral data were collected for masses of 150–1,200 amu at maximum resolution. A common pooled reference serum sample was prepared before the study and aliquots of this pooled serum were extracted with each batch of study samples and run on the mass spectrometer at the beginning, middle, and end of each run batch to monitor and correct for batch-to-batch variance throughout the study. Phospholipid species of interest were identified based upon their (M-H)− or (M) or (M + H)+ accurate masses (mass accuracy <1 ppm). Only accurate mass species represented by single Gaussian peaks subjected to baseline resolution from any surrounding mass peaks were included in the analyses. The intensity of each species was determined by averaging 20 contiguous scans.

Serological Analyses

Catalase activity capacity (ThermoFisher Scientific), superoxide dismutase activity capacity (Cayman Chemical Company), and malondialdehyde levels (Northwest Life Science Specialties) were measured according to the manufacturer’s specifications.

Statistical Analyses

Stata (version 14.2) was used for all statistical analyses.

Results

Pharmacokinetic Evaluation of DHA-AAG on Serum Levels of Omega-3 and Omega-6 Containing Ethanolamine Phospholipids.

To evaluate the dose effects of DHA-AAG administration on serum ethanolamine phospholipid levels, four composite indices representative of the key serum omega-6 [linoleic acid (LA) and arachidonic acid (AA)] and omega-3 (DHA) phosphatidylethanolamine (PE) and ethanolamine plasmalogen (PL) species were created (Table 1). From these four composite indices, three omega-3/6 ratio indices were created: DHA-PE/(LA + AA)-PE, DHA-PL/(LA + AA)-PL and DHA-PL/(LA + AA)-PE. These seven indices were then used to evaluate the absolute and relative effects of an escalating DHA-AAG dose on serum ethanolamine phospholipid levels (Figures 1A,B, Supplementaray Table S1). The serum level of each index for each participant at all time points was normalized to the respective baseline group mean of that index.

TABLE 1

Ethanolamine phospholipid indices.

Index	Species	Molecular formula	[M-H]-
(LA + AA)-PE	PtdEtn 18:0/18:2	C41H78NO8P	742.5392
PE Omega-6 Index	PtdEtn 16:0/20:4	C41H74NO8P	738.5079
	PtdEtn 18:0/20:4	C43H78NO8P	766.5392
DHA-PE	PtdEtn 16:0/22:6	C43H74NO8P	762.5079
PE Omega-3 Index	PtdEtn 18:0/22:6	C45H78NO8P	790.5392
(LA + AA)-PL	PlsEtn 18:0/18:2	C41H78NO7P	726.5443
PL Omega-6 Index	PlsEtn 16:0/20:4	C41H74NO7P	722.5130
	PlsEtn 18:0/20:4	C43H78NO7P	750.5443
DHA-PL	PlsEtn 16:0/22:6	C43H74NO7P	746.5130
PL Omega-3 Index	PlsEtn 18:0/22:6	C45H78NO7P	774.5443

FIGURE 1

(A)-Serum levels of direct (DHA-PL), indirect (DHA-PE (LA + AA)-PL), and non ((LA + AA)-PE) target phospholipid species (B)-serum levels of selected phospholipid ratios (C)-serum levels of DHA-PL in persons with high versus low baseline DHA-PL/(LA + AA)-PE levels. Values are means ± SEM.*, p < 0.05 versus baseline, student’s t-test (two-tailed).

Since DHA-AAG is comprised of a plasmalogen backbone with DHA covalently bound at sn-2 it is a direct precursor to DHA-PL; an indirect precursor to DHA-PE and (LA + AA)-PL; and is biochemically unrelated to (LA + AA)-PE. Figure 1A illustrates that the plasmalogen precursor DHA-AAG dose-dependently elevated both direct and indirect target species [DHA-PL, DHA-PE, and (LA + AA)-PL] and had no effect on the levels of the biochemically unrelated PE species index (LA + AA)-PE. DHA-AAG had a greater elevating effect on its direct target, DHA-PL than its indirect targets. The 1-month washout period resulted in decreased levels of both the direct and indirect target species and no effect on the unrelated PE species.

To more precisely evaluate the effects of DHA-AAG on the levels of the direct, indirect, and unrelated ethanolamine phospholipid species, internal ratios of the omega-3 and omega-6 indices were evaluated in each subject over the course of the study as illustrated in Figure 1B. The relative ratio of the direct target DHA-PL to the unrelated (LA + AA)-PE was observed to exhibit the greatest elevation with dose and time. The relative ratio of the indirect DHA-PE to the unrelated (LA + AA)-PE exhibited the second greatest dose and time elevation and the relative ratio of the direct DHA-PL to the indirect (LA + AA)-PL exhibited the smallest dose and time effect. Figures 1A,B illustrate that DHA-AAG is converted to its direct and indirect target species in humans as predicted from animal studies on similar AAG plasmalogen precursors (Wood et al., 2011d).

Participants were not evaluated for DHA-PL levels prior to enrollment. To evaluate the effect of baseline DHA-PL levels on DHA-AAG pharmacokinetics, the participants were divided into either lower or upper halves based upon their baseline DHA-PL (Figure 1C) or their DHA-PL/(LA + AA)-PE (Figure 1D) levels. As illustrated in Figures 1C,D, DHA-AAG elevated target species levels regardless of baseline DHA plasmalogen levels. However, participants with low baseline DHA-PL or DHA-PL/(LA + AA)-PE ratios experienced a greater relative improvement due to their low baseline levels and this relative improvement persisted even after the 1-month washout. Each participant’s baseline mean-normalized DHA-PL/(LA + AA)-PE ratio at baseline, end of month 4, and the maximum ratio observed is presented in Table 4.

Higher age was associated with lower levels of DHA-PL (LA + AA)-PL, higher levels of (LA + AA)-PE and lower levels of DHA-PL/(LA + AA)-PE and DHA-PE/(LA + AA)-PE (Supplementary Table S1). These data are consistent with previously published results in a large random population cohort (Wood et al., 2011a). Male sex was associated with lower levels of DHA-PE and (LA + AA)-PE (Supplementary Table S1). Lower levels of DHA-PE in males is consistent with previously published results in a large elderly cohort (Goodenowe and Senanayake, 2019).

Pharmacodynamic Evaluation of DHA-AAG on Serum Malondialdehyde, Catalase, and Superoxide Dismutase

The vinyl ether bond of the target ethanolamine plasmalogen species chemically reacts with reactive oxygen species to neutralize and prevent peroxidation of polyunsaturated fatty acids (Sindelar et al., 1999; Stadelmann-Ingrand et al., 2001). To determine if the DHA-PL elevating effect of DHA-AAG had a pharmacodynamic effect, levels of malondialdehyde (MDA), catalase (CAT), and superoxide dismutase (SOD) were measured at baseline, and at end of months 3, 4, and 5. MDA is a final end-product of lipid peroxidation of LA and AA. Penultimate to lipid peroxidation of all polyunsaturated fatty acids such as LA and AA is the insufficient neutralization of hydrogen peroxide. Excess hydrogen peroxide in the presence of superoxide anion can undergo conversion to the hydroxyl radical, which can then react with polyunsaturated fatty acids via a series of free radical reactions to form lipid peroxides. The superoxide anion is neutralized by SOD into molecular oxygen and hydrogen peroxide. Accordingly, SOD is the main producer of hydrogen peroxide. Catalase is a ubiquitous enzyme that neutralizes the hydrogen peroxide produced by SOD into water and molecular oxygen. Both SOD and CAT are potent inhibitors of lipid peroxidation (Gutteridge, 1984). SOD is a self-inducing enzyme in that the product of its activity (hydrogen peroxide) induces SOD synthesis (Yoo et al., 1999). In contrast, catalase is inactivated by hydrogen peroxide (Kokkaliari et al., 1992), and in an animal model of sarcopenia, increased superoxide anion is associated with increased SOD, increased hydrogen peroxide and decreased catalase (Sullivan-Gunn and Lewandowski, 2013).

Linear regression analysis of the seven phospholipid indices, MDA, CAT, and SOD is presented in Table 2. MDA is derived from the lipid peroxidation of LA or AA, so MDA levels are presumed to be influenced by both total LA + AA levels and overall peroxidation load. Interestingly (LA + AA)-PE, but not (LA + AA)-PL was positively associated with MDA levels. This observation indicates that the PL vinyl ether bond is likely protecting the PL bound AA from peroxidation in vivo as predicted by previous in vitro studies (Sindelar et al., 1999) thereby disassociating (LA + AA)-PL from MDA formation. Although both DHA-PL and DHA-PE levels were elevated by DHA-AAG treatment, only DHA-PL was observed to be negatively associated with MDA levels indicating that it is the PL vinyl ether bond, not DHA that is responsible for the negative association with MDA levels. All three omega-3/6 ratio indices were negatively associated with MDA levels. Catalase activity was negatively associated with MDA levels and DHA-PL was both positively associated with catalase activity and negatively associated with MDA.

TABLE 2

Relationship between key serological indices.

Variable	MDA (coef, p)		CAT (coef, p)		SOD (p)	PE (LA + AA) (Coef, p)		PE (DHA) (Coef, p)
(LA + AA)-PE	0.718	1.5e-07	-	NS	NS	-	-	-	-
DHA-PE	-	NS	-	NS	NS	0.503	1.1E-14	-	-
DHA/(LA + AA)-PE	−0.427	5.7e-04	0.596	4.3e-03	NS	-	-	-	-
(LA + AA)-PL	-	NS	-	NS	NS	0.254	2.4E-03	0.260	1.1e-02
DHA-PL	−0.233	3.3e-02	0.549	2.2e-03	NS		NS	0.431	1.7e-07
DHA/(LA + AA)-PL	−0.372	8.9e-04	0.736	6.1e-05	NS	−0.298	7.3E-05	0.291	1.6e-03
PL Omega-3/PE Omega-6	−0.349	6.4e-06	0.397	2.9e-03	NS	-	-	-	NS
MDA	-	-	−0.474	7.9e-03	NS	-	-	-	-
CAT	-	-	-	-	NS	-	-	-	-

All variables were mean normalized and log10 transformed prior to linear regression analysis. Abbreviations: MDA = Malondialdehyde, CAT = Catalase, SOD = Superoxide Dismutase. For description of PE and PL species and índices see Table 1.

Since it is unclear from the binary associations in Table 2 as to the dominance, independence, or relative contributions of the serological biomarkers to MDA and CAT levels, multivariate linear regression analysis was performed using multiple models (Table 3). This analysis showed that (LA + AA)-PE was the dominant predictor MDA levels. CAT had a strong negative association with MDA levels (Model 5), but this association was lost when PL species were included (Model 7). The increase in R-squared value when CAT was added to the PL model (Model 7 vs. 2) was minimal indicating that the effect of CAT on MDA levels was being caused by the effect of the PL species on CAT. This is clearly observed by comparing Model 9 vs. 14 wherein the PL species exhibited the strongest association with CAT (Model 9) which was minimally affected by the addition of MDA (Model 14). Collectively, these data indicate that the elevation of DHA-PL by DHA-AAG was independently associated with an increase in (LA + AA)-PL, CAT, and a decrease in MDA (Model 15).

TABLE 3

Multivariate analyses of selected serological markers associated with catalase and malondialdehyde.

Model	Outcome	Variables	Coef	p	R-squared
1	MDA	DHA-PE (LA + AA)-PE	−0.225	5.4e-02	0.313
			0.846	3.8e-08
2	MDA	DHA-PL (LA + AA)-PL	−0.368	2.1e-03	0.124
			0.380	1.1e-02
3	MDA	DHA-PL (LA + AA)-PE	−0.146	1.3e-01	0.301
			0.685	5.6e-07
4	MDA	DHA-PL CAT	−0.233	3.3e-02	0.053
5	MDA		−0.474	7.9e-03	0.081
6	MDA	DHA-PL CAT	−0.156	1.6e-01	0.102
			−0.141	3.6e-02
7	MDA	DHA-PL (LA + AA)-PL CAT	−0.290	2.5e-02	0.147
			0.316	4.1e-02
			−0.101	1.4e-01
8	CAT	DHA-PE (LA + AA)-PE	0.577	1.0e-02	0.094
			−0.634	2.0e-02
9	CAT	DHA-PL (LA + AA)-PL	0.776	8.3e-05	0.179
			−0.639	8.4e-03
10	CAT	DHA-PL (LA + AA)-PE	0.525	3.9e-03	0.113
			−0.187	4.3e-01
11	CAT	DHA-PL	0.549	2.2e-03	0.106
12	CAT	MDA	−0.474	7.9e-03	0.081
13	CAT	DHA-PL MDA	0.463	9.7e-03	0.153
			−0.368	3.6e-02
14	CAT	DHA-PL (LA + AA)-PL MDA	0.680	8.9e-04	0.200
			−0.540	3.0e-02
			−0.262	1.4e-01
15	DHA-PL	(LA + AA)-PL CAT MDA	0.639	1.5e-07	0.378
			0.186	8.9e-04
			−0.207	2.5e-02
16	DHA-PL	DHA-PE (LA + AA)-PE	0.807	1.2e-15	0.403
			−0.716	7.0e-10

All variables were mean normalized and log10 transformed prior to linear regression analysis. Abbreviations: MDA = Malondialdehyde, CAT = Catalase, SOD = Superoxide Dismutase. For description of PE and PL species and índices see Table 1.

To investigate potential ceiling or floor effects on MDA, CAT, and SOD, participants were grouped based upon their baseline levels and the effect of DHA-AAG treatment evaluated in the lower and upper halves of each (Figure 2). This analysis revealed that DHA-AAG treatment normalized MDA in persons with high baseline MDA levels, SOD activity in persons with high baseline SOD activity, and CAT activity in persons with low baseline CAT activity.

FIGURE 2

(A) serum Malondialdehyde levels (B) Catalase capacity, and (C) superoxide Dismutase capacity. All values where normalized to the total baseline average. values represent the mean ± SEM. *,p < 0.05 versus baseline of that cohort subset, student’s t-test (two-tailed).

Clinical Evaluation of DHA-AAG on Cognition and Mobility

Of the 22 participants who completed the study, cognition improved in 9 (41%), declined in 4 (18%) and remained stable in 9 (41%) during the 4-months treatment period (Table 4). No relationship between baseline DHA-PL levels and response or lack of response was observed (5 in lower half and four in upper half). However, a higher proportion of persons with more severe baseline cognitive impairment improved than persons with mild cognitive impairment (3/4 subjects with baseline CDR of 2; 2/4 subjects with baseline CDR of 1, and 4/14 subjects with baseline CDR = 0.5). Mobility improved in 12 participants (55%), remained stable in 5 (23%) and declined in 4 (18%). Using a random non-response based upon the observed decline rate as the predictor, the observed response rates were significant for both cognition and mobility (Table 5). At the end of the trial each participant was asked to self-evaluate the overall effect of the DHA-AAG treatment using the Global Rating of Change scale (Kamper et al., 2009). Of the eighteen participants who completed the GRC, twelve reported that their health improved over the 4-month trial and six reported no change. No participant reported a negative change. The individual participant responses are included in Table 4.

TABLE 5

Categorical treatment response summary.

Clinical Observation	CDR (observed)	CDR (predicted)	Sit/Stand (observed)	Sit/Stand (predicted)
Improvement	9	4	12	4
No Change	9	14	5	13
Decline	4	4	4	4
Chi Squared p-value	1.8e-02		2.9e-05

Predicted responses were based upon an assumed random non-response rate based upon the observed decline rate for each outcome.

Discussion

This open-label investigational study evaluated the clinical and serological effects of an escalating dose of DHA-AAG (900 mg/day—3,600 mg/day) in cognitively impaired persons. Each dose was administered for at least 1 month and a 1-month washout at the end of the trial was used. Pharmacokinetic, pharmacodynamic, and clinical outcomes were monitored.

The key pharmacological observation was that the plasmalogen precursor DHA-AAG exhibited a dose-dependent and species-selective elevating effect on serum ethanolamine phospholipids. Specifically, DHA-containing PL species were preferentially elevated. Non-DHA containing PL species and DHA-containing PE species were also elevated, but to a lesser extent. Non-DHA PE species were unaffected by the DHA-AAG administration. These observations are consistent with the previously proposed metabolic fate of AAG (Mankidy et al., 2010; Wood et al., 2011a; Wood et al., 2011d) and summarized in Figure 3. In brief, 1-O-alkyl, 2,3-diacylglycerols are metabolized by gut lipases to 1-O-alkyl, 2-acylglycerol which is absorbed into the blood stream and then converted to 1-O-alkyl-2-acylglycerophosphoethanolamine which is then desaturated to the final vinyl ether ethanolamine plasmalogen in endoplasmic reticulum of the cells of the body. Since no peroxisome-specific biochemical steps are required to convert AAG plasmalogen precursors into vinyl ether plasmalogens, AAG plasmalogen precursors bypass the obligate rate-limiting peroxisomal enzymes necessary for endogenous plasmalogen biosynthesis.

FIGURE 3

Relationship between endogenous plasmalogeon biosynthesis pathways, plasmalogeon precursor supplement administration and serum plasmalogeon levels.

Several key pharmacodynamic observations and interpretations were made. First, serum MDA levels exhibited a strong positive correlation with serum levels of AA and LA containing PE species, but serum levels of AA and LA containing PL species were not correlated with MDA levels. It is hypothesized that, consistent with in vitro observations (Sindelar et al., 1999), the sn-1 vinyl ether bond of plasmalogens protects the sn-2 AA and LA from peroxidation and thus blocks the formation of MDA from AA and LA containing PL species. A higher level of serum DHA-PL was associated with a lower MDA level independent of LA and AA PE levels indicating a direct anti-peroxidation effect of serum DHA-PL. Secondly, MDA was negatively and DHA-PL was positively associated with serum CAT capacity. Detailed multivariate statistical analyses revealed that the positive association between serum DHA-PL levels and CAT capacity was independent of the MDA lowering effect of DHA-PL which is suggestive of a more generalized improvement in peroxisomal function following DHA-AAG supplementation—perhaps due to reduced endogenous plasmalogen synthesis demand. Thirdly, the effect of DHA-AAG on SOD activity appeared more complicated and less clear. Since SOD is inducible as well as degradable, we looked at the effect of DHA-AAG administration on persons with high or low SOD. DHA-AAG normalized both groups of participants. Further investigation is needed to confirm this observation, however it is possible that persons with a robust SOD biosynthesis capacity exhibit elevated SOD in the presence of excess hydrogen peroxide, which is alleviated by DHA-AAG whereas persons with a weak SOD biosynthesis capacity exhibit decreased SOD, which is enhanced by DHA-AAG.

Due to the small investigational nature of the study, cognition, as measured by QDRS and sarcopenia, as measured by the sit-stand test were evaluated as preliminary indices of potential clinical benefit from DHA-AAG supplementation. Despite the small number of participants, a clear participant benefit was observed. Participants self-reported increased energy, clarity of thought, and fluidity of movement. Two-thirds of the participants reported an increase in their global rating of change evaluation and one-third reported no change. None reported a decline (Table 4). QDRS is an objective evaluation of a person (the trial participant) by a third-party witness with intimate knowledge of the daily activities of the person. According to such third person observation, 9 (41%) of the participants displayed significant cognitive improvement, nine remained stable and 4 declined. Participants with the most severe cognitive impairment at baseline were observed to preferentially benefit from the DHA-AAG therapy in that three of the four participants with moderate dementia (CDR = 2) exhibited clinically meaningful improvement and two of the four participants with mild dementia (CDR = 1) exhibited clinically meaningful improvement. Improved mobility, as measured by the sit-stand test was more generally observed. Only one participant exhibited a decline in both cognition and mobility, whereas five participants exhibited improvements in both cognition and mobility and ten exhibited improvements in either cognition or mobility.

Summary and Conclusion

The study has several obvious attributes and limitations. It was designed to investigate the pharmacokinetic and pharmacodynamic effects of an escalating oral dose of DHA-AAG. It was not designed to critically evaluate clinical response. The pharmacokinetic (dose dependent increase in serum levels of the target DHA-PL species) and pharmacodynamic (increased CAT activity and decreased MDA levels) are robust and consistent with previous research results in animal models and in vitro studies. The DHA-AAG was well tolerated at the doses and durations administered. The small number of participants (22), short duration (4-months), and the lack of a sufficient placebo control or cross-over design are obvious limitations as to the interpretation of the positive clinical effects on cognition and mobility observed. Clinical response data should be interpreted with caution. However, it is clear that subsequent clinical trials designed to more critically evaluate the clinical utility of DHA-AAG in dementia and sarcopenia are warranted.

Impact Statement

The study presented is the first targeted plasmalogen precursor treatment evaluation in humans. Numerous epidemiological and post-mortem studies have described structure-specific associations between plasmalogen deficiencies and reduced cognition and mobility. Numerous preclinical studies have similarly described structure-specific biological activities of plasmalogens. An escalating dose of a DHA-specific plasmalogen precursor (DHA-AAG) was administered to cognitively impaired persons and the pharmacokinetic, pharmacodynamic, and clinical effects evaluated. A dose-dependent elevation in DHA-plasmalogen levels was observed. Oxidative stress biomarkers (malondialdehyde, catalase, superoxide dismutase) improved and this improvement was correlated with higher DHA-plasmalogen levels. A statistically significant improvement in cognition and mobility was observed. The research results establish that blood levels of structurally specific plasmalogen species can be preferentially targeted and modulated and that this is a therapeutically viable approach worthy of further investigation and optimization for the treatment of plasmalogen deficiency mediated diseases.