Tuesday, January 5, 2010

Plastic Surgery for Men Question of the Day (QotD) : Ok to take L-arginine before surgery?


PLASTIC SURGERY FOR MEN  ----QUESTION OF THE DAY: Ok to take L-arginine before surgery?

To answer your question I did some research about Arginine and found the following information:

Natural Standard Research Collaboration

Synonyms

Arg, arginine, arginine hydrochloride (intravenous formulation), ibuprofen-arginate (SpedifenxAE), L-arg, L-arginine, 2-amino-5-guanidinopentanoic acid.

Note: Arginine vasopressin is different from arginine/L-arginine, with an entirely different mechanism. NG-monomethyl-L-arginine is different from arginine/L-arginine, and functions as an inhibitor of nitric oxide synthesis.

Dietary sources of arginine: Walnuts, filberts, pecans, Brazil nuts, sesame and sunflower seeds, brown rice, raisins, coconut, gelatin, buckwheat, almonds, barley, cashews, cereals, chicken, chocolate, corn, dairy products, meats, oats, peanuts.

Background

L-arginine was first isolated in 1886. In 1932, L-arginine was found to be required for the generation of urea, which is necessary for the removal of toxic ammonia from the body. In 1939, L-arginine was also shown to be required for the synthesis of creatine. Creatine degrades to creatinine at a constant rate, and is cleared from the body by the kidney.

Arginine is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required (for example, due to inborn errors of urea synthesis, protein malnutrition, excess ammonia production, excessive lysine intake, burns, infection, peritoneal dialysis, rapid growth, or sepsis). Symptoms of arginine deficiency include poor wound healing, hair loss, skin rash, constipation, and fatty liver.

Arginine is a precursor of nitric oxide, which causes blood vessel relaxation (vasodilation). Preliminary evidence suggests that arginine may be useful in the treatment of medical conditions that are improved by vasodilation, such as angina, atherosclerosis, coronary artery disease, erectile dysfunction, heart failure, intermittent claudication/peripheral vascular disease, and vascular headache. Arginine also stimulates protein synthesis and has been studied for wound healing, bodybuilding, enhancement of sperm production (spermatogenesis), and prevention of wasting in people with critical illness.

Arginine hydrochloride contains high chloride content and has been used for the treatment of metabolic alkalosis. This use should be under the supervision of a qualified healthcare professional.

Most people likely do not need to take arginine supplements because the body usually makes sufficient amounts.

Evidence

Growth hormone reserve test / pituitary disorder diagnosis

Intravenously administered arginine can be used to evaluate growth hormone reserve in individuals with suspected growth hormone deficiency. For example, in patients with suspected panhypopituitarism, growth/stature abnormalities, gigantism/acromegaly, or pituitary adenoma. This is an FDA labeled indication for arginine.

Grade: A

Inborn errors of urea synthesis

In patients with inborn errors of urea synthesis, high blood ammonia levels and metabolic alkalosis may occur, particularly in patients with ornithine carbamoyl transferase (OCT) deficiency or carbomoyl phosphate synthetase (CPS) deficiency. Arginine can be a helpful treatment by shifting the way the body processes nitrogen, but should be avoided in patients with hyperargininemia (high arginine levels). Other drugs may have similar benefits, such as citrulline, sodium benzoate, or sodium phenylbutyrate, although dialysis may be necessary initially. This use of arginine should be supervised by a qualified healthcare professional.

Grade: A

Adrenoleukodystrophy (ALD)

Adrenoleukodystrophy (ALD) is a rare inherited metabolic disorder characterized by the loss of fatty coverings (myelin sheaths) on nerve fibers in the brain, and progressive destruction of the adrenal gland. ALD is inherited as an x-linked genetic trait that results in dementia and adrenal failure. Injections of arginine have been proposed to help manage this disorder, although most study results are inconclusive. Further research is needed to evaluate the use of arginine in ALD.

Grade: C

Burns

A randomized, controlled clinical trial designed to evaluate immune function of patients given 15 milligrams of arginine orally suggests that arginine may help with the recovery of immune function and protein function in partial-thickness burn patients. Further research is necessary in this area before a conclusion can be drawn.

Grade: C

Coronary artery disease / angina

There is initial evidence from several studies that arginine taken by mouth or by injection improves exercise tolerance and blood flow in arteries of the heart. Benefits have been shown in some patients with coronary artery disease and angina. A small randomized, controlled clinical trial studied the effects of a medical food bar enriched with L-arginine and a combination of other nutrients in the management of chronic stable angina. The authors found that this arginine-rich medical food, when used with traditional therapy, improves vascular function, exercise capacity and aspects of quality of life in these patients. However, further research is needed to confirm these findings and to establish doses that may be safe and effective.

Grade: C

Critical illness

Some studies suggest that arginine may provide benefits when added to nutritional supplements during critical illnesses (for example, in patients being treated in intensive care units). However, it is unclear what the specific role of arginine may be in improving recovery. A randomized, controlled clinical trial was designed to study the effects of a high-protein formula enriched with arginine, fiber, and antioxidants in early nutrition therapy of critically ill patients. The study measured infections in the hospital intensive care unit (ICU), length of hospital stay, and death rates. Patients fed the high-protein diet enriched with arginine, fiber and antioxidants developed fewer hospital infections than patients fed a standard high-protein diet. There was no difference in length of ICU hospital stay or death rate.

Overall the scientific data to date does not show benefit for only L-arginine supplementation, nor does it show harm. At this time there is no rationale for the routine supplementation of arginine alone to enhance recovery from serious illness. Because of the potential for harm, this amino acid should only be administered to critically ill patients in large doses under carefully monitored study conditions.

Grade: C

Dental pain (ibuprofen arginate)

A well-designed multicenter, randomized, controlled clinical trial found that ibuprofen-arginate (SpedifenxAE) reduced pain faster after dental surgery compared to conventional ibuprofen alone. The study included 498 patients who were given ibuprofen-arginate, ibuprofen, or placebo after dental surgery. The degree of pain relief, onset of action, and tolerability of both ibuprofen-arginate and ibuprofen were compared. It was found that ibuprofen arginate relieved pain faster and adverse events with ibuprofen-arginate were similar to those seen with ibuprofen alone. Another similar trial concluded that patients treated with ibuprofen-arginate rated its overall effectiveness higher than those treated with ibuprofen alone. Adverse event profiles were similar across all treatment groups. Further research is merited in this area.

Grade: C

MELAS syndrome

One study found that two years of supplementation with oral L-arginine significantly improved endothelial function in patients with MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke). Further research is merited in this area.

Grade: C

Erectile dysfunction

Early studies propose that men with low nitrate levels in their blood or urine may find arginine supplements to be useful for managing erectile dysfunction (ED). A randomized, controlled clinical trial reported improvements in patients with mild-to-moderate ED following use of a combination of L-arginine, glutamate and yohimbine hydrochloride. Notably, yohimbine hydrochloride is an FDA-approved therapy for this condition, and the effects caused by arginine alone in this combination therapy are difficult to determine. It is not clear what doses of arginine may be safe or effective in treating this condition, and comparisons have not been made with other agents used for ED.

Grade: C

Gastrointestinal cancer surgery

Supplementation with an oral combination of arginine and omega-3 fatty acids may reduce length of hospital stay and infections after surgery in gastrointestinal cancer patients. There is conflicting evidence as to when to give the combination (either before or after surgery). Both strategies have been reported as superior to conventional treatment (no artificial nutrition) at reducing infections after surgery and reducing hospital stay.

In a large, randomized, controlled clinical trial, malnourished cancer patients were given oral enteral nutrition supplemented by arginine, omega-3 fatty acids and RNA before surgery. It was found that supplementation with the combination before surgery reduced complications after surgery and hospital stay. A different randomized, controlled clinical trial in patients with gastrointestinal cancer studied the effects of an enteral diet supplemented with arginine, omega-3 fatty acids and glutamine (administered after surgery) on immune function and inflammatory response. This study reported the supplement to be well-tolerated with positive effects on immune and inflammatory response. Further research is needed to determine the possible effects of arginine alone.

Grade: C

Heart failure (CHF)

Studies of arginine in patients with chronic heart failure have shown mixed results. Some studies report improved exercise tolerance. Additional studies are needed to confirm these findings before a firm conclusion can be drawn.

Grade: C

Heart protection during coronary artery bypass grafting (CABG)

Arginine-supplemented "blood cardioplegic solution" is proposed to have protective properties for the heart. A randomized, controlled clinical trial using this solution in patients undergoing heart surgery (coronary artery bypass grafting) reports improved heart protection. Further research is needed before a firm conclusion can be drawn.

Grade: C

High blood pressure

A small study suggests that arginine taken by mouth may dilate the arteries and temporarily reduce blood pressure in hypertensive patients with type 2 diabetes. Larger, high-quality studies are needed before a recommendation can be made.

Grade: C

Immunomodulator

Preliminary study results suggest that arginine supplementation may enhance the immune response elicited by the pneumococcal vaccine in older people. More studies are needed to confirm these results.

Grade: C

Migraine headache

Preliminary studies suggest that adding arginine to ibuprofen therapy may decrease migraine headache pain.

Grade: C

Myocardial infarction

Study results of arginine supplementation after myocardial infarction (heart attack) are mixed. Further research is needed before a recommendation can be made. A cardiologist and pharmacist should be consulted prior to initiation of arginine therapy.

Grade: C

Peripheral vascular disease / claudication

Intermittent claudication is a condition characterized by leg pain and fatigue due to buildup of cholesterol plaques or clots in leg arteries. A small number of studies report that arginine therapy may improve walking distance in patients with claudication. Further research is needed before a firm conclusion can be drawn.

Grade: C

Pre-eclampsia (high blood pressure in pregnancy)

Early study suggests that prolonged dietary supplementation with L-arginine may decrease blood pressure that is too high in pregnant women. Further research is needed to confirm these results.

Grade: C

Pressure ulcers

Studies of arginine for pressure ulcers show mixed results. Further research is needed before a conclusion can be drawn.

Grade: C

Recovery after surgery

One study suggests that arginine may provide benefits when used as a supplement after surgery. It is not clear what the specific role of arginine may be in improving immune function, or what dose is safe or effective.

Grade: C

Transplants

Dietary supplementation with L-arginine and canola oil has been associated with decreased rejection rates after the first month in renal transplant patients. Due to reductions in cardiac events, long-term benefits for patient survival may be particularly important. Further research is needed to confirm these results.

Grade: C

Wound healing

Arginine has been suggested to improve the rate of wound healing in elderly individuals. A randomized, controlled clinical trial reported improved wound healing after surgery in head and neck cancer patients, following the use of an enteral diet supplemented with arginine and fiber. Arginine has also been used topically (on the skin) to attempt to improve wound healing. Further research is necessary in this area before a firm conclusion can be drawn.

Grade: C

Acute mountain sickness (AMS)

Based on preliminary study, L-arginine supplementation is not beneficial in the prophylactic treatment of AMS.

Grade: D

Cyclosporine toxicity

Animal studies report that arginine blocks the toxic effects of cyclosporine, a drug used to prevent organ transplant rejection. However, results from studies in humans have not found that arginine offers any protection from cyclosporine-induced toxicity.

Grade: D

Exercise performance

Overall, currently available study results conclude that arginine supplementation does not improve exercise performance.

Grade: D

Infertility

Although there are several studies in this area, it is not clear what effects arginine has on improving the likelihood of getting pregnant. Early evidence does not support the finding that arginine has any benefits in women who are undergoingin vitrofertilization, or in men with abnormal sperm.

Grade: D

Interstitial cystitis

Arginine has been proposed as a treatment for interstitial cystitis (inflammation of the bladder). However, most well-designed studies in humans have not found that arginine offers any improvements in treating symptoms such as urinary frequency or urgency.

Grade: D

Kidney disease

It has been suggested that arginine may be a useful supplement in people diagnosed with kidney failure. However, results from available studies do not support this claim. A small randomized, controlled clinical trial studied the ability of L-arginine to improve dilation of blood vessels in children with chronic renal failure. Results showed that blood vessel dilation (endothelial function) was not improved with oral L-arginine suggesting that dietary supplementation is not a beneficial or useful clinical approach in children with chronic renal failure.

Grade: D

Kidney protection during angiography

The contrast media or dye used during angiography to map a patient's arteries (or during some CT scans) can be toxic to the kidneys, especially to people with pre-existing kidney disease. A randomized, parallel, double-blind clinical trial studied the use of L-arginine to protect kidneys in patients with chronic renal failure undergoing angiography. The authors found no evidence that injections of L-arginine protect the kidney from damage due to contrast.

Other therapies, such as N-acetylcysteine (NAC), have been found beneficial at protecting the kidneys from contrast-induced damage, particularly in patients at high-risk such as those with diabetes.

Grade: D

Asthma

Although it has been suggested that arginine may be a treatment for asthma, studies in humans have actually found that arginineworsensinflammation in the lungs andcontributesto asthma symptoms. Therefore, taking arginine by mouth or by inhalation is not recommended in people with asthma.

Grade: F
No Evidence

AIDS/HIV, ammonia toxicity, anti-aging, beta-hemoglobinopathies, cancer, cardiac syndrome X, cold prevention, cystic fibrosis, dementia, diabetes, glaucoma, growth hormone stimulation, hemolytic uremic syndrome (HUS), hepatic encephalopathy, high cholesterol, increased muscle mass, infantile necrotizing enterocolitis, infection, inflammatory bowel disease, ischemic stroke, liver disease, lower esophageal sphincter relaxation, low sperm count, metabolic acidosis, obesity, osteoporosis, pain, peritonitis, pre-term labor contractions, pulmonary hypertension (high blood pressure in the lungs), Raynaud's phenomenon, sepsis, sexual function in women, sickle cell anemia, stomach motility disorders, stomach ulcer, stroke, supplementation to a low protein diet, thrombotic thrombocytopenic purpura (TTP), tumors.

Dosing

Standardization

Intravenous arginine hydrochloride is available as a 10% solution (950 mOsm/L), with 47.5mEq chloride ion per 100mL. There is no established standardization for oral arginine products.

Note: Most people likely do not need to take arginine supplements because the body usually makes sufficient amounts.
Adults (18 years and older)

Tablets/capsules: There are no standard or well-established doses of arginine, and many different doses have been used and studied. A dose that has been studied for treating coronary artery disease is two to three grams taken by mouth three times daily for three to six months. For short-term treatment, up to 10 grams for four weeks has also been used. A studied dose for heart failure is 5.6 to 12.6 grams taken by mouth every day, divided into two or three equal doses, taken for six weeks. For myocardial infarction, 3 grams of L-arginine three times per day for 30 days has been used. For erectile dysfunction, 1.6 grams taken by mouth three times daily for six weeks has been studied. For low sperm count, 4 grams daily for three months has been used. For women undergoing in vitro (test tube) fertilization, a dose of 16 grams daily by mouth has been studied, although this therapy should be discussed with the healthcare provider coordinating the in vitro program. For interstitial cystitis, 500 milligrams taken by mouth three times daily for six weeks has been used. For the long-term management of inborn disorders of the urea cycle, doses between 0.5 to 2 grams daily have been used. 8.5 grams of arginine daily has been studied in patients with pressure ulcers for four weeks. For immune enhancement following vaccination in the elderly, 15 grams daily arginine for four weeks has been used.

Intravenous: Doses of arginine used intravenously depend on specific institutional dosing guidelines and should be given under the supervision of a healthcare provider.
Children (younger than 18 years)

Arginine supplements are not recommended in children because there is not enough scientific information available and because of potential side effects.
Safety

Allergies

Anaphylaxis (severe allergic reaction) has occurred after arginine injections. People with a known allergy should avoid arginine. Signs of allergy may include rash, itching or shortness of breath.
Side Effects and Warnings

Arginine has been well tolerated by most people in studies lasting for up to six months, although there is a possibility of serious adverse effects in some individuals.

Stomach discomfort, including nausea, stomach cramps or an increased number of stools, may occur. People with asthma may experience a worsening of symptoms if arginine is inhaled, which may be related to allergy. Headache has also been reported.

Other potential side effects include low blood pressure and changes in numerous chemicals and electrolytes in the blood. Examples include high potassium, high chloride, low sodium, low phosphate, high blood urea nitrogen and high creatinine levels. People with liver or kidney disease may be especially sensitive to these complications and should avoid using arginine except under medical supervision. After injections of arginine, low back pain, flushing, headache, numbness, restless legs, venous irritation and death of surrounding tissues have been reported.

In theory, arginine may increase the risk of bleeding. Patients using anticoagulants (blood thinners) or antiplatelet drugs, or with underlying bleeding disorders, should speak with a qualified healthcare provider before using arginine and should be monitored.

Arginine may increase blood sugar levels. Caution is advised in patients taking prescription drugs to control sugar levels.
Pregnancy and Breastfeeding

Arginine cannot be recommended as a supplement during pregnancy and breast-feeding because there is not enough scientific information available.

L-arginine has been used in women with preeclampsia until day 10 postpartum but should not be used without supervision of an OB/GYN and pharmacist.
Interactions

Interactions with Drugs

Because arginine can increase the activity of some hormones in the body, many possible drug interactions may occur. The prescription drugs aminophylline and the sweetening agent xylitol can decrease the effect that arginine has on glucagon.

Estrogens (found in birth control pills and hormone replacement therapies) may increase the effects of arginine on growth hormone, glucagon and insulin. In contrast, progestins (also found in birth control pills and some hormone replacement therapies) may decrease the responsiveness of growth hormone to arginine.

When used with arginine, some diuretics such as spironolactone (AldactonexAE) or ACE-inhibitor blood pressure drugs such as enalapril (VasotecxAE) may cause potassium levels in the blood to get too high. Monitoring of blood potassium levels may be required.

Arginine should be used carefully with drugs such as nitroglycerin or sildenafil (ViagraxAE) because blood pressure may fall too low. Other adverse effects such as headache and flushing may occur when arginine is used with these drugs.

Because arginine may cause the stomach to make more acid, it may reduce the effectiveness of drugs that block stomach acid such as ranitidine (ZantacxAE) or esomeprazole (NexiumxAE).

In theory, arginine may increase the risk of bleeding when used with anticoagulants (blood thinners) or antiplatelet drugs. Examples include warfarin (CoumadinxAE), heparin and clopidogrel (PlavixxAE). Some pain relievers may also increase the risk of bleeding if used with arginine. Examples include aspirin, ibuprofen (MotrinxAE, AdvilxAE) and naproxen (NaprosynxAE, AlevexAE, AnaproxxAE).

It is also possible that arginine may raise blood sugar levels. Patients taking oral drugs for diabetes or using insulin should be monitored closely by their health care provider while using arginine. Dosing adjustments may be necessary.

Studies suggest that a combination of ibuprofen and arginine (ibuprofen-arginate/SpedifenxAE) has a faster onset of pain relief than ibuprofen alone. Use of other ibuprofen-based pain relievers such as MotrinxAE or AdvilxAE with ibuprofen-arginate may increase the risk of toxic effects. Patients should consult their healthcare provider before combining these medications.
Interactions with Herbs and Dietary Supplements

Arginine may block the benefits of lysine in treating cold sores. It may increase the activity of growth hormone if used with ornithine.

In theory, arginine may increase the risk of bleeding when taken with herbs and supplements that are believed to increase the risk of bleeding. Multiple cases of bleeding have been reported with the use of Ginkgo biloba, and fewer cases with garlic and saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases. Some examples include: alfalfa, American ginseng, angelica, anise, Arnica montana, asafetida, aspen bark, bilberry, birch, black cohosh, bladderwrack, bogbean, boldo, borage seed oil, bromelain, capsicum, cat's claw, celery, chamomile, chaparral, clove, coleus, cordyceps, danshen, devil's claw, dong quai, EPA (eicosapentaenoic acid, found in fish oils), evening primrose oil, fenugreek, feverfew, fish oil, flaxseed/flax powder (not a concern with flaxseed oil), ginger, grapefruit juice, grapeseed, green tea, guggul, gymnestra, horse chestnut, horseradish, licorice root, lovage root, male fern, meadowsweet, nordihydroguairetic acid (NDGA), omega-3 fatty acids, onion, papain, Panax ginseng, parsley, passionflower, poplar, prickly ash, propolis, quassia, red clover, reishi, Siberian ginseng, sweet clover, rue, sweet birch, sweet clover, turmeric, vitamin E, white willow, wild carrot, wild lettuce, willow, wintergreen, and yucca.

Arginine may raise blood sugar levels. People using other herbs or supplements that may raise blood sugar levels such as cocoa, DHEA, ephedra (when combined with caffeine) or melatonin should be monitored closely by their healthcare provider while using arginine. Dosing adjustments may be necessary.
resource: revolutionhealth.com
webmd.com states:

Possibly Effective for:

  • Improving recovery after surgery. Taking L-arginine with ribonucleic acid (RNA) and eicosapentaenoic acid (EPA) before surgery or afterwards seems to help reduce the recovery time, reduce the number of infections, and improve wound healing after surgery.
  • Congestive heart failure. Taking L-arginine along with usual treatment seems to help eliminate extra fluids that are a problem in congestive heart failure. But taking L-arginine doesn’t always improve exercise tolerance or quality of life. L-arginine should not be used instead of the usual treatments ordered by a healthcare provider.
  • Chest pain associated with coronary artery disease (angina pectoris). Taking L-arginine seems to decrease symptoms and improve exercise tolerance and quality of life in people with angina. But L-arginine doesn’t seem to improve the disease itself.
  • Bladder inflammation. Taking L-arginine seems to improve symptoms, but it may take up to three months of treatment to see improvement.
  • Wasting and weight loss in people with HIV/AIDS, when used with hydroxymethylbutyrate (HMB) and glutamine. This combination seems to increase body weight, particularly lean body mass, and improve the immune system.
  • Preventing loss of effect of nitroglycerin in people with angina pectoris.
  • Problems with erections of the penis (erectile dysfunction).
  • Improving kidney function in kidney transplant patients taking cyclosporine.
  • Preventing inflammation of the digestive tract in premature infants.
  • Cramping pain and weakness in the legs associated with blocked arteries (intermittent claudication).

RISKS OF ARGININE SUPPLEMENTS:


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