Biochimica et Biophysica Acta 1790 (2009) 1149–1160

Contents lists available at ScienceDirect

Biochimica et Biophysica Acta

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / b b a g e n

Review

Alpha-lipoic acid as a dietary supplement: Molecular mechanisms and

therapeutic potential
Kate Petersen Shay a, Régis F. Moreau a, Eric J. Smith a,b, Anthony R. Smith a, Tory M. Hagen a,b,⁎
a
Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
b
Department of Biochemistry and Biophysics, Oregon State University, Corvallis, OR, USA

a r t i c l e i n f o a b s t r a c t

Article history: Alpha-lipoic acid (LA) has become a common ingredient in multivitamin formulas, anti-aging supplements,
Received 12 June 2009 and even pet food. It is well-defined as a therapy for preventing diabetic polyneuropathies, and scavenges
Received in revised form 23 July 2009 free radicals, chelates metals, and restores intracellular glutathione levels which otherwise decline with age.
Accepted 29 July 2009
How do the biochemical properties of LA relate to its biological effects? Herein, we review the molecular
Available online 4 August 2009
mechanisms of LA discovered using cell and animal models, and the effects of LA on human subjects. Though
Keywords:
LA has long been touted as an antioxidant, it has also been shown to improve glucose and ascorbate
Alpha-lipoic acid handling, increase eNOS activity, activate Phase II detoxification via the transcription factor Nrf2, and lower
Antioxidant expression of MMP-9 and VCAM-1 through repression of NF-kappa B. LA and its reduced form, dihydrolipoic
Aging acid, may use their chemical properties as a redox couple to alter protein conformations by forming mixed
Glutathione disulfides. Beneficial effects are achieved with low micromolar levels of LA, suggesting that some of its
Diabetes therapeutic potential extends beyond the strict definition of an antioxidant. Current trials are investigating
Dietary supplement whether these beneficial properties of LA make it an appropriate treatment not just for diabetes, but also for
the prevention of vascular disease, hypertension, and inflammation.
© 2009 Elsevier B.V. All rights reserved.

1. Introduction already exist that outline the metabolic role of LA as a covalently

bound enzyme cofactor, only a brief summary of this particular aspect
Alpha-lipoic acid (LA), or 1,2-dithiolane-3-pentanoic acid, is a of LA function will be presented herein. Instead, a focus mainly on the
naturally occurring dithiol compound synthesized enzymatically in cellular actions of orally supplied, nonprotein-bound LA will be
the mitochondrion from octanoic acid. LA is a necessary cofactor for presented. Pertinent clinical benefits of LA will also be discussed in
mitochondrial α-ketoacid dehydrogenases, and thus serves a critical light of these molecular mechanisms.
role in mitochondrial energy metabolism. In addition to synthesis, LA
is also absorbed intact from dietary sources, and it transiently 2. De novo synthesis of LA and its use as a cofactor
accumulates in many tissues. There is growing evidence that orally
supplied LA may not be used as a metabolic cofactor but instead, elicits α-Lipoic acid, also known as 1,2-dithiolane-3-pentanoic acid or
a unique set of biochemical activities with potential pharmacother- thioctic acid, has one chiral center and therefore exists in both R- and
apeutic value against a host of pathophysiologic insults. LA has been S-enantiomeric forms (Fig. 1). However, only R-LA is conjugated to
described as a potent biological antioxidant, a detoxification agent, conserved lysine residues in an amide linkage, thus making this
and a diabetes medicine; it has been used to improve age-associated isoform essential as a cofactor in biological systems [9]. Enzymes
cardiovascular, cognitive, and neuromuscular deficits, and has been containing lipoamide are typically mitochondrial multi-enzyme
implicated as a modulator of various inflammatory signaling path- complexes that catalyze the oxidative decarboxylation of α-keto
ways [1–8]. This impressive array of cellular and molecular functions acids (e.g. pyruvate dehydrogenase, 2-oxo-glutarate dehydrogenase,
has piqued considerable interest among the lay public and the and transketolase) and glycine cleavage [10].
research community for the use of LA both as a nutritive supplement Though de novo synthesis appears to supply all the necessary LA
and as a pharmacotherapy. In light of this growing interest, we will needed for its role in intermediary metabolism, LA can also be
attempt to provide an update on the biochemical, toxicological, and absorbed from the diet. While the direct roles of LA as a cofactor are
pharmacological mechanisms of LA. As many excellent reviews well understood, less is known about the precise metabolic functions
of orally supplied LA. The following sections will summarize the
⁎ Corresponding author. Linus Pauling Institute, Oregon State University, Corvallis,
accumulating evidence suggesting that LA from the diet is both
OR 97331-6512, USA. Tel.: +1 541 737 5083; fax: +1 541 737 5077. bioavailable, safe in moderate doses, and elicits a surprising array of
E-mail address: [email protected] (T.M. Hagen). metabolic and clinical effects.

0304-4165/$ – see front matter © 2009 Elsevier B.V. All rights reserved.
doi:10.1016/j.bbagen.2009.07.026
1150 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160

the R enantiomer would be the most appropriate form to provide as

oral supplements; however, S-LA in the racemic mixture may prevent
the polymerization of R-LA and thereby enhance overall bioavailabil-
ity. It has yet to be established whether R-LA, its salt form, or a racemic
mixture would be best to use in future clinical studies.

3.2. Tissue distribution and metabolic fate

Rapid gastrointestinal uptake of LA and appearance in the plasma

is followed by an equally rapid clearance, reflecting both transport
into tissues as well as glomerular filtration and renal excretion [25]. LA
primarily but transiently accumulates in the liver, heart, and skeletal
Fig. 1. The R and S enantiomers of lipoic acid. muscle, but is found in other tissues as well. LA has been shown to
cross the blood–brain barrier in a limited number of studies; i.v. doses
of 25 mg/kg b.w. given to rats resulted in its accumulation in cerebral
3. Uptake, bioavailability, and safety of orally supplied LA cortex within 60 min of administration [26], and i.p. doses of 100 mg/
kg b.w. for 7–14 days in both young and old rats showed LA
3.1. Dietary uptake accumulation in various brain regions [27]. A more recent study,
however, did not find significant levels of LA in the brain after oral
The potential biochemical and therapeutic actions of oral LA intake gavage of 50 mg/kg b.w. in rats [28], particularly after correcting for
can only be appreciated with an understanding of its bioavailability, residual blood volume. In light of the clinical benefits LA has on the
tissue accumulation and metabolic fate. It is now clear that cells brain, further research should attempt to measure not only LA, but its
maintain active systems to transport, utilize, and excrete nonprotein- metabolites and its reduced form, dihydrolipoic acid (DHLA), any of
bound LA. Typical dietary sources of LA are muscle meats, heart, which may exert therapeutic effects. Methods of administration
kidney, and liver, and to a lesser degree, fruits and vegetables [11–13]. should also be compared to determine whether this causes a
Though available from these normal nutritional sources, it is not likely difference in tissue distribution.
that appreciable amounts of LA are consumed in the typical Western Following its uptake into tissues, LA is subject to extensive
diet; rather, dietary supplements that typically range from 50 to catabolism. Schupke et al. used liquid chromatography/tandem
600 mg are the primary sources of LA, and most information as to its mass spectrometry to confirm that β-oxidation is the major metabolic
bioavailability comes from studies using supplements. fate of LA in vivo [29]. For rodents and dogs, no less than twelve major
Takaishi et al. explored the mechanisms involved in LA uptake LA metabolites were observed that comprised sequential degradation
from dietary sources using a CACO-2 cell transwell model for of the carbon backbone and/or mono- and bis-methylation of the
transepithelial transport. Results showed that LA rapidly traversed sulfhydryl groups. Regardless of the animal species studied, the most
the cell monolayer in a pH-dependent manner [14]. LA transport was common metabolites of LA appear to be bisnorlipoate, tetranorlipoate,
also inhibitable by benzoic acid and medium-chain fatty acids, β-hydroxy-bisnorlipoate, or the bis-methylated mercapto derivatives
suggesting that the monocarboxylate transporter was the likely of these compounds [25] (Fig. 2). In addition to its catabolism, in vitro
carrier responsible for intestinal absorption of LA. In addition to this studies indicate that LA is rapidly reduced to DHLA (Fig. 2), which is
transporter, other in vitro studies identified LA as a substrate for the equally rapidly excreted from cells [30]. In all animal models studied,
Na+-dependent multivitamin transporter, which may not only LA and its metabolites are readily excreted, primarily in the urine [33].
contribute to its gastrointestinal uptake, but also may be involved in Thus LA, either from dietary sources or as a nutritional supplement, is
LA transport into tissues from the blood plasma [15,16]. Thus, LA readily absorbed, metabolized and excreted, resulting in negligible
bioavailability may be dependent on multiple carrier proteins. free LA being retained in tissues in the post-fed state.
Identification of such a multifaceted uptake and tissue distribution
system suggests that various factors (e.g. substrate competition, 3.3. Safety and toxicity
transcriptional, translational and post-translational regulatory
mechanisms) could influence overall LA absorption characteristics. The use of LA as a nutriceutical supplement has increased
In concert with its multimodal means of transport, gastrointestinal significantly, and therefore questions as to its safety and effectiveness
absorption of LA appears to be quite variable. For example, Teichert have also arisen. While no upper limit for LA consumption in humans
et al. measured plasma LA in volunteers given 200 mg R,S-LA (the has been established, safe levels for acute oral LA intake have been
racemic mixture obtained by the manufacturing process) and defined in animals, with marked differences depending on the species
observed that approximately 20–40% was absorbed [17]. The (Table 2). For dogs, a LD50 of 400–500 mg LA/kg b.w. has been
efficiency of LA uptake was also lowered by its administration in reported [32]; however, rats appear to be more tolerant of LA, as the
food, suggesting uptake competition with other nutrients for the acute LD50 for this species is N2000 mg/kg b.w. At 2000 mg/kg b.w.,
carrier protein(s) involved. Carlson et al. followed the appearance of some rats “were reported to show signs of reduced well-being,
R-LA in plasma following administration of its sodium salt to human including sedation, apathy, piloerection, hunched posture, and/or eye
subjects, and observed that both peak plasma appearance (Cmax) and closure. There was no effect of treatment observable on body weight
total LA absorbed (area under the curve) were higher than that of the gain or on gross pathological examination [35].” In the case of
free acid [18]. Thus, overall LA bioavailability may fluctuate depending chronically administered LA to male and female rats for four weeks by
on whether it is ingested as a free acid or a salt, and with a meal or not. gavage, a “NOAEL” (no observed adverse effect level) was calculated
Table 1 lists selected studies of the pharmacokinetics of LA in humans. to be 61.9 mg LA/kg b.w. per day based on “slight alterations in liver
Additionally, as most commercially available LA supplements are a enzymes as well as histopathological effects on the liver and
mixture of both R and S enantiomers, questions as to preferential mammary gland” [35]. Additional work on long-term (24 month)
uptake of one isomer versus the other have arisen. In one study, oral LA supplementation to both male and female rats showed no
volunteers were given 600 mg of R,S-LA, and plasma concentrations of adverse effects with regard to weight, histopathology and blood
R-LA were 40–50% higher than S-LA [19], the latter of which was chemistry up to 60 mg/kg per day LA. However, at a higher chronic
apparently more rapidly cleared than R-LA. These results suggest that dose (180 mg/kg), body weight gain and food consumption were
 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160 1151

Table 1
Select lipoic acid (LA) studies in healthy volunteers.
a,b
Reference LA dose administered to human subjects AUC of LA in plasma Cmax of LA in plasmaa Subjects

Teichert et al. [17] a) 200 mg racemic LA, oral tablet a) 46.82 ± 21.46 µg min/ml a) 0.66 ± 0.33 µg/ml 12 (crossover)
b) 600 mg racemic LA, oral tablets b) 157.83 ± 35.82 µg min/ml b) 2.85 ± 1.49 µg/ml
c) 200 mg racemic LA, intravenous c) 157.97 ± 35.05 µg min/ml c) 8.32 ± 2.35 µg/ml
Carlson et al. [18] 600 mg Na-R-LA, oral solution 441.6 ± 160.2 µg min/ml 16.0 ± 6.32 µg/ml 12
Breithaupt-Grogler et al. [19] 600 mg racemic LA, oral tablet R-LA: 2348.04 h ng/ml R-LA: 1812.32 ng/ml 15
S-LA: 1243.24 h ng/ml S-LA: 978.20 ng/ml
Mignini et al. [20] a) 600 mg Thioctacid, oral tablet a) 3510.9 ± 1088.6 ng h/ml a) 1338.6 ± 751.8 ng/ml 16 (crossover)
b) 600 mg Tioctil N, oral tablet b) 3563.5 ± 1374.1 ng h/ml b) 1215.8 ± 560.5 ng/ml
Bernkop-Schnurch et al. [21] 766.8 mg LA bound to chitosan, once by oral 0–12 h: 183.8 ± 101.4 µg min/ml 0–12 h: n/a 8
sustained release tablets 0–6 h: 108.1 ± 61.5 µg min/ml 0–6 h: 1354.5 ± 807.1 ng/ml
6–12 h: 75.7 ± 94.8 µg min/ml 6–12 h: 497.5 ± 1074 ng/ml
Amenta et al. [22] a) 600 mg Thioctacid, oral tablet a) 3270.9 ± 372.8 ng h/g a) 1266.2 ± 237.7 ng/g 8 (crossover)
b) 600 mg Tiocronal, oral tablet b) 2925.2 ± 448.4 ng h/g b) 2290.5 ± 286.6 ng/g
c) 600 mg Biodynoral, oral tablet c) 3142.3 ± 331.5 ng h/g c) 2262.8 ± 392.8 ng/g
d) 600 mg Tiobec retard, oral tablet d) 3187.4 ± 152.8 ng h/g d) 1397.7 ± 070.4 ng/g
Teichert et al. [23]c 600 mg racemic LA, oral dose, q.d. for 4 days Day 1: 891.0 nmol min/ml Day 1: 19.8 nmol/ml 8
Day 4: 995.5 nmol min/ml Day 4: 21.1 nmol/ml
Teichert et al. [24] 600 mg racemic LA, oral dose, q.d. for 4 days Day 1: 923.5 ± 216.91 nmol min/ml Day 1: 36.19 ± 10.35 nmol/ml 9
Day 4: 998.91 ± 145.8 nmol min/ml Day 4: 31.45 ± 8.2 nmol/ml
a
Values are reported in the original units.
b
Areas under the curve (AUCs) are from the last time measured, except the study [21] using sustained release LA tablets.
c
This study also included patients with kidney disease, not reported here.

decreased [35,36], though no gross pathology was evident. On that Cakatay et al. conducted a series of experiments in aged rats with
basis, a NOAEL of 60 mg/kg/day for long-term LA supplementation in intraperitoneal administration of racemic LA (100 mg/kg b.w./day for
rats was established. 2 weeks) and showed that this high chronic dose (the equivalent of 5
For humans, a number of clinical trials using LA have been to 10 g per day in humans) increased plasma lipid hydroperoxide
undertaken which also assessed adverse health effects in the levels and oxidative protein damage [48]. LA-mediated protein
participants (Table 3). The ALADIN (I, II, and III), SYDNEY (I and II), damage was noted in the rat heart [49] and brain [50] but lipid
and ORPIL clinical trials used LA supplements up to 2400 mg/day with hydroperoxide levels were beneficially decreased in both these
no reported adverse effects versus placebo. LA has also been organs. Apparently in keeping with its metal chelating abilities (see
administered intravenously in doses of 600 mg/day for three weeks below), this group noted that LA lowered selenium levels in the
with no evidence of serious side-effects [37]. Oral doses of 1800 mg LA serum, heart, brain, and muscle; manganese was lowered only in the
(600 mg t.i.d.) for 6 months did not elicit significant adverse effects heart, but increased in the brain and muscle [51]. Thus, while intake of
compared to placebo [39]. LA has been used in Germany for over moderate doses of LA has relatively few adverse side-effects, LA may
50 years as a therapy for diabetic neuropathy and retinopathy. mediate oxidative insult at higher doses or when administered
However, despite the evidence attesting to its safety in moderate intraperitoneally. More research is therefore warranted regarding
doses, precautions for the oral intake of LA have also been voiced. both the safety and optimal dose of LA.

Fig. 2. Lipoic acid and its reduced form, dihydrolipoic acid, with the 5 most common metabolites.
1152 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160

Table 2 The oxidized and reduced forms bind a number of metal ions, but
Toxicity of lipoic acid (LA) in animals. with different properties depending on the metal chelated. In vitro
Model LD50 (acute oral) Ref. studies show that LA preferentially binds to Cu2+, Zn2+ and Pb2+, but
cannot chelate Fe3+, while DHLA forms complexes with Cu2+, Zn2+,
Dog 400–500 mg/kg [32]
Mouse 500 mg/kg [33] Pb2+, Hg2+ and Fe3+ [63]. We provided in vitro evidence that DHLA,
Cat 30 mg/kg [34] but not LA, strongly inhibited Cu(II)(histidine)2-mediated ascorbate
Rat N2000 mg/kg [35] oxidation in a concentration-dependent manner [64]. These results
were in agreement with a report showing that only DHLA prevented
Cu(II)-mediated oxidation of LDL in vitro [6]. DHLA-mediated
4. Mechanisms of action chelation of iron and copper in the brain had a positive effect in the
pathobiology of Alzheimer's disease by lowering free radical damage
Despite the relatively transient and low cellular accumulation of [65]. Thus, a growing body of evidence suggests that DHLA chelates
LA following its oral intake, numerous studies have now shown that transition metals in a redox-inactive manner, and in turn mitigates
LA elicits an array of cellular actions, ranging from a potent metal-catalyzed free radical reactions in conditions where they
antioxidant to a metal chelator to a mediator of cell signaling accumulate.
pathways. We will now discuss evidence for the biochemical Whether LA/DHLA effectively chelates and removes transition
interactions of LA with respect to particular cellular targets, which metals in vivo is still to be fully elucidated. In this regard, Goralska
lead to this diverse mode of action. et al. showed that treating lens epithelial cells with LA significantly
lowered the rate of iron uptake and the size of the intracellular labile
4.1. LA/DHLA as an antioxidant iron pool [66]. Feeding R-LA to old rats for 2 weeks reversed the age-
related increase in cerebral cortex iron [64]. Importantly, feeding LA
The chemical reactivity of LA is mainly conferred by its dithiolane did not affect either normal metal levels in young rats or lower iron
ring. The oxidized (LA) and reduced (DHLA) forms create a potent status in old rats below that seen in young animals. Nor was LA or
redox couple that has a standard reduction potential of −0.32 V. This DHLA capable of removing iron from aconitase or copper from
makes DHLA one of the most potent naturally occurring antioxidants superoxide dismutase. These results imply, but do not yet prove, that
[52]. In fact, there is evidence that both LA and DHLA are capable of LA supplementation may modulate the labile pool of redox-active
scavenging a variety of reactive oxygen species (Table 4). Both LA and transition metals, without causing metal depletion.
DHLA may scavenge hydroxyl radicals and hypochlorous acid, while
LA also terminates singlet oxygen [2,3,55,57,58,60]. Neither species is 4.3. Is LA a direct-acting antioxidant?
active against hydrogen peroxide [2,60]. LA, and especially DHLA,
have the ability to prevent protein carbonyl formation by scavenging Although strong in vitro evidence supports the role of the LA/DHLA
hypochlorite [61]. Furthermore, DHLA appears to regenerate other couple as a potent antioxidant, it remains questionable whether they
endogenous antioxidants (e.g. vitamins C and E) [33,62] and has can scavenge free radicals effectively in vivo. Because LA only transiently
the salubrious property of neutralizing free radicals without itself accumulates in vivo and is rapidly catabolized, it is difficult to envision
becoming one in the process. how LA could augment endogenous antioxidant capacity on a sustained
basis. The antioxidant properties of LA in vitro may be explained as
4.2. LA as a metal chelator follows: i) cell culture studies are often conducted with LA concentra-
tions that are several fold higher than what has been seen in plasma or
In addition to being direct reactive oxygen species scavengers, tissues after an oral dose (Table 1), and ii) LA and DHLA are not cleared
both LA and DHLA chelate redox-active metals in vitro and in vivo. from the culture media in a rate that replicates disposal in the body,

Table 3
Select clinical trials using lipoic acid (LA).

Clinical trial Ref. LA dose administered to human subjects Subjects Parameters measureda
receiving LA

Diabetes: ALADIN [37] 100, 600, or 1200 mg, intravenous for 3 weeks 328 Neuropathic symptoms, HPAL, NDS
Diabetes: ALADIN II [38] a) 600 mg, intravenous, for 5 days + 600 mg, orally for 2 years a) 27 NDS, electrophysiological attributes of the sural and
b) 1200 mg, intravenous for 5 days + 1200 mg, orally for 2 years b) 18 tibial nerves
Diabetes: ALADIN III [39] a) 600 mg, intravenous, for 3 weeks + 1800 mg (600 mg t.i.d.) for 6 months a) 165 TSS, NIS
b) 600 mg, intravenous, for 3 weeks + placebo for 6 months b) 173
Diabetes [40] a) 600 mg, oral, for 4 weeks a) 19 Insulin-stimulated glucose disposal
b) 1200 mg (600 mg b.i.d.), orally for 4 weeks b) 18
c) 1800 mg (600 mg t.i.d.), orally for 4 weeks c) 18
Diabetes: ORPIL [41] 1800 mg (600 mg t.i.d.), orally for 3 weeks 12 TSS, HPAL, NDS
Diabetes: SYDNEY [42] 600 mg, intravenous, 5 days a week for 14 treatments 60 NCS, TSS, NIS, quantitative sensation test,
autonomic test
Diabetes: SYDNEY II [43] a) 600 mg, orally for 5 weeks a) 45 TSS, NCS, NIS
b) 1200 mg, orally for 5 weeks b) 47
c) 1800 mg, orally for 5 weeks c) 46
Diabetes: DEKAN [44] 800 mg (200 mg q.i.d.), orally for 4 months 39 Cardiac autonomic nerve function
Diabetes [45] 600 mg/day, orally for 3 months 33 Plasma lipid hydroperoxides, alpha-tocopherol,
cholesterol
Multiple sclerosis [46] a) 1200 mg q.d. a) 9 Serum LA, matrix metalloproteinase-9, and
b) 1200 mg (600 mg b.i.d.) b) 7 intercellular adhesion molecule-1
c) 2400 mg (1200 mg b.i.d.) b) 7
Metabolic [47] 300 mg, orally for 4 weeks 15 Endothelial function and proinflammatory markers
syndrome: ISLAND
a
HPAL = Hamburg Pain Adjective List, NDS = Neuropathy Disability Score, NIS = Neuropathy Impairment Score, NSC = Neuropathic Symptoms and Change Score, TSS = Total
Symptom Score.
 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160 1153

Table 4 4.5. Signal transduction

Antioxidant activities of lipoic acid (LA) and dihydrolipoic acid (DHLA).

Oxidant Scavenged by LA? Scavenged by DHLA? Through changes in intracellular thiol redox status, the protein
Rate constant and reference Rate constant and reference structures of signaling molecules may be changed, resulting in the
Peroxynitrite Yes, 1.4 × 103 M− 1 s− 1 [53] Yes, 2.5 × 102 M− 1 s− 1 [53] alteration of transcription factor activities. Localized bursts of H2O2
Nitric oxide No [54] Yes, 3.19 M− 1 s− 1 [54] upon ligand engagement of receptors have been shown to cause
Hydroxyl radical Yes, 4.7 × 1010 M− 1 s− 1 [2] No [2] autophosphorylation and the induction of signaling cascades [75]. In a
Yes [55] Yes [55]
similar fashion, LA may oxidize sulfhydryl groups or form mixed
Superoxide No [2,55] No [2]
Yes, 3.3 × 105 M− 1 s− 1 [55] disulfides on proteins. The multiplicative nature of signal transduction
Yes [56] may explain some of LA's beneficial effects, since LA accumulates at
Singlet oxygen Yes, 1.3 × 108 M− 1 s− 1 [57] No [58] only micromolar levels, whereas the intracellular antioxidant GSH is
Yes [3,58] present at millimolar levels. Indeed, clinical studies show that a 200–
Peroxyl radical Yes, 1.8 × 108 M− 1 s− 1 [2] Yes, 2.3 × 107 M− 1 s− 1 [2]
600 mg LA dose of orally supplied LA results in less than a 50 µM
No [59] Yes [56,59]
Hypochlorous acid Yes [2,60] Yes [2,60] accumulation in the blood plasma (Table 1) with a Tmax of less than
Hydrogen peroxide No [2] No [2,60] 90 min. [17]; hepatic levels of nonprotein-bound LA similarly peaked
at ~60 µM in rats given 40 mg/kg b.w. i.p. (TMH, personal observa-
tion). This suggests that LA may not be present at high enough levels
to directly recycle GSH, but that the positive clinical effects of LA may
where 98% of radiolabeled LA is excreted in the urine within 24h [29]. in fact be due to changes in the thiol redox status of signaling
Thus, typical cell culture conditions likely overestimate the direct molecules.
antioxidant capacity of LA via one-on-one interaction with free radicals.
Alternatively, the ability of LA to indirectly induce or maintain 4.5.1. LA-mediated induction of GSH through transcription factor Nrf2
endogenous antioxidant levels even in times of oxidative or toxicolog- In several cases, the stereochemistry of LA has been important for
ical stress may be more relevant than a direct-acting antioxidant role, protection against ischemic damage, perhaps indicating that LA was
and the data to support this will now be discussed. not acting as a direct antioxidant, but instead was modulating GSH.
For example, Kilic et al. [76] showed that in a cataract model, R-LA,
unlike S-LA, was protective, and that it exerted its effect by
4.4. LA as an inducer of endogenous antioxidants maintaining GSH levels. In a rodent model of cerebral ischemia,
Wolz et al. [77] reported that R- or S-LA (100 mg/kg b.w.) was as
There is growing evidence that LA may act indirectly to maintain protective as DHLA (50 mg/kg b.w) 2 h after subcutaneous adminis-
cellular antioxidant status by either inducing the uptake or enhancing tration. The investigators suggest that LA is reduced to DHLA to
the synthesis of endogenous low molecular weight antioxidants or provide this effect. While both R- and S-LA are reduced to DHLA, the
antioxidant enzymes. For instance, reports show that LA increases conversion of S-LA by lipoamide dehydrogenase is 28 times slower
intracellular ascorbate levels. Even in rats, which synthesize ascor- than the natural isoform [78]. Thus after 4 h, DHLA formed from R-LA
bate, LA feeding increases hepatic ascorbate levels, which otherwise may have been cleared, because only S-LA was protective at this time
decline with age [67]. Michels et al. extended this research to show point. Hagen et al. showed that R-LA was protective against t-BuOOH
that an age-related loss of sodium-dependent vitamin C transporter 1 toxicity in hepatocytes from aged rats whereas S-LA provided no
(SLC23A1) was at least partly responsible for the decline in hepatic benefit [79].
ascorbate [68]. Feeding LA to old rats may therefore induce ascorbate Building on the above work from Hagen et al. showing that GSH
uptake from the exogenous milieu. Rat cardiomyocytes exhibit an levels decrease with age in rat hepatocytes [79], Suh et al. found that
age-related decline in ascorbate concentrations, but dietary R-LA GSH was 35% lower on an age basis in whole liver tissue [5]. Activity of
restored ascorbate levels and lowered the rate of oxidant production the rate-limiting enzyme in GSH synthesis, γ-glutamyl cysteine ligase
to the level seen in young rats [69]. Moreover, Xu et al. observed that (GCL), was 50% lower with age, which resulted from a significant loss
the reduction of dehydroascorbic acid to ascorbate in rat liver in levels of its two protein subunits. As both subunits of GCL are
mitochondria was enhanced in the presence of LA [70]. These studies products of genes that contain the Antioxidant Response Element
thus indicate that LA may improve endogenous ascorbate levels (ARE), it was hypothesized that GSH synthetic capacity ultimately
indirectly by inducing uptake from the blood plasma. declined with age from deficits in ARE-mediated gene transcription.
In concert with improving ascorbate status, LA markedly increases Indeed, it was observed that nuclear Nrf2 levels, the most important
intracellular glutathione (GSH), an abundant natural thiol antioxidant transcription factor regulating ARE-mediated genes, declined precip-
and co-substrate for detoxification enzymes, in a variety of cell types itously in rat livers on an age basis. However, old rats receiving R-LA
and tissues [71,72]. Packer et al. showed that LA treatment enhanced (40 mg/kg b.w. i.p.) displayed significant increases in GCL activity and
GSH levels in human cell lines and primary cells, including T cells, GSH concentration in the liver, up to the levels found in young control
erythrocytes, lymphocytes, and glial and neuroblastoma cells [73]. animals. As Nrf2 is critical for the Phase II detoxification response, it is
These authors concluded that DHLA reduced cystine to cysteine, likely that there is a mechanism in place to assure that Nrf2 responds
which is the limiting substrate for GSH synthesis. Additionally, LA may to oxidative or electrophilic stress. In this case, LA may act as a pro-
also increase cellular cysteine levels by enhancing cystine uptake from oxidant to cause a mild cellular insult that induces nuclear localization
plasma followed by its reduction to cysteine. In this regard, we of Nrf2. Moini et al. [80] buttressed this concept when they observed
reported that LA reverses the age-related decline in myocardial GSH that administration of R-LA in a cell culture model increased GSH only
by increasing cysteine availability, thereby removing the constraints after 24 h, a result that suggests an Nrf2-dependent mechanism rather
of this limiting substrate on GSH synthesis [74]. These results than a direct antioxidant or GSH-recycling one.
demonstrate that LA is an effective agent to restore both the age- LA, acting as a pro-oxidant, may increase Nrf2-dependent
associated decline in thiol redox ratio as well as increase GSH levels transcriptional activity by forming lipoyl-cysteinyl mixed disulfides
that otherwise decline with age. However, LA has also proven to be an on Keap1 [81], the protein that sequesters Nrf2 and bridges it to
effective regulator of signaling pathways. Some of our recent work has ubiquitin ligases [82]. In this case, Nrf2 may not be released by Keap1,
shown that LA induces de novo GSH synthesis transcriptionally [5], but rather, Nrf2 synthesized de novo would fail to bind Keap1 and
and this process will now be discussed. would not be degraded [83–85] (Fig. 3). In support of this concept,
1154 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160

ii) stimulate GLUT4 translocation via inactivation of the Akt substrate

of 160 kDa (AS160) independently of the IRS1/PI3K/Akt signaling
cascade [112,113].

4.5.3. Insulin pathway and glucose handling

The interaction of LA and intracellular signaling is perceived to
account for LA's beneficial effects observed at 24 h post-administra-
tion [5,80], a time point that is much delayed from the plasma LA Tmax
of ~1 h [18]. This temporal difference is interesting in light of the rapid
metabolism of LA and suggests a different mode of action versus other
stimuli that LA mimics. For example, in cultured cells, insulin induced
glucose uptake after 10 min and a maximal effect after 30 min [114],
while LA required 1 h to induce its maximal effect on glucose uptake,
which could be achieved by insulin in half the time [115]. This delay is
even evident when comparing the phosphorylation of Akt on Ser473
Fig. 3. Proposed action of LA for induction of Phase II genes through Nrf2-mediated as induced by insulin versus LA [95]. Such a delay suggests that the
transcription. LA may oxidize critical thiols on the Keap1 dimer to halt Nrf2
effect of LA on glucose handling is not direct but necessitates the
degradation, and to prevent Keap1 from binding newly synthesized Nrf2. LA may
also activate protein kinase signaling pathways that cause phosphorylation of Nrf2 on activation of additional mediator(s), and also supports the notion that
Ser40. This is the event that allows it to dissociate from Keap1 [68,69]. Nrf2 can then LA or DHLA modulates the IR/PI3K/Akt pathway at different levels
localize to the nucleus and bind to the ARE, promoting transcription of genes for the (Fig. 4).
Phase II detoxification response. In skeletal muscle, LA is proposed to recruit GLUT4 from its storage
site in the Golgi to the sarcolemma, so that glucose uptake is
recent research shows that the mutation of Keap1 critical cysteines stimulated by the local increase in transporter abundance. Evidence
273 and 288 is not sufficient to release Nrf2 from Keap1, but prevents from cell culture experiments supports the involvement of the
its degradation under normal conditions [84,86]. Cysteine 151 also insulin-signaling cascade in LA-stimulated translocation of GLUT1
must be oxidized in order to halt Nrf2 degradation under conditions of and GLUT4. Klip's group [116] investigated the effects of R- and S-LA
stress [86] because this residue is necessary for Keap1's interaction on glucose uptake in L6 myotubes and 3 T3-L1 adipocytes. R-LA
with the Cul3 ubiquitin ligase [87]. The phosphorylation of Nrf2 on stimulated larger and more rapid glucose uptake than did S-LA or the
Ser40, which allows it to dissociate from Keap1, represents an racemic mixture, and when used in conjunction with insulin,
alternative trigger of Nrf2 nuclear translocation. It is known that enhanced its glucose uptake action. The cellular distribution of
certain protein kinases can phosphorylate Nrf2 [88–90], but whether GLUT1 and GLUT4 glucose transporters responded to R-LA in a similar
this control mechanism is also impaired with age is not currently fashion as seen with insulin, and glucose uptake in response to all
known. Other kinases have been investigated that could also forms of LA was PI3K-dependent, as determined by the use of the
phosphorylate Nrf2, but direct evidence of Nrf2's release from inhibitory compound, LY294002. Using the same cell culture models,
Keap1 due to phosphorylation by kinases other than protein kinase Moini et al. [80] showed that R-LA stimulated glucose transport for up
C (PKC) is lacking, primarily because Ser40 is the only site on Nrf2 that to 6 h. While S-LA and the racemic mixture produced the same effect,
has been definitively associated with the binding of Nrf2 to Keap1. It is DHLA did not. R-LA also resulted in tyrosine phosphorylation of the
currently not known whether LA may directly activate PKC in a redox- insulin receptor, and glucose uptake was PI3K dependent, as shown
active manner, but it has been shown that PKCδ is activated in by using wortmannin.
response to LA during Fas-mediated apoptosis [91]. In contrast to the above work done mainly in tissue culture,
Henriksen et al. found that the action of LA on glucose uptake is not
4.5.2. Interaction of LA with kinases and phosphatases always PI3K-dependent [117]. This group incubated 2 mM R,S-LA
In addition to PKCδ, LA activates Erk1/2 [92,93], p38 MAPK [94], with skeletal muscle isolated from either lean or obese Zucker rats (a
PI3 kinase [94], and Akt [94–97]. LA was also found to enhance model for insulin resistance) and showed that a significant portion
expression of the insulin receptor substrate 1 (IRS1) protein in muscle (~75%) of LA-stimulated glucose uptake was independent of PI3K. The
of obese Zucker rats, and it also elicited association of IRS1 with the disparity between muscle cell lines and intact muscle preparations
p85 regulatory subunit of PI3K [98]. In addition, LA decreases the indicates that LA has the potential to impact various components of
activities of protein tyrosine phosphatase 1B [99], protein phospha- cellular signaling, depending on the chosen model and experimental
tase 2A [95], and the phosphatase and tensin homolog PTEN [95], all of conditions. Of note, these in vitro studies used LA concentrations that
which contain critical thiols that, when oxidized, repress their are much greater than peak plasma concentrations seen in healthy
activities [100–103]. While LA may not target specific signaling volunteers administered with 200–600 mg [17,18].
molecules (the insulin receptor may be an exception, see Diesel et al. Tritschler's group directly tested the effects of R- and S-LA by i.p.
[104]), changes in the LA/DHLA redox couple may affect the redox administration on glucose metabolism in the skeletal muscle of
status of critical cysteine residues on these proteins, causing Zucker rats [118]. On an acute basis (100 mg/kg b.w. for 1 h), only R-
conformational changes that activate or repress their activities. For LA increased glucose uptake. Chronic 10-day administration of S-LA
instance, the suppression of PTEN and PP2A activities by LA (50 mg/kg b.w.) did improve glucose uptake, but by less than half that
contributes to the LA-induced increase in Akt phosphorylation of R-LA (30 mg/kg b.w.). This group also measured plasma insulin,
observed in cultured primary hepatocytes treated with 50 µM LA, as finding it to be decreased by R-LA but increased by S-LA. Only R-LA
well as in the liver tissue of rats gavaged with LA at 120 mg/kg b.w. was able to increase glycogen synthesis and glucose oxidation. In their
[95]. model, GLUT4 levels were slightly reduced by chronic S-LA treatment,
Moreover, the well-established regulation of muscle glucose an undesirable effect. The evidence presented argues that R- and S-LA
uptake by exercise/muscle contraction through protein kinases, may not be equally useful in the treatment of diabetes.
including AMP-activated protein kinase (AMPK) [105,106], is of Importantly, combining LA intake (30 mg/kg per day for 15 days)
interest because LA activates peripheral AMPK [107–109]. Thus, with endurance exercise training in an animal model of insulin
through AMPK, LA is thought to i) induce the phosphorylation of IRS1 resistance improved glucose transport activity and whole-body
Ser789 and activation of the IRS1/PI3K signaling [110,111] and glucose tolerance further than either intervention alone [98]. A
 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160 1155

Fig. 4. Role of lipoic acid in IR/PI3K/Akt-dependent activation of glucose uptake in skeletal muscle. Diesel et al. put forth the notion that LA may directly bind to and activate the
tyrosine kinase domain of the insulin receptor (IR) β-subunit [84]. The authors based their claim on a computer modeling of the IR tyrosine kinase domain where LA would
theoretically fit in a pocket located between Leu1133 and Phe1186. In contrast to a direct role of LA on IR, LA was proposed to oxidize critical cysteine thiols in protein tyrosine
phosphatase B1 (PTPB1) thereby preventing the PTPB1-mediated inhibitory dephosphorylation of the IR tyrosine kinase domain [79]. Alternatively, LA was found to enhance the
insulin receptor substrate 1 (IRS1) protein expression in muscle of obese Zucker rats and association of IRS1 with the p85 regulatory subunit of PI3K [78]. Moreover, the well-
established regulation of muscle glucose uptake by exercise/muscle contraction through protein kinases, including AMP-activated protein kinase (AMPK) [85,86] is of interest
because LA activates peripheral AMPK [87,89,139]. Thus, through AMPK, LA is thought to i) induce the phosphorylation of IRS1 Ser789 and activation of the IRS1/PI3K signaling
[90,91] and ii) stimulate GLUT4 translocation via inactivation of the Akt substrate of 160 kDa (AS160) independently of the IRS1/PI3K/Akt signaling cascade [92,93]. The effects of LA
on IR/IRS1 will increase IRS1 association with PI3K and PI3K activity in the membrane environment. PtdIns-3,4,5-P3 (PIP3) production by PI3K recruits PtdIns-dependent kinase 1
(PDK1) to the membrane by Pleckstrin Homology domain:PIP3 interaction and stimulates PDK1-mediated phosphorylation of Akt Thr308. Following Ser473 phosphorylation, fully
activated Akt regulates the trafficking of GLUT4 between storage vesicles and the plasma membrane through a mechanism involving the phosphorylation of AS160. In its active
dephosphorylated form, AS160 inhibits GLUT4 vesicle trafficking to the plasma membrane by preventing Rab-GTP association with the vesicle. Akt-mediated phosphorylation of
AS160 opposes the repressor role of AS160 and allows Rab-GTP binding to the GLUT4 vesicle. Domain structure analysis revealed that AS160 has a Rab-GAP (GTPase-activating
protein) domain at the C-terminus and that the Rab-GAP activity promotes the hydrolysis of small G proteins Rab-GTP to Rab-GDP [140]. In its inactive GDP-loaded form, Rab is
unable to associate with the GLUT4 vesicle nor elicit translocation to the plasma membrane. But Akt-mediated phosphorylation of AS160 inactivates the Rab-GAP activity of AS160
thus favoring the association of GTP-loaded active form of Rab with the GLUT4 vesicle.

potential mechanism for this additive effect is the upregulation of followed by oral LA (600 mg t.i.d.) or placebo for 6 months. The oral
GLUT4 protein expression in exercised muscle [119] combined with phase of this trial, however, was without clinically significant benefits
the enhanced translocation of GLUT4 to the plasma membrane [39]. One possible conclusion from these studies was that LA
induced by LA. Whether this combination of dietary supplement administered intravenously was more efficacious than oral LA,
and exercise is beneficial to diabetic subjects remains to be which may be due to either greater bioavailability or poor solubility
investigated. of the medication in the stomach acid. However, some additional
studies have found that oral LA is very effective. For example, the oral
5. Clinical and therapeutic effects of LA pilot (ORPIL) study showed a reduction in diabetic polyneuropathic
symptoms after three weeks with 600 mg LA t.i.d. [41]. While the first
5.1. Diabetic polyneuropathies SYDNEY trial used i.v. LA, [42], the SYDNEY II study used oral LA at 600,
1200, or 1800 mg q.d. for 5 weeks [43]; consequently, both studies
The interaction of LA with regulatory components of the insulin- showed significant improvements in neuropathic endpoints.
signaling cascade has proved functionally beneficial to skeletal muscle
glucose uptake, whole-body glucose tolerance, and helpful against 5.2. Effects of LA on the vascular system
insulin resistance in animal models [118,120]. Improvements in
glucose disposal were also observed in human patients with type 2 Vascular endothelial cells, which line the blood vessel lumen, form
diabetes receiving LA either intravenously or orally [120–122]. Several the physical interface between the blood and the vessel wall,
clinical trials have been conducted to measure the efficacy of racemic preventing platelet adhesion and regulating blood vessel patency.
LA in decreasing symptoms of diabetic polyneuropathies; these are The elasticity of the vessel wall is regulated by nitric oxide (NO), a gas
the “alpha-lipoic acid in diabetic neuropathy” (ALADIN) trials and the produced by endothelial nitric oxide synthase (eNOS). Loss of eNOS
“symptoms of diabetic polyneuropathy” (SYDNEY) trials. LA was activity causes endothelial dysfunction due to NO limitation, and is
given orally, intravenously, or i.v. with oral follow-up. A meta-analysis characterized by reduced vasodilation, a proinflammatory milieu, and
of four clinical trials using i.v. LA, including ALADIN, SYDNEY, and the a prothrombic state. Oxidative stress has been implicated in
first 3 weeks of ALADIN III, showed a significant improvement in endothelial dysfunction on the basis that antioxidants, such as
diabetic polyneuropathies of the feet and lower limbs in patients ascorbate and LA, improve the redox state of the plasma and
infused with LA 600 mg/day, for three weeks [123]. Diabetic patients endothelium-dependent NO-mediated vasodilation [124,125]. But
in the ALADIN II trial were administered with LA i.v. at 600 or the question remains as to how LA achieves this significant result. It
1200 mg/day for 5 days, then oral LA for 2 years, resulting in is known, for instance, that the PI3K/Akt signaling pathway, cascading
improved indices of neuropathy [38]. Patients in the ALADIN III from the insulin receptor and stimulated by LA, plays an important role
study received LA (600 mg/day i.v.) or placebo for three weeks, in eNOS activation [126,127]. Treating human aortic endothelial cells
1156 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160

with LA significantly increases NO synthesis [128], and LA improves oxidant production and oxidative damage have been investigated for
the loss in eNOS phosphorylation seen in aorta from aged rats through decades in various models of inflammation.
Akt [97]. Furthermore, i.p. injection of LA into old rats restores In keeping with this strategy, LA has been studied for its
vasorelaxation, characterized by an increased phosphorylation of both antioxidant properties in cytokine-induced inflammation; it is also
eNOS and Akt, as well as a decrease in neutral sphingomyelinase widely known as an inhibitor of NF-kappaB [32]. Results show that LA
activity and a concomitant decrease in ceramide [129]. These studies lowers the expression of vascular cell adhesion molecule-1 (VCAM-1)
using in vitro and animal models strengthen our understanding of the and endothelial adhesion of human monocytes [139], and inhibits NF-
role of the insulin-signaling pathway in vasomotor function, and kappaB-dependent expression of metalloproteinase-9 in vitro [140].
underscore the health potential of LA therapy. Thus far, however, only Similarly, LA (25–100 µg/ml = 122–486 µM) prevents the upregula-
the ISLAND clinical trial has examined LA as a potential remedy for tion of intercellular adhesion molecule-1 (ICAM-1) and vascular cell
endothelial dysfunction [47]. This trial was a randomized, double- adhesion molecule-1 (VCAM-1) in spinal cords and in TNF-alpha
blind, placebo-controlled study comparing LA to irbesartan, an stimulated cultured brain endothelial cells [141]. Collagen-induced
angiotensin II receptor antagonist used mainly for the treatment of arthritis was attenuated by LA (10–100 mg/kg i.p.) in DBA/1 mice by
hypertension. Results showed that the oral administration of LA the reduction of inflammatory cytokines like TNF-alpha, and partial
(300 mg/day for 4 weeks) and/or irbesartan (150 mg/day for inhibition of NF-kappaB binding to DNA [142]. In this study, LA also
4 weeks) to 14–15 patients with metabolic syndrome improved inhibited osteoclast formation, suggesting that LA may be useful in the
endothelial-dependent flow-mediated vasodilation, which was mea- prevention of bone erosion and joint destruction in rheumatoid
sured by using the noninvasive brachial artery reactivity test. arthritis. In another study, pretreatment of collagen sheets with LA
However, larger and more long-term studies are necessary in order (2 mg) prior to implantation decreased TNF-alpha-induced bone
to establish the efficacy of LA as a therapeutic for vascular endothelial resorption in ICR mice [142]. In experimental autoimmune enceph-
dysfunction. alomyelitis (an animal model of multiple sclerosis) LA-treated mice
showed marked improvement in central nervous system infiltrating
5.3. LA as a hypotensive agent T-cells and macrophages, decreased demyelination and spinal cord
expression of adhesion molecules (ICAM-1 and VCAM-1) [141,143].
Hypertension is a risk factor for stroke, heart attack and arterial The downregulation of surface CD4 seen in LA-treated blood
aneurysm, and a leading cause of chronic kidney failure. Even mononuclear cells was proposed to account, at least in part, for the
moderate elevation in arterial blood pressure correlates with modulation of inflammatory cell infiltration into the central nervous
shortened life expectancy. The rationale for the therapeutic use of system [144]. This is because co-receptor CD4 amplifies the signal
LA against hypertension stemmed from its ability to increase tissue generated at the T-cell receptor by recruiting lymphocyte protein
GSH levels and prevent deleterious sulfhydryl group modification in kinase Lck, which in turn triggers a cascade of events leading to T-cell
Ca2+ channels. Feeding LA to hypertensive rats normalized systolic activation. Interestingly, DHLA did not downregulate CD4 from the
blood pressure and cytosolic free Ca2+, and attenuated adverse renal surface of human peripheral blood mononuclear cells [144]. As an
vascular changes [130–134]. The role of LA in regenerating reduced alternative or in addition to CD4 downregulation, the immunomod-
GSH was further put forth by El Midaoui and de Champlain [135,136] ulatory properties of LA may involve the upregulation of cAMP in T-
who associated the restoration of glutathione peroxidase activity seen cells and natural killer cells [145]. Cell migration and neovasculariza-
in LA-fed rats with the normalization of aortic superoxide production tion were also inhibited by LA (86 µg/day in drinking water) in c57/
and blood pressure. It was also suggested that dietary LA inhibits renal black mice injected with Kaposi's sarcoma in a matrigel sponge, as
and vascular overproduction of endothelin-1, a vasoconstrictor well as in nude mice injected with KS cells [146]. In a mouse model of
secreted by the endothelium [137]. Because NO is the main bronchial asthma, dietary LA significantly attenuated airway hyper-
vasodilator in conduit arteries and of the recent finding that LA responsiveness, lowered the eosinophil count among bronchoalveolar
improves endothelial NO synthesis [129], pharmacologists have a new lavage cells, and significantly improved pathologic lesion scores of the
rationale to investigate the role of LA and high blood pressure. lungs [147]. LA inhibits TNF-alpha-induced NF-kappaB activation and
Clinically, LA administration (in combination with acetyl-L-carnitine) adhesion molecule expression in human aortic endothelial cells via a
showed some promise as an anti-hypertensive therapy by decreasing mechanism seemingly distinct from antioxidants, such as ascorbate or
systolic pressure in high blood pressure patients and subjects with the reduced GSH, but consistent with the workings of a metal chelator
metabolic syndrome [138]. In contrast, the administration of LA [148]. Recently, the inhibition of endotoxin-induced acute inflamma-
(300 mg/day for 4 weeks) to patients with the metabolic syndrome tion by LA was associated with the stimulation of the PI3K/Akt
had no significant effect on blood pressure compared to placebo group pathway [96].
[47]. To date, the anti-inflammatory properties of LA have rarely been
investigated in humans. The ISLAND trial showed a 15% significant
5.4. LA as an anti-inflammatory agent decrease in serum interleukin-6 levels following 4 weeks of supple-
mentation with LA (300 mg/day) [47]. This finding may prove
Inflammation results from the innate biological response of important to human health because interleukin-6 is a recognized
vascular tissues to harmful agents, such as pathogens or irritants. It marker of inflammation in coronary atherosclerotic plaques, and also
is an attempt by the organism to remove the injurious stimuli, protect regulates the expression of other inflammatory cytokines, such as
the surrounding tissue, and initiate the healing process. However, interleukin-1 and TNF-alpha [149]. However, the body of evidence is
unabated chronic inflammation also contributes to a host of diseases, currently too limited to be conclusive.
such as atherosclerosis, asthma, and rheumatoid arthritis. Elevated
levels of oxidative stress play an important role in chronic 6. Summary and future directions
inflammation. Oxidative stress-associated inflammation is thought
to provoke early vascular events in atherogenesis, including the As described in this review, the biological role(s) of diet-derived
upregulation of vascular adhesion molecules and matrix metallopro- LA are quite diverse (Fig. 5). In fact, to our knowledge there are few
teinase activity. These events require the activation of NF-kappaB, a compounds as multifaceted as LA as a bioactive agent. It is an inducer
transcription factor that induces expression of many genes involved in of cellular signaling pathways, an insulin mimetic, a hypotriglyceri-
inflammation and endothelial cell migration. Given the oxidative demic agent, a vasorelaxant/anti-hypertensive compound, a metal
nature of inflammation, therapeutic strategies aimed at mitigating chelator, and an adjuvant for neuro-cognitive function. Thus, it will be
 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160 1157

sclerosis), limit progression of cardiovascular disease, mitigate

chronic inflammatory conditions, as well as improve or maintain
antioxidant/detoxification defenses that otherwise decline with age.
Prior to any large-scale clinical work using LA, an initial focus should
be placed on optimizing conditions as to effective dose, as well as
identification of the appropriate enantiomeric isoform.

Acknowledgements

We are indebted to Dr. Dove Keith, Dr. Alexander Michels, and Judy
A. Butler for the careful review and helpful comments.

References
[1] A.R. Smith, S.V. Shenvi, M. Widlansky, J.H. Suh, T.M. Hagen, Lipoic acid as a
potential therapy for chronic diseases associated with oxidative stress, Curr. Med.
Fig. 5. Proposed biological actions of lipoic acid.
Chem. 11 (2004) 1135–1146.
[2] B.C. Scott, O.I. Aruoma, P.J. Evans, C. O'Neill, A. Van der Vliet, C.E. Cross, H.
Tritschler, B. Halliwell, Lipoic and dihydrolipoic acids as antioxidants. A critical
important to define the precise cause-and-effect relationship between evaluation, Free Radic. Res. 20 (1994) 119–133.
[3] T.P. Devasagayam, M. Subramanian, D.S. Pradhan, H. Sies, Prevention of singlet
LA and its cellular targets of immediate action. An area that warrants oxygen-induced DNA damage by lipoate, Chem. Biol. Interact. 86 (1993) 79–92.
further study is whether LA directly regulates hormonal signals, [4] J. Liu, E. Head, A.M. Gharib, W. Yuan, R.T. Ingersoll, T.M. Hagen, C.W. Cotman, B.N.
which in turn initiate downstream biochemical actions on target Ames, Memory loss in old rats is associated with brain mitochondrial decay and
RNA/DNA oxidation: partial reversal by feeding acetyl-L-carnitine and/or R-
organs. In this regard, LA stimulates an AMPK-dependent anorectic alpha-lipoic acid, Proc. Natl. Acad. Sci. USA 99 (2002) 2356–2361.
effect in rodents [107] and improves learning and short-term memory [5] J.H. Suh, S.V. Shenvi, B.M. Dixon, H. Liu, A.K. Jaiswal, R.M. Liu, T.M. Hagen, Decline
in aged rodents [4,31,150,151]. Thus diet-derived LA may owe some of in transcriptional activity of Nrf2 causes age-related loss of glutathione synthesis,
which is reversible with lipoic acid, Proc. Natl. Acad. Sci. USA 101 (2004)
its diverse physiological actions on stimulating neuro-hormonal
3381–3386.
function and thereby indirectly influencing multiple cell signaling [6] J.K. Lodge, M.G. Traber, L. Packer, Thiol chelation of Cu2+ by dihydrolipoic acid
pathways in peripheral tissues. prevents human low density lipoprotein peroxidation, Free Radic. Biol. Med. 25
(1998) 287–297.
In concert with its potential for centralized action, it is also
[7] B. Anuradha, P. Varalakshmi, Protective role of DL-alpha-lipoic acid against
apparent that orally supplied LA affects multiple signaling and mercury-induced neural lipid peroxidation, Pharmacol. Res. 39 (1999) 67–80.
transcriptional paradigms at the cellular level. Again, the question [8] D. Han, C.K. Sen, S. Roy, M.S. Kobayashi, H.J. Tritschler, L. Packer, Protection
that immediately arises is whether LA has multiple or only a few actual against glutamate-induced cytotoxicity in C6 glial cells by thiol antioxidants, Am.
J. Physiol. 273 (1997) R1771–R1778.
cellular targets, in the latter case mediating its strong antioxidant and [9] L. Reed, Multienzyme complexes, Acc. Chem. Res. 7 (1974) 40–46.
metabolic effects indirectly. For example, LA acts as an insulin mimetic [10] T.J. Vanden Boom, K.E. Reed, J.E. Cronan Jr., Lipoic acid metabolism in Escherichia
in that it improves glucose handling; however, the timing to which LA coli: isolation of null mutants defective in lipoic acid biosynthesis, molecular
cloning and characterization of the E. coli lip locus, and identification of the
stimulates glucose metabolism is significantly delayed from that of lipoylated protein of the glycine cleavage system, J. Bacteriol. 173 (1991)
insulin itself. Thus, it is still to be determined whether LA truly targets 6411–6420.
the insulin-signaling pathway via thiol/disulfide interactions on the [11] S. Akiba, S. Matsugo, L. Packer, T. Konishi, Assay of protein-bound lipoic acid in
tissues by a new enzymatic method, Anal. Biochem. 258 (1998) 299–304.
insulin receptor or its direct protein substrates or alternatively, [12] L. Packer, K. Kraemer, G. Rimbach, Molecular aspects of lipoic acid in the
indirectly influences this pathway by affecting phosphatases. prevention of diabetes complications, Nutrition 17 (2001) 888–895.
As this review was being compiled, we were struck by the lack of [13] S.D. Wollin, P.J. Jones, Alpha-lipoic acid and cardiovascular disease, J. Nutr. 133
(2003) 3327–3330.
consistency and sheer magnitude of dose used to examine LA action,
[14] N. Takaishi, K. Yoshida, H. Satsu, M. Shimizu, Transepithelial transport of alpha-
particularly for in vitro models. Low micromolar to millimolar lipoic acid across human intestinal Caco-2 cell monolayers, J. Agric. Food Chem.
concentrations of LA have been employed for cultured cells where 55 (2007) 5253–5259.
[15] K. Balamurugan, N.D. Vaziri, H.M. Said, Biotin uptake by human proximal tubular
LA has variously been shown to induce apoptosis, directly act as an
epithelial cells: cellular and molecular aspects, Am. J. Physiol., Renal Physiol. 288
antioxidant, induce H2O2 release, and stimulate stress response (2005) F823–F831.
mechanisms to name a few. Considering the transient cellular [16] P.D. Prasad, H. Wang, R. Kekuda, T. Fujita, Y.J. Fei, L.D. Devoe, F.H. Leibach, V.
accumulation of LA following an oral dose, which does not exceed Ganapathy, Cloning and functional expression of a cDNA encoding a mammalian
sodium-dependent vitamin transporter mediating the uptake of pantothenate,
low micromolar levels, it is entirely possible that some of the cellular biotin, and lipoate, J. Biol. Chem. 273 (1998) 7501–7506.
effects of LA when given at supraphysiological concentrations may not [17] J. Teichert, J. Kern, H.J. Tritschler, H. Ulrich, R. Preiss, Investigations on the
be clinically or physiologically relevant. This may be particularly pharmacokinetics of alpha-lipoic acid in healthy volunteers, Int. J. Clin.
Pharmacol. Ther. 36 (1998) 625–628.
important in characterizing the cellular role of LA or DHLA as effective [18] D.A. Carlson, A.R. Smith, S.J. Fischer, K.L. Young, L. Packer, The plasma
direct-acting cellular antioxidants. One must ask how a dithiol agent pharmacokinetics of R-(+)-lipoic acid administered as sodium R-(+)-lipoate
that only transiently accumulates at very low levels in vivo could act to healthy human subjects, Altern. Med. Rev. 12 (2007) 343–351.
[19] K. Breithaupt-Grogler, G. Niebch, E. Schneider, K. Erb, R. Hermann, H.H. Blume, B.S.
as a potent antioxidant on a stoichiometric basis. Significantly more Schug, G.G. Belz, Dose-proportionality of oral thioctic acid—coincidence of assess-
research is necessary to understand physiological uptake, accumula- ments via pooled plasma and individual data, Eur. J. Pharm. Sci. 8 (1999) 57–65.
tion and metabolism of LA and its metabolites in order to set up [20] F. Mignini, V. Streccioni, D. Tomassoni, E. Traini, F. Amenta, Comparative
crossover, randomized, open-label bioequivalence study on the bioequivalence
appropriate cell-based models to examine LA action. Only then will
of two formulations of thioctic acid in healthy volunteers, Clin. Exp. Hypertens.
the most biologically relevant cellular actions of LA be elucidated. 29 (2007) 575–586.
Although some important aspects of LA's mechanism of action in [21] A. Bernkop-Schnurch, E. Reich-Rohrwig, M. Marschutz, H. Schuhbauer, M.
Kratzel, Development of a sustained release dosage form for alpha-lipoic acid.
vivo are yet to be uncovered, it is apparent that oral LA supplements
II. Evaluation in human volunteers, Drug Dev. Ind. Pharm. 30 (2004) 35–42.
are clinically effective in mitigating complications of diabetes and [22] F. Amenta, E. Traini, D. Tomassoni, F. Mignini, Pharmacokinetics of different
potentially, other vascular diseases. Because current evidence is based formulations of tioctic (alpha-lipoic) acid in healthy volunteers, Clin. Exp.
mainly on data from rodent studies, additional placebo-controlled Hypertens. 30 (2008) 767–775.
[23] J. Teichert, T. Tuemmers, H. Achenbach, C. Preiss, R. Hermann, P. Ruus, R. Preiss,
trials are advisable to determine the potential for LA to maintain or Pharmacokinetics of alpha-lipoic acid in subjects with severe kidney damage and
improve neurological disorders (e.g. Alzheimer's disease, multiple end-stage renal disease, J. Clin. Pharmacol. 45 (2005) 313–328.
1158 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160

[24] J. Teichert, R. Hermann, P. Ruus, R. Preiss, Plasma kinetics, metabolism, and [49] U. Cakatay, R. Kayali, A. Sivas, F. Tekeli, Prooxidant activities of alpha-lipoic acid
urinary excretion of alpha-lipoic acid following oral administration in healthy on oxidative protein damage in the aging rat heart muscle, Arch. Gerontol.
volunteers, J. Clin. Pharmacol. 43 (2003) 1257–1267. Geriatr. 40 (2005) 231–240.
[25] E.H. Harrison, D.B. McCormick, The metabolism of dl-(1, 6–14C)lipoic acid in the [50] R. Kayali, U. Cakatay, T. Akcay, T. Altug, Effect of alpha-lipoic acid supplemen-
rat, Arch. Biochem. Biophys. 160 (1974) 514–522. tation on markers of protein oxidation in post-mitotic tissues of ageing rat, Cell
[26] M. Panigrahi, Y. Sadguna, B.R. Shivakumar, S.V. Kolluri, S. Roy, L. Packer, V. Biochem. Funct. 24 (2006) 79–85.
Ravindranath, alpha-Lipoic acid protects against reperfusion injury following [51] U. Cakatay, R. Kayali, A.R. Kiziler, B. Aydemir, Postmitotic tissue selenium and
cerebral ischemia in rats, Brain Res. 717 (1996) 184–188. manganese levels in alpha-lipoic acid-supplemented aged rats, Chem. Biol.
[27] P. Arivazhagan, S. Shila, S. Kumaran, C. Panneerselvam, Effect of DL-alpha-lipoic Interact. 171 (2008) 306–311.
acid on the status of lipid peroxidation and antioxidant enzymes in various brain [52] R.L. Searls, D.R. Sanadi, alpha-Ketoglutaric dehydrogenase. 8. Isolation and some
regions of aged rats, Exp. Gerontol. 37 (2002) 803–811. properties of a flavoprotein component, J. Biol. Chem. 235 (1960) 2485–2491.
[28] H.T. Chng, L.S. New, A.H. Neo, C.W. Goh, E.R. Browne, E.C. Chan, Distribution study [53] M. Trujillo, R. Radi, Peroxynitrite reaction with the reduced and the oxidized
of orally administered lipoic acid in rat brain tissues, Brain Res. 1251 (2009) forms of lipoic acid: new insights into the reaction of peroxynitrite with thiols,
80–86. Arch. Biochem. Biophys. 397 (2002) 91–98.
[29] H. Schupke, R. Hempel, G. Peter, R. Hermann, K. Wessel, J. Engel, T. Kronbach, [54] M.F. Vriesman, G.R. Haenen, G.J. Westerveld, J.B. Paquay, H.P. Voss, A. Bast, A
New metabolic pathways of alpha-lipoic acid, Drug Metab. Dispos. 29 (2001) method for measuring nitric oxide radical scavenging activity. Scavenging
855–862. properties of sulfur-containing compounds, Pharm. World Sci. 19 (1997)
[30] W. Jones, X. Li, Z.C. Qu, L. Perriott, R.R. Whitesell, J.M. May, Uptake, recycling, and 283–286.
antioxidant actions of alpha-lipoic acid in endothelial cells, Free Radic. Biol. Med. [55] Y.J. Suzuki, M. Tsuchiya, L. Packer, Thioctic acid and dihydrolipoic acid are novel
33 (2002) 83–93. antioxidants which interact with reactive oxygen species, Free Radic. Res.
[31] S.A. Farr, H.F. Poon, D. Dogrukol-Ak, J. Drake, W.A. Banks, E. Eyerman, D.A. Commun. 15 (1991) 255–263.
Butterfield, J.E. Morley, The antioxidants alpha-lipoic acid and N-acetylcysteine [56] Y.J. Suzuki, M. Tsuchiya, L. Packer, Antioxidant activities of dihydrolipoic acid and
reverse memory impairment and brain oxidative stress in aged SAMP8 mice, J. its structural homologues, Free Radic. Res. Commun. 18 (1993) 115–122.
Neurochem. 84 (2003) 1173–1183. [57] S. Kaiser, P. di Mascio, H. Sies, Lipoat und Singulettsauerstoff, in: H.O. Borbe, H.
[32] L. Packer, E.H. Witt, H.J. Tritschler, alpha-Lipoic acid as a biological antioxidant, Ulrich (Eds.), Thioctseure, pmi Verlag GmbH, Frankfurt, 1989, pp. 69–76.
Free Radic. Biol. Med. 19 (1995) 227–250. [58] T.P. Devasagayam, P. Di Mascio, S. Kaiser, H. Sies, Singlet oxygen induced single-
[33] G.P. Biewenga, G.R. Haenen, A. Bast, The pharmacology of the antioxidant lipoic strand breaks in plasmid pBR322 DNA: the enhancing effect of thiols, Biochim.
acid, Gen. Pharmacol. 29 (1997) 315–331. Biophys. Acta 1088 (1991) 409–412.
[34] A.S. Hill, J.A. Werner, Q.R. Rogers, S.L. O'Neill, M.M. Christopher, Lipoic acid is 10 [59] V.E. Kagan, A. Shvedova, E. Serbinova, S. Khan, C. Swanson, R. Powell, L. Packer,
times more toxic in cats than reported in humans, dogs or rats, J. Anim. Physiol. Dihydrolipoic acid—a universal antioxidant both in the membrane and in the
Anim. Nutr. (Berl.) 88 (2004) 150–156. aqueous phase. Reduction of peroxyl, ascorbyl and chromanoxyl radicals,
[35] D.R. Cremer, R. Rabeler, A. Roberts, B. Lynch, Safety evaluation of alpha-lipoic acid Biochem. Pharmacol. 44 (1992) 1637–1649.
(ALA), Regul. Toxicol. Pharmacol. 46 (2006) 29–41. [60] G.R. Haenen, A. Bast, Scavenging of hypochlorous acid by lipoic acid, Biochem.
[36] D.R. Cremer, R. Rabeler, A. Roberts, B. Lynch, Long-term safety of alpha-lipoic Pharmacol. 42 (1991) 2244–2246.
acid (ALA) consumption: a 2-year study, Regul. Toxicol. Pharmacol. 46 (2006) [61] L.J. Yan, M.G. Traber, H. Kobuchi, S. Matsugo, H.J. Tritschler, L. Packer, Efficacy of
193–201. hypochlorous acid scavengers in the prevention of protein carbonyl formation,
[37] D. Ziegler, M. Hanefeld, K.J. Ruhnau, H.P. Meissner, M. Lobisch, K. Schutte, F.A. Arch. Biochem. Biophys. 327 (1996) 330–334.
Gries, Treatment of symptomatic diabetic peripheral neuropathy with the anti- [62] A. Bast, G.R. Haenen, Lipoic acid: a multifunctional antioxidant, Biofactors 17
oxidant alpha-lipoic acid. A 3-week multicentre randomized controlled trial (2003) 207–213.
(ALADIN study), Diabetologia 38 (1995) 1425–1433. [63] P. Ou, H.J. Tritschler, S.P. Wolff, Thioctic (lipoic) acid: a therapeutic metal-
[38] M. Reljanovic, G. Reichel, K. Rett, M. Lobisch, K. Schuette, W. Moller, H.J. chelating antioxidant? Biochem. Pharmacol. 50 (1995) 123–126.
Tritschler, H. Mehnert, Treatment of diabetic polyneuropathy with the [64] J.H. Suh, R. Moreau, S.H. Heath, T.M. Hagen, Dietary supplementation with (R)-
antioxidant thioctic acid (alpha-lipoic acid): a two year multicenter randomized alpha-lipoic acid reverses the age-related accumulation of iron and depletion of
double-blind placebo-controlled trial (ALADIN II). Alpha Lipoic Acid in Diabetic antioxidants in the rat cerebral cortex, Redox Rep. 10 (2005) 52–60.
Neuropathy, Free Radic. Res. 31 (1999) 171–179. [65] A.I. Bush, Metal complexing agents as therapies for Alzheimer's disease,
[39] D. Ziegler, M. Hanefeld, K.J. Ruhnau, H. Hasche, M. Lobisch, K. Schutte, G. Kerum, Neurobiol. Aging 23 (2002) 1031–1038.
R. Malessa, Treatment of symptomatic diabetic polyneuropathy with the [66] M. Goralska, R. Dackor, B. Holley, M.C. McGahan, Alpha lipoic acid changes iron
antioxidant alpha-lipoic acid: a 7-month multicenter randomized controlled uptake and storage in lens epithelial cells, Exp. Eye Res. 76 (2003) 241–248.
trial (ALADIN III study). ALADIN III Study Group. Alpha-Lipoic Acid in Diabetic [67] J. Lykkesfeldt, T.M. Hagen, V. Vinarsky, B.N. Ames, Age-associated decline in
Neuropathy, Diabetes Care 22 (1999) 1296–1301. ascorbic acid concentration, recycling, and biosynthesis in rat hepatocytes—
[40] S. Jacob, P. Ruus, R. Hermann, H.J. Tritschler, E. Maerker, W. Renn, H.J. Augustin, G.J. reversal with (R)-alpha-lipoic acid supplementation, FASEB J. 12 (1998)
Dietze, K. Rett, Oral administration of RAC-alpha-lipoic acid modulates insulin 1183–1189.
sensitivity in patients with type-2 diabetes mellitus: a placebo-controlled pilot [68] A.J. Michels, N. Joisher, T.M. Hagen, Age-related decline of sodium-dependent
trial, Free Radic. Biol. Med. 27 (1999) 309–314. ascorbic acid transport in isolated rat hepatocytes, Arch. Biochem. Biophys. 410
[41] K.J. Ruhnau, H.P. Meissner, J.R. Finn, M. Reljanovic, M. Lobisch, K. Schutte, D. (2003) 112–120.
Nehrdich, H.J. Tritschler, H. Mehnert, D. Ziegler, Effects of 3-week oral treatment [69] J.H. Suh, E.T. Shigeno, J.D. Morrow, B. Cox, A.E. Rocha, B. Frei, T.M. Hagen,
with the antioxidant thioctic acid (alpha-lipoic acid) in symptomatic diabetic Oxidative stress in the aging rat heart is reversed by dietary supplementation
polyneuropathy, Diabet. Med. 16 (1999) 1040–1043. with (R)-(alpha)-lipoic acid, FASEB J. 15 (2001) 700–706.
[42] A.S. Ametov, A. Barinov, P.J. Dyck, R. Hermann, N. Kozlova, W.J. Litchy, P.A. Low, D. [70] D.P. Xu, W.W. Wells, alpha-Lipoic acid dependent regeneration of ascorbic acid
Nehrdich, M. Novosadova, P.C. O'Brien, M. Reljanovic, R. Samigullin, K. Schuette, I. from dehydroascorbic acid in rat liver mitochondria, J. Bioenerg. Biomembranes
Strokov, H.J. Tritschler, K. Wessel, N. Yakhno, D. Ziegler, The sensory symptoms of 28 (1996) 77–85.
diabetic polyneuropathy are improved with alpha-lipoic acid: the SYDNEY trial, [71] A. Bast, G.R. Haenen, Interplay between lipoic acid and glutathione in the
Diabetes Care 26 (2003) 770–776. protection against microsomal lipid peroxidation, Biochim. Biophys. Acta 963
[43] D. Ziegler, A. Ametov, A. Barinov, P.J. Dyck, I. Gurieva, P.A. Low, U. Munzel, N. (1988) 558–561.
Yakhno, I. Raz, M. Novosadova, J. Maus, R. Samigullin, Oral treatment with alpha- [72] E. Busse, G. Zimmer, B. Schopohl, B. Kornhuber, Influence of alpha-lipoic acid on
lipoic acid improves symptomatic diabetic polyneuropathy: the SYDNEY 2 trial, intracellular glutathione in vitro and in vivo, Arzneimittelforschung 42 (1992)
Diabetes Care 29 (2006) 2365–2370. 829–831.
[44] D. Ziegler, H. Schatz, F. Conrad, F.A. Gries, H. Ulrich, G. Reichel, Effects of [73] D. Han, G. Handelman, L. Marcocci, C.K. Sen, S. Roy, H. Kobuchi, H.J. Tritschler, L.
treatment with the antioxidant alpha-lipoic acid on cardiac autonomic Flohe, L. Packer, Lipoic acid increases de novo synthesis of cellular glutathione by
neuropathy in NIDDM patients. A 4-month randomized controlled multicenter improving cystine utilization, BioFactors 6 (1997) 321–338.
trial (DEKAN study). Deutsche Kardiale Autonome Neuropathie, Diabetes Care 20 [74] J.H. Suh, H. Wang, R.M. Liu, J. Liu, T.M. Hagen, (R)-alpha-lipoic acid reverses the
(1997) 369–373. age-related loss in GSH redox status in post-mitotic tissues: evidence for
[45] V. Borcea, J. Nourooz-Zadeh, S.P. Wolff, M. Klevesath, M. Hofmann, H. Urich, P. increased cysteine requirement for GSH synthesis, Arch. Biochem. Biophys. 423
Wahl, R. Ziegler, H. Tritschler, B. Halliwell, P.P. Nawroth, alpha-Lipoic acid (2004) 126–135.
decreases oxidative stress even in diabetic patients with poor glycemic control [75] S.R. Lee, K.S. Kwon, S.R. Kim, S.G. Rhee, Reversible inactivation of protein-tyrosine
and albuminuria, Free Radic. Biol. Med. 26 (1999) 1495–1500. phosphatase 1B in A431 cells stimulated with epidermal growth factor, J. Biol.
[46] V. Yadav, G. Marracci, J. Lovera, W. Woodward, K. Bogardus, W. Marquardt, L. Chem. 273 (1998) 15366–15372.
Shinto, C. Morris, D. Bourdette, Lipoic acid in multiple sclerosis: a pilot study, [76] F. Kilic, G.J. Handelman, K. Traber, K. Tsang, L. Packer, J.R. Trevithick, Modelling
Mult. Scler. 11 (2005) 159–165. cortical cataractogenesis XX. In vitro effect of alpha-lipoic acid on glutathione
[47] S. Sola, M.Q. Mir, F.A. Cheema, N. Khan-Merchant, R.G. Menon, S. Parthasarathy, concentrations in lens in model diabetic cataractogenesis, Biochem. Mol. Biol. Int.
B.V. Khan, Irbesartan and lipoic acid improve endothelial function and reduce 46 (1998) 585–595.
markers of inflammation in the metabolic syndrome: results of the Irbesartan [77] P. Wolz, J. Krieglstein, Neuroprotective effects of alpha-lipoic acid and its
and Lipoic Acid in Endothelial Dysfunction (ISLAND) study, Circulation 111 enantiomers demonstrated in rodent models of focal cerebral ischemia,
(2005) 343–348. Neuropharmacology 35 (1996) 369–375.
[48] U. Cakatay, R. Kayali, Plasma protein oxidation in aging rats after alpha-lipoic acid [78] G.P. Biewenga, M.A. Dorstijn, J.V. Verhagen, G.R. Haenen, A. Bast, Reduction of lipoic
administration, Biogerontology 6 (2005) 87–93. acid by lipoamide dehydrogenase, Biochem. Pharmacol. 51 (1996) 233–238.
 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160 1159

[79] T.M. Hagen, V. Vinarsky, C.M. Wehr, B.N. Ames, (R)-alpha-lipoic acid reverses the [107] M.S. Kim, J.Y. Park, C. Namkoong, P.G. Jang, J.W. Ryu, H.S. Song, J.Y. Yun, I.S.
age-associated increase in susceptibility of hepatocytes to tert-butylhydroper- Namgoong, J. Ha, I.S. Park, I.K. Lee, B. Viollet, J.H. Youn, H.K. Lee, K.U. Lee, Anti-
oxide both in vitro and in vivo, Antioxid. Redox Signal. 2 (2000) 473–483. obesity effects of alpha-lipoic acid mediated by suppression of hypothalamic
[80] H. Moini, O. Tirosh, Y.C. Park, K.J. Cho, L. Packer, R-alpha-lipoic acid action on cell AMP-activated protein kinase, Nat. Med. 10 (2004) 727–733.
redox status, the insulin receptor, and glucose uptake in 3 T3-L1 adipocytes, [108] W.J. Lee, I.K. Lee, H.S. Kim, Y.M. Kim, E.H. Koh, J.C. Won, S.M. Han, M.S. Kim, I. Jo, G.
Arch. Biochem. Biophys. 397 (2002) 384–391. T. Oh, I.S. Park, J.H. Youn, S.W. Park, K.U. Lee, J.Y. Park, Alpha-lipoic acid prevents
[81] A.T. Dinkova-Kostova, W.D. Holtzclaw, R.N. Cole, K. Itoh, N. Wakabayashi, Y. endothelial dysfunction in obese rats via activation of AMP-activated protein
Katoh, M. Yamamoto, P. Talalay, Direct evidence that sulfhydryl groups of Keap1 kinase, Arterioscler. Thromb. Vasc. Biol. 25 (2005) 2488–2494.
are the sensors regulating induction of phase 2 enzymes that protect against [109] W.J. Lee, K.H. Song, E.H. Koh, J.C. Won, H.S. Kim, H.S. Park, M.S. Kim, S.W. Kim, K.U.
carcinogens and oxidants, Proc. Natl. Acad. Sci. USA 99 (2002) 11908–11913. Lee, J.Y. Park, Alpha-lipoic acid increases insulin sensitivity by activating AMPK in
[82] D.D. Zhang, S.C. Lo, J.V. Cross, D.J. Templeton, M. Hannink, Keap1 is a redox- skeletal muscle, Biochem. Biophys. Res. Commun. 332 (2005) 885–891.
regulated substrate adaptor protein for a Cul3-dependent ubiquitin ligase [110] K. Paz, R. Hemi, D. LeRoith, A. Karasik, E. Elhanany, H. Kanety, Y. Zick, A molecular
complex, Mol. Cell. Biol. 24 (2004) 10941–10953. basis for insulin resistance. Elevated serine/threonine phosphorylation of IRS-1
[83] A. Kobayashi, M.I. Kang, Y. Watai, K.I. Tong, T. Shibata, K. Uchida, M. Yamamoto, and IRS-2 inhibits their binding to the juxtamembrane region of the insulin
Oxidative and electrophilic stresses activate Nrf2 through inhibition of receptor and impairs their ability to undergo insulin-induced tyrosine phos-
ubiquitination activity of Keap1, Mol. Cell. Biol. 26 (2006) 221–229. phorylation, J. Biol. Chem. 272 (1997) 29911–29918.
[84] A.L. Eggler, G. Liu, J.M. Pezzuto, R.B. van Breemen, A.D. Mesecar, Modifying [111] S.N. Jakobsen, D.G. Hardie, N. Morrice, H.E. Tornqvist, 5′-AMP-activated protein
specific cysteines of the electrophile-sensing human Keap1 protein is insufficient kinase phosphorylates IRS-1 on Ser-789 in mouse C2C12 myotubes in response
to disrupt binding to the Nrf2 domain Neh2, Proc. Natl. Acad. Sci. USA 102 (2005) to 5-aminoimidazole-4-carboxamide riboside, J. Biol. Chem. 276 (2001)
10070–10075. 46912–46916.
[85] F. Hong, K.R. Sekhar, M.L. Freeman, D.C. Liebler, Specific patterns of electrophile [112] J.T. Treebak, S. Glund, A. Deshmukh, D.K. Klein, Y.C. Long, T.E. Jensen, S.B.
adduction trigger Keap1 ubiquitination and Nrf2 activation, J. Biol. Chem. 280 Jorgensen, B. Viollet, L. Andersson, D. Neumann, T. Wallimann, E.A. Richter, A.V.
(2005) 31768–31775. Chibalin, J.R. Zierath, J.F. Wojtaszewski, AMPK-mediated AS160 phosphorylation
[86] T. Yamamoto, T. Suzuki, A. Kobayashi, J. Wakabayashi, J. Maher, H. Motohashi, M. in skeletal muscle is dependent on AMPK catalytic and regulatory subunits,
Yamamoto, Physiological significance of reactive cysteine residues of Keap1 in Diabetes 55 (2006) 2051–2058.
determining Nrf2 activity, Mol. Cell. Biol. 28 (2008) 2758–2770. [113] Q.W. Shen, M.J. Zhu, J. Tong, J. Ren, M. Du, Ca2+/calmodulin-dependent protein
[87] G. Rachakonda, Y. Xiong, K.R. Sekhar, S.L. Stamer, D.C. Liebler, M.L. Freeman, kinase kinase is involved in AMP-activated protein kinase activation by {alpha}-
Covalent modification at Cys151 dissociates the electrophile sensor Keap1 from lipoic acid in C2C12 myotubes, Am. J. Physiol., Cell Physiol. 293 (4) (2007)
the ubiquitin ligase CUL3, Chem. Res. Toxicol. 21 (2008) 705–710. C1395–C1403.
[88] H.C. Huang, T. Nguyen, C.B. Pickett, Phosphorylation of Nrf2 at Ser-40 by protein [114] T. Tsakiridis, H.E. McDowell, T. Walker, C.P. Downes, H.S. Hundal, M. Vranic, A.
kinase C regulates antioxidant response element-mediated transcription, J. Biol. Klip, Multiple roles of phosphatidylinositol 3-kinase in regulation of glucose
Chem. 277 (2002) 42769–42774. transport, amino acid transport, and glucose transporters in L6 skeletal muscle
[89] D.A. Bloom, A.K. Jaiswal, Phosphorylation of Nrf2 at Ser40 by protein kinase C in cells, Endocrinology 136 (1995) 4315–4322.
response to antioxidants leads to the release of Nrf2 from INrf2, but is not [115] K. Yaworsky, R. Somwar, T. Ramlal, H.J. Tritschler, A. Klip, Engagement of the
required for Nrf2 stabilization/accumulation in the nucleus and transcriptional insulin-sensitive pathway in the stimulation of glucose transport by alpha-lipoic
activation of antioxidant response element-mediated NAD(P)H:quinone oxido- acid in 3T3-L1 adipocytes, Diabetologia 43 (2000) 294–303.
reductase-1 gene expression, J. Biol. Chem. 278 (2003) 44675–44682. [116] D.E. Estrada, H.S. Ewart, T. Tsakiridis, A. Volchuk, T. Ramlal, H. Tritschler, A. Klip,
[90] H.C. Huang, T. Nguyen, C.B. Pickett, Regulation of the antioxidant response Stimulation of glucose uptake by the natural coenzyme alpha-lipoic acid/thioctic
element by protein kinase C-mediated phosphorylation of NF-E2-related factor 2, acid: participation of elements of the insulin signaling pathway, Diabetes 45
Proc. Natl. Acad. Sci. USA 97 (2000) 12475–12480. (1996) 1798–1804.
[91] C.K. Sen, R. Sashwati, L. Packer, Fas mediated apoptosis of human Jurkat T-cells: [117] E.J. Henriksen, S. Jacob, R.S. Streeper, D.L. Fogt, J.Y. Hokama, H.J. Tritschler,
intracellular events and potentiation by redox-active alpha-lipoic acid, Cell Death Stimulation by alpha-lipoic acid of glucose transport activity in skeletal muscle of
Differ. 6 (1999) 481–491. lean and obese Zucker rats, Life Sci. 61 (1997) 805–812.
[92] Y.J. Suzuki, S.S. Shi, R.M. Day, J.B. Blumberg, Differential regulation of MAP kinase [118] R.S. Streeper, E.J. Henriksen, S. Jacob, J.Y. Hokama, D.L. Fogt, H.J. Tritschler,
signaling by pro- and antioxidant biothiols, Ann. N.Y. Acad. Sci. 899 (2000) 159–167. Differential effects of lipoic acid stereoisomers on glucose metabolism in insulin-
[93] S.S. Shi, R.M. Day, A.D. Halpner, J.B. Blumberg, Y.J. Suzuki, Homocysteine and resistant skeletal muscle, Am. J. Physiol. 273 (1997) E185–E191.
alpha-lipoic acid regulate p44/42 MAP kinase phosphorylation in NIH/3 T3 cells, [119] V.A. Hughes, M.A. Fiatarone, R.A. Fielding, B.B. Kahn, C.M. Ferrara, P. Shepherd, E.C.
Antioxid. Redox Signal. 1 (1999) 123–128. Fisher, R.R. Wolfe, D. Elahi, W.J. Evans, Exercise increases muscle GLUT-4 levels
[94] D. Konrad, R. Somwar, G. Sweeney, K. Yaworsky, M. Hayashi, T. Ramlal, A. Klip, and insulin action in subjects with impaired glucose tolerance, Am. J. Physiol. 264
The antihyperglycemic drug alpha-lipoic acid stimulates glucose uptake via both (1993) E855–E862.
GLUT4 translocation and GLUT4 activation: potential role of p38 mitogen- [120] S. Jacob, R.S. Streeper, D.L. Fogt, J.Y. Hokama, H.J. Tritschler, G.J. Dietze, E.J.
activated protein kinase in GLUT4 activation, Diabetes 50 (2001) 1464–1471. Henriksen, The antioxidant alpha-lipoic acid enhances insulin-stimulated
[95] K. Petersen Shay, T.M. Hagen, Age-associated impairment of Akt phosphorylation glucose metabolism in insulin-resistant rat skeletal muscle, Diabetes 45 (1996)
in primary rat hepatocytes is remediated by alpha-lipoic acid through PI3 kinase, 1024–1029.
PTEN, and PP2A, Biogerontology 10 (2009) 443–456. [121] S. Jacob, E.J. Henriksen, A.L. Schiemann, I. Simon, D.E. Clancy, H.J. Tritschler, W.I.
[96] W.J. Zhang, H. Wei, T. Hagen, B. Frei, Alpha-lipoic acid attenuates LPS-induced Jung, H.J. Augustin, G.J. Dietze, Enhancement of glucose disposal in patients with
inflammatory responses by activating the phosphoinositide 3-kinase/Akt type 2 diabetes by alpha-lipoic acid, Arzneimittelforschung 45 (1995) 872–874.
signaling pathway, Proc. Natl. Acad. Sci. USA 104 (2007) 4077–4082. [122] T. Konrad, P. Vicini, K. Kusterer, A. Hoflich, A. Assadkhani, H.J. Bohles, A. Sewell, H.J.
[97] A.R. Smith, T.M. Hagen, Vascular endothelial dysfunction in aging: loss of Akt- Tritschler, C. Cobelli, K.H. Usadel, alpha-Lipoic acid treatment decreases serum
dependent endothelial nitric oxide synthase phosphorylation and partial lactate and pyruvate concentrations and improves glucose effectiveness in lean
restoration by (R)-alpha-lipoic acid, Biochem. Soc. Trans. 31 (2003) 1447–1449. and obese patients with type 2 diabetes, Diabetes Care 22 (1999) 280–287.
[98] V. Saengsirisuwan, F.R. Perez, J.A. Sloniger, T. Maier, E.J. Henriksen, Interactions of [123] D. Ziegler, H. Nowak, P. Kempler, P. Vargha, P.A. Low, Treatment of symptomatic
exercise training and alpha-lipoic acid on insulin signaling in skeletal muscle of diabetic polyneuropathy with the antioxidant alpha-lipoic acid: a meta-analysis,
obese Zucker rats, Am. J. Physiol., Endocrinol. Metab. 287 (2004) E529–E536. Diabet Med. 21 (2004) 114–121.
[99] K.J. Cho, H. Moini, H.K. Shon, A.S. Chung, L. Packer, Alpha-lipoic acid decreases [124] T. Heitzer, B. Finckh, S. Albers, K. Krohn, A. Kohlschutter, T. Meinertz, Beneficial
thiol reactivity of the insulin receptor and protein tyrosine phosphatase 1B in effects of alpha-lipoic acid and ascorbic acid on endothelium-dependent, nitric
3T3-L1 adipocytes, Biochem. Pharmacol. 66 (2003) 849–858. oxide-mediated vasodilation in diabetic patients: relation to parameters of
[100] T.D. Foley, L.A. Petro, C.M. Stredny, T.M. Coppa, Oxidative inhibition of protein oxidative stress, Free Radic. Biol. Med. 31 (2001) 53–61.
phosphatase 2A activity: role of catalytic subunit disulfides, Neurochem. Res. 32 [125] C.M. Sena, E. Nunes, T. Louro, T. Proenca, R. Fernandes, M.R. Boarder, R.M. Seica,
(2007) 1957–1964. Effects of alpha-lipoic acid on endothelial function in aged diabetic and high-fat
[101] B. Boivin, S. Zhang, J.L. Arbiser, Z.Y. Zhang, N.K. Tonks, A modified cysteinyl- fed rats, Br. J. Pharmacol. 153 (5) (2007) 894–906.
labeling assay reveals reversible oxidation of protein tyrosine phosphatases in [126] M. Montagnani, L.V. Ravichandran, H. Chen, D.L. Esposito, M.J. Quon, Insulin
angiomyolipoma cells, Proc. Natl. Acad. Sci. USA 105 (2008) 9959–9964. receptor substrate-1 and phosphoinositide-dependent kinase-1 are required for
[102] S.H. Ross, Y. Lindsay, S.T. Safrany, O. Lorenzo, F. Villa, R. Toth, M.J. Clague, C.P. insulin-stimulated production of nitric oxide in endothelial cells, Mol. Endocri-
Downes, N.R. Leslie, Differential redox regulation within the PTP superfamily, nol. 16 (2002) 1931–1942.
Cell. Signal. 19 (2007) 1521–1530. [127] M. Federici, R. Menghini, A. Mauriello, M.L. Hribal, F. Ferrelli, D. Lauro, P. Sbraccia,
[103] S.R. Lee, K.S. Yang, J. Kwon, C. Lee, W. Jeong, S.G. Rhee, Reversible inactivation of L.G. Spagnoli, G. Sesti, R. Lauro, Insulin-dependent activation of endothelial nitric
the tumor suppressor PTEN by H2O2, J. Biol. Chem. 277 (2002) 20336–20342. oxide synthase is impaired by O-linked glycosylation modification of signaling
[104] B. Diesel, S. Kulhanek-Heinze, M. Holtje, B. Brandt, H.D. Holtje, A.M. Vollmar, A.K. proteins in human coronary endothelial cells, Circulation 106 (2002) 466–472.
Kiemer, Alpha-lipoic acid as a directly binding activator of the insulin receptor: [128] T.M. Hagen, R. Moreau, J.H. Suh, F. Visioli, Mitochondrial decay in the aging rat heart:
protection from hepatocyte apoptosis, Biochemistry 46 (2007) 2146–2155. evidence for improvement by dietary supplementation with acetyl-L-carnitine and/or
[105] N. Jessen, L.J. Goodyear, Contraction signaling to glucose transport in skeletal lipoic acid, Ann. N.Y. Acad. Sci. 959 (2002) 491–507.
muscle, J. Appl. Physiol. 99 (2005) 330–337. [129] K. Petersen Shay, R.F. Moreau, E.J. Smith, T.M. Hagen, Is alpha-lipoic acid a
[106] G.D. Cartee, J.F. Wojtaszewski, Role of Akt substrate of 160 kDa in insulin- scavenger of reactive oxygen species in vivo? Evidence for its initiation of stress
stimulated and contraction-stimulated glucose transport, Appl. Physiol. Nutr. signaling pathways that promote endogenous antioxidant capacity, IUBMB Life
Metab. 32 (2007) 557–566. 60 (2008) 362–367.
1160 K.P. Shay et al. / Biochimica et Biophysica Acta 1790 (2009) 1149–1160

[130] S. Vasdev, V. Gill, L. Longerich, S. Parai, V. Gadag, Salt-induced hypertension in [141] P. Chaudhary, G.H. Marracci, D.N. Bourdette, Lipoic acid inhibits expression of
WKY rats: prevention by alpha-lipoic acid supplementation, Mol. Cell. Biochem. ICAM-1 and VCAM-1 by CNS endothelial cells and T cell migration into the spinal
254 (2003) 319–326. cord in experimental autoimmune encephalomyelitis, J. Neuroimmunol. 175
[131] S. Vasdev, C.A. Ford, S. Parai, L. Longerich, V. Gadag, Dietary lipoic acid (2006) 87–96.
supplementation prevents fructose-induced hypertension in rats, Nutr. Metab. [142] E.Y. Lee, C.K. Lee, K.U. Lee, J.Y. Park, K.J. Cho, Y.S. Cho, H.R. Lee, S.H. Moon, H.B.
Cardiovasc. Dis. 10 (2000) 339–346. Moon, B. Yoo, Alpha-lipoic acid suppresses the development of collagen-induced
[132] S. Vasdev, C.A. Ford, S. Parai, L. Longerich, V. Gadag, Dietary alpha-lipoic acid arthritis and protects against bone destruction in mice, Rheumatol. Int. 27 (2007)
supplementation lowers blood pressure in spontaneously hypertensive rats, J. 225–233.
Hypertens. 18 (2000) 567–573. [143] M. Morini, L. Roccatagliata, R. Dell'Eva, E. Pedemonte, R. Furlan, S. Minghelli, D.
[133] S. Vasdev, V. Gill, S. Parai, V. Gadag, Dietary lipoic acid supplementation Giunti, U. Pfeffer, M. Marchese, D. Noonan, G. Mancardi, A. Albini, A. Uccelli,
attenuates hypertension in Dahl salt sensitive rats, Mol. Cell. Biochem. 275 Alpha-lipoic acid is effective in prevention and treatment of experimental
(2005) 135–141. autoimmune encephalomyelitis, J. Neuroimmunol. 148 (2004) 146–153.
[134] M. Louhelainen, S. Merasto, P. Finckenberg, R. Lapatto, Z.J. Cheng, E.M. Mervaala, [144] G.H. Marracci, W.E. Marquardt, A. Strehlow, G.P. McKeon, J. Gross, D.C. Buck, L.B.
Lipoic acid supplementation prevents cyclosporine-induced hypertension and Kozell, D.N. Bourdette, Lipoic acid downmodulates CD4 from human T
nephrotoxicity in spontaneously hypertensive rats, J. Hypertens. 24 (2006) lymphocytes by dissociation of p56(Lck), Biochem. Biophys. Res. Commun. 344
947–956. (2006) 963–971.
[135] A. El Midaoui, J. de Champlain, Prevention of hypertension, insulin resistance, [145] R.V. Schillace, N. Pisenti, N. Pattamanuch, S. Galligan, G.H. Marracci, D.N.
and oxidative stress by alpha-lipoic acid, Hypertension 39 (2002) 303–307. Bourdette, D.W. Carr, Lipoic acid stimulates cAMP production in T lymphocytes
[136] A.E. Midaoui, A. Elimadi, L. Wu, P.S. Haddad, J. de Champlain, Lipoic acid prevents and NK cells, Biochem. Biophys. Res. Commun. 354 (2007) 259–264.
hypertension, hyperglycemia, and the increase in heart mitochondrial superox- [146] P. Larghero, R. Vene, S. Minghelli, G. Travaini, M. Morini, N. Ferrari, U. Pfeffer, D.M.
ide production, Am. J. Hypertens. 16 (2003) 173–179. Noonan, A. Albini, R. Benelli, Biological assays and genomic analysis reveal lipoic
[137] M. Takaoka, Y. Kobayashi, M. Yuba, M. Ohkita, Y. Matsumura, Effects of alpha- acid modulation of endothelial cell behavior and gene expression, Carcinogenesis
lipoic acid on deoxycorticosterone acetate-salt-induced hypertension in rats, 28 (2007) 1008–1020.
Eur. J. Pharmacol. 424 (2001) 121–129. [147] Y.S. Cho, J. Lee, T.H. Lee, E.Y. Lee, K.U. Lee, J.Y. Park, H.B. Moon, alpha-Lipoic acid
[138] C.J. McMackin, M.E. Widlansky, N.M. Hamburg, A.L. Huang, S. Weller, M. inhibits airway inflammation and hyperresponsiveness in a mouse model of
Holbrook, N. Gokce, T.M. Hagen, J.F. Keaney Jr., J.A. Vita, Effect of combined asthma, J. Allergy Clin. Immunol. 114 (2004) 429–435.
treatment with alpha-lipoic acid and acetyl-L-carnitine on vascular function and [148] W.J. Zhang, B. Frei, Alpha-lipoic acid inhibits TNF-alpha-induced NF-kappaB
blood pressure in patients with coronary artery disease, J. Clin. Hypertens. activation and adhesion molecule expression in human aortic endothelial cells,
(Greenwich) 9 (2007) 249–255. FASEB J. 15 (2001) 2423–2432.
[139] T. Kunt, T. Forst, A. Wilhelm, H. Tritschler, A. Pfuetzner, O. Harzer, M. Engelbach, A. [149] U. Ikeda, T. Ito, K. Shimada, Interleukin-6 and acute coronary syndrome, Clin.
Zschaebitz, E. Stofft, J. Beyer, Alpha-lipoic acid reduces expression of vascular cell Cardiol. 24 (2001) 701–704.
adhesion molecule-1 and endothelial adhesion of human monocytes after [150] S.J. Wang, H.H. Chen, Presynaptic mechanisms underlying the alpha-lipoic acid
stimulation with advanced glycation end products, Clin. Sci. (Lond.) 96 (1999) facilitation of glutamate exocytosis in rat cerebral cortex nerve terminals,
75–82. Neurochem. Int. 50 (2007) 51–60.
[140] H.S. Kim, H.J. Kim, K.G. Park, Y.N. Kim, T.K. Kwon, J.Y. Park, K.U. Lee, J.G. Kim, I.K. [151] S. Stoll, H. Hartmann, S.A. Cohen, W.E. Muller, The potent free radical scavenger
Lee, Alpha-lipoic acid inhibits matrix metalloproteinase-9 expression by alpha-lipoic acid improves memory in aged mice: putative relationship to NMDA
inhibiting NF-kappaB transcriptional activity, Exp. Mol. Med. 39 (2007) 106–113. receptor deficits, Pharmacol. Biochem. Behav. 46 (1993) 799–805.