Categories
Tutorials

How to Understand Clinical Research, Part I: Accessing and Reading Research

researchA major part of the intrigue surrounding nootropics has to do with the fact that many of these compounds have not been largely studied. In effect, we are gambling with our neurochemistry in order to gain some benefit in our mental functions. But we are not without resources which can improve our chances of using nootropics safely & effectively. While the body of evidence behind nootropic agents is not large, it is growing, & will likely continue to grow with increasing rapidity as public interest in nootropics increases. Drawing upon this background of research can help us understand how nootropic agents work, in whom they work, & what the risks are. To this end, I will be launching a multi-part tutorial on how to understand & interpret clinical trials, designed for both novices & more advanced users. Topics we’ll cover include:

  • Validity & bias
  • Types of studies & hierarchy of evidence
  • Reading results (graphs & tables)
  • Methodology
  • Basic biostatistics

How to access clinical research

Pubmed search
A Pubmed search with limitations for clinical trials, free full text, & publication within the last 5 years.

First of all, clinical research is generally accessible by online databases through universities or hospitals. If you have access to some of these databases through your institution, such as Medline or Ebscohost, I highly recommend familiarizing yourself with them. For those without institutional database access, Pubmed offers a large open-access catalog of many journal articles. Google Scholar is another option for finding studies, but does not offer advanced search functions.

Pubmed screenshot 2
The abstract is shown, as well as full-text links on the right side.

Here are some other tips when searching for journal articles:

  • I would generally recommend limiting one’s search to full text articles, as abstracts do not often reveal the full story of a study.
  • Searching by MeSH terms (analogous to tags for topics) usually provides more relevant results than a basic keyword search. This involves searching for a MeSH term, selecting it, then running the search.
  • More recent results (preferably within the last 5 years) are preferable, as scientific research can move fast. Depending on the topic area, however, you might find yourself stretching your search to include up to 10 years.
  • Be aware of the country of origin of the article, as standards for publication may vary.
  • Authors who write many articles on the same topic may be biased &/or highly knowledgeable.
Pubmed screenshot 3
Select the desired MeSH term, add it to your search on the right side, then run your search.

Structure of a journal article

So you have located a journal article of interest. Fortunately, every journal article generally follows a similar structure. This organisation is designed to present the details of the study in an intuitive order.

  • The abstract is a short summary of study’s methods & results.
  • The background section reviews the current state of understanding in the topic area of interest. The investigators conducting the study also explain what they are trying to show.
  • In the methods portion, key details of how the study works are defined:
    • Endpoints or outcomes are what is being measured, such as performance on a cognitive test
    • Experimental variables are what is being tested, such as the study drug & the control against which it is compared (placebo or standard treatment)
    • The type of individuals the investigators wanted to analyse in their study as test subjects
    • The allocation or assignment of enrolled individuals to either treatment groups (who receive the study drug) or control groups is typically visualized in a flowchart
    • Statistical tests used to analyse the data
  • The results section is where authors list their findings only (without interpretation). These include:
    • Baseline characteristics– a description of the final sample. Most often, this is summarized in table labelled as Table 1. When reading this section, think about the age, race, geography, & health status of the sample, & whether they are similar to you.
    • Outcomes– how did people who took the drug do in comparison to those who took the control? These data will be presented in tables, charts, graphs, & text.
  • Considered to be the most important section, the discussion area is where investigators interpret the results- what they mean, whether they are significant, where there could be error, the weaknesses of their study, & areas for further research. What is stated in this section can sometimes be highly contentious.

Some tips for reading an article:

  • The background section is not usually necessary unless if the topic area is new to the reader- if you are extensively researching a drug by reading multiple articles, you will find that many of their background sections are similar. However, if you don’t understand what’s covered in the background section, bring yourself up to speed with other resources such as Wikipedia.
  • Some prefer to read the abstract first to obtain a rapid summary of the study, then the discussion second for a detailed look at how the authors felt about the findings.
  • Always compare the raw numbers from the results section against the authors’ interpretation in the discussion section. Never take what the authors state at face value. Do the numbers actually show what they claim is happening?
  • Yes, the word «data» is plural.
  • I personally prefer to print out the pdf article & write comments on the hard copy as I read.
  • It’s not uncommon to read the same article several times. These subjects are quite advanced, & many details are important.
  • Check the articles cited in the bibliography for other studies that might be related to your topic.
Table 1.
A (very short) table 1. More meticulous studies will list more baseline characteristics of test subjects.

Summary

In review, using clinical data can provide a powerful edge when making decisions about nootropics. The informed nootropic user is better able to discern which nootropics are safe & effective.

  • Clinical research is accessible within databases which are offered through institutions. The general public can access some research through resources such as Pubmed or Google Scholar.
  • All journal articles follow the same general format consisting of an abstract, background, methods, results, & discussion sections. Knowing where to find what information you need within an article can make reading articles faster.
Categories
Methylene Blue Nootropics Reviews

Methylene Blue as a Nootropic? (Review)

Since its initial synthesis in 1886, the phenothiazine derivative methylene blue (MB) has been established as a highly versatile chemical agent with a diverse span of uses, ranging from treating malaria to dying textiles[1]. Within the past few years, preclinical research has suggested a possible neuroprotective benefit from MB administration. MB is believed to promote neuronal cell health by supporting mitochondrial function. Animal studies have yielded promising results in neurocognitive tests[2][3]. Here is what you need to know if you’re interested in using methylene blue.

How does Methylene Blue work?

Mitochondria are organelles within cells that play the key role of energy production. Cellular energy is stored in the form of adenosine triphosphate (ATP), one of the most important molecules in the cell. As the name suggests, ATP contains three linked phosphate groups. Removal of each group releases a large amount of energy, which is expended in supporting cellular function. Subsequent removal of ATP produces ADP (adenosine diphosphate) & AMP (adenosine monophosphate). ATP is produced within mitochondria as a final product of respiration, a series of biochemical reactions that extract energy from glucose. These biochemical reactions require oxygen & electron carriers (e.g. NADH).

Poteet E, Winters A, Yan L, Shufelt K, Green KN, Simpkins JW, et al. Neuroprotective actions of methylene blue & its derivatives. PLoS One. 2012;7(10):e48279-.
Methylene blue acts as an artificial electron carrier, promoting mitochondrial respiration. The net outcome is more energy available as ATP for cellular processes.[4]
Methylene blue supports mitochondrial respiration by functioning as an additional electron carrier[5]. MB receives electrons from NADH through mitochondrial complex I, itself being reduced to leuco-MB (MBH2). Leuco-MB then donates the electrons to cytochrome C, upon which it is recycled back to MB. These reactions serve to create a high proton (H+) concentration in the space between the inner & outer mitochondrial membranes. This leads to the passage of H+ down the concentration gradient, through mitochondrial complex V. In doing so, ADP & a phosphate (Pi) are joined to form ATP. Leuco-MB can also act as a free radical scavenger, neutralising superoxides by accepting electrons & itself becoming oxidized back to MB[6]. In this way, leuco-MB acts to prevent direct oxidative damage caused by free radicals.

Rojas JC, Bruchey AK, Gonzalez-Lima F. Neurometabolic mechanisms for memory enhancement and neuroprotection of methylene blue. Prog Neurobiol. 2012 Jan;96(1):32-45.
Methylene blue preferentially accumulates in more active neurones (A), & potentiates mitochondrial & synaptic activity (B). These processes result in increased & improved neurotransmission (C), which is thought to be the mechanism behind the neurocognitive benefits associated with MB.[7]
MB has been observed to preferentially localise in neurones that are more active[3]. Stimulated mitochondria in these neurones modulate genomic expression of proteins that further potentiate mitochondrial respiration via nuclear respiratory transcription factor (NRF-1), resulting in increased expression of cytochrome oxidase (COX), nitric oxide synthase (NOS-1), NMDA receptors, & AMPA receptors. Strengthened synaptic connections as a result of these processes result in improved memory.

The pharmacologic mechanism behind the neuroprotective activity of methylene blue is unique in that it does not involve a receptor-ligand interaction, as do most drugs. In addition, MB also exhibits an atypical dose-response curve– one that has been described as hormetic[8]. Hormesis is a phenomenon where lower doses produce optimum responses while higher doses or exposures may actually produce the opposite effect. Hormesis is an intriguing pattern that may explain the dose-responses associated with exercise & oxidative stress, where the right amount of exercise-induced oxidative stress induces a cascade of favourable physiologic adaptations that can mitigate more severe stressors[9].

Rojas JC, Bruchey AK, Gonzalez-Lima F. Neurometabolic mechanisms for memory enhancement and neuroprotection of methylene blue. Prog Neurobiol. 2012 Jan;96(1):32-45.
An example hormetic dose-response curve. Note the inverse response caused with higher doses.[10]
As previously mentioned, metabolism of MB involves reduction to leukomethylene blue (MBH2). MB is primarily eliminated in the urine (75%)[11].

What is it like?

I have tested BlueBrainBoost’s formulation with the following results. I have noticed increased energy and decreased fatigue, with an onset of up to 1 hour and duration of 2-4 hours. The only adverse effects were discolouration of the mouth and urine. I used a dosage of 10 mg (20 drops) in the morning sublingually before brushing my teeth. During this time, I was also taking 30 mg/day coluracetam, 500 mg/day ashwagandha, & 600 mg/day NAC. I suspect that coadministration of CoQ10 and creatine may have a synergistic effect based on the pharmacologic site and mechanism of action.

Is it safe?

methylene blue nootropicMethylene blue is associated with a very favourable safety profile. It is generally well-tolerated at doses lower than 2 mg/kg.[12] The most noticeable side effect of MB is blue discolouration of the oral cavity and blue or blue-green discoloration of the urine. These effects are reversible and not harmful. [13] Staining of the teeth can be removed with repeated tooth-brushing, and discolouration of the urine ceases after the drug is fully removed from the system. Other reported adverse effects include a mild headache and dizziness[14].

MB does exhibit some serotonergic activity. This is due to its inhibition of enzymatic degradation of serotonin by MAO-A. Intravenous doses higher than 5 mg/kg have led to the development of serotonin syndrome. This risk is increased in individuals already taking other serotonergic agents (e.g. tianeptine, St. John’s Wort, common antidepressants, dextromethorphan, tramadol). For these reasons, individuals at risk should avoid coadministration of MB with serotonergic agents by at least 2 weeks (or more depending upon the agent), start at low doses, & increase carefully to an effective dose.

Neurotoxicity has been associated with some preparations of MB as a result of chemical impurities. The presence of heavy metals used in the synthesis of MB can have adverse effects on neurones. Thus, only pharmaceutical grade formulations are recommended for human consumption – not lab grade, & not aquarium grade. These formulations may not meet USP standards and may contain up to 11% contaminants.

How should I take it?

Because MB’s role as a neuroprotective agent in humans is still being studied, there is as yet no recommended dosage. The animal doses used in preclinical trials roughly converts to a human equivalent dose of 0.16–0.64 mg/kg administered sublingually. Sublingual administration may produce higher bioavailability than oral administration, but causes more staining of the mouth. I calculated my dose like so:

  1. 0.16 to 0.64 mg/kg × 54.43 kg = 8.71 mg to 34.84 mg per dose
  2. 10 mg/1 mL = 8.71 mg/x mL → 0.87 mL × 20 gtt/1 mL = 17 gtt to 3.5 mL per dose SL (gtt = drops)

It should be noted that due to the hormetic dose-response curve, the response to MB may decrease with higher doses. MB is typically formulated as a 10 mg/mL solution, where 1 drop = 0.05 mL = 0.5 mg. The bottle should be shaken well before administration.

Summary

Overall, I would recommend methylene blue to individuals looking for an inexpensive extra boost in energy. I have not tested MB long enough to notice changes in cognition or memory, but the pre-clinical studies & pharmacologic literature seem to support this benefit.

  • Methylene blue supports mitochondrial respiration & strengthens synaptic connections, which may lead to decreased fatigue and enhanced cognition & recall. MB exhibits a hormetic dose-response curve.
  • The safety profile has been well-characterised, and MB has generally been shown to be well-tolerated. I believe the most important warnings are those concerning serotonin syndrome and chemical impurities.
  • The best-estimated dosage is only an approximation from animal studies. MB is not yet recommended for human consumption for the purpose of improving cognition and memory.
  • Only pharmaceutical grade formulations of MB should be used.
Methylene Blue
7.5
Focus
8
Mood
7.5
Memory
8
Stimulation
5.5
Relaxation
6.5
Safety
Reviewer 8.3
Summary
Methylene Blue improves mood, memory and energy levels, as well as mitochondrial function (and may also delay aging). I think it is a powerful tool to have in your arsenal, and the BBB solution is cheap and convenient, therefore I highly recommend it to anyone.

References   [ + ]

1. Ginimuge PR, Jyothi SD. Methylene blue: revisited. J Anaesthesiol Clin Pharmacol.
2. Callaway NL, Riha PD, Bruchey AK, Munshi Z, Gonzalez-Lima F. Methylene blue improves brain oxidative metabolism & memory retention in rats. Pharmacol. Biochem. Behav. 2004; 77:175–181.
3, 7. Rojas JC, Bruchey AK, Gonzalez-Lima F. Neurometabolic mechanisms for memory enhancement & neuroprotection of methylene blue. Prog Neurobiol. 2012 Jan;96(1):32-45.
4. Poteet E, Winters A, Yan L, Shufelt K, Green KN, Simpkins JW, et al. Neuroprotective actions of methylene blue & its derivatives. PLoS One. 2012;7(10):e48279-.
5. Gonzalez-Lima F, Barksdale BR, Rojas JC. Mitochondrial respiration as a target for neuroprotection & cognitive enhancement. Biochem Pharmacol. 2014 Apr 15;88(4):584-93.
6. Miclescu A, Basu S, Wiklund L. Methylene blue added to a hypertonic-hyperoncotic solution increases short-term survival in experimental cardiac arrest. Crit. Care Med. 2006; 34:2806–2813.
8. Bruchey AK, Gonzalez-Lima F. Behavioral, physiological, and biochemical hormetic responses to the auto-oxidizable dye methylene blue. Am. J. Pharm. & Toxicol. 2008; 3:72–79.
9. Ji LL, Gomez-Cabrera MC, Vina J. Role of free radicals & antioxidant signaling in skeletal muscle health and pathology. Infect Disord Drug Targets. 2009;9(4):428–444.
10. Rojas JC, Bruchey AK, Gonzalez-Lima F. Neurometabolic mechanisms for memory enhancement and neuroprotection of methylene blue. Prog Neurobiol. 2012 Jan;96(1):32-45.
11. Medscape® 5.1.2, (electronic version). Reuters Health Information, New York, New York.
12, 14. Ginimuge PR, Jyothi SD. Methylene blue: revisited. J Anaesthesiol Clin Pharmacol. 2010 Oct;26(4):517-20.
13. Gillett MJ, Burnett JR. Medications and green urine. Intern Med J. 2006 01;36(1):64-6.