THE EFFECTIVENESS OF INOSITOL SUPPLEMENTATION IN WOMEN WITH POLYCYSTIC OVARY SYNDROME

Wendy Thompson

Graduate Seminar

ANNU 696

March 27th, 2014

2

Outline• Background

• PCOS• Insulin Resistance• Inositol

• Objective• Results

• Relationship between PCOS and inositol• Possible mechanism of action• Effectiveness of myo-inositol • Compare the effectiveness of inositol isoforms

• Conclusions/Implications• Limitations• Questions

3

The Significance of the PCOS

National Institutes of Health Office of Disease Prevention, 2012

• Complex, Multifactorial

• Heterogeneity

• Under-diagnosed

4 Billion Dollars!

4

Pathophysiology of P

CO

S

Rotstein, A., Srinivasan, R., Wong, E.McMaster Pathophysiology Review (MPR), 2013

5

How is PCOS Diagnosed?

NIH 1990 Rotterdam 2003 AE-PCOS Society 2006

• Hyperandrogenism• Chronic Anovulation

---Both criteria needed

• Hyperandrogenism• Oligo-and/or anovulation• Polycystic ovaries

---2 of 3 criteria needed

• Hyperandrogenism• Ovarian dysfunction

---Both criteria needed

First developed and most commonly used criteria today

Formulated to expand on NIH diagnostic definition

Formulated to provide an evidence-based definition

*All possible related disorders must be ruled out

NIH Evidenced Based Methodology Workshop on PCOS, 2012

6

Insulin Resistance and PCOS

Tony T. Lee; Mary E. Rausch, 2012

Thecal Cells

7

Inositol Structures

Croze M, 2013

8

Where do we get MYO?• Intake

• ~900mg per 2500kcal• Range: 300mg to 2,000mg

• Absorption• Bioavailability

• Free Form ~ 99%• Phytate form ~ 50%

• Synthesis• From glucose in kidneys ~4g/day

Clement R, 1980; Croze M, 2013; Clements R, 1979

9

Inositol Pathways

• Phosphorylated compounds • Component of cell membranes• Signal transduction/cellular signaling

• Epimerase activity

Croze M, 2013

10

Objective

To determine the effectiveness of inositol supplements on improving insulin sensitivity and

metabolic parameters in women with PCOS

11

WHAT IS THE CONNECTION BETWEEN PCOS AND INOSITOL?

Heimark D, McAllister J, Larner, J. (2014) Decreased myo-inositol to chiro-inositol (M/C) ratios and increased M/C epimerase activity in PCOS theca cells demonstrate increased insulin sensitivity compared to controls. Endocrine Journal. 61(2);111-117.

12

Methods

Ovarian Theca CellsFrom size-matched follicles

from age-matched subjects

Age: 28-40

PCOS:

Oligoovulation

Hyperandrogenism

(n=5+)

Control:

Normal Ovulation/Fertile

Normal Insulin Sensitivity

(n=5+)

Cells were cultured, scraped, processed and analyzed

13

MYO to CI Epimerase Values

0.006 ± 0.002 (n=10) vs. 0.017 ± 0.003 (n=11)

14

MYO to CI Ratio

18 ± 3 (n=6) vs. 5 ± 2 (n=7)

15

Conclusions/Limitations

• Conclusions:

• CI is overproduced and there is an implied deficiency of MYO in

PCOS theca cells

• MYO/CI ratios and epimerase activity are likely associated with

insulin resistance

• Limitations:

• Small sample size

• Used cultured cells

• Reasons for hysterectomy

• dysfunctional uterine bleeding, endometrial cancer, pelvic pain

16

Pathophysiology of P

CO

S

Alex Rotstein, Raginin Srinivasan, Erin WongMcMaster Pathophysiology Review (MPR), 2013

MECHANISM

Relationship of the insulin pathway to phosphatidylinositols

Phosphatidylinositol Synthase

Myo-Inositol

CMP

Phosphatidylinositol

CDP-DAGcytidine-

diphosphate diacylglycerol

M.L. Croze, C.O. Soulage (2013)

18Coustan D.,2013

myo-inositol may increase insulin

sensitivity by making more

phosphatidylinositol available

glucose transport (GLUT4), glycogen synthesis

glycogen synthesis, gluconeogenesis

glucose transport (GLUT4)

IRSs - insulin receptor substratesP13K - phosphatidyl inositol 3-kinasePDK1 - phosphoinositide-dependent kinase 1PKB - protein kinase B p85 - regulatory subunit p110 - catalytic subunit

19

DOES MYO SUPPLEMENTATION IMPROVE INSULIN SENSITIVITY IN WOMEN WITH PCOS?

Gerli S, Mignosa M, DI Renzo GC. (2003) Effects of inositol on ovarian function and metabolic factors in women with PCOS: a randomized double blind placebo-controlled trial. Euro Rev Med Pharmacol Sci. 7; 151-159.

20

Methods

Women with PCOS

Age: ≤35 years

MYO:

100mg 2x/day

(n=136)

Control:

placebo

(n=147)

• Not taking any medications that could influence hormonal profiles• No significant differences between groups at baseline

Study Design:RandomizedDouble-blindPlacebo-controlled

Length:16-weeks

21

Effects of Myo-Inositol

No significant change recorded for fasting insulin, insulin AUC in response to the glucose challenge, or fasting glucose

22

Subgroup Analysis

Morbidly Obese

BMI ≥ 37

BMI• No significant Δ• Pre: 42.5• Post: 42.3

HDL• No significant Δ• Pre: 0.95 mmol/L• Post: 0.95 mmol/L

Leaner

BMI < 37

BMI• P = 0.01• Pre: 29.4• Post 28.5

HDL• P = 0.02• Pre: 1.21 mmol/L• Post: 1.32 mmol/L

23

Conclusion

• Not effective in improving glucose or insulin parameters

• May have a beneficial side effect of weight loss with an associated increase in HDL

• Had no effect on BMI or HDL in morbidly obese women

200mg MYO12-16 weeks

24

Limitations

• Inconsistent timing of measurements

• 12-16 weeks

• High drop out rate

• 30% of treatment group

• Compliance

• Lifestyle changes

• Did not report CI for post-treatment

• Mean BMI = 35

25

WOULD WE SEE AN IMPROVEMENT IN INSULIN SENSITIVITY WITH AN INCREASED DOSE?

Costantino D, Minozzi G, Minozzi F, Guaraldi C. (2009) Metabolic and hormonal effects of myo-inositol in women with polycystic ovary syndrome: a double blind trial. Euro Rev Med Pharmacol Sci. 13; 105-110.

26

Methods

Women with PCOS

Age: 18 - 40 years

Treatment:

4g MYO + 400mcg FA

(n=23)

Control:

400mcg FA

(n=19)

• Instructed to not change usual habits of food, sport, and lifestyle• No significant differences between groups at baseline

Study Design:RandomizedDouble-blindPlacebo-controlled

Length:12-16 weeks

27

Changes in Metabolic Parameters

Plasma triglycerides decreased by 52%

28

Glucose and Insulin Measurements

Plasma insulin AUC decreased by 36%

ISIcomp increased by 84%

29

Conclusions

• Improved glucose tolerance and glucose handling

• Reduced the amount of insulin secreted in response to a

meal

• Provided minor benefits to cardiovascular health

independent from weight loss

• BP, Triglycerides, Cholesterol

4g MYO12-16 weeks

30

Limitations

• Small sample size (N=42)

• Inconsistent timing of measurements

• 6-8 weeks: OGTT

• Compliance was not measured or reported

• ~30% taking medications during the 2 months before the

study

• High variation in the glucose AUC

31

WHICH IS MORE EFFECTIVE – MYO OR DCI IN WOMEN WITH PCOS?

Pizzo A, Laganà AS, Barbaro L. (2014) Comparison between effects of myo-inositol and d-chiro-inositol on ovarian function and metabolic factors in women with PCOS. Gynecol Endocrinol. 30(3); 205-208

32

Methods

Women with PCOS

4g MYO + 400mcg FA

(n=25)

1g DCI + 400mcg FA

(n=25)

• No medication during the previous 6 months or during the study• No significant differences between groups at baseline

Study Design:RandomizedDouble-blind

Length:6 months

33

Effects of MYO and DCIMYOpre

MYOpost Δ%

DCIpre

DCIpost Δ%

BMI 25.1 ± 5.2 24.7 ± 4.6 - 24.37 ± 5.3 23.87 ± 4.5 -

Glic/IRI Ratio 5.52 ± 1.7 9.72 ± 3.8 +43.2% 5.83 ± 1.5 10.56 ± 3.7 +44.8%

HOMA 3.51 ± 1.7 1.75 ± 0.8 -100.6% 3.14 ± 1.1 1.61 ± 0.7 -95.0%

SBP (mmHg) 104.5 ± 14.0 96 ± 6.6 -8.9% 103.75 ± 14.3 96.25 ± 6.9 -7.8%

DBP (mmHg) 68.5 ± 8.2 64.5 ± 6.0 -6.2% 68.12 ± 9.3 64.37 ± 6.2 -

Glucose/Immunoreactive Insulin Ratio (Glic/IRI ratio)Homeostasis Model Assessment (HOMA)

34

Comparative Analysis of MYO and DCI

Δ% with MYOpost-treatment

Δ% with DCIpost-treatment

Δ% between MYO and DCI P-

value

Glic/IRI Ratio +43.21 +44.79% 1.58% 0.174

HOMA -100.57% -95.03% 5.54% 0.032

Systolic BP (mmHg) -8.85% -7.79% 1.06% 0.204

Glucose/Immunoreactive Insulin Ratio (Glic/IRI ratio)Homeostasis Model Assessment (HOMA)

35

Conclusion/Limitations

• Conclusions:

• Both effective in improving insulin sensitivity and SBP

• MYO had a greater decrease on DBP and insulin resistance

• Limitations:

• 4g of MYO vs. 1g of DCI

• Physiological ratio 40:1

• Small sample size (N=50)

• Did not control for lifestyle changes

• Compliance was not measured or reported

4g MYO vs 1g DCI6 months

36

Summary of Effectiveness100mg MYO 4g MYO + 400mcg FA 4g MYO +

400mcg FA1g DCI + 400mc FA

Length 3-4 months <2 months 6 months

N* 238 42 50

Age at Baseline

28.6 ± 1.7 28.8 ± 1.5 20.25 ± 4.47 19.25 ± 3.47

BMI (kg/m2) at Baseline

34.2 ± 2.5 22.8 ± 0.3 25.1 ± 5.2 24.37 ± 5.31

Metabolic Parameters Measured

BMI, WHR, Triglycerides,

VLDL, LDL, HDL

BMI, WHR, Triglycerides, Cholesterol, BP

BMI, BP

Insulin/Glucose Measured

Fasting glu/ins, AUC glu/ins

Fasting glu/ins, AUC glu/ins, ISIcomp

Glic/IRI ratio, HOMA

Significant Results

BMI, Leptin, HDL

SBP/DBPTriglycerides

Cholest. Glu AUC Ins AUC

SBP/DBPGlic/IRI ratio

HOMA

SBPGlic/IRI

ratio HOMA

Conclusions Not Effective/Effective

Effective Effective Effective

37

Safety of Inositol

• Very well tolerated• Dosage of 4g/day

• Minimal to no side effects

• Doses or 12-30g/day• Mild GI Distributions:

• Nausea• Flatus• Diarrhea

• Considered safe• 18g/day for 3 months• 2g/day for 1 year

Carlomagno G, Unfer V. Inositol Safety: Clinical Evidences. (2011) Euro Rev Med Pharmacol Sci. 15; 931-936.

38

Conclusion/Implications

• Conclusion:• 4g of MYO/400mcg FA may be beneficial to women with

PCOS in improving some metabolic parameters and insulin sensitivity

• Implications:• Lifestyle intervention should be the first-line of treatment• Could be beneficial to women who cannot tolerate

metformin due to side-effects• More research is needed

39

Limitations

• Short study length

• Varied diagnostic criteria

• Varied baseline measures

• Many different phenotypes

• No comparison insulin-sensitizing medications

• What happens if they stop taking inositol?

• Long-term safety

• Limited information on effectiveness of morbidly obese women

40

References• ACOG Practice Bulletin No. 108: Polycystic Ovary Syndrome. Obstet Gynecol. 2009;114(4):936–949.• Rotstein, A., Srinivasan, R., Wong, E. (2013) McMaster Pathophysiology Review (MPR)• Clements, R.S . Jr., Diethelm, A.G. (1979). The metabolism of myo-inositol by the human kidney. J. Lab.

Clin. Med. 93:210-19• Clement R. & Darnell, B. (1980) Myo-inositol content of common foods: development of a high-myo-

inositol diet. Am J. Clin. Nutr. 33: 1954067• Croze M. & Soulage C. (2013) Potential role and therapeutic interests of • myo-inositol in metabolic diseases. Biochemie. 95(10);1811-1827• Coustan D R Dia Care 2013;36:777-779• Heimark D, McAllister J, Larner, J. (2014) Decreased myo-inositol to chiro-inositol (M/C) ratios and

increased M/C epimerase activity in PCOS theca cells demonstrate increased insulin sensitivity compared to controls. Endocrine Journal. 61(2);111-117.

• Gerli S, Mignosa M, DI Renzo GC. (2003) Effects of inositol on ovarian function and metabolic factors in women with PCOS: a randomized double blind placebo-controlled trial. Euro Rev Med Pharmacol Sci. 7; 151-159.

• Costantino D, Minozzi G, Minozzi F, Guaraldi C. (2009) Metabolic and hormonal effects of myo-inositol in women with polycystic ovary syndrome: a double blind trial. Euro Rev Med Pharmacol Sci. 13; 105-110.

• Pizzo A, Laganà AS, Barbaro L. (2014) Comparison between effects of myo-inositol and d-chiro-inositol on ovarian function and metabolic factors in women with PCOS. Gynecol Endocrinol. 30(3); 205-208

• Carlomagno G, Unfer V. Inositol Safety: Clinical Evidences. (2011) Euro Rev Med Pharmacol Sci. 15; 931-936.

41

EXTRA CONTENT

43

Summary of Baseline Data100mg MYO 4g MYO +

400mcg FA4g MYO + 400mcg FA

1g DCI + 400mc FA

Length 3-4 months <2 months 6 months 6 months

N* 91 23 25 25

Age at Baseline

28.6 ± 1.7 28.8 ± 1.5 20.25 ± 4.47 19.25 ± 3.47

BMI (kg/m2) at Baseline

34.2 ± 2.5 22.8 ± 0.3 25.1 ± 5.2 24.37 ± 5.31

WHR at Baseline

0.88 ± 0.2 0.88 ± 0.2 - -

Fasting Insulin mIU/L

16.7 ± 3.7 32.5 ± 4.1 - -

PCOS Diagnostic Criteria

OO/OA & PCO OO & high serum free T AND/OR hirsutism

Rotterdam = 2/3 of the following: HA, OO/OA, PCO

Rotterdam = 2/3 of the following: HA, OO/OA, PCO

OO = oligoovulation; AO = anovulation; HA = hyperandrogenism; PCO = polycystic ovaries

44

100mg MYO 4g MYO + 400mcg FA

4g MYO + 400mcg FA

1g DCI + 400mc FA

BMI 0.9% NS NS NS

Triglycerides NS 52% - -

HDL 5.6% - - -

Total Cholesterol NS 18.6% - -

Systolic Blood Pressure - 3.1% 8.1% 7.1%

Diastolic Blood Pressure - 6.8% 5.8% NS

Fasting Insulin NS NS - -

Fasting glucose NS NS - -

GTT insulin AUC NS 36% - -

GTT Glucose AUC - 15.8% - -

ISIcomp - 84% - -

Glic/IRI Ratio - - 76.1% 81.1%

HOMA - - 50.1% 48.7%

45M.L. Croze, C.O. Soulage/ Ciochimie 95 (2013) 1811 - 1827

Phosphatidylinositol Synthase

46

Calculation for Whole-Food Consumption

• ---Remember this 4g supplement is on top of normal daily consumption, which is estimated to be 900mg in 2,500kcal

• ---In theory, you would need to consume 5g to have similar effects:

47

Sample 5g Myo-Inositol Diet

• Breakfast:• ½ cantaloupe (710mg)• 1 C milk (10mg)• 1 C bran flakes (110mg)• 3 Walnuts (13g)• ½ C grapefruit juice (456mg)

• Snack:• 2 dried prunes (94mg)• 16 almonds (84mg)• 1 Kiwi (136mg)

• Lunch:• 1 orange (307mg)• 2 slices of stone ground wheat

bread (576mg)• 2 T of Peanut Butter (122mg)• ½ C Kidney Beans (250mg)

• Snack:• 1 C Lima beans (300mg)• 1 Mango (99mg)• 1 slice stone ground wheat bread (288

mg)

• Dinner:• 1C Great Northern Beans (880mg)• 1/2 C artichoke hearts, canned (116mg)• 1 C tomatoes (54mg)• ¼ C onion, yellow (22mg)• 6 oz. chicken (14mg)

• Dessert:• 1 Grapefruit (400mg)

Totals: MYO: 5,068mg*

kcal: 2,342

48

Inositol Food Sources

Clements RS Jr, Darnell B. Myo-inositol content of common foods: development of a high-myo-inositol diet. Am J Clin Nutr. (1980)

49Croze M. & Soulage C. (2013) Potential role and therapeutic interests of myo-inositol in metabolic diseases. Biochemie. 95(10);1811-1827

50

Diagnostic ValuesDiagnosis/Test Criteria

Insulin Resistance in Women 3 or more of the following:• Waist Circumference > 88cm • Triglycerides ≥ 150 mg/dL• HDL Cholesterol <50 mg/dL• Blood Pressure ≥ 130/85 mm/Hg• Fasting Glucose ≥ 100 mg/dL

Fasting Glucose/Insulin Ratio Insulin Resistance:• <4.5 in obese, euglycemic, non-Hispanic white

adult PCOS patients• <7.0 in adolescents

75g Oral Glucose Tolerance Test (at 2-hours)

Normal: <140mg/dLImpaired GT: 140-199 mg/dLDiabetes: ≥200 mg/dL

Fasting Insulin Hyperinsulinemia: 5 mIU/L (34.73 pmol/LL)

Waist to Hip Ratio (WHR) Females:• 0.80 or below = Low Risk• 0.81 to 0.85 = Moderate Risk• 0.85 or above = High Risk

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH)