**7. Conclusions**

new chelators, or the efficacy of antioxidant formulas [166, 167]. Raman spectroscopic techni‐ que has been developed for the monitoring of Raman hemoglobin bands to evaluate oxygen‐ ation capability, oxidative stress and deformities of thalassemic erythrocytes and to assess the responses to drug therapies [168]. Consistent with the study, in reference [169], serum PON activity and total antioxidant capacity were significantly lower in patients with the β-thalas‐ semia trait patients, MDA and carotid artery intima-media thickness were significantly higher in β-thalassemia trait. The total antioxidant capacity, MDA, and CIMT levels were correlated with serum PON1 (r = 0.945, -0.900, 0.940 and -0.922 respectively). Additionally, serum total

An earlier study in 1986 showed that patients with Hb H diseases, including α-thalassemia 1 or α-thalassemia 2 and 21 with α-thalassemia 1/Hb Constant Spring, had increased activities of erythrocyte SOD, GPx, and CAT when compared with those of the controls. The α-thalas‐ semia 1/Hb CS patients had higher SOD and GPx activities, but lower CAT activity than the patients with α-thalassemia 1/2 [171, 172]. One year later, a study of oxidative stress and the antioxidants in β-thalassemia/hemoglobin E patients in Thailand was conducted [173]. Significantly higher levels of urine N-acetyl-β-D-glycosaminidase, MDA and β2-microglobulin along with aminoaciduria and proximal tubular abnormalities were found in pediatric αthalassemia patients (Hb H disease and HbS/CS), and this was possibly due to increased oxidative stress [174]. A one-year treatment with DFP significantly decreased serum ferritin, NTBI, and MDA (*p* <0.05) of transfusion-independent β-thalassemia/HbE patients. Mean pulmonary arterial pressure and pulmonary vascular resistance were diminished significantly (*p* <0.05). All those parameters were still improved after subgroup analysis was done for the high ferritin group (>2500 ng/ml). The results imply that DFP therapy alone improved iron overload and oxidative stress and the compliance was positive [175]. Oxidative stress was increased in Thai HbE/β-thalassemia patients, as the blood GSH decreased, GSH/GSSG ratio reduced markedly, superoxide anion released from blood cells elevated highly, and γglutamylcysteine ligase activity was increased. Additionally, basal forearm blood flow was significantly increased whereas forearm vasodilatory response to reactive hyperemia was

When using ESR spectroscopic quantification of hemin, the serum hemin readily catalyzed free radical reactions and it would be a major pro-oxidant in the blood circulation of βthalassemia Hb E patients [177]. A previous study showed a precipitous decrease in αtocopherol and increased TBARS concentrations in both plasma and lipoproteins obtained by Thai β-thalassemia Hb E patients. Cholesteryl linoleate showed a reduction of 70% in LDL, while other cholesterol ester levels showed a lower reduction. A good correlation of NTBI and TBARS (*p* <0.01) in LDL strongly supported the contention that iron overload is responsible for initiating the lipid peroxidation in thalassemia patients [178]. The ESR results demonstrated a magnitude of increased lipid fluidity in thalassemic lipoproteins. Lipid fluidity at the LDL and HDL cores showed a good correlation with the oxidative stress markers and the αtocopherol level, suggesting that the hydrophobic region of the thalassemic lipoprotein would be a target site for oxidative damage [179]. Gas chromatography/mass spectrometric (GS/MS) technique has been validated in quantifying ortho- and meta-tyrosine as biomarkers of protein

antioxidant capacity and MDA levels were well correlated (r = -0.979) [170].

140 Pharmacology and Nutritional Intervention in the Treatment of Disease

depressed [176].

Under iron overload, oxidative stress plays a major role in the pathophysiologic complications of thalassemia patients. Free extracellular toxic iron (e.g. NTBI and LPI) and intracellular redox iron (e.g. LIP and plasma membrane nonheme iron) that have been identified in thalassemic blood and tissues are responsible for the generation of oxidative stress by catalyzing a formation of oxygen radicals over the antioxidant capacity of the cells. Consequently, there is a rationale to support iron chelation therapy for the elimination of the free-iron species and to promote the free-radical scavenging activity of the antioxidants. Not only synthetic (vitamin C, vitamin E and NAC) but natural (e.g. polyphenolics, flavonoids and fish oils) antioxidants are also capable of ameliorating such increased levels of oxidative stress. Taken together with an effective iron chelator, antioxidants may provide a substantial improvement in hemolytic anemia cases, and particularly in thalassemia patients. Most importantly, natural antioxidants are ubiquitous and very cheap whereas antioxidant supplements are free from the side effects commonly encountered in iron chelation and chemotherapeutic treatments.

#### **Abbreviations**



PMA = phorbol myristyl acetate

PMN = polymorphonuclear cells

RES = reticuloendothelial system ROS = reactive oxygen species

SOD = superoxide dismutase

TBI = transferrin-bound iron TBRG = Thai black rice grass TFRG = Thai fragrant rice grass TRRG = Thai red rice grass

TIBC = total iron-binding capacity

**Acknowledgements**

**Author details**

Thailand

Somdet Srichairatanakool1

kornpathom, Thailand

through Professor Suthat Fucharoen, MD.

This work was partially supported by the Office of Higher Education Commission and Mahidol University under the National Research University Initiative, Thailand Research Fund through Professor Suthat Fucharoen, MD. and by a Research Chair Grant from the National Science and Technology Development Agency (NSTDA) and Mahidol University

Antioxidants as Complementary Medication in Thalassemia

http://dx.doi.org/10.5772/57372

143

1 Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai,

2 Thalassemia Research Center, Institute of Molecular Bioscience, Mahidol University, Na‐

and Suthat Fucharoen2\*

\*Address all correspondence to: suthat.fuc@mahidol.ac.th

WG = wheat grass XO = xanthine oxidase

TBARS = thiobarbituric acid reactive substances

PON1 = paraoxonase 1

RBC = red blood cells

*sc* = subcutaneously SI = serum iron

