The clinical and biological effects of ASEA ionized saline water /”redox supplement”
(co-administered with L-carnitine and omega-3 fatty acids plus multivitamins
dietary supplements) in a ~3-year-old boy with Duchenne muscular dystrophy (DMD)
from Romania – a case report
Wiki-like medical article (Open development interval: 2018 - ?)
- working paper preprint[
Version 1.1 (1.08.2018)
] (version 1.0 published on: 26.05.2017; last update on: 1.08.2018)
Pediatrician specialist with medical, interdisciplinary and transdisciplinary independent research
(Bucharest, Romania), E-mail: email@example.com
Important note: The latest (free) version of this article can be downloaded from this URL.
1st Motto: „ASEA works at some fundamental level in the body that we may never understand” (2011,
Dr. Chase N. Peterson MD [1999-2014], the former president of the University of Utah from 1983 to
2nd Motto: „ASEA is based on technology that the scientist don’t yet understand.” (2013, Dr. A.S.
Narain Naidu MD Phd, microbiologist, immunologist and researcher, author of the reference volume
3rd Motto: „We didn’t think that drinking ASEA would shift metabolites chronically. We thought it
would do something during exercise, but not after a week of drinking it [without concomitant exercise:
author’s note]. After working with the bioinformatics statistical division, we were able to determine that
drinking ASEA over one week caused a shift in 43 metabolites, not a little shift: it was a large shift that
caught us by surprise.” (David Christopher Nieman [URL2, URL3] PhD and full professor at the College of
Health Sciences at Appalachian State University, and director of the Human Performance Lab at the
North Carolina Research Campus (NCRC) in Kannapolis, NC) (video interview URL, from minute 5:40)
4th Motto: „Pediatrics – what a joy, what a feeling of accomplishment when helping Nature heal its
children or prevent their diseases and accidents!” (Andrei-Lucian Drăgoi, pediatrician specialist and
] Online paper preprint: DOI: 10.13140/RG.2.2.21420.36486
] Andrei-Lucian Dragoi research pages on: ResearchGate, Academia.edu, ViXra, GSJournal;
This paper presents a case report on the clinical and biological effects of (ionized saline water called) “ASEA
redox supplement” (ASEA-rs) oral solution (co-administered with L-carnitine and omega-3 fatty acids plus
multivitamins dietary supplements) in a ~3-year-old boy with Duchenne muscular dystrophy (DMD) from
ASEA-rs was tested on both animals and humans. In vitro studies on various human cells showed that
ASEA-rs is a very potent NRF2 selective activator (with transient effect): the studies conducted in vivo (on
both animals and humans) also support this main pharmacological mechanism of ASEA-rs, with no toxicity up
to high doses (in contrast with corticosteroids which are usually reserved in Romania for DMD children with
age above 4 years, given their toxicity profile and adverse effects including immunosuppression, growth delay,
osteopenia, osteoporosis and overweight) and a satisfactory bioavailability especially in the vital organs (in
which NRF2 also reaches its highest intracellular cytoplasmatic concentrations), which assures the strong NRF2
activation effects of ASEA-rs indirectly observed in vivo.
ASEA was clearly demonstrated to activate tissular lipases (probably also via NRF2 pathway) and to
significantly increase some fatty acids serum levels that are further internalized by skeletal muscles and
myocardium and used as “fuel” by muscular cells (myocytes) (and cardiomyocytes), partially sparing the
glycogen reserves of myocytes/cardiomyocytes and so raising the resistance of skeletal muscles to effort and
possibly the resistance and contractility of myocardium.
Based on its demonstrated potent selective NRF2 activation effect, its beneficial effects on muscle effort
resistance and its excellent safety profile, I have prescribed ASEA-rs to this ~3-year-old child with DMD, with
a minimal set of clinical signs at his age, but with significant biological alternations in the biochemical markers
of muscular damage (rhabdomyolysis): the results (after the first 3 months with ASEA-rs, associated with L-
carnitine and omega-3 fatty acids plus multivitamins supplements) were a significant reduction in the creatine
(phospho)kinase (CK/CPK) and CK-MB isoform serum levels.
Keywords: ASEA redox supplement (ASEA-rs) oral solution, 3-year-old boy, Duchenne muscular dystrophy
(DMD), Romania, NRF2 selective activator, tissular lipase activator, skeletal muscles and myocytes,
myocardium and cardiomyocytes, corticosteroids, creatine (phospho)kinase (CK/CPK), CK-MB isoform
Important note (1). This atypical URL-rich paper (which maximally exploits the layer of hyperlinks in this
document), chooses to use Wikipedia links for all the important terms used. The main motivation for this
approach was that each Wikipedia web-article contains all the main reference (included as endnotes) on the
most important terms used in this paper: it’s simply the most practical way to cite entire collections of important
articles/books without using an overwhelming list of footnote/endnote references. The secondary motivation
(for using Wikipedia hyperlinks directly included in keywords) was to assure a “click-away“ distance to short
encyclopedic monographs on all the (important) terms used in this paper, so that the flow of reading to be
Important note (2). This paper also exploits the advantages of the hierarchic tree-like model of presenting
informational content which is very easy to be kept updated and well organized.
I. Essential information on Duchenne muscular dystrophy (DMD)
1) Etiology, epidemiology and pathophysiology. Duchenne muscular dystrophy (DMD)[URL2a, URL2b] is a
severe X-linked recessive muscular dystrophy caused by a mutation (inherited from a person's parent in
~2/3 of DMD cases and non-inherited de novo mutation in ~1/3 of DMD cases) in the gene coding the
dystrophin (dys) protein, which is a cytoplasmic protein and a vital part of a protein complex (with many
subunits) that connects the myocyte cytoskeleton to the surrounding basal lamina of the extracellular
matrix through the muscular cell membrane (sarcolemma). Normal skeletal myocytes contain small
amounts of dystrophin but its total/partial absence or abnormal length leads to excess calcium cations
penetrating the sarcolemma and causing excess water to enter into all mitochondria which then burst and
lead (by several [not clearly understood yet] aberrant intracellular signaling pathways) to increased
intracellular oxidative stress, sarcolemma permanent damage and myocytes necrosis. Skeletal muscles
progressive destruction (rhabdomyolysis) causes muscular fibers to be progressively replaced by adipose
and connective tissue (pseudohypertrophic muscular dystrophy or muscular pseudohypertrophy, for
example calf and tongue pseudohypertrophy): that is why affected muscles may look larger than normal
(which is due to increased fat content) and may show contractures (caused by muscle fibers shortening
and fibrosis). DMD is the most common type of muscular dystrophy and has an incidence of ~1/3600
born male infants.
2) Clinical signs and symptoms. Muscle weakness associated with progressive muscle atrophy (with
secondary fatigability, frequent falls and progressive difficulty in walking and getting up from lying or
sitting position) usually begins around the age of 4 years in boys and worsens quickly. Typically muscle
loss initially occurs in the lower limbs (thighs, calves) and pelvis/hip (causing difficulties in standing up)
followed by those of the upper arms (shoulders), neck, spinal and thoracic muscles: Most DMD boys are
unable to walk by the age of 12 years. Scoliosis and lumbar hyperlordosis are common and due to axial
muscles damage (with decrease in spinal muscular tonus). Advanced stages DMD patients may have
respiratory disorders (due to respiratory muscles damage), swallowing difficulties (with high risk of
aspiration pneumonia). DMD patients may also present neurobehavioral, learning and memory disorders
(also believed to be the result of absent or dysfunctional dys in the brain). Females with a single copy of
the defective dys-gene may also show mild signs and symptoms (without being classified as DMD)
depending on their pattern of X-inactivation: DMD may occur in females who have an affected father and
a carrier mother, which is a very rare situation however.
3) Labs and other tests. DMD patients have extremely high creatine kinase (CK) and possibly (very) high
CK-MB isomer serum levels: the serum levels of aspartate transaminase (AST) and alanine transaminase
(ALT) are also very increased. Consequently, myoglobin (produced by rhabdomyolysis) also attains high
concentrations in serum and urine. Electromyography (EMG) distinguishes the weakness caused by
destruction of muscle tissue. Echocardiography may show dilative cardiomyopathy secondary to
myocardial fibrosis (which can occasionally lead to congestive heart failure and/or arrhythmias)
4) Positive diagnosis. DNA testing demonstrating mutation(s) in one or more of the 79 exons of dys-gene
(located on the short [p] arm of X chromosome, at locus 21 [Xp21]) can often make the diagnosis at birth
or confirm the diagnosis in most suspected cases.
a. Muscle needle biopsy (with immunocytochemistry and immunoblotting for dystrophin) may be
performed when DNA testing fails to find the mutation: dystrophin absence indicates DMD and
dystrophin presence helps to distinguish DMD from milder dystrophinopathy phenotypes (depending
on the amount and molecular size of dystrophin)
5) Differential diagnosis (DD). DD includes Becker's muscular dystrophy (BMD) (with incidence of 1.5-6/
100 000 born boys, much less common than DMD) and other MDs.
6) The pathophysiological and symptomatic DMD treatment. DMD doesn’t have a curative treatment,
but only a pathophysiological and symptomatic treatment which may delay the onset of symptoms and
increase the quality of life.
a. Avoiding inactivity (such as prolonged bed rest), physical therapies (to minimize the development of
contractures and deformity, to assist with breathing exercises and methods of clearing secretions),
swimming, orthoses (to delay the onset of contractures) and corrective surgery may help in muscular
symptoms and skeletal complications.
b. Non-invasive/invasive assisted ventilation may be required in those with advanced respiratory muscles
c. Pacemaker implant for patients with cardiac rhythm and conduction disorders.
d. Medications: steroids such as prednisolone and deflazacort (which were demonstrated to slow muscle
degeneration and to produce short-term improvements in muscle strength and function up to 2 years,
including walking period prolongation according to some reports); β2 agonists such as salbutamol
(which were demonstrated to increase muscle strength, but don’t modify disease progression),
anticonvulsants (to possible seizures control) and immunosuppressants (to delay damage to dying
muscle cells). Important note: steroids (including prednisone) were demonstrated to increase the
myocyte production of utrophin (a fetal protein homologous to dys, encoded by UTRN gene, a 900 kb
gene found on the long arm [q] of human chromosome 6) which closely resembles dys and partially
compensates its lack in DMD patients, in which utrophin expression is dramatically increased.
e. Genetic counseling for people with family history of DMD.
7) The etiology-targeted DMD treatment (still under research).
a. Exon-skipping gene therapy (ESGT) with antisense oligonucleotides (oligos/AONs like eteplirsen
or drisapersen) to trigger skipping of an exon (adjacent to the exon affected by mutation) so that to
restore the reading frame and production of a (still-truncated but) more functional version of dys:
ESGT essentially converts DMD phenotype into a BMD phenotype. Clinical improvement in 12
patients in a Phase 1-2a study was shown, in which patients whose performance had been declining
instead improved, from 385 meters to 420 meters at the 6-minute walk distance test. For ESGT to be
efficient on medium and long term, AONs must be periodically redelivered into muscles.
b. Stem cell replacement therapy (SCRT) with pericytes (a type of multipotent stem cells which have
the ability to be delivered systemically and uptaken by crossing the vascular barrier, then to fuse and
form myotubes) injected arterially, crossing through arterial walls into muscles, where they can
differentiate into potentially functional myocytes.
c. CRISPR/Cas9-mediated genome editing (not currently feasible in humans, but potentially feasible in
the future) which can precisely remove a targeted mutation of dys-gene, by allowing the DNA repair
mechanisms of myocytes to replace that mutant dys-gene with a normal dys-gene.
d. Ataluren (PTC124/ Translarna®) indicated for DMD patients that can walk and are more than 5 years
old. Ataluren probably makes ribosomes less sensitive to premature stop codons, especially for 'UGA'
(by promoting insertion of certain near-cognate transfer RNA [tRNA] at the site of nonsense codons,
with no apparent effects on downstream mRNA transcription, processing, stability nor on the resultant
protein) thus helping to produce a functional dys similar to the non-mutated dys, as it was already
demonstrated in DMD, where ataluren treatment increases expression of full-length dys.
Unfortunately, Phase II trial of ataluren in DMD human patients was suspended when participants did
not show significant increases in the 6-minute walk distance test.
e. Sildenafil was demonstrated to improve the muscular blood flow in DMD boys (in a small study
published in May 2014 in the journal “Neurology”): a larger and longer trial on tadalafil was designed
and initiated so that to determine if this increased muscular blood flow will translate into clinical
improvement in muscle function of DMD patients.
f. Rimeporide, a sodium–hydrogen antiporter 1 inhibitor is speculated to reduce sodium and calcium
overload in cells of DMD patients: rimeporide is in preclinical trials as of May 2015.
8) Prognosis. The average life expectancy of DMD patients is 26 years (with a maximum between 30-50
years in rare cases who benefit from excellent care). Most DMD patients become wheelchair-dependent
early in life, and the gradual development of cardiac hypertrophy and/or restrictive respiratory
insufficiency typically results in premature death between ages of 20-30 years.
II. Essential information on ASEA “redox supplement” (ASEA-rs) and NRF2 activators
1) Production, patents and chemical properties of ASEA-rs. ASEA-rs is produced by an international
direct selling and multi-level marketing company called “ASEA” [URL2] founded in 2007 and
headquartered in Salt Lake City, Utah, USA. The present ASEA-rs is based on a technology developed
and patented[URL2] by Medical Discoveries, Inc, and was previously called “MDI-P”.
a. ASEA-rs is a clear, colorless liquid generated by electrolysis of a highly purified sterile saline. ASEA-
rs is distributed in ~1 liter plastic bottles. ASEA-rs has a saline concentration of ~0.27g NaCl /100ml
(0.27%) and additionally contains (in a total concentration of about 1%) highly reactive chlorine and
oxygen species: the oxidant (OX) species from ASEA-rs include hydrogen peroxide (H2O2),
superoxide anions species (O2- and HO2-), hypochlorous acid (HOCl), hydronium cation (H3O+),
hypochlorite radical (OCl*), singlet oxygen 1[O2], (partially soluble) oxygen biatomic molecules (in
triplet ground state) and triatomic molecules (O3) (ozone) etc.; the reductive (RED) species from
ASEA-rs include hypochlorite anions (ClO−) (also paired as sodium hypochlorite Na+ClO− [NaOCl]),
chlorine anions (Cl−), biatomic molecules (Cl2), (partially soluble) hydrogen biatomic molecules (H2),
hydrogen anions (H-) etc.
b. MDI-P had a relatively high concentration (~25-50%) of those reactive species and was initially tested
for its microbicidal properties: it was found to be a very fast-acting, broad-spectrum microbicidal
solution effective against Staphylococcus aureus, Pseudomonas aeruginosa, Legionella pneumophila
and Candida albicans[URL1, URL2].
2) Certifications of ASEA-rs. After obtaining its certificate of safety for oral consuming [URL2a - ASEA-rs safety,
classification and certifications brochure; URL2b, URL3a, URL3b], ASEA began selling ASEA-rs as a dietary supplement from
2009. ASEA-rs is currently produced in a production facility which is FDA registered, NSF certified,
GMP compliant [URL2a - ASEA-rs safety, classification and certifications brochure; URL2b].
a. In 2015, ASEA partnered with BioAgilytix Labs (specialized in biomarker testing) which validates the
existence of reactive oxygen species in ASEA-rs and product quality.
b. The first European country in which ASEA-rs was registered as a dietary supplement was Italy, under
the name “ASEA advancing life” with index number 54229 in the official list of dietary supplements
approved in Italy (see page 168 of the linked pdf list). ASEA-rs also appears in the list of dietary
supplements approved in EU with no. NUT 1936 (see page 842 of the linked pdf list)
3) ASEA-rs as a NRF2 selective activator. ASEA-rs was tested on both animals and humans. In vitro
studies on various human cells showed that ASEA-rs is a very potent (but transient) selective NRF2
activator (even in low concentrations in vitro), avoiding the activation of NF-kb (having interesting
favorable immunomodulating properties) [URL2a – ASEA-rs main in vitro study, URL2b]: the studies conducted in vivo
(on both animals and humans) also support this main pharmacological mechanism of ASEA-rs, with no
toxicity up to high doses (calculated per kilogram of body mass) and a satisfactory bioavailability (which
assures the strong effect demonstrated in vivo) [URL2a - ASEA-rs safety, classification and certifications brochure; URL2b]. All
studies on ASEA-rs are briefly presented in one official brochure published by ASEA [URL1a – ASEA-rs
studies - brochure, URL1b]. NRF2 governs the Phase II cellular stress response [URL2] so that NRF2 activation can
induce over-expression in more than 150 genes (which are involved in the Phase II cellular stress
response): five of these genes were demonstrated to be over-expressed by ASEA-rs oral consumption
[URL1a – ASEA-rs gene study, URL1b, URL1c]. As NRF2 is ubiquitously expressed with the highest concentrations in
the cytoplasm of cells from the vital organs (in descending order: the kidney, muscle, lung, heart, liver,
and brain) [URL], it is expected that ASEA-rs to mainly protect human vital organs (with the additional
argument that these vital organs have the largest blood supply, which is directly proportional with the
concentration ASEA-rs may reach in these vital organs).
a. “Brief Summary of Results for Objective (2): An 800% increase in GPx antioxidant efficacy in HMVEC-L cells was seen
after 24 hours exposure from low-concentration ASEA (no concentration dependence seen). A transitory increase of up to
500% was seen in SOD antioxidant efficacy between 30 to 90 min. again after exposure to low-concentration ASEA (<
1%). In both cases, the low concentrations of ASEA were comparable to blood concentrations possible from oral dosing,
though data is not available to confirm this. Concentration dependence at very low concentrations might be seen if such
was carefully investigated. Exposure to high-concentration ASEA, in comparison, elicited only a small relative increase in
GPx antioxidant efficacy that was not concentration dependent. An increase in SOD efficacy was not seen for either high-
concentration ASEA or after long (24 hr) exposures. In subsequent investigations, this information will be used to
determine optimal concentrations and time points to study concentration dependence (less than 0.1% and 0-120 minutes).”
[URL1a – ASEA-rs main in vitro study, URL1b]
4) ASEA-rs was also shown to be induce apoptosis in “cultures of dysfunctional, stressed or damaged
cells”. See below some paragraphs extracted from the cited study.
a. “The induction of cell death in cultures of dysfunctional, stressed or damaged cells by ASEA infusion should also be
explored. Natural healing processes involve a repair or replace mechanism by which marginally damaged cells are
repaired, when possible, or undergo apoptosis, programmed death, if they cannot be repaired and then are replaced through
mitosis of healthy neighboring cells. It is fairly evident that ASEA infusion, of itself, is not causing direct stress to exposed
cells, however, it might tend to increase the efficiency of certain cytokine “death domain” messengers (Cachexin) that are
designed to induce cell death in dysfunctional or damaged cells. The nuclear translocation of NRF2 can be considered part
of the phase II oxidative defense response which includes expression of antioxidants, DNA repair molecules and other
known repair mechanisms.” [URL1a – ASEA-rs main in vitro study, URL1b]
5) Additionally, ASEA activates human tissular lipases (most probably via NRF2 pathway) and
significantly increases the fatty acids serum levels that are further internalized by skeletal muscles and
myocardium and used as “fuel” by muscular cells (myocytes) (and cardiomyocytes), partially sparing the
glycogen reserves of myocytes/cardiomyocytes and so raising the resistance of skeletal muscles to effort
and possibly the resistance and contractility myocardium: see prof. D.C. Nieman’s first metabolomics
study on ASEA-rs [URL-ASEA-rs first metabolomics study].
a. Based on prof. D.C. Nieman’s first metabolomics study on ASEA-rs (and its encouraging results),
University of North Carolina (Chapel Hill) also started a second trial on ASEA-rs called “Effect of
ASEA on Energy Expenditure and Fat Oxidation in Humans” [URL – ASEA-rs second trial on
metabolism] with results summarized in ASEA-rs main “all-studies” brochure [URL1a – ASEA-rs studies -
brochure, URL1b] at page 2, in a rubric entitled “Influence of ASEA redox supplement ingestion on
6) Antidoping certification of ASEA-rs. Given its antidoping certification, ASEA-rs is also widely used in
the present by various athletes around the world.
7) Comparison between ASEA-rs and other NRF2 activators. There are many known natural molecules
(especially flavonoids) and plant extracts that were demonstrated to be NRF2 activators in vitro and/or in
vivo [see also the author’s site subdomain nrf2.dragoii.com]: sulforaphane [URL2], resveratrol [URL2],
quercetin [URL2], curcumin [URL2], Ginkgo biloba [URL2], ginseng [URL2], catechins [URL2] etc. There are also
some synthetic NRF2 activators like: dimethyl fumarate [URL2], monomethyl fumarate, metformin [URL2]
etc. However, all these molecules have tissular toxicity (especially liver toxicity) at high doses in contrast
with ASEA-rs which was demonstrated to have an excellent safety profile [URL - ASEA main in vitro
study]. Calorie restriction (which was demonstrated to prolong life span in humans and animals) was also
demonstrated to also imply a significant NRF2 activation effect (due to induced oxidative stress in calorie
restricted cells): physical exercise has a similar activation effect on NRF2. See below some paragraphs
extracted from the main in vitro study on ASEA-rs:
a. “At this point it is worth mentioning that NRF2 activity has been clearly detected in conjunction with low-concentration
ASEA exposure without the normal prior NF-kb activity. This suggests that phase II antioxidant defense mechanisms have
been stimulated without the normal prior phase I toxic response. This behavior has no precedent or is extremely rare. It
appears from the data that ASEA is able to stimulate antioxidant expression without ever eliciting a prior low-level phase I
toxic response.” [URL1a – ASEA-rs main in vitro study, URL1b]
b. “The infusion of a certain balanced mixture of redox signaling molecules, ASEA, into viable HMVEC-L and JB6 cell
cultures has been seen to elicit distinct bioactivity. No indications of toxicity or the expression of inflammatory cytokines
were observed and yet there was increased antioxidant and protective enzyme expression (as evidenced by increased
nuclear NRF2) and greatly increased efficacy for the two master antioxidants, GPx [glutathione peroxidase] and SOD
[superoxide dismutase]. This behavior suggests that ASEA infusion might tend to induce and enhance oxidative defense
mechanisms without inducing toxic or inflammatory responses in such cells. Such action is unprecedented or extremely
rare. Normally, low-level toxicity induces slight oxidative stress and inflammatory response which in turn induces
oxidative defense and cell repair mechanisms. It would be of interest to determine concentration dependency of this effect
with ultra-low-concentration ASEA infusions” [URL1a – ASEA-rs main in vitro study, URL1b]
c. “No toxic response was observed for any healthy cell culture in normal random phases(HMVEC-L or JB6) upon exposure to
high concentrations (up to 20%) of serum ASEA. Two methods were used to determine toxic response, the translocation
and accumulation of NF-kB and P-Jun in the nuclei. Both of these methods are known to be sensitive to low-levels of
toxicity, as verified by the positive control. A complete lack of toxic indication and/or inflammatory cytokines was
observed.” [URL1a – ASEA-rs main in vitro study, URL1b]
8) Topical forms of ASEA-rs. ASEA-rs has also topical variants (gels), which have higher concentration in
free radicals than the oral solution form: “RENU 28” and “RENU Advanced Skin Care”, which are briefly
presented in one official brochure published by ASEA [URL1a – RENU 28 studies - brochure, URL1b].
III. The main information on the child with Duchenne muscular dystrophy (DMD) clinical case
(with ASEA-rs prescription motivations/arguments)
1) Important argumentative note on ASEA-rs prescription in children with DMD under 12 years of
age. One of the warnings marked on its bottle recommends that ASEA-rs “should not be given to children
under 12 years of age” (a warning mainly addressed to parents who can freely buy ASEA-rs dietary
supplement from US and EU, as ASEA-rs doesn’t need a medical prescription to can be consumed for
health preventive purposes or by sick adolescents and adults). Given the excellent safety profile of ASEA-
rs (based on its extensive list of safety studies), I’ve personally considered that warning not an absolute
but only a relative contraindication, because I’ve personally estimated (based on some published studies
on steroids in DMD children) that benefits-to-risks ratio is much larger for ASEA-rs than for steroids
when applied to DMD children under 4 years of age: that is why I have decided to prescribe ASEA-rs to
this ~3-year-old DMD child (boy), a decision that showed biological and clinical benefits of ASEA-rs in
this medical case, with no side effects until present (as shall be detailed next)
2) Second argument for motivation of ASEA-rs prescription in a ~3-year-oled DMD child. Based on its
demonstrated immunomodulation properties (including its strong selective NRF2 activation effect), its
beneficial effects on muscle effort resistance and its excellent safety profile (no toxicity even for high
doses, in contrast with corticoids which are usually reserved in Romania for DMD children with age
above 4 years, given their toxicity profile and adverse effects including immunosuppression, growth
delay, osteopenia, osteoporosis and overweight), ASEA-rs was prescribed to this ~3-year-old child with
DMD, with a minimal set of clinical signs at his age, but with significant biological alternations in the
biochemical markers of muscular damage (rhabdomyolysis): the results (after the first 3 months with
ASEA-rs, associated with L-carnitine [Carnil solution produced by Anfarm Hellas] and omega-3 fatty
acids supplement [Omega 3 Junior syrup produced by Doppelherz] were a significant reduction in the
creatine (phospho)kinase (CK/CPK) and CK-MB isoform serum levels concomitant to only a slight
increase in muscular aspartate transaminase (AST) and alanine transaminase (ALT).
3) The first consult of the DMD boy in my pediatric office (from January 11th 2018, at 2 years and 8
months of age). The DMD boy first came to my pediatric office for consult in January 11th 2018 when
he was aged approximately 2 years and 8 months.
a. Anamnesis. When he was ~1-year-old (in the summer of year 2016), the boy had a high fever episode
and he was suspected for high risk bacterial infection, so that he was hospitalized in “Victor Gomoiu”
Children Hospital from Bucharest where he received a short cure (7 days) with antibiotics for urinary
tract infection (UTI) with Escherichia coli (with a slight enlargement of the left kidney, but no other
abnormalities on the abdominal ultrasound): with that hospitalization, the boy was discovered to have
high serum levels of AST, ALT and CK. After being discharged from the “V. Gomoiu” hospital, the
boy was redirected to the children neurology ward of “Alexandru Obregia” Hospital from Bucharest,
for further investigations and diagnosis: the genetic tests (ready on September 12th 2016) of both the
child and the mother showed the same mutation in the 52nd exon of dys-gene (a duplication of the
nucleotide number 7547) which very probable implies a premature interruption of dys-gene reading
from exon 53 to its last exon 79. Based on this genetic result, the boy was then diagnosed by the
neurologist with “oligosymptomatic progressive muscular dystrophy” and was recommended
physical therapy and periodic control (at every 6 months) in the children neurology ward (but with no
reassessment of the muscle damage biological markers at that time). The mother also gave information
about her brother (the maternal uncle of her boy) who “couldn’t walk and was immobilized to
bed from 7 years of age until his death at 18 years of age” (but she couldn’t present any medical
documents of her brother and his diagnosis). As expected, the mutation-carrier mother has no
biological or clinical signs of muscle damage (including no biological markers of heart muscle
damage and normal electrocardiography (ECG). The parents were told by the neurologist to wait until
the boy will be 4-year-old, for him to start a cure with Prednisone to delay the progress of the disease:
this (quite long) Prednisone temporization (decided by the neurologist) and the symptoms/signs of the
boy at that time (impaired extension of one limb when walking and running plus calves
enlargement) worried parents and these were the main reason which determined the parents to ask a
second medical opinion from me as a pediatrician specialist at Sika Medical clinic (also from
b. Physical examination. The main clinical signs found were: impaired extension of the right limb
(when walking), calves pseudohypertrophy (with 23/23cm maximum circumference of both
calves), slight tonus deficit of the axial/spinal muscles, extreme anxiety at the physical exam,
hyperkinetic child, moderate language delay (he only used ~20 correctly pronounced words at
that age and only used pairs of words, but rarely sentences with verbs). The rest of the physical
examination exam results were normal: cranial nerves tests in normal limits, normal breath rate and
pulmonary sounds, normal heart rate (with no heart murmurs), normal abdomen (without clinically
detectable hepato/splenomegaly), but with increased consistency stools (with defective discomfort),
normal diuresis and urination (with no kidney pain/sensibility), normal genital apparatus. Body mass:
14kg (Age: 2y8m) (in the normal range for sex and age). Body height: 91cm (Age: 2y8m) (in the
normal range for sex and age).
4) Based on diagnosis, anamnesis and physical examination (previously presented), I have requested
some basic imaging and laboratory exams (see next).
5) Medical imaging exams of the DMD boy (in chronological order):
a. Heart ultrasound (January 28th 2018): echographically normal (with the reserve that the child was
very anxious and hyperkinetic during this examination)
b. Abdominal ultrasound (*April 10th 2018; *parents delayed this exam because of objective
reasons): minimal hepatomegaly; all the other examined organs were echographically normal (with
the reserve that the child was very anxious and hyperkinetic during this examination)
6) Laboratory exams (rhabdomyolysis and inflammatory markers) of the DMD boy (in chronological
a. Gamma-glutamyl-transferase (GGT) (January 16th 2018): 10 U/ml (within the normal range)
b. AST – serum level (January 16th 2018): 473 U/L (~10 times the superior limit of the normal range; of
muscle origin, given the normal level of GGT)
c. ALT – serum level (January 16th 2018): 558 U/L (~17 times the superior limit of the normal range; of
muscle origin, given the normal level of GGT)
d. CK – serum level (January 16th 2018): 34 453 U/L (~200 times the superior limit of the normal range;
of muscle origin)
e. CK-MB – serum level (January 16th 2018): 1241 U/L (~52 times the superior limit of the normal
range; of heart muscle origin)
f. Myoglobin (MG) – serum level (January 22nd 2018): 2006 ng/mL (~28 times the superior limit of the
normal range; of muscle origin) (the child didn’t want to cooperate for urine sampling for determining
MG serum level)
g. C-reactive protein (CRP) – serum level (January 22nd 2018): 0.61 mg/L (within the normal range)
h. Erythrocyte sedimentation rate (ESR) – serum level (January 22nd 2018): 9 mm/h (within the normal
7) Given all the DMD patient information previously given, I have decided to give the following
recommendations (including medical treatment):
a. ASEA-rs solution, per os 30+30+0ml/day (~4ml/body_kg/day) (started from ~ January 22nd 2018)
b. L-carnitine as Carnil oral solution (conc. 1g/10ml, 10ml vials) (produced by Anfarm Hellas), per
os 0+½+0vials/day (after lunch, with fruit juice) (also started from ~ January 22nd 2018). Important
note. L-carnitine acts as a transporter of long-chain fatty acids into the mitochondria (where to be
oxidized for energy production): given the anticipated high levels of fatty acids produced by ASEA-rs
(as shown by the metabolomics study conducted by prof. Nieman on ASEA-rs [see Part II]), I have
used L-carnitine as an adjuvant for ASEA-rs.
c. Omega-3 fatty acids plus multivitamins oral supplement as Omega 3 Junior syrup (produced by
Doppelherz) (conc. ~8mg DHA/ml, 1.8mg EPA/ml; also containing vitamins A, D, C, E, B1
(thiamine), B2 (riboflavin), B6, B12 (cobalamin), niacin [vitamin B3], pantothenic acid [vitamin B5],
biotin [vitamin B7]) (started from ~ January 22nd 2018) 1.5+1.5+1.5ml/day (4.5ml/day in total).
Important note. I have chosen this DHA-EPA-multivitamin mix especially for the boy’s language
delay: I have chosen however a very small dose (4.5ml/day) given the age and the possibility that the
multivitamin (antioxidant) mix may inhibit ASEA-rs effect (by partially/totally neutralizing the free
radicals from ASEA-rs already absorbed in the blood)
d. Physical therapy: the parents weren’t compliant to this recommendation with the argument that their
boy “is already very active and full of energy”.
e. Psychological Consult: the parent’s weren’t compliant to this recommendation either, because of
some prejudice on this kind of consult, as they consider their boy psychologically “normal”.
8) I have then consulted the child monthly on: January 22nd 2018 (for reading the imaging/laboratory
exams results), February 15th 2018 (for routine checkup), March 22nd 2018 (for routine checkup and for
the list of laboratory exams to be repeated after April 8th 2018 [the Easter period in Romania])
9) (April 2018) Medical imaging exams of the DMD boy (in chronological order):
a. Abdominal ultrasound (*April 10th 2018; *parents delayed this exam because of objective
reasons): minimal hepatomegaly; all the other examined organs were echographically normal (with
the reserve that the child was very anxious and hyperkinetic during this examination).
10) (April 2018, after ~3 months of ASEA-rs 60ml/day plus L-carnitine 0.5/day, omega-3 fatty acids
supplement ~44mg/day and multivitamins mix) Laboratory exams (selected rhabdomyolysis
markers) of the DMD boy (in chronological order):
a. AST – serum level (April 17th 2018): 453 U/L (~9 times the superior limit of the normal range; of
muscle origin, given the normal level of GGT; versus 473 U/L on January 16th 2018)
b. ALT – serum level (April 17th 2018): 712 U/L (~22 times the superior limit of the normal range; of
muscle origin, given the normal level of GGT; versus 558 U/L on January 16th 2018)
c. CK – serum level (April 17th 2018): 25 426 U/L (~148 times the superior limit of the normal range; of
muscle origin; versus 34 453 U/L on January 16th 2018)
d. CK-MB – serum level (April 17th 2018): 632 U/L (~26 times the superior limit of the normal range;
of heart muscle origin; versus 1241 U/L on January 16th 2018)
11) Checkpoint conclusion. The ASEA-rs-based treatment from January-April 2018 (~3 months) was
associated with a slight AST serum level decrease of ~5%, an ALT serum level increase of ~28%, a
CK serum level decrease of ~26% and a very significant CK-MB serum level decrease of ~50%
(which was the main target of my ASEA-rs recommendation and may be explained by the fact that
ASEA-rs has stronger NRF2 activation effect on the myocardium, where the expression of NRF2 is larger
than in skeletal muscles)
12) ASEA-rs new increased daily dose. Given the encouraging CK-MB serum level decrease of ~50% (as
determined on April 17th 2018) I have transmitted to the family (without a new clinical consult until May
17th 2018) my updated recommendation to increase the ASEA-rs dose to 50+40+0ml/day (for a daily dose
of 90ml/day, which is equivalent to ~6.5ml/body_kg/day) from April 18th 2018 until August 1st 2018. I
a. I have also recommended a new set of laboratory exams for the last week of July 2018: AST,
ALT, GGT, CK, CK-MB and MG serum levels.
13) The consult from May 17th 2018. This consult was on May 17th 2018 (for routine checkup), when the
boy was ~3 years old.
a. Physical and mental examination. Normal extension of the right limb (when walking), calves
pseudohypertrophy (with ~23/23cm maximum circumference of both calves), no apparent tonus
deficit of the axial/spinal muscles, no anxiety at the physical exam, no agitation, slight language
delay (he uses ~30 correctly pronounced words at this age, but he builds true sentences using
verbs and some simple phrases). The rest of the physical examination exam results were normal:
cranial nerves tests in normal limits, normal breath rate and pulmonary sounds, normal heart rate (with
no heart murmurs), normal abdomen (without clinically detectable hepato/splenomegaly), but with
increased consistency stools (with defective discomfort), normal diuresis and urination (with no
kidney pain/sensibility), normal genital apparatus. Body mass: ~14.1kg (Age: 3 years) (in the normal
range for sex and age). Body height: 93.5cm (Age: 3 years) (in the normal range for sex and age).
14) Discussions (1). Given the small age of the boy, the small number of signs/symptoms up to present, the
fact that there is no “cut-off” exon number for a dys-gene mutation to exactly predict when an affected
boy will develop a DMD phenotype and when he will develop a BMD phenotype (additionally, in 1990
England et al. even noticed that a patient with mild Becker muscular dystrophy was lacking 46% of his
coding region for dystrophin [URL]), the diagnosis of DMD isn’t 100% sure yet: however, the severe form
of MD of his maternal uncle (with loss of walking from 7 years of age until his death at 18 years of age)
indicates this boy’s duplication of the nucleotide number 7547 from 52nd exon of dys-gene (which is
probably shared with his maternal uncle and surely inherited from his maternal grandmother [also mother
of his maternal uncle]) will more probably generate a DMD phenotype: additionally, there is a study in
which a targeted disruption of exon-52 in the mouse dys-gene had induced muscle degeneration similar to
that observed in DMD [URL]. The extremely (initial) high CK and CK-MB serum levels also
indicate/suggest a DMD phenotype found in its clinically oligosymptomatic initial stage. That is why I
have decided to start an aggressive therapy with ASEA-rs at least one year before the age of 4 years
(when he was temporized to begin a corticosteroid treatment or other treatment like ataluren or even
experimental treatments with AONs or stem cell [pericytes] replacement therapy)
a. The significant decrease of both CK and CK-MB serum levels (with ~28% and 50%
respectively) may be explained by an important decrease of the oxidative stress in DMD
myocytes: this effect may be produced by ASEA-rs via NRF2 pathway (an effect more
pronounced in myocardium than in skeletal muscles, due to NRF2 higher concentration in the
heart muscles versus skeletal muscles).
b. As ASEA-rs was not associated with any raise in AST/ALT (implying that ASEA-rs has no
detectable liver toxicity) in prof. Nieman’s 1st metabolomics study (see pages 20 and 21 from URL-
ASEA-rs first metabolomics study), it is improbable that the increase of ALT serum level by
~28% (observed in this ~3years DMD boy) to be caused by ASEA-rs through liver toxicity. As
ALT serum level is the only result that goes anti-trend (by increasing when all the other
enzymes serum level decrease), a laboratory ALT determination error is not excluded. ALT
increase by liver toxicity or hemolysis is also very improbable, AST serum levels would have also
raised. ASEA-rs was demonstrated to be an inductor of apoptosis in damaged cells in vitro, so it is
possible that the observed increased ALT serum level to be produced by a raise in apoptosis rate of
skeletal (and possibly myocardial) myocytes: the increased apoptosis rate may be concomitant to an
increase rate of new myocyte production (which may co-explain the decrease of CK and CK-MB,
secondarily to the important decrease in the DMD myocytes plausibly produced by ASEA-rs).
c. The future extensive set of laboratory exams I have scheduled in the last week of July 2018 will
surely clarify this observed increase in ALT serum level (from April versus January 2018).
15) The last consult (up to present) from July 31st 2018. The last consult (up to present) was on July 31st
2018 (for routine checkup and lab result reading), when the boy was ~3 years and 2 months old.
a. Physical and mental examination. Normal extension of the right limb (when walking), calves
pseudohypertrophy (with ~23[right]/23cm[left] maximum circumference of both calves), no
apparent tonus deficit of the axial/spinal muscles, no anxiety at the physical exam, no agitation,
slight language delay (he uses ~30-40 correctly pronounced words at this age, but he can imitate
over 100 words and builds true sentences using verbs and some simple phrases). The rest of the
physical examination exam results were normal: cranial nerves tests in normal limits, normal breath
rate and pulmonary sounds, normal heart rate (with no heart murmurs), normal abdomen (without
clinically detectable hepato/splenomegaly), normal stools without any defecation discomfort (after
dietary measures), normal diuresis and urination (with no kidney pain/sensibility), normal genital
apparatus. Body mass: ~14.2kg (Age: 3 years and 2 months) (in the normal range for sex and age) vs
~14.1kg (Age: 3 years and 2 months). Body height: 96.5cm (Age: 3 years and 2 months) vs 93.5cm
(Age: 3 years) (in the normal range for sex and age).
b. July 31st 2018, after ~2.5 months [March, April plus ~1st half May 2018] of ASEA-rs 60ml/day
[~4ml/body-kg/day] plus L-carnitine 0.5/day, omega-3 fatty acids supplement ~44mg/day and
multivitamins mix) AND other ~2.5months [~2nd half of May, June and July 2018] of ASEA-rs
90ml/day (40+50+0ml/day~6.5ml/body-kg/day) plus L-carnitine 0.5/day, omega-3 fatty acids
supplement ~44mg/day and multivitamins mix) - Laboratory exams (selected rhabdomyolysis
markers) of the DMD boy (in chronological order):
c. AST – serum levels: 205 (July 24th 2018) vs 453 U/L (April 17th 2018) vs 473 U/L (January 16th
2018) (a total decrease of ~56% in the last ~6 months)
d. ALT – serum levels: 492 (July 24th 2018) vs 712 U/L (April 17th 2018) (~22 times the superior limit
of the normal range; of muscle origin, given the normal level of GGT) vs 558 U/L on January 16th
2018) (a total decrease of ~ 12% in the last ~6 months)
e. GGT normal serum level of 10U/L (July 24th 2018) indicates no liver toxicity induced by ASEA.
f. CK – serum levels: 13 900 (July 24th 2018) vs 25 426 U/L (April 17th 2018) (~148 times the superior
limit of the normal range; of muscle origin) vs 34 453 U/L (January 16th 2018) (a total decrease of ~
60% in the last ~6 months).
g. CK-MB – serum levels: 365 (July 24th 2018) vs 632 U/L (April 17th 2018) (~26 times the superior
limit of the normal range; of heart muscle origin) vs 1241 U/L (January 16th 2018) (a total decrease
of ~ 70% in the last ~6 months)
h. Myoglobin – serum levels: 886ng/ml (July 24th 2018) vs 2006 U/L (April 17th 2018) (~28 times the
superior limit of the normal range) (a total decrease of ~ 55% in the last ~6 months)
i. The next consult (with the next set of control labs) is scheduled in the first week of December
16) Checkpoint conclusion. The ASEA-rs-based treatment from January-July 2018 (with 60ml ASEA/day
[~4ml/body-kg/day] in the first ~2.5 months and 90ml/day [~6.5ml/body-kg/day] in the next ~2.5 months)
was associated with a slight ALT serum level decrease of ~12%, an AST serum level decrease of
~56% (with normal GGT serum levels, thus no detectable liver toxicity of ASEA), a CK serum level
decrease of ~60%, a myoglobin serum level decrease of ~55% and a very significant CK-MB serum
level decrease of ~70% (which was the main target of my ASEA-rs recommendation and may be
explained by the fact that ASEA-rs has stronger NRF2 activation effect on the myocardium, where the
expression of NRF2 is larger than in skeletal muscles). This results suggest that ASEA may have very
potent muscular (including myocardial) protective effects, significantly limiting the muscular damage in
DMD patients, with the potential of even stronger effects in (milder) BMD phenotypes: this comes in the
“same pack” with no liver toxicity, no adverse effect on growth and development of the child and no other
adverse effects in other clinical spheres.
17) Final conclusions (at this stage of observation).
a. The significant decrease of both CK and CK-MB serum levels may be explained by a
(significant) decrease of the oxidative stress in DMD myocytes, a decrease produced by ASEA-rs
via NRF2 pathway (and more pronounced in the myocardium).
b. Similarly to steroids, it is not excluded that ASEA may also induce additional overexpression of
UTRN gene and utrophin synthesis subsequently [URL]. ASEA may act on UTRN gene via NRF2
pathway or, more probably (and also by NRF2-pathway), by upregulating sarcospan (SSPN) (a
25-kDa transmembrane protein located in the dystrophin-associated protein complex of skeletal
muscle cells; SSPN depends on dys for its proper transmembrane localization). SSPN
upregulates the levels of Utrophin-glycoprotein complex (UGC) to compensate dys loss in the
neuromuscular junction of DMD patients: utrophin expression is extremely increased in DMD
patients (and also female carriers) as a compensatory mechanism, both in dys-lacking muscle
fibers and in rare (revertant) fibers that express dystrophin, as a small proportion of muscle
fibers of DMD patients continue to show strong dystrophin staining (and these "revertant
fibers" are thought to arise by a mechanism that restores the reading frame [URL]). Normally,
SSPN upregulates both UGC and Dystrophin-associated Glycoprotein Complex (DGC) [URL1,
URL2]. SSPN regulates the amount of utrophin produced by the UGC to restore laminin binding
due to dys absence or inefficiency (of too-short dys isoforms from DMD phenotypes): if laminin
binding is not restored by SSPN, the cell membrane diminishes its surface and its adherence to
the extracellular matrix. In dystrophic mdx mice, SSPN increases levels of utrophin (by
inducing UTRG gene overexpression) and restores the levels of laminin binding, reducing the
symptoms of DMD [URL]. SSPN is also an essential regulator of Akt/PKB signaling pathways:
these signaling pathways will be hindered and muscle regeneration will not occur in the absence
c. There is also a small probability for ASEA to modify the sensibility of ribosomal protein
synthesis (translation) to stop codons, so that ASEA may also induce other DMD isoforms
(based on the skipping of reading stop codons) like Ataluren is hypothesized to act.
d. It is not excluded that ASEA may also (directly or indirectly) partially restore the reading frame
of dys-gene and so to increase the percent of "revertant fibers" in DMD patients.
18) New possible future studies based on this specific DMD case treated with ASEA-rs.
a. Given its clinical and biological effects in this DMD child case and its “prototype” selective NRF2
activator features, ASEA-rs and all the other known NRF2 activators may be tested in DMD and
BMD patients (in future blinded [b] randomized controlled trials [bRCTs]).
b. RCTs on NRF2 activators versus steroids in DMD/BMD cases (started before OR after 4 years of age)
may also be conducted.
c. DMD patients treated with ASEA can be verified for UTRN gene overexpression and utrophin high
d. DMD patients treated with ASEA can also be verified for intracellular existence of DMD isoforms
other the DMD pathological isoform expected in the specific exon-52 mutation (or other dys-exons
mutations) of each DMD patient in part.
e. Histological study on ASEA muscular effects, to check if ASEA actually increases the percent of
"revertant fibers" in DMD patients.
f. Only ~5% of DMD patients have exon-52 dys mutations [URL1, URL2], so that ASEA may have a great
potential to be tested in all types of mutation on all dys-gene exons, including in the patients with
milder BMD phenotype.
g. ASEA may be an important potential tool to test for and combat cellular oxidative stress in vital
organs (where NRF2 reaches its highest concentrations) and muscles (including the heart muscle, of
19) Important notes.
a. I have obtained the verbal consent of both parents to publish this medical case in both English and
Romanian, with the only condition to not mention the names of the child, parents or other relatives.
b. I shall periodically update this paper with fresh information on DMD, ASEA-rs and this specifically
c. From my (extensive) information, this case is the first documented case published in the world on
ASEA effects in a child with DMD.
IV. References were already integrated as URLs in the paper