ALIF-1 EBOO SAFE: TREATMENT

OF CORONARY ARTERY DISEASES

HEALTH TECHNOLOGY ASSESSMENT SECTION

MEDICAL DEVELOPMENT DIVISION
MINISTRY OF HEALTH MALAYSIA
016/2011
i
DISCLAIMER
Technology review is a brief report, prepared upon request, which draws on restricted
reviews from analysis of pertinent literature, on expert opinion and / or regulatory status
where appropriate. It is subjected to an external review process. While effort has been
made to do so, this document may not fully reflect all scientific research available.
Additionally, other relevant scientific findings may have been reported since completion
of this review.

Please contact: htamalaysia@moh.gov.my, if you would like further information.

Health Technology Assessment Section (MaHTAS),

Medical Development Division
Ministry of Health Malaysia
Level 4, Block E1, Precinct 1
Government Office Complex
62590 Putrajaya

Tel: 603 88831246

Fax: 603 8883 1230

Available at the following website: http://www.moh.gov.my

ii
Prepared by:
Puan Maharita Ab Rahman
Pharmacist
Health Technology Assessment Section (MaHTAS)
Ministry of Health

Reviewed by:
Datin Dr Rugayah Bakri
Deputy Director
Health Technology Assessment Section (MaHTAS)
Ministry of Health Malaysia

Dr Junainah Sabirin
Senior Principal Assistant Director
Health Technology Assessment Section (MaHTAS)
Ministry of Health Malaysia

External Reviewer:
Dato’ Dr. Omar Bin Ismail
Consultant Cardiologist & Head of Department
Department of Cardiology
Hospital Pulau Pinang

Dr. Roshida Hassan

Director
National Blood Centre,
Kuala Lumpur

DISCLOSURE

The author of this report has no competing interest in this subject and the preparation of
this report is totally funded by the Ministry of Health, Malaysia

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EXECUTIVE SUMMARY
Introduction
Ozone is a gas which was discovered in the mid-nineteenth century. It consists of three
oxygen atoms to form unstable molecule structure; O3. The gas is colourless with acrid
odour and can partially dissolve in water, but at standard pressure and temperature the
solubility of ozone is higher than oxygen. Concentrated mixtures of ozone and oxygen
that contain more than 20% of ozone can become explosive in both fluids and gases. The
ozone is toxic for animals and humans. The degree of damages caused by the ozone
depends on its concentration, temperature, humidity and exposure time.

This technology, Alif-1 EBOO SAFE® is newly available in Malaysia to treat CAD but
not in government health care facilities. Hence, Organization of Medical Ozone
Therapies Malaysia is planning to introduce this technology into Ministry of Health
(MOH) health care facilities. Therefore, this technology review was requested by Deputy
Director General (Medical), Medical Development Section, to find out the
effectiveness/efficacy, safety and cost-effectiveness of this technology in management of
coronary artery diseases.

Objective/Aim
The objective of this technology review was to assess the safety, efficacy/effectiveness
and cost-effectiveness of Alif-1 EBOO SAFE® in the management of coronary artery
diseases

Results and conclusions

Insufficient high quality scientific evidence was found on the effectiveness/efficacy and
safety of Alif-1 EBOO SAFE® in management of coronary artery diseases. Although as a
single machine, the ultrafiltration technology (claimed as similar technology with SAFE)
was discovered many years ago, in combination with Alif-1 EBOO technology, Alif-1
EBOO SAFE® demands for more evidence on human especially in the management of
coronary artery disease.

Methods
Electronic databases were searched, included PubMed, 1990-2011 EBM Reviews –
Cochcrane Databases of Systematic Reviews, 1990-2011 EBM Reviews – Cochcrane
Databases of Controlled Trial, National Horizon Scanning, INAHTA and FDA website,
for published reports. There was no limit in the search. Additional articles were identified
from reviewing the bibliographies of retrieved articles and information from Organization
of Medical Ozone Therapies Malaysia.

iv
 ALIF-1 EBOO SAFE®:
TREATMENT OF CORONARY ARTERY DISEASE

1. INTRODUCTION

Ozone is gas which is discovered in the mid-nineteenth century. It consists of three

oxygen atoms to form unstable molecule structure; O3. The gas is colourless with acrid
odour1 and can partially dissolve in water, but at standard pressure and temperature the
solubility of ozone is higher than oxygen.2 Concentrated mixtures of ozone and oxygen
that contain more than 20% of ozone can become explosive in both fluids and gases.2 The
ozone is toxic for animals and humans, even at low concentrations. The degree of
damages caused by the ozone depends on its concentration, temperature, humidity and
exposure time.1

Ozone was first discovered by the German chemist Christian Frederick Schonbein in the
year 1840. Ozone was used for the first time to disinfect operating rooms in 1856 and
subsequently for water treatment in 1860. The German Army used ozone to treat battle
wounds and other infections during World War I.3 According to the Europe based
Medical Society for Ozone and the National Centre for Scientific Research in Cuba,
physicians are currently treating the following diseases with different forms of ozone:
abscesses, acne, AIDS, allergies, anal fissures, arthritis, asthma, cancerous tumors,
cerebral sclerosis, circulatory disturbances, cirrhosis of liver, constipation, corneal ulcers,
cystitis, decubitus ulcers (bedsores), diarrhea, fungal diseases, gangrene, gastroduodenal
ulcers, glaucoma, hepatitis, herpes simplex and zoster, hypercholesterolemia,
osteomyelitis, Parkinson’s disease, Raynaud’s disease, rheumatoid arthritis, senile
dementia, sepsis, sinusitis, spondylitis, thrombophlebitis, wound healing and others. This
list is not exhaustive.3

However, ozone therapy requires precise therapeutic level to make sure that the treatment
works. Otherwise, the treatment will fail if the dose is too low or toxic if the dose is too
high.1,4 Another claim is the potential ozone in the management of coronary artery
diseases. Coronary artery disease is the most common type of heart diseases. The
problem happen when arteries involved supplying blood to heart muscle become
hardened and narrowed due to formation of cholesterol and other material called plaque
(atherosclerosis) on the inner walls of the arteries. As a result the blood supply to the
heart will be blocked and lead to heart attack.

Ozone therapy is claimed to have a potential in treating coronary artery diseases (CAD)
in conjunction with standard care. This technology, Alif-1 EBOO SAFE® is newly
available in Malaysia to treat CAD but not available in Ministry of Health (MOH) health
care facilities. Hence, the Organization of Medical Ozone Therapies Malaysia is planning
to introduce this technology into the MOH health care facilities.

Therefore, this technology review was requested by Deputy Director General (Medical),
Medical Development Section, to find out the efficacy, effectiveness, safety and cost-
effectiveness of this technology in the management of coronary artery diseases.

5
2. OBJECTIVE/AIM

The objective of this technology review was to assess the safety, efficacy/effectiveness
and cost-effectiveness of Alif-1 EBOO SAFE® in the treatment of coronary artery
diseases.

3. TECHNICAL FEATURES

Alif-1 EBOO SAFE® (Figure 1) is claimed as therapeutic ozoniser that produces

automatic different ozone concentrations in a continuous and reproducible way in all
therapeutic range. Alif-1 is referring to the ozone generators, EBOO is an Extracorporeal
Blood Oxygenation and Ozonation which is similar to the haemodylisis technology and
SAFE is stands for Simple Access Fluid Extraction or ultrafiltration. All together this
technology is claimed to be a new remedy for cardiac problems especially coronary
artery disease.5

Figure 1: Alif-1 EBOO SAFE® Straight to the Heart

3.1 Mechanism of Action of Ozone in Blood

6
 In blood, ozone will dissolve in plasma and instantly decomposes in a cascade of reactive
oxygen species (ROS), including hydrogen peroxide (H2O2), superoxide anion (O2¯),
hydroxyl radical (HO•) and hypochlorous acid (HClO). Most of the ozone dose that
comes into contact with blood is partly reduced by water-soluble anti-oxidants and partly
transformed into ROS including lipid peroxides and other bioactive molecules, which are
also checked by the antioxidant and scavenger systems before they can damage blood
cells. A first pharmacological effect of ozone is due to the slight excess of ROS acting as
chemical messengers for membrane receptors and various biological functions, whereas
bioactive molecules such as some lipid peroxides may act on practically all cells after re-
infusion of ozonized blood.6

The oxidation chemistry of ozone is known to produce H2O2. In red blood cells (RBCs),
H2O2 shifts the hemoglobin dissociation curve to the right and facilitates release of
oxygen. While in leukocytes and endothelial cells it can stimulate the production of
interleukins, interferons, growth factors and nitric oxide. In platelets, it favors the release
of growth factors. In other cells types such as macrophages and respiratory epithelial
cells; H2O2 stimulates cell activation, cytokine secretion and long-term efficiency of
antioxidant systems in adaptation to its pro-oxidant action.6

3.2 Effects of Ozone Therapy6

Ozone Therapy is claimed can induce the following biological responses:

a) Ozone therapy improves blood circulation and oxygen delivery ischemic tissue
owing to the concerted effect of nitrogen monoxide (NO) and carbon monoxide
(CO) and increase of intra-erythrocytic 2,3-DPG level.
b) Ozone therapy will improve oxygen delivery then, enhances the general
metabolism.
c) Ozone therapy may up-regulates the cellular antioxidant enzymes.
d) Ozone therapy induces a mild activation of the immune system and enhances the
release of growth factors.
e) Ozone therapy does not have late side effects.
f) Ozone therapy may stimulate the neuro-endocrine system to enhance body
wellness.

3.3 Mechanism of Ultrafiltration

Ultrafiltration or convection is a process where fluid flow through semi-permeable

membrane in response to a transmembrane pressure gradient (forced by a difference
pressure on the two sides of dialyzer).7,8 The process mimics what actually happens in the
normal human kidney. The rate of ultrafiltration depends upon the porosity of the
membrane and the hydrostatic pressure of the blood, which depends upon blood flow. It
is claimed that this process is very effective to remove fluid and middle sized molecules
such as cytokines.7

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 In order to achieve ultrafiltration, earlier dialysis machines will controlled dialysate
pressure or pressure difference across the membrane. However the modern dialysis
machines are generally volumetric; it controls the volume of fluid removed from the
patient directly and allowing the dialysate pressure to change as it will. Volumetric
control is generally achieved either by controlling the flow of dialysate in and out of the
dialyzer at different rates with two flow controllers, or by having equal flow rates in and
out of the dialyzer and removing fluid between these equal flows.7,8

Figure 2: Ultrafiltration Process

3.4 Mechanism of Alif-1 EBOO SAFE®

Basically the device work by withdrawing venous blood and the same blood is infused
into an oxygen-ozone gas exchange filter in and or an upward direction. The device is
using a specialized guideline with a computerized peristaltic pump to control the rate of
withdrawal. The medical ozone from the device is introduced into the hydrophobic and
ozone resistant gas exchange filter in the opposite direction from top going downwards.
Then the ozonation of blood begins.5

To avoid coagulation during the process, heparin is administered just before the blood is
infused into the filter. After passing through the oxygen-ozone gas exchange filer, treated
blood is re-infused to the patient. Upon establishment of extracorporeal circuit, the
withdrawal rate will be increased to a range of 60-80ml per minute depending on the
patient’s condition.5

Alif-1 EBOO SAFE® can facilitate and treat 3 to 4 liters of blood with medical ozone in
extracorporeal circulation for a period of 60 to 90 minutes for patients with coronary
artery disease. For satisfactory result, the patient has to undergo 15 to 35 hours therapy
depending on the state of the disease.5

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 Figure 3: The EBOO Apparatus (1) Oxygen supply. (2) Alif 1 (Ozone generator). (3)
Dialysis. (4) Ultrafication liquid reservoir. (5) Bypass chamber. (6) Syringe (vacuum).
(7) Blood pump. (8) Dextrose. (sorce: Extracorporeal Blood Oxygenation and Ozonation (EBOO).
At http://www.ozonerejuvenation.com/tretment-6)

4. METHODOLOGY

4.1. Searching

Electronic databases were searched, included PubMed, 1990-2011 EBM Reviews –

Cochcrane Databases of Systematic Reviews, 1990-2011 EBM Reviews – Cochcrane
Databases of Controlled Trial, National Horizon Scanning, CADTH, INAHTA and FDA
website, for published reports. There was no limit in the search. Additional articles were
identified from reviewing the bibliographies of retrieved articles and information from
documents provided by Organization of Medical Ozone Therapies Malaysia.

The search strategy used the terms which were either used singly or in various
combinations. Such as ‘EBOO’, ‘EBOO AND coronary artery diseases’, ‘ozone therapy’,
‘ozone therapy for coronary artery disease’, and ‘ozone, ‘extracorporeal membrane
oxygenation, ‘ultrafiltration’, ‘ultrafiltration AND heart failure’ and ‘ecmo’.

4.2. Selection

All published articles which were related to the effectiveness/efficacy, safety, and cost-
effectiveness of Alif-1 EBOO SAFE® in the treatment of coronary artery disease (CAD)
and related to that were included. Studies conducted in other diseases were excluded.

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5. RESULTS AND DISCUSSION

No study on the effectiveness/efficacy, safety and cost-effectiveness was found on Alif-1

EBOO SAFE® in the treatment of coronary artery diseases. However, abstract from one
randomized control trial on this technology in the treatment of peripheral artery disease
was included in this report. No study on safety and cost-effectiveness of Alif-1 EBOO
SAFE® was found. Additional to that, three studies about ultrafiltration technology alone
were also included.

The information provided by the Organization of Medical Ozone Therapies Malaysia

could not be used as scientific evidence because most of the information was case notes
from general practitioners (GPs) and were not supported with proper research such as
randomized control trials (RCTs). The organization also plans to conduct a ‘Bicentre
Prospective Study on Patients with Multivessels Coronary Artery Disease Who Refused
Surgery: Outcomes after Treatment with Extracorporeal Blood Oxygenation, Ozonation
(EBOO) and Simple Access Fluid Extraction (SAFE)’. The purpose of the study is to
determine whether complimentary medicine such as ozone therapy has any role in
treating patients with coronary artery disease.9

5.1 Effectiveness/Efficacy of EBOO Technology

The abstract was from one randomized controlled trial conducted by Di Paolo N. et al
(2005). However, the quality of this study could not be determined as the full text was not
available. The trial involved twenty-eight patients with peripheral artery disease to verify
the hypotheses that extracorporeal blood oxygenation and ozonation (EBOO) might
improved skin lesions which was related to the disease. The study used two types of
intervention, EBOO and intravenous (IV) prostacyclin. The primary efficacy parameters
were regression skin lesions, pain and improvement in quality of life and vascularisation.
The results found that patients treated with EBOO showed highly significant regression
of skin lesions with respect to the patients treated with prostacyclin. However, no
significant difference in vascularisation of the lower limbs was found before and after
both treatments.10

5.2 Effectiveness/Efficacy of Ultrafiltration in Heart Diseases

Bart BA et al. conducted a multicenter randomized control trial involved six hospitals in
Minneapolis-St. Paul associated with Minnesota Heart Failure Consortium with a small
number of participants. Forty hospitalized patients with primary diagnosis of coronary
heart failure (CHF) patients were involved. All patients were enrolled and randomized
from the six hospitals between July 2003 and May 2004. Twenty patients were
randomized to usual care group and the other 20 patients in ultrafiltration plus usual care
group. Those patients were required to have at least 2+ oedema of the lower extremities

10
and at least one of the problems: elevated jugular venous pressure > 10cm H2),
pulmonary oedema or pleural effusion on chest X-ray, pulmonary rales, pulmonary
wedge or left ventricular end diastolic pressure > 20mmHg, ascites, or pre-sacral oedema.
The primary end point of the study was weight loss 24 hours after obtaining consent.
Other end points were total volume removal at 24 hours and 48 hours, global CHF and
dyspnea assessments, serum electrolytes and length of hospital stays. The authors used
intention-to-treat analysis and any differences between groups was tested using a two-
sided Fisher exact test for 2 by 2 contingency tables and a two-sided Wilcoxon rank sum
test for continuous variables except weight loss. The results showed that volume removal
24 hours after the time of consent was 4,650ml in ultrafiltration plus usual care group and
2,838ml in usual care groups with p = 0.001. After 48 hours, fluid removal was 8,415ml
and 5,375ml in ultrafiltration plus usual care group and usual care group respectively
with p = 0.012. By looking at the primary outcome, weight loss at 24 hours was greater in
the ultrafiltration plus usual care group but failed to reach statistical significance (p =
0.240). The authors also reported that all patients in ultrafiltration plus usual care group
experienced significant improvement in dyspnea and CHF symptoms compared to usual
care group at 48 hours (p = 0.039 for dyspnea and p = 0.023 for CHF symptoms). The
median length of hospital stay was not significant for both groups. However, in
ultrafiltration plus usual care group one death was reported during the 30 days follow-up
period but was claimed not related to ultrafiltration process and one catheter site infection
that required a 4-weeks course of intravascular antibiotics. The authors concluded that,
the ultrafiltration process require for larger clinical trial in order to determine the relative
efficacy and safety of ultrafiltration versus standard care in acute decompensate heart
failure with respect to renal function and anaemia.11, Level 1

Costanzo MR et al. conducted another multicenter randomized control trial to compare

the ultrafiltration therapy with intravenous (IV) diuretics alone. The study was involved
200 patients which were enrolled from June 2004 until July 2005 at 28 United State
Centres experienced in the use of Aquadex FlexFlow (ultrafiltration device) which
funded by the CHF Solution, INC. The patients were at least 18 years old and were
hospitalized with heart failure and hypervolemic by at least two of the following:
peripheral oedema ≥2+, jugular venous distension ≥7cm, radiographic pulmonary
oedema or pleural effusion, enlarged liver or ascites or pulmonary rales, paroxysmal
nocturnal dyspnea or orthopnea. Along the study, all the patients received 2g sodium
daily and 2000ml fluid intake restriction. Angiotensin-converting enzyme (ACE)
inhibitors, angiotensin receptor blockers (ARBs) and beta-blockers were continued
throughout the study as tolerated in all patients. All patients were randomized into two
groups; 100 patients in standard care group (treated with intravenous diuretics) and the
other 100 patients in ultrafiltration group. All of them were followed up for 90 days or
until death. During the first 48 hours after enrolment, hypervolemia was treated
exclusively with ultrafiltration and intravenous (IV) diuretics were prohibited. All the
patients were weighted in kilograms at randomization, daily during hospitalization, at
discharge, and days 10, 30 and 90. Total fluid intake and output (ultrafiltrate and urine)
measured during the first 48 hours after randomization were used to calculate net fluid
losses. Meanwhile weighted loss was the weight recorded at subsequent evaluations. The
primary efficacy endpoints were weight loss and patient’s dyspnea assessment 48 hours

11
 after randomization. The primary safety outcomes were changes in serum blood urea
nitrogen (BUN), creatinine and electrolytes and episodes of hypotension at 48 hours after
randomization. After 48 hours of the study, weight loss was found greater in the
ultrafiltration group compared to standard–care group (5.0±3.1kg [range 14.1 loss to
1.3kg gain] versus 3.1±3.5kg [range 11.3 loss to 2.5 gain]; p = 0.0001). Dyspnea score at
48 hours improves to a similar degree in the both groups. Subgroup analyses revealed
that there was no heterogeneity in the effect of ultrafiltration on 48 hours weight loss. In
both groups, a significant correlation existed between the 48 hours weight loss (r = -0.60)
and fluid loss (r = -0.40) with p = 0.001. However, there was no correlation, between the
48 hours dyspnea score and either 48 hours weight or fluid loss. There was no correlation
between net fluid removed and changes in serum creatinine in the ultrafiltration (r = -
0.050; p = 0.695) or in the intravenous diuretics group (r = 0.028; p = 0.820), the changes
in serum creatinine were similar in both groups. No clinically significant changes in
serum blood urea nitrogen, sodium, chloride, and bicarbonate as well as episodes of
hypotension occurred in either group.12, Level 1

Canadian Agency for Drugs and Technologies in Health (CADTH) conducted a rapid
response report on Aquadex FlexFlow for patients with Congestive Heart Failure:
Clinical and Cost Effectiveness in March 2011. Three health technology assessments
(HTA); one HTA13 described about the efficacy of Aquadex Flexflow and the other two
HTA14 also described about economic analysis and two articles describing the
randomized controlled trial by Costanzo MR et al. were included in the rapid response
report. Overall the report concluded that Aquadex Flexflow ultrafiltration units appears to
be more costly but more effective at fluid reduction and reducing rehospitalisation rates
than diuretics in patients with congestive heart failure but require for further study.15

Ultrafiltration is also considered as one of alternative treatment in three heart failure

management guidelines. In clinical practice guideline of management of heart failure
2007 by Ministry of Health of Malaysia, the ultrafiltration is considered in patients who
are fluid overloaded (Class of recommendation IIb, level of evidence B) however its
relief is temporary.16 Then, in 2008 European Society of Cardiology (ESC) guideline, the
ultrafiltration is considered to reduce fluid overload (pulmonary and/or peripheral
oedema) in selected patients and correct hyponatremia in symptomatic patients refractory
to diuretics (Class of recommendation IIa, level of evidence B).17 The third guideline is
from American College of Cardiology Foundation, American Heart Association
(ACCF/AHA), updated in 2009; ultrafiltration is reasonable for patients with refractory
congestion not responding to medical therapy. (Class of recommendation IIa, level of
evidence B).18

5.3 Safety of Alif-1 EBOO SAFE®

No safety data was available from United State of Food and Drug Administration
(USFDA) on Alif-1 EBOO SAFE®. However, Di Paolo N. et al (2005) claimed that there
were no side effects or complications during the EBOO treatment.5, Level III Another
narrative review by Bocci V. et al (2009) concluded that ozone acted as a natural drug for
oxidative stress with minimal cost and no side effects. However, this claim was not

12
 supported by clinical research. In another review by Bocci V. et al (2009), the authors
claimed that, ozone therapy also procures useful clinical benefits that can be maintained
with a bimonthly administration.19, Level III

In another review by Paolo ND (2005), one in vivo experiment on EBOO technology was
conducted using an animal model (sheep). The study showed that ozonation for more
than 60 minutes with a blood flow of 100ml/min and exposure to an oxygen/ozone
mixture with ozone concentrations of 20-60µg/ml did not cause any clinical side effects
during and after the treatment. However, slight hemolysis occurred if an ozone
concentration above level of 20µg/ml was used.6, Level III

5.4 Safety of Ultrafiltration Technology

There was many type of ultrafiltration machine received 510(k) Clearance from USFDA
including Aquadex FlexFlow System which was stated in document submitted by
Organization of Medical Ozone Therapies Malaysia. There were two adverse event
reported by Manufacturer and User Facility Device Experience (MAUDE) in USFDA
website regarding the use of ultrafiltration and one case on ozone generator.

The first case reported in 2003 due to rusted cylinder of ultrafiltration pump which
caused the pump failed to remove weight (excess water). The patient was having
congestive heart failure after the ultrafiltration process and was hospitalized with
appropriate intervention.20 Another cases was reported in 2007 on Aquadex System
Ultrafiltration 500 where patient with severe acute decompensate heart failure received
48 hours of ultrafiltration at 200ml/hr. After second sessions the patient started to twitch
and went into pulse-less ventricular tachycardia and could not be save (cardiopulmonary
resuscitation [CPR] was unsuccessful).21 Then, the third adverse event was involved
ozone generator in major autohemotherapy for ovarian cancer. The procedure basically
was included removal of 250cc of blood which was ozonated with 250cc ozone and
returned to the patient. After the third set of ozone treatments, the patient awoke with
abdominal cramp, nausea and vomiting which was required for emergency admission to
hospital for treatment of small bowel obstruction and gastrointestinal bleeding. The
patient died three weeks later.22

In June 2009, advisory committee of Gastroenterology and Urology Devices Panel met to
discuss and provide recommendations for FDA regarding general issues of ultrafiltration
devices in the treatment of extracellular fluid overload with a focus in heart failure
patients. The Panel specifically addressed the use of ultrafiltration in the following terms:
identifying the most appropriate heart failure patients, for whom these treatments should
be indicated, determining where these treatments fit within the spectrum of treatment
options, and defining what level of clinical evidence was necessary to adequately
evaluate and provide labelling for these devices. The Panel believed that the treatment of
fluid overload was not the same in all patient populations that could benefit from
ultrafiltration. It was due to varies underlying etiologies and different physiological
conditions which make it inappropriate to treat all fluid overload patients with the same
treatment. They also believed that there were needs for more data from prospective

13
 randomized controlled trials with appropriate comparators for specify disease or
condition such as, for the treatment of heart failure. Additional to that, the Panel felt that
there was inadequate data available to support the use of ultrafiltration as an adjunct or
alternative therapy to treat heart failure, but the panel felt that the use of ultrafiltration as
a tool to treat fluid overload in general was reasonable for the physician to consider when
standard medical care options were exhausted. Furthermore, there was no data from
randomized controlled studies demonstrating ultrafiltration was safe and effective for first
line therapy in the treatment of heart failure. Thus, with respect to study design, the Panel
felt that a sponsor should study the specific patient population that would be reflected
with use of ultrafiltration, and considered the safety, quality of life and other measures of
patient benefit, such as rehospitalisation as a primary endpoints and mortality as a
secondary endpoint. However it is important to measure kidney function throughout the
course of the trial, and that patients be followed for one year to assess the safety of the
treatment.23

Costanzo MR et al. found several adverse events while conducted RCT as previously
discussed. Two patients were having problem while five ultrafiltration filters were
clotted, but treatment was completed after filter replacement. Transient discomfort at the
venous access site occurred in 3 ultrafiltration patients. One central venous catheter
infection occurred in the ultrafiltration group. One patient received hemodialysis because
volume overload was refractory to ultrafiltration. There were 9 deaths (9.6%) in the
ultrafiltration group due to HF (n = 3), renal failure (n = 1), and causes unrelated to HF or
treatment (n = 5). Meanwhile, Eleven patients (11.6%) died in the standard-care group
because of HF (n = 5), myocardial infarction (n = 1), other causes (n = 3), and unknown
causes (n = 2).12, Level I

5.4 COST-EFFECTIVENESS OF ALIF-1 EBOO SAFE®

No study on cost-effectiveness of Alif-1 EBOO SAFE® was found. However, there was a
claim stated that this technology involved a minimal cost (the machine is about USD
40,000 per unit).

6. CONCLUSION
Insufficient high quality scientific evidence was found on the effectiveness/efficacy and
safety of Alif-1 EBOO SAFE® in management of coronary artery diseases. Although as a
single machine, the ultrafiltration technology (claimed as similar technology with SAFE)
was discovered many years ago, in combination with Alif-1 EBOO technology; Alif-1
EBOO SAFE® demands for more evidence on human especially in the management of
coronary artery disease.

14
7. REFERENCES

1. Paolo ND, Bocci V, Gaggiotti E. Ozone Therapy. The International Journal of Artificial
Organs. 2004; 27(3):168-175 Available at:
http://www.ossigenoozono.it/Ozone%20therapy.htm Accessed on 21st June 2011

2. Properties and Structures of Ozone. Available at: http://www.lenntech.com/ozone/ozone-

properties.htm Accessed on: 10/11/2011.

3. Sivalal S, Sivasampu S, Nik Mat NJ. Ozone Therapy. Health Technology Asssessment 2005.
Malaysia Health Technolgy Assessment.

4. Bocci VA, Zanardi I, Travagli V., Ozone Acting On Human Blood Yields a Hormetic Dose-
Response Relationship. Journal of Translational Medicine.2011;9:66

5. Alif-1 EBOO SAFE® Straight to the Heart. Health Living With Ozone. 2011; Issue 01:Vol
01

6. Paolo ND, Gaggiotti E, Galli F. Extracorporeal Blood Oxygenation and Ozonation: Clinical
and Biological Implications of Ozone Therapy. Redox Report.2005;10(3).

7. Neligan P. Dialysis & Renal Replacement Therapy. Critical Care Medicine Tutorials.
Available at: http://www.ccmtutorials.com/renal/RRT/page2.htm Accessed on: 27/10/2011

8. How Hemodylisis (Dialysis) Works Availabale at:

http://www.toltec.biz/how_hemodialysis_works.htm Accessed On: 2 November 2011

9. Fakta Tambahan Penilaian Teknologi Kesihatan EBOO & SAFE. Pertubuhan Pengamal
Perubatan Ozon Malaysia.

10. Paolo ND, Bocci V, Salvo DP. et al. Extracorporeal Blood Oxygenation and Ozonation
(EBOO): a Controlled Trial in Patients With Peripheral Artery Disease. International Journal
Artificial Organs. 2005;28(10):1039-1050

11. Bart BA, Boyle A, Bank AJ et al. Ultrafiltration Versus Usual Care for Hospitalized Patients
with Heart Failure: The Relief for Acutely Fluid-Overloaded Patients with Decompensated
Congestive Heart Failure (RAPID-CHF) Trial. Journal of the American College
Cardiology.2005;46:2043-2046.

12. Costanzo MR, Guglin ME, Saltzberg MT et al. Ultrafiltration Versus Intravenous Diuretics
for Patients Hospitalized for Acute Decompensated Heart Failure. Journal of the American
Colege of Cardiology. 2007;49:675-683.

13. Flyn K. Brief Overview: Ultrafiltration for Decompensated Heart Failure. Veterens Health
Administration Office of Patient Care Services Technology Assessment Program (VATAP).
2011. Available from: http://www.va.gov/VATAP/docs/Ultrafiltration2011.pdf Accessed on:
25/10/2011

15
14. Colechin ES, Bower L, Sims AJ. Evidence review: ultrafiltration therapy for fluid overload
in heart failure [Internet]. London: Centre for Evidence-Based Purchasing, NHS Purchasing
and Supply Agency (UK); 2007 Available from:
http://nhscep.useconnect.co.uk/ShowDocument.ashx?id=54&i=true Accessed on: 25/10/2011

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8. APPENDIX

8.1 Appendix 1

DESIGNATION OF LEVELS OF EVIDENCE

I Evidence obtained from at least one properly designed randomized controlled trial.

II-I Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably
from more than one centre or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic
results in uncontrolled experiments (such as the results of the introduction of penicillin
treatment in the 1940s) could also be regarded as this type of evidence.

III Opinions or respected authorities, based on clinical experience; descriptive studies and
case reports; or reports of expert committees.

SOURCE: US/CANADIAN PREVENTIVE SERVICES TASK FORCE (Harris 2001)

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