Pharmacologic Basis of

Tocotrienol in Ischemic
Stroke
Roberto Y. Ysla, M.D., FPCPM
 Topics to be covered
• All about Vitamin E family
• The Tocotrienols
• Pharmacology of tocotrienols
– Absorption
– Distribution
– Pharmaco-kinetics/dynamics
– Dosage

• Possible role in Ischemic Stroke

– Experimental or laboratory studies
– Human clinical trials
 Vitamin E family

• one of the most important phytonutrients

in edible oils essential for health and
function of the nervous system

• Eight naturally occurring isomers,

– 4 tocopherols (alpha, beta, gamma and delta)
and
– 4 tocotrienols (alpha, beta, gamma and delta)
homologues.
 The Vitamin E
Chemical Structure
The HEAD, or chroman ring
The TAIL – phytyl/ Farnesyl
HYDROXY GROUP – active group on head
 Nomenclature
• chromanol head named by α, β, γ or
δ according to the position and
degree of methylation [1,2]

• The division into the “pherol” or

“trienol” group –saturated phytyl or
the unsaturated isoprenoid or
Farnesyl tail
1. Sen CK, Khanna S, Roy S: Tocotrienols in health and disease:
the other half of the natural vitamin E family.
Mol Aspects Med 2007, 28(5–6):692-
728. PubMed Abstract | Publisher Full Text |PubMed Centr
al Full Text
2. Nesaretnam K: Multitargeted therapy of cancer by
tocotrienols.
Cancer Lett 2008, 269(2):388-395.
Nomenclature
Natural Sources of Tocotrienols
TE are found in highest concentrations
seeds of monocotyledons that include
• wheat,
• rice,
• barley, and
• palm
• Annatto - richest source of δ-TCT
• Choo YM, Ma AN, Chuah CH, Khor HT, Bong SC: A developmental study on the
appearance of tocopherols and tocotrienols in developing palm mesocarp (Elaeis guineensis).
Lipids 2004, 39(6):561-564. PubMed Abstract
• Ng MH, Choo YM, Ma AN, Chuah CH, Hashim MA: Separation of vitamin E (tocopherol,
tocotrienol, and tocomonoenol) in palm oil. Lipids 2004, 39(10):1031-1035. PubMed Abstract
| Publisher Full Text
• Schauss AG, Endres JR, Clewell A: Safety of unsaturated vitamin e tocotrienols and their
isomers. In Tocotrienols: Vitamin E beyond tocopherols. 2nd edition. Edited by Tan B,
Watson RR, Preedy VR. Boca Raton, Florida: CRC Press, Taylor and Francis Group; 2013.
Natural Sources of Tocotrienols

Bharat B. Aggarwal et al, Tocotrienols, the vitamin E of the 21st century: Its potential
against cancer and other chronic diseases; Biochemical Pharmacology 80 (2010) 1613–
1631
Pharmacology of Vitamin E

TOCOTRIENOLS
WHAT DO WE KNOW?
 FACTS
• Fewer human studies available
– Fairus S, Nor RM, Cheng HM, Sundram K: Postprandial metabolic fate of
tocotrienol-rich vitamin E differs significantly from that of alpha-tocopherol. Am J
Clin Nutr 2006, 84(4):835-
– Yap SP, Yuen KH, Wong JW: Pharmacokinetics and bioavailability of alpha-, gamma-
and delta-tocotrienols under different food status. J Pharm armacol 2001, 53(1):67
– Pouton CW: Lipid formulations for oral administration of drugs: non-emulsifying,
self-emulsifying and ‘self-microemulsifying’ drug delivery systems. Eur J Pharm Sci
2000, 11(Suppl 2):S93—

• Differences in ratios of analogues

(alpha, gamma, delta) in commercial
preparations lead to mixed results
 Absorption - Facts
• Absorption of tocotrienols - route
– negligible when administered via the
intraperitoneal and intramuscular route,
– incomplete absorption was observed
when given via the oral route in rats +
• Yap SP, Yuen KH, Lim AB: Influence of route of administration on the absorption
and disposition of alpha-, gamma- and delta-tocotrienols in rats.
Pharm Pharmacol 2003, 55(1):53-

• Plasma concentrations of tocotrienols

were found to be much lower ~ TCP
 Absorption - Facts
• Absorption increases 2-fold under fed
state

• The significant increase in tocotrienol

bioavailability under fed state was most
probably due to the increase of TAG
after a high fat meal, followed by bile
secretion

– Yap SP, Yuen KH, Wong JW: Pharmacokinetics and bioavailability of alpha-, gamma- and
delta-tocotrienols under different food status. J Pharm armacol 2001, 53(1):67
 Absorption - Facts
• Pharmacologic and pharmaceutical
preparations make use of self-
emulsifying innovations to address
problems with absorption regardless of
food intake. (SupraBio)
 Plasma concentration
Plasma concentration following
supplémentation 250 mg/dl Tocotrienol
(tocotrienyl acetate)

• alpha-T3 0.98 +/- 0.80 micromol/l,

• gamma-T3 0.54 +/- 0.45 micromol/l, and
• delta-T3 0.09 +/- 0.07 micromol/l.

• O'Byrne D et al, Studies of LDL oxidation following alpha-, gamma-, or delta-tocotrienyl

acetate supplementation of hypercholesterolemic humans. Free Radic Biol Med. 2000 Nov
1;29(9):834-45.
 Distribution - Facts
• Transported in triacylglycerol (TAG)-
rich fractions after administration
– containing chylomicrons and VLDL, LDL and HDL cholesterols

• α-tocotrienol emerged as the major

homologue detected in both plasma and
lipoproteins
Fairus S, Nor RM, Cheng HM, Sundram K: Postprandial metabolic fate of
tocotrienol-rich vitamin E differs significantly from that of alpha-tocopherol.
Am J Clin Nutr 2006, 84(4):835-
 Pharmacokinetics
• Alpha-tocotrienol -secreted by small
HDL particles

• Selectively distributed to organs and

tissues high in adipose content i.e.
epididymal fat, perirenal fat and skin
and brain.

• TCT – mainly detected in the HDL

cholesterol at 4 to 8 hrs. before clearance
Gee PT: Unleashing the untold and misunderstood observations on
vitamin E. Genes Nutr 2011, 6(1):5-
 Pharmacokinetics
• The unsaturated side chain of
tocotrienol allows for more efficient
penetration into tissues that have
saturated fatty layers, such as the
brain and liver;

• Alpha Tocotrienols 40 – 60 X more

potent than normal Tocopherols
making it one of the most powerful
lipids soluble anti oxidants available.
 Evidence based data
• Ohio State University Medical Center - clinical
trial to determine if oral vitamin E (pherol and
trienol forms) are transported to vital organs
Dosage used: 200 mg bid x 12 weeks
N= 80 participants
Blood concentration taken ave . 20 wks. (1-96 wks)

Result
• Clear evidence -oral TE supplementation
enriches its concentration in whole blood,
adipose, skin, brain, cardiac muscle, and liver.

• Viren Patel et al ; The Journal of Nutrition 2011; pp 513-519

 Dosage/schedule
• Half-lives of tocotrienols – 4 hours
• approximately 4 to 5-fold lower than that of
tocopherols (4 hours vs 20 hours),
• Less risk of accumulation

• A dosing schedule of twice daily is

sufficient to reach the steady state
within 3 days* #
• Yap SP, Yuen KH, Wong JW: Pharmacokinetics and bioavailability of alpha-, gamma- and delta-
tocotrienols under different food status. J Pharm Pharmacol 2001, 53(1):67–71

# Julianto T, Yuen KH, Noor AM: Improved bioavailability of vitamin E with a self emulsifying
formulation. Int J Pharm 2000, 200(1):53–57.
 Dosage/schedule

• During the MOPC Conference in KL

August 2, 2015 Prof Yuen –presented
paper on WML and TE

• Dosage recommendations:
– Maintenance – 50 mg daily
– High risk and post stroke patients
• 100 mg bi.d
Dosage/schedule
 Dosage/schedule Toco-E

• Mixed vitamin E mixture

• Dosing – cosider the tocopherol mg
content 128.5 mg
• This must not begiven beyond 400
mg/day since it could accumulate
beyong daily dose of 400 daily.
– Why: Halp life ia 20 hours

– So for patients post stroke

• 2 softels in AM
• 2 softgels in pm
 TOCOTRIENOL IN
ISCHEMIC STROKE
Facts based on animal, laboratory studies
validated by human clinical trials
Facts
Among Asians age 18 and older, 2%have
had a stroke.

In 2004, death rate of stroke was 44.2% for

Asian males and 38.9% for females. *
 

* Statistical Fact Sheet – Populations, 2008 Update; American Heart

Association, 2008
Facts
• The brain is highly susceptible to
oxidative damage due to high oxygen
consumption (oxidative stress)

• Furthermore, the high lipid content of the

brain makes it susceptible to lipid
peroxidation
Facts
• During ischemic brain injury, glutamate
accumulation leads to overstimulation of
postsynaptic glutamate receptors with
intracellular Ca++ overload and neuronal cell
death.
Maria Ankarcrona at al, Glutamate-induced Neuronal Death: A succession of necrosis or apoptosis
depending on mitochondrial function; Neuron, Vol. 15, 961-973, October 1995

• It has been demonstrated that … activation of

neuronal 12-LOX leads to the production of
peroxides, the influx of Ca2+, and ultimately
to cell death.
Li Y, Maher P, Schubert D. Neuron 1997;19:453–463. [PubMed: 9292733]
Facts
 Molecular basis of
neuroprotection
Experimental and Animal Studies
Animal Studies
Khanna et al in 2005 Study in rodents
• Stroke induced in rats with and without
tocotrienol supplementation
• Results
– Brain lesions of treated animals significantly
smaller than controls after induction of stroke
Rink et al in 2011 Study in canines
• Stroke induced in dogs with and without
tocotrienol supplementation
• Results
– Supplemented dog has smaller lesions
Animal Studies in 2000
• Sen et al * and Khanna et al # showed
that α-tocotrienol at nanomolar
concentrations was able to block
glutamate-induced neuronal cell death
by suppressing early activation of c-Src
kinase and 12-lipoxygenase pathway

* Sen CK, Khanna S, Roy S, Packer L. Molecular basis of vitamin E action. Tocotrienol
potently inhibits glutamate-induced pp60(c-Src) kinase activation and death of HT4
neuronal cells. J Biol Chem. 2000;275:13049–13055.

# Khanna S, Roy S, Ryu H, Bahadduri P, Swaan PW, Ratan RR, et al. Molecular basis of
vitamin E action: tocotrienol modulates 12-lipoxygenase, a key mediator of glutamate-
induced neurodegeneration.J Biol Chem. 2003;278:43508–43515.
 Molecular Basis of Vitamin E Action
• Glutamate toxicity - major contributor to
pathological cell death within the NS.
• 12-lipoxygenase - central role in executing
glutamate-induced neurodegeneration by
oxidizing AA to form 12-HPETE (toxic)
• α-tocotrienol may hinder the access of
arachidonic acid to the catalytic site of 12-
lipoxygenase by binding to the opening of a
solvent cavity close to the active site
Chandan K. Sen et al, Molecular Basis of Vitamin E Action. Tocotrienol Modulates 12-Lipoxygenase, a Key
Mediator of Glutamate-Induced Neurodegeneration; J Biol Chem. 2003 October 31; 278(44): 43508–43515.
Ischemic pathway
Hypoxic-ischemic insult pathways
 Clinical Investigation of the Protective Effects of
Palm Vitamin E Tocotrienols on Brain White Matter
• RCT on 121 volunteers with HPN and MRI-
confirmed White Matter Lesion (WML)
– WMLs are regarded as manifestations of cerebral small vessel disease, reflecting
varying degrees of neurodegeneration and tissue damage with potential as a surrogate
end point in clinical trials.

• Double-blind, placebo controlled

• Two groups treated for 2 years with placebo or 200
mg mixed tocotrienols
• Parameters of observation:
– MRI baseline, 1 and 2 years
– Blood chemistry every 3 months
 Clinical Investigation of the Protective Effects of
Palm Vitamin E Tocotrienols on Brain White Matter

Results:
• Mixed tocotrienols were found to be
neuroprotective and that they attenuate
the progression of WMLs.
• Prof Kah Hay Yuen, Yogheswaran Gopalan et al; Clinical Investigation
of the Protective Effects of Palm Vitamin E Tocotrienols on Brain
White Matter, Stroke AHA Journal March 2014, pp 1422-1428
In summary
Tocotrienol’s neuroprotective property
lies in its ability to regulate specific
mediators of cell death
– inhibition of inducible c-Src and 12-
lipoxygenase pathways at very small dosage
(nanomolar).
– Based on Pharmaco-K/D studies a dose of
200 mg daily is sufficient to obtain steady
state post 3 days oral intake
 Tocotrienol Neuroprotection

• a-tocotrienol certified by the U.S. FDA

as Generally Recognized As Safe
(GRN307) and is not a drug with
potential side effects.

• Thus, -TCT may be considered as a

preventive nutritional countermeasure
for people at high risk for stroke.

Chandan Sen et al, Natural Vitamin E α-Tocotrienol Protects Against Ischemic Stroke by Induction of
Multidrug Resistance-Associated Protein 1; Stroke. 2011 August ; 42(8): 2308–2314.
doi:10.1161/STROKEAHA.110.608547.
 Disclosure
• Speaker is a Consultant of CCM
International Philippines, Inc.
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