Safety and efficacy of a new micronized formulation of the ALIAmide palmitoylglucosamine in preclinical models of inflammation and osteoarthritis pain
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Osteoarthritis is increasingly recognized as the result of a complex interplay between inflammation, chrondrodegeneration, and pain. Joint mast cells are considered to play a key role in orchestrating this detrimental triad. ALIAmides down-modulate mast cells and more generally hyperactive cells. Here we investigated the safety and effectiveness of the ALIAmide N-palmitoyl-d-glucosamine (PGA) in inflammation and osteoarthritis pain.
Acute toxicity of micronized PGA (m-PGA) was assessed in rats following OECD Guideline No.425. PGA and m-PGA (30 mg/kg and 100 mg/kg) were orally administered to carrageenan (CAR)-injected rats. Dexamethasone 0.1 mg/kg was used as reference. Paw edema and thermal hyperalgesia were measured up to 6 h post-injection, when also myeloperoxidase activity and histological inflammation score were assessed. Rats subjected to intra-articular injection of sodium monoiodoacetate (MIA) were treated three times per week for 21 days with PGA or m-PGA (30 mg/kg). Mechanical allodynia and motor function were evaluated at different post-injection time points. Joint histological and radiographic damage was scored, articular mast cells were counted, and macrophages were immunohistochemically investigated. Levels of TNF-α, IL-1β, NGF, and MMP-1, MMP-3, and MMP-9 were measured in serum using commercial colorimetric ELISA kits. One- or two-way ANOVA followed by a Bonferroni post hoc test for multiple comparisons was used.
Acute oral toxicity of m-PGA resulted in LD50 values in excess of 2000 mg/kg. A single oral administration of PGA and m-PGA significantly reduced CAR-induced inflammatory signs (edema, inflammatory infiltrate, and hyperalgesia), and m-PGA also reduced the histological score. Micronized PGA resulted in a superior activity to PGA on MIA-induced mechanical allodynia, locomotor disability, and histologic and radiographic damage. The MIA-induced increase in mast cell count and serum level of the investigated markers was also counteracted by PGA and to a significantly greater extent by m-PGA.
The results of the present study showed that PGA is endorsed with anti-inflammatory, pain-relieving, and joint-protective effects. Moreover, it proved that particle size reduction greatly enhances the activity of PGA, particularly on joint pain and disability. Given these results, m-PGA could be considered a valuable option in the management of osteoarthritis.
KeywordsOsteoarthritis Pain Mast cells ALIAmides N-palmitoyl-D-glucosamine Palmitoylethanolamide Micronization
Autacoids local injury antagonism
N-Acylethanolamine acid amidase
Nerve growth factor
Pain withdrawal latency
Pain withdrawal threshold
Tumor necrosis factor
Osteoarthritis (OA) is a joint degenerative disease and a leading cause of disability in elderly populations worldwide , with a 104.9% rise in disability-adjusted life-years from 1990 to 2016 . Once viewed as a disease primarily affecting cartilage, OA is currently considered a whole joint disease, also involving subchondral bone, synovial membrane, periarticular muscles, nerves, and ligaments . According to OARSI, OA is “a disorder involving movable joints characterized by cell stress and extracellular matrix degradation initiated by micro- and macro-injury that activates maladaptive repair responses including pro-inflammatory pathways of innate immunity. The disease manifests first as a molecular derangement (abnormal joint tissue metabolism) followed by anatomic, and/or physiologic derangements (characterized by cartilage degradation, bone remodeling, osteophyte formation, joint inflammation and loss of normal joint function), that can culminate in illness” . Chondrodegeneration can thus no longer be viewed as the sole pathogenetic mechanism of OA. The disease pathophysiology is much more complex and involves a vicious circle between chondrodegeneration, low-grade chronic inflammation, and pain . In this triad, a special consideration has recently been paid to articular hyperactive cells, especially mast cells . The latter are now believed to orchestrate neuroinflammatory processes and OA pain, suggesting they could be a new target for the treatment of OA [7, 8, 9]. ALIAmides are a class of both synthetic and naturally occurring fatty acid amides , whose parent molecule (i.e., N-palmitoyl ethanolamine, PEA) has anti-inflammatory and pain-relieving functions . The main mechanism of action of ALIAmides (i.e., ALIA, autacoid local injury antagonism) mainly relies on the down-modulation of cell hyperactivity following injury , as first shown on mast cells by the late Nobel laureate Rita Levi Montalcini . A decrease in PEA levels was reported in the synovial fluid of OA patients , and oral treatment with PEA has proved to benefit patients with temporomandibular joint OA and mild to moderate knee OA [15, 16]. N-Palmitoyl-d-glucosamine (PGA, also referred to as Glupamid) is one of the less studied among ALIAmides, and only few reports on this compound have been published so far [17, 18, 19]. Chemically speaking, PGA is the amide of palmitic acid and glucosamine and a highly lipophilic compound with a predicted logP value of 5.6 . Similarly to fatty acid amides, it is hydrolysed by fatty acid amide hydrolases [21, 22], resulting in the intracellular release of glucosamine. PGA might thus exert a dual effect, i.e., the ALIA effect down-modulating cell hyperactivity  and the putative effect of glucosamine on the anabolic/catabolic balance of cartilage [23, 24]. These actions well fit within the new understanding of OA pathogenesis, and PGA may help overcome currently unmet needs in the treatment of OA. The aim of this study was to evaluate the anti-inflammatory, chondroprotective, and pain-relieving effects of PGA and investigate whether micronization could improve the effects of this highly lipophilic compound, similarly to findings obtained with the congener PEA [25, 26]. An acute toxicity study on micronized PGA (m-PGA) was performed prior to the main study, in order to investigate its safety.
This study was performed on Sprague-Dawley male (200–230 g, 7 weeks old) and female (230–250 g, 8 weeks old) rats supplied by Envigo RMS Srl, S. Pietro al Natisone, Udine, Italy. Nulliparous and non-pregnant female rats were used for toxicity study, since females are generally slightly more sensitive than males to toxic effects. Rats were housed in individual polycarbonate cages (two for each group) and maintained under a 12:12 light-dark cycle at 21 ± 1 °C and 50 ± 5% humidity. The cage bedding material was corn cob and was changed twice per week. Food and water were available ad libitum. The study was approved by the University of Messina Review Board for the care of animals. Animal care was in accordance with Italian regulations on protection of animals used for experimental and other scientific purposes (D.M.116192) as well as with EEC regulations (O.J. of E.C. L 358/1 12/18/1986) and in compliance with the requirements of Italian Legislative Decree no. 26/2014 and subsequent guidelines issued by the Italian Ministry of Health on March 16, 2015.
PGA and micronized PGA (m-PGA, particle size from 0.6 to 10 μm) were kindly provided by Epitech group SpA (Saccolongo, Italy). All other compounds were obtained from Sigma-Aldrich, Milan, Italy. All chemicals were of the highest commercial grade available. All stock solutions were prepared in non-pyrogenic saline (0.9% NaCl, Baxter International, Rome, Italy).
The experiment was divided in two steps. First, acute toxicity testing was conducted. Then, the effect of micronization on the activity of PGA was evaluated in two standard models of inflammation and OA pain, subplantar injection of carrageenan (CAR), and intra-articular injection of sodium monoiodoacetate (MIA) respectively.
Acute toxicity testing
To date, no experimental data have been published concerning PGA safety. In the present study, we thus assessed the acute toxicity of m-PGA administered by gavage using a stomach tube as per OECD Guideline No.425 . This method permits estimation of an LD50 and minimizes the numbers of animals used. In particular, the limit test, i.e., a sequential test that uses few animals, is suggested for studying compounds likely to be nontoxic, as it is the case here. Actually, micronized PEA has LD50 > 2000 mg/kg , and LD50 of oral glucosamine is approximately 8000 mg/kg with no adverse effects at 2700 mg/kg for 12 months . The limit test was used accordingly for m-PGA. Under this procedure, one animal is dosed at the limit dose (i.e., 2000 mg/kg), and if it survives, additional animals are dosed sequentially, at 48-h intervals. Animals are observed with a special attention given during the first 4 h and daily thereafter, for a total of 14 days . Results to be recorded include body weight, observations of any sign(s) of toxicity, and any gross pathological changes. The LD50 is greater than 2000 mg/kg if three or more animals survive after 14 days . The complete guideline is available at https://www.oecd-ilibrary.org/content/publication/9789264071049-en).
Control group (a single dose by oral gavage of carboxymethylcellulose 1%, n = 6).
m-PGA group (a single dose by oral gavage 2000 mg/kg body weight, of m-PGA dissolved in an aqueous suspension of carboxymethylcellulose 1%, n = 6).
Body weight, mortality, signs of toxicity (i.e., tremors, convulsions, salivation, diarrhea, lethargy, sleep, and coma) and gross pathological changes of all animals were recorded and evaluated. At the end of the study (i.e., 14 days after administration of the tested compound/vehicle), the animals were sacrificed and the samples were collected. Briefly, paraffin tissue sections (thickness, 7 μm) were deparaffinized with xylene, stained with hematoxylin and eosin, and studied by light microscopy (AxioVision, Zeiss, Milan, Italy) by an experienced histopathologist. Each histological analysis was completed in a blinded fashion. Tissue sections of brain, spinal cord, heart, liver, kidney, bladder, lung, uterus, stomach, colon, and bowel were examined.
Rats were anesthetized with 5.0% isoflurane in 100% O2 (Baxter International, Rome, Italy) and received a subplantar injection of CAR (0.1 ml/rat of a 1% suspension in saline) (Sigma-Aldrich, Milan, Italy) with a 27-gauge needle into the right hind paw, as previously described [30, 31]. The animals were sacrificed at 6 h post CAR injection by isoflurane overdose. All analyses conducted in CAR-injected rats were performed in a blinded manner.
MIA induction model
OA was induced by intra-articular injection of MIA in the right knee joint as previously described [31, 32]. Briefly, rats were anesthetized with 5.0% isoflurane in 100% O2 and a volume of 25 μl saline + 3 mg of MIA was injected into the knee joint. The left knee received an equal volume of saline. MIA was prepared in sterile conditions and injected into the joint using a 50 μl Hamilton syringe with a 27-gauge needle. On day 21 post-MIA injection, rats were sacrificed by anesthetic overdose and perfused with 4% paraformaldehyde. All analyses conducted in MIA-injected rats were performed in a blinded manner.
CAR + vehicle: rats were subjected to CAR-induced paw edema, as described above and administered vehicle;
CAR + PGA 30: same as the CAR + vehicle group but non-micronized PGA 30 mg/kg was administered instead of vehicle;
CAR + PGA 100: same as the CAR + vehicle group but non-micronized PGA 100 mg/kg was administered instead of vehicle;
CAR + m-PGA 30: same as the CAR + vehicle group but micronized PGA 30 mg/kg was administered instead of vehicle;
CAR + m-PGA 100: same as the CAR + vehicle group but micronized PGA 100 mg/kg was administered instead of vehicle;
CAR + Dex: same as the CAR + vehicle group but dexamethasone 0.1 mg/kg was administered instead of vehicle;
Control group: saline was administered instead of CAR.
MIA + vehicle: rats were subjected to MIA intra-articular injection, as described above and administered vehicle;
MIA + PGA 30: same as the MIA + vehicle group but non-micronized PGA 30 mg/kg was administered instead of vehicle;
MIA + m-PGA 30: same as the MIA + vehicle group but micronized PGA 30 mg/kg was administered instead of vehicle;
Control group: saline was administered instead of MIA.
Doses were chosen based on a dose-response study carried out in our lab. PGA at 30 mg/kg dose only was used in MIA-induced OA pain, given that the higher dose (whether micronized or not) did not show any advantage over the lower one in CAR-induced inflammation.
Assessment of CAR-induced paw edema
Edema was expressed as increase in paw volume (ml) after CAR injection relative to pre-injection value and measured using a plethysmometer (Ugo Basile, Varese, Italy), as previously described [30, 31]. Paw volume was measured immediately prior to CAR injection and thereafter at 30 min and hourly intervals for 6 h.
Pain-related behavioral analysis in the CAR-induced inflammation
The hyperalgesic response to heat was determined at different time points (0, 30 min, and hourly intervals for 6 h) based on the method described by Hargreaves et al. , using a Basile Plantar Test (Ugo Basile, plantar test apparatus 7371; power requirement: 230-115 V, 60-50 Hz, 60VA maximum) as previously described . Results are expressed as paw withdrawal latency changes (seconds).
Histological analysis following CAR injection
Histological analysis of hematoxylin and eosin-stained paw tissue, collected 6 h after intraplantar CAR injection, was performed as previously described . Briefly, the degree of tissue damage was evaluated according to Bang and Coll ., on a 6-point score, from 0 (no inflammation) to 5 (severe inflammation). The photographs obtained (n = 5 photos from five slides for each sample) were collected from all animals in each experimental group. The histological coloration (five slides for each same sample) was repeated three times on different days.
Myeloperoxidase (MPO) activity following CAR injection
MPO activity, an index of neutrophilic granulocyte infiltration, was evaluated as previously described . Briefly, the rate of change in absorbance was measured spectrophotometrically at 650 nm. MPO activity was measured as the quantity of enzyme degrading 1 mM of peroxide min− 1 at 37 °C and expressed in units per gram of wet tissue weight.
Assessment of MIA-induced mechanical allodynia
Mechanical allodynia was evaluated using a dynamic plantar Von Frey hair esthesiometer on day 0 and 3, 7, 14, and 21 days post-injection (Ugo Basile, Comerio, Italy) as previously described . Briefly, when the esthesiometer was activated, the Von Frey–type 0.5-mm filament began to move below the metatarsal region, with a gradually increasing force on the plantar surface, starting below the threshold of detection and increasing until the stimulus became painful and the rat removed its paw. The force required to produce a paw withdrawal reflex (i.e., the paw withdrawal threshold, PWT) and the time interval between the stimulus and the response (i.e., paw withdrawal latency, PWL) were automatically detected and recorded (in grams and seconds respectively). A maximum force of 50 g and a ramp speed of 20 s were used for all the esthesiometry tests.
Motor function analysis following MIA injection
Motor functional recovery of the rear limb was evaluated by walking track analysis, a reliable and easily quantifiable noninvasive method based on gait analysis by means of specific footprint parameters as previously described . Walking track analysis was performed before MIA injection and 3, 7, 14, and 21 days post-injection. From the footprints, several measurements are taken between different anatomic landmarks and then incorporated in a mathematical formula. More specifically, the measurements were the following: (i) the print length (PL, i.e., the distance from the heel to toe), (ii) the toe spread (TS, i.e., the distance from the first to the fifth toes), (iii) the intermediary toe spread (IT, i.e., the distance from the second to fourth toes). These measures were recorded for the MIA-injected and contralateral normal limb with the prefix E and N being added respectively. The motor functional recovery was calculated using the following formula, whose numerical value is termed SFI (sciatic functional index): − 38.3 [(EPL − NPL)/NPL] + 109.5 [(ETS-NTS)/NTS] + 13.3 [(EIT − NIT)/NIT] − 8.8 . SFI values in the control group were assumed as zero.
Histological analysis of MIA-injected rats
The MIA- and vehicle-injected tibiofemoral joints were dissected immediately after sacrifice and post-fixed in neutral buffered formalin (containing 4% formaldehyde) as previously described . Mid-coronal tissue sections (5 μm) were stained with H/E, observed using a Leica DM6 microscope at × 10 magnification (Leica Microsystems SpA, Milan, Italy) equipped with a motorized stage and associated with Leica LAS X Navigator software (Leica Microsystems SpA, Milan, Italy). Collagen content was assayed according to the manufacturer’s protocol (Bio-Optica, Italy, Milan), with tissue sections being stained with Masson’s trichrome. Proteoglycan depletion and cartilage destruction were assayed using Safranin O/Fast green staining. The number and degranulation extent of mast cells were also assessed in tissue sections stained with toluidine blue as previously described .
Finally, a modified Mankin histologic scoring system was used to evaluate cartilage damage, from 0 (normal histology) to 12 (complete disorganization and hypocellularity) . The photographs obtained (n = 5 photos from five slides for each sample) were collected from all animals in each experimental group. The histological coloration (five slides for each same sample) was repeated three times on different days.
Radiographic analysis of MIA-injected rats
Radiographic analysis was performed by X-ray (Bruker FX Pro instrument, Milan, Italy). Radiographs were evaluated by an expert observer and scored using a semi-quantitative grading scale as previously indicated . Briefly, the study features were scored as follows: joint space, from 0 (normal) to 3 (complete loss of joint space); subchondral bone sclerosis, from 0 (normal) to 3 (severe); osteophyte formation, from 0 (normal) to 3 (osteophytes present on both tibial and femoral condyle).
Serum concentration of inflammatory, nociceptive, and matrix degradation markers following MIA injection
On day 21 post-MIA injection, rats were sacrificed and serum were taken and stored at − 80 °C. Subsequently, the concentration of tumor necrosis factor alpha (TNF-α), interleukin-1beta (IL-1β), nerve growth factor (NGF), and matrix metalloproteinase-1-3-9 (MMP-1, MMP-3, MMP-9) were measured in serum using commercial colorimetric ELISA kits (TNF-α, IL-1β, and NGF: Thermo Fisher Scientific, DBA s.r.l. Milan Italy; MMP-1, MMP-3, and MMP-9: Cusabio, DBA s.r.l. Milan Italy).
Immunohistochemistry in CAR- and MIA-injected rats
Paw and joint knee sections were immunostained with CD68 as previously described by Cordaro and coll .. Slices were incubated overnight with anti-CD68 antibody (1:100 in PBS, v/v, Santa Cruz Biotechnology, Heidelberg, Germany). All immunohistochemical analyses were carried out by an observer blind to treatments.
Data are expressed as mean ± standard error of the mean (SEM) of N observations, N representing the number of animals analyzed, with the exception of the ordinal level variable (i.e., histological score), for which median and range were used. In experiments involving histology, the figures are representative of at least three independent experiments performed on different days. The results were analyzed by one- or two-way ANOVA followed by a Bonferroni post hoc test for multiple comparisons. Kruskal-Wallis test followed by Dunn’s test for post hoc comparisons with Bonferroni-Holm p correction was used for the histological score, due the ordinal level nature of the variable (i.e., 0- to 5-point scale). Data were analyzed using SAS v9.2 (SAS Institute, Cary, NC, USA). The significance threshold was set at 0.05. Exact p values are reported, unless less than 1 out of 10,000 (reported as p < 0.0001), 0.0001 being the lower limit for the statistical program.
Effect of m-PGA on CAR-induced inflammation
Effect of the study treatments on CAR-induced neutrophil infiltration
Effect of the study treatments on CAR-induced histological damage
P (vs CAR)
Effect of m-PGA on CAR-induced inflammatory pain
Effect of m-PGA on pain and motor function deficits following MIA induction
Effect of m-PGA on histologic and radiographic MIA-induced joint damage
Effects of m-PGA on plasma concentration of inflammatory, nociceptive and matrix degradation markers
Effect of MIA injection on plasma concentration of inflammatory, nociceptive, and matrix degradation markers in vehicle-treated animals
Effect of m-PGA on joint inflammatory cell hyper-activation following MIA injection
The present study showed m-PGA is safe, with LD50 ≥ 2000 mg/kg, i.e., 20 to 66 fold higher than the dose having beneficial therapeutic effects. In particular, the effects on CAR-induced inflammatory responses induced by a single oral administration of m-PGA were comparable to those of dexamethasone (particularly for the higher PGA dose). The finding is consistent with the results of previous studies which found that PGA endogenous congener, PEA (especially in micronized formulations) or the inhibitor of its degradative enzyme (i.e., the NAAA inhibitor ARN726) showed anti-inflammatory effects, which were comparable in efficacy to those exerted by dexamethasone [40, 41, 42]. The superior efficacy shown by micronized over non-micronized PGA in CAR-induced inflammatory responses was even more evident in OA-associated mechanical allodynia. This was shown by the significantly superior effect of m-PGA over PGA on MIA-induced decrease in pain withdrawal threshold and latency. In our view, this is a very interesting point since allodynia is a prominent feature of neuropathic pain, which represents a debilitating form of treatment-resistant, and possibly OA-related, chronic pain [43, 44, 45]. The superior effect of the tested micronized formulation is in agreement with previous studies which showed that reducing particle size of PGA parent molecule, PEA, highly and significantly increased both bioavailability and pain-relieving effect [25, 26]. Moreover, the observed effects on MIA-induced allodynia might suggest that possible mechanisms on peripheral and central sensitization are involved in m-PGA effect, similarly to those recently described for m-PEA in the experimentally inflamed temporomandibular joint . It is interesting to note that oral supplementation with m-PGA in MIA-injected animals resulted in an anti-allodynic effect similar to that recently seen with intra-articular injection of PEA [47, 48]. The latter treatment option also benefited locomotor activity in MIA-injected rats , similarly to what was found here in orally administered animals. Of note, m-PGA resulted in a superior and earlier locomotor improvement compared to naïve non-micronized PGA. The MIA model is a well-established model of OA for both pain-related behaviors as well as histopathological changes [36, 49, 50]. Besides reducing allodynia and improving locomotor function in MIA-injected rats, PGA and even more so m-PGA also limited histological and radiographic damage and protected against MIA-induced loss of proteoglycans and collagen. The findings are consistent with those of a previous study reporting that the ALIAmide adelmidrol (a further PGA congener) limited MIA-induced cartilage degeneration and suchondral bone changes .
Finally, the present study showed that PGA significantly counteracted MIA-induced increase in joint inflammatory cells and plasma levels of IL-1β, TNF-α, metalloproteases, and NGF. Interestingly, hyperactive synovial cells (e.g., mast cells and macrophages) and chondrocytes are considered to the main sources of these pro-inflammatory and degradative bioactive mediators [7, 52, 53, 54]. The effect of PGA observed in the present study is thus consistent with the ALIA mechanism (i.e., down-modulation of cell hyperactivity) shown to be the main mechanism of action of the ALIAmide parent molecule PEA [11, 55, 56] and its congeners, i.e., adelmidrol  and PGA itself . Once again, m-PGA showed superior efficacy over PGA in limiting the increase in the serum levels of IL-1β, TNF-α, metalloproteases, and NGF. Given the role played by the latter neurokine in OA pain [58, 59], the superior effect of m-PGA might explain its greater anti-allodynic effect over the non-micronized formulation.
There are multiple potential limitations to this study. The first pertains to the MIA model that is generally regarded as not accurately representing early pathophysiological alterations of human OA, while being considered one of the preferred models when studying OA pain . Actually, representative histopathological findings of OA were recently shown in MIA-injected knees [36, 61] thus overcoming—at least in part—the potential limitation. The second is the lack of a glucosamine-treated group for reference. To the best of our knowledge, only one study has been published on glucosamine in the MIA-induced OA model and oral daily dose of 100 mg/kg for a 2-month duration was needed to show beneficial effects . Different preclinical OA models were also used to evaluate glucosamine efficacy, the active daily dose ranging from 20 mg/kg to up to 1000 mg/kg (reviewed by Henrotin and coll .). In the present study, the dose used—and proved to be effective—was lower, i.e., 30 mg/kg PGA either micronized or not, corresponding to a glucosamine equimolar dose of 15 mg/kg. Moreover, the treatment frequency/duration was shorter (three times per week for 3 weeks) compared to the aforementioned OA preclinical studies on therapeutic potential of glucosamine. Although a glucosamine-treated group was actually lacking from our experiments, from the above one could conceivably reject the hypothesis that the observed effects were solely dependent on glucosamine released from PGA.
Overall, the results of the present study showed that PGA had a global benefit, limiting joint inflammation, pain, and tissue damage, confirming preliminary findings by Costa and colleagues . Moreover, it proved that particle size reduction greatly enhances the activity of the lipophilic compound PGA on joint pain and locomotor disability. Given these results, m-PGA could be considered a valuable option to concurrently counteract the pathogenic triad in OA (i.e., chondrodegeneration, inflammation, and pain). Clinical studies in human and veterinary patients are warranted to further evaluate therapeutic potential for m-PGA in naturally occurring OA.
The authors would like to thank Miss Valentina Malvagni for editorial support with the manuscript.
MC and RS contributed to the conception, design, and drafting of the manuscript; RD, AFP, and EG made the experiments; RC, RF, and DI contributed to the acquisition of the data and interpretation; CS contributed to the analysis of the data; SC and RDP revised critically the manuscript. All authors have read and approved the final manuscript.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethics approval and consent to participate
The study was approved by the University of Messina Review Board for the care of animals. Animal care was in accordance with Italian regulations on protection of animals used for experimental and other scientific purposes (D.M.116192) as well as with EEC regulations (O.J. of E.C. L 358/1 12/18/1986) and in compliance with the requirements of Italian Legislative Decree no. 26/2014 and subsequent guidelines issued by the Italian Ministry of Health on March 16, 2015.
Consent for publication
Dr. Salvatore Cuzzocrea, researcher on the study team, is co-inventor on patent WO2013121449A8 (Epitech Group SpA) which deals with compositions and methods for the modulation of amidases capable of hydrolysing N-acylethanolamines applied in the therapy of inflammatory diseases. Moreover, Dr. Cuzzocrea is also a co-inventor with Epitech group on the following patent:
The other authors declare that they have no competing interests.
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