Several papers have demonstrated that an imbalance of the endocannabinoid system (ECS) and alterations in the levels of PEA occur in acute and chronic inflammation. For instance, during β-amyloid-induced neuroinflammation the deregulation of cannabinoid receptors and their endogenous ligands accompanies the development and progression of disease.
Palmitoylethanolamide was discovered in 1957. Indications for its use as an anti-inflammatory and analgesic date from before 1980. In that year, researchers described what they called "N-(2-hydroxyethyl)-palmitamide" as a natural anti-inflammatory agent. They stated: " We have succeeded in isolating a crystalline anti-inflammatory factor from soybean lecithin and identifying it as (S)-(2-hydroxyethyl)-palmitamide. The compound also was isolated from a phospholipid fraction of egg yolk and from hexane-extracted peanut meal."
In 1975 Czech physicians described the results of a clinical trial using it for joint pain,. The analgesic action of 3 grams of aspirin during the day was compared to PEA 1.8 gram/day. Both drugs were reported to enhance joint movements and decrease pain. In 1970 the drug manufacturer Spofa introduced "Impulsin" tablets of 500 mg PEA for the treatment and prophylaxis of flu and respiratory infections in Czechoslovakia; the company Almirall introduced "Palmidrol", as either tablets or as a suspension, in Spain in 1976 for the same indications. As research into the endocannabinoid system has evolved, PEA has garnered more attention from scientists and manufacturers, which led to more advanced product formulations, including liposomal palmitoylethanolamide for improved bioavailability.
In the 1990s, the relation between anandamide and PEA was described; the expression of mast cell receptors sensitive to the two molecules was first demonstrated by the research group of Nobel prize winner Rita Levi-Montalcini. During this period, more insight into the functions of endogenous fatty acid derivatives emerged, and compounds such as oleamide, palmitoylethanolamide, 2-lineoylglycerol and 2-palmitoylglycerol were explored for their capacity to modulate pain sensitivity and inflammation via what at that time was thought to be the endocannabinoid signalling pathway. One group demonstrated that PEA could alleviate, in a dose-dependent manner, pain behaviors elicited in mice-pain models, and could downregulate hyperactive mast cells. PEA and related compounds such as anandamide also seem to have synergistic effects in models of pain and analgesia.
In a variety of animal models, PEA seems to have some promise; researchers have been able to demonstrate relevant clinical efficacy in a variety of disorders, from multiple sclerosis to neuropathic pain.
Chronic pain and neuropathic pain are indications for which there is high unmet need in the clinic. PEA has been tested in a variety of animal models for chronic and neuropathic pain. As cannabinoids, such as THC, have been proven to be effective in neuropathic pain states. The analgesic and antihyperalgesic effects of PEA in two models of acute and persistent pain seemed to be explained at least partly via the de novo neurosteroid synthesis. In chronic granulomatous pain and inflammation model, PEA could prevent nerve formation and sprouting, mechanical allodynia, and PEA inhibited dorsal root ganglia activation, which is a hallmark for winding up in neuropathic pain. The mechanism of action of PEA as an analgesic and anti-inflammatory molecule is probably based on different aspects. PEA inhibits the release of both preformed and newly synthesised mast cell mediators, such as histamine and TNF-alpha. PEA, as well as its analogue adelmidrol (di-amide derivative of azelaic acid), can both down-regulate mast cells. PEA reduces the expression of cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) and prevents IkB-alpha degradation and p65 NF-kappaB nuclear translocation, the latter related to PEA as an endogenous PPAR-alpha agonist.
In 2012 it became clear that PEA can also reduce reperfusion injury and the negative impact of shock on various outcome parameters, such as renal dysfunction, ischemic injury and inflammation, most probably via the PPAR-alpha pathway. Among the reperfusion and inflammation markers measured PEA could reduce the increase in creatinine, γGT, AST, nuclear translocation of NF-κBp65; kidney MPO activity and MDA levels, nitrotyrosine, PAR and adhesion molecules expression, the infiltration and activation of mastcells and apoptosis.
PEA seems to be produced in human as well as in animals as a biological response and a repair mechanism in chronic inflammation and chronic pain. In a model of visceral pain (inflammation of the urinary bladder) PEA was able to attenuate the viscero-visceral hyper-reflexia induced by inflammation of the urinary bladder, one of the reasons why PEA is currently explored in the painful bladdersyndrome. In a different model for bladder pain, the turpentine-induced urinary bladder inflammation in the rat, PEA also attenuated a referred hyperalgesia in a dose-dependent way. Chronic pelvic pain in patients seem to respond favourably to a treatment with PEA.
Activity in non-neuronal cells
PEA, as an N-acylethanolamine, has physico-chemical properties comparable to anandamide, and, while it is not strictly an endocannabinoid, it is often studied in conjunction with anandamide because of their overlapping synthetic and metabolic pathways. N-acylethanolamines, such as PEA, often act as signaling molecules, activating receptors and regulating a variety of physiological functions.PEA is known to activate intracellular, nuclear and membrane-associated receptors, and to regulate many physiological functions related to the inflammatory cascade and chronic pain states. Endocannabinoid lipids like PEA are widely distributed in nature, in a variety of plant, invertebrate, and mammalian tissues.
PEA's mechanism of action sometimes is described as Autacoid Local Injury Antagonism (acronym ALIA), and PEA under this nomenclature is an ALIAmide. It was the group of the Nobel prize laureate Rita Levi-Montalcini who in 1993 first presented evidence that lipid amides of the N-acylethanolamine type (such as PEA) are potential prototypes of naturally occurring molecules capable of modulating mast cell activation; her group coined the acronym ALIA in that paper. An autocoid is a regulating molecule, locally produced. An ALIAmide is an autocoid synthesized on-demand in response to injury, and acts locally to counteract such pathology. soon after the breakthrough paper of Levi-Montalcini, The mast cell appeared to be an important target for the anti-inflammatory activity of PEA. Since 1993, at least 25 papers have been published on the various effects of PEA on mast cells. These cells are often found in proximity to sensory nerve endings, and their degranulation can enhance the nociceptive signal, the reason why peripheral mast cells are considered to be pro-inflammatory and pro-nociceptive. PEA's activity is currently seen as a new inroad in the treatment of neuropathic pain and related disorders based on overactivation of glia and glia-related cells, such as in diabetes and glaucoma. Microglia plays a key role in the winding up phenomena and central sensitization.
PEA has been explored in humans; spanning various clinical trials in a variety of pain states, for inflammatory and pain syndromes. Its positive influence in atopic eczema for instance seems to originate from PPAR alpha activation. PEA is available for human use as a dietary supplement.
In a 2012 review, all clinical trials to date were summarized. In a 2015 analysis of a double blind placebo controlled study of PEA in sciatic pain, the Numbers Needed to Treat was 1.5. Its positive influence in chronic pain, and inflammatory states such as atopic eczema, seems to originate mainly from PPAR alpha activation. Since 2012 a number of new trials have been published, among which studies in glaucoma. PEA also seems to be one of the factors responsible for the decrease in pain sensitivity during and after sport, comparable to the endogenous opiates (endorphines).
From a clinical perspective the most important and promising indications for PEA are linked to neuropathic and chronic pain states, such as diabetic neuropathic pain, sciatic pain, CRPS, pelvic pain and entrapment neuropathic painstates. In a blind pilot trial in 25 patients affected by temporomandibular joint's (TMJ) osteoarthritis or synovitis pain, patients were randomly to PEA or ibuprofen 600 mg three times a day for two weeks. Pain decrease after two weeks of treatment was significantly higher in PEA treated patients than in patients receiving the NSAID (p=0.0001) Masticatory function also improves more on PEA compared to the NSAID. In 2012, 20 patients suffering from thalidomide and bortezomib induced neuropathy were reported to have improved nerve functions and less pain after a two months treatment with PEA 600 mg daily. The authors pointed out that although a placebo effect might play a role in the reported pain relief, the changes in neurophysiological measures clearly indicated that PEA exerted a positive action on the myelinated fibre groups. 30 patients suffering from neuropathic pain, which were refractory to treatment with analgesics, included pregabalin, were responding well in 45 days, with a decrease of painscores > 50% when pregabalin was tapered in again, up to 600 mg/day in combination with PEA, without signs of drug-drug interaction. In 2013 a review was published on the clinical efficacy and safety of PEA in flu, based on a 6 double blind placebo controlled RCT's. This review underscores the anti-inflammatory action of PEA. These effects are also the explanation of PEA's retinoprotectant effects.
^O'Sullivan, S. E.; Kendall, D. A. (2010). "Cannabinoid activation of peroxisome proliferator-activated receptors: Potential for modulation of inflammatory disease". Immunobiology. 215 (8): 611–616. doi:10.1016/j.imbio.2009.09.007. PMID19833407.
^De Filippis, D.; d’Amico, A.; Cipriano, M.; Petrosino, S.; Orlando, P.; Di Marzo, V.; Iuvone, T.; Iuvone, T. (2010). "Levels of endocannabinoids and palmitoylethanolamide and their pharmacological manipulation in chronic granulomatous inflammation in rats". Pharmacological Research. 61 (4): 321–328. doi:10.1016/j.phrs.2009.11.005. PMID19931394.
^Walker, J. M.; Krey, J. F.; Chu, C. J.; Huang, S. M. (2002). "Endocannabinoids and related fatty acid derivatives in pain modulation". Chemistry and Physics of Lipids. 121 (1–2): 159–172. doi:10.1016/s0009-3084(02)00152-4. PMID12505698.
^Lambert, D. M.; Vandevoorde, S.; Jonsson, K. O.; Fowler, C. J. (2002). "The palmitoylethanolamide family: A new class of anti-inflammatory agents?". Current Medicinal Chemistry. 9 (6): 663–674. doi:10.2174/0929867023370707. PMID11945130.
^Mazzari, S.; Canella, R.; Petrelli, L.; Marcolongo, G.; Leon, A. (1996). "N-(2-hydroxyethyl)hexadecanamide is orally active in reducing edema formation and inflammatory hyperalgesia by down-modulating mast cell activation". European Journal of Pharmacology. 300 (3): 227–236. doi:10.1016/0014-2999(96)00015-5. PMID8739213.
^Piomelli, D.; Calignano, A.; Rana, G. L.; Giuffrida, A. (1998). "Control of pain initiation by endogenous cannabinoids". Nature. 394 (6690): 277–281. doi:10.1038/28393. PMID9685157.
^Loría, F.; Petrosino, S.; Mestre, L.; Spagnolo, A.; Correa, F.; Hernangómez, M.; Guaza, C.; Di Marzo, V.; Docagne, F. (2008). "Study of the regulation of the endocannabinoid system in a virus model of multiple sclerosis reveals a therapeutic effect of palmitoylethanolamide". European Journal of Neuroscience. 28 (4): 633–641. doi:10.1111/j.1460-9568.2008.06377.x. hdl:10261/73342. PMID18657182.
^Costa, B.; Comelli, F.; Bettoni, I.; Colleoni, M.; Giagnoni, G. (2008). "The endogenous fatty acid amide, palmitoylethanolamide, has anti-allodynic and anti-hyperalgesic effects in a murine model of neuropathic pain: Involvement of CB1, TRPV1 and PPARγ receptors and neurotrophic factors". Pain. 139 (3): 541–550. doi:10.1016/j.pain.2008.06.003. PMID18602217.
^Yu, H. L.; Deng, X. Q.; Li, Y. J.; Li, Y. C.; Quan, Z. S.; Sun, X. Y. (2011). "N-palmitoylethanolamide, an endocannabinoid, exhibits antidepressant effects in the forced swim test and the tail suspension test in mice". Pharmacological Reports : PR. 63 (3): 834–839. doi:10.1016/s1734-1140(11)70596-5. PMID21857095.
^Gagliano, C.; Ortisi, E.; Pulvirenti, L.; Reibaldi, M.; Scollo, D.; Amato, R.; Avitabile, T.; Longo, A. (2011). "Ocular Hypotensive Effect of Oral Palmitoyl-ethanolamide: A Clinical Trial". Investigative Ophthalmology & Visual Science. 52 (9): 6096–6100. doi:10.1167/iovs.10-7057. PMID21705689.
^Esposito, E.; Paterniti, I.; Mazzon, E.; Genovese, T.; Di Paola, R.; Galuppo, M.; Cuzzocrea, S. (2011). "Effects of palmitoylethanolamide on release of mast cell peptidases and neurotrophic factors after spinal cord injury". Brain, Behavior, and Immunity. 25 (6): 1099–1112. doi:10.1016/j.bbi.2011.02.006. PMID21354467.
^Garcia-Ovejero, D.; Arevalo-Martin, A.; Petrosino, S.; Docagne, F.; Hagen, C.; Bisogno, T.; Watanabe, M.; Guaza, C.; Di Marzo, V.; Molina-Holgado, E. (2009). "The endocannabinoid system is modulated in response to spinal cord injury in rats". Neurobiology of Disease. 33 (1): 57–71. doi:10.1016/j.nbd.2008.09.015. hdl:10261/73343. PMID18930143.
^Schomacher, M.; Müller, H. D.; Sommer, C.; Schwab, S.; Schäbitz, W. R. D. (2008). "Endocannabinoids mediate neuroprotection after transient focal cerebral ischemia". Brain Research. 1240: 213–220. doi:10.1016/j.brainres.2008.09.019. PMID18823959.
^Sasso, O.; Russo, R.; Vitiello, S.; Raso, G.; d'Agostino, G.; Iacono, A.; Rana, G.; Vallée, M.; Cuzzocrea, S.; Piazza, P. V.; Meli, R.; Calignano, A. (2011). "Implication of allopregnanolone in the antinociceptive effect of N-palmitoylethanolamide in acute or persistent pain". Pain. 153 (1): 33–41. doi:10.1016/j.pain.2011.08.010. PMID21890273.
^Raso GM, Esposito E, Vitiello S, Iacono A, Santoro A, D'Agostino G, et al. (July 2011). "Palmitoylethanolamide stimulation induces allopregnanolone synthesis in C6 Cells and primary astrocytes: involvement of peroxisome-proliferator activated receptor-α". J. Neuroendocrinol. 23 (7): 591–600. doi:10.1111/j.1365-2826.2011.02152.x. PMID21554431.
^Cerrato, S.; Brazis, P.; Della Valle, M. F.; Miolo, A.; Puigdemont, A. (2010). "Effects of palmitoylethanolamide on immunologically induced histamine, PGD2 and TNFα release from canine skin mast cells". Veterinary Immunology and Immunopathology. 133 (1): 9–15. doi:10.1016/j.vetimm.2009.06.011. PMID19625089.
^Di Paola, R.; Impellizzeri, D.; Mondello, P.; Velardi, E.; Aloisi, C.; Cappellani, A.; Esposito, E.; Cuzzocrea, S. (2012). "Palmitoylethanolamide Reduces Early Renal Dysfunction and Injury Caused by Experimental Ischemia and Reperfusion in Mice". Shock. 38 (4): 356–66. doi:10.1097/SHK.0b013e318267bbb9. PMID22772472.
^ abDarmani, N. A.; Izzo, A. A.; Degenhardt, B.; Valenti, M.; Scaglione, G.; Capasso, R.; Sorrentini, I.; Di Marzo, V. (2005). "Involvement of the cannabimimetic compound, N-palmitoyl-ethanolamine, in inflammatory and neuropathic conditions: Review of the available pre-clinical data, and first human studies". Neuropharmacology. 48 (8): 1154–1163. doi:10.1016/j.neuropharm.2005.01.001. PMID15910891.
^Jaggar, S. I.; Hasnie, F. S.; Sellaturay, S.; Rice, A. S. (1998). "The anti-hyperalgesic actions of the cannabinoid anandamide and the putative CB2 receptor agonist palmitoylethanolamide in visceral and somatic inflammatory pain". Pain. 76 (1–2): 189–199. doi:10.1016/S0304-3959(98)00041-4. PMID9696473.
^Farquhar-Smith, W. P.; Rice, A. S. (2001). "Administration of endocannabinoids prevents a referred hyperalgesia associated with inflammation of the urinary bladder". Anesthesiology. 94 (3): 507–513, discussion 513. doi:10.1097/00000542-200103000-00023. PMID11374613.
^Calabrò, R. S.; Gervasi, G.; Marino, S.; Mondo, P. N.; Bramanti, P. (2010). "Misdiagnosed Chronic Pelvic Pain: Pudendal Neuralgia Responding to a Novel Use of Palmitoylethanolamide". Pain Medicine. 11 (5): 781–784. doi:10.1111/j.1526-4637.2010.00823.x. PMID20345619.
^ abcIndraccolo, U.; Barbieri, F. (2010). "Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations". European Journal of Obstetrics & Gynecology and Reproductive Biology. 150 (1): 76–79. doi:10.1016/j.ejogrb.2010.01.008. PMID20176435.
^Donvito, G; Bettoni, I; Comelli, F; Colombo, A; Costa, B (2015). "Palmitoylethanolamide relieves pain and preserves pancreatic islet cells in a murine model of diabetes". CNS & Neurological Disorders Drug Targets. 14 (4): 452–62. PMID25921749.
^Nakagawa, T.; Kaneko, S. (2010). "Spinal astrocytes as therapeutic targets for pathological pain". Journal of Pharmacological Sciences. 114 (4): 347–353. doi:10.1254/jphs.10r04cp. PMID21081837.
^ abcdEberlein, B.; Eicke, C.; Reinhardt, H. -W.; Ring, J. (2007). "Adjuvant treatment of atopic eczema: Assessment of an emollient containing N-palmitoylethanolamine (ATOPA study)". Journal of the European Academy of Dermatology and Venereology. 22 (1): 73–82. doi:10.1111/j.1468-3083.2007.02351.x. PMID18181976.
^ abConigliaro, R.; Drago, V.; Foster, P. S.; Schievano, C.; Di Marzo, V. (2011). "Use of palmitoylethanolamide in the entrapment neuropathy of the median in the wrist". Minerva Medica. 102 (2): 141–147. PMID21483401.
^ abPhan, N. Q.; Siepmann, D.; Gralow, I.; Ständer, S. (2009). "Adjuvant topical therapy with a cannabinoid receptor agonist in facial postherpetic neuralgia". Journal der Deutschen Dermatologischen Gesellschaft. 8 (2): 88–91. doi:10.1111/j.1610-0387.2009.07213.x. PMID19744255.
^Cerrato, S.; Brazis, P.; Valle, M. F. D.; Miolo, A.; Petrosino, S.; Marzo, V. D.; Puigdemont, A. (2011). "Effects of palmitoylethanolamide on the cutaneous allergic inflammatory response in Ascaris hypersensitive Beagle dogs". The Veterinary Journal. 191 (3): 377–82. doi:10.1016/j.tvjl.2011.04.002. PMID21601500.
^Costagliola, C; Romano, M. R.; Dell'Omo, R; Russo, A; Mastropasqua, R; Semeraro, F (2014). "Effect of palmitoylethanolamide on visual field damage progression in normal tension glaucoma patients: Results of an open-label six-month follow-up". Journal of Medicinal Food. 17 (9): 949–54. doi:10.1089/jmf.2013.0165. PMID24827384.
^Pescosolido, N; Librando, A; Puzzono, M; Nebbioso, M (2011). "Palmitoylethanolamide effects on intraocular pressure after Nd:YAG laser iridotomy: An experimental clinical study". Journal of Ocular Pharmacology and Therapeutics. 27 (6): 629–35. doi:10.1089/jop.2010.0191. PMID21830944.
^Habib AM, Okorokov A, Hill MN, Bras JT, Lee MC, Li S, Gossage SJ, van Drimmelen M, Morena M, Houlden H, Ramirez JD, Bennett DL, Srivastava D, Cox JJ (2019). "Microdeletion in a pseudogene identified in a patient with high anandamide concentrations and pain insensitivity". British Journal of Anaesthesia. 123: 249–253. doi:10.1016/j.bja.2019.02.019. PMID30929760.