2006;22(3):235–239. 43. Birklein F , Schmelz M, Schifter S, Weber M. The important role of neuropeptides in 
complex regional pain syndrome. Neurology. 2001;57:2179–2184. 44. Oaklander AL, Rissmiller JG, Gelman LB, Zheng L, Chang Y , Gott R. Evidence of focal 
small-fiber axonal degeneration in complex regional pain syndrome-I (reflex sympa -
thetic dystrophy). Pain . 2006;120:235–243. 45. Cossins L, Okell RW, Cameron H, Simpson B, Poole HM, Goebel A. Treatment of com -
plex regional pain syndrome in adults: A systematic review of randomized controlled trials published from June 2000 to February 2012. Eur J Pain . 2013;17(2):158–173. 46. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent com -
plex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007;89(7):1424–1431. 47. Correll GE, Maleki J, Gracely EJ, Muir JJ, Harb ut RE. Subanesthetic ketamine infusion 
therapy: A retrospective analysis of a novel therapeutic approach to complex regional pain syndrome. Pain Med. 2004;5(3):263–275. 48. Collins S, Sigtermans MJ, Dahan A, Zuurmond WW, Perez RS. NMDA receptor antag -
onists for the treatment of neuropathic pain. Pain Med . 2010;11(11):1726–1742. 49. Kiefer R T, Rohr P, Ploppa A et al. A pilot open-label study of the efficacy of subanes -
thetic isomeric S(+)-ketamine in refractory CRPS patients. Pain Med. 2008;9(1):44–54. 50. Sunder RA, Toshniwal G, Dureja GP. Ketamine as an adjuvant in sympathetic blocks for 
management of central sensitization following peripheral nerve injury. J Brachial Plex 
Peripher Nerve Inj . 2008;25(3):22. 51.  v an Dieten HE, Perez RS, van Tulder MW, de Lange JJ, Zuurmond WW, Ader HJ, 
V ondeling H, Boers M. Cost effectiveness and cost utility of acetylcysteine versus dimethyl sulfoxide for reflex sympathetic dystrophy. Pharmacoeconomics . 2003;21(2):139–148. 52. Repine JE, Pfenninger O W, Talmage DW, Berger EM, Pettijohn DE. Dimethyl sulfox -
ide prevents DNA nicking mediated by ionizing radiation or iron/hydrogen peroxide-
generated hydroxyl radical. Proc Natl Acad Sci USA . 1981;78(2):1001–1003. 53. Rosenblum WI, El-Sabban F. Dimethyl sulfoxide (DMSO) and glycerol, hydroxyl 
radical scavengers, impair platelet aggregation within and eliminate the accompanying 
vasodilation of, injured mouse pial arterioles. Stroke. 1982;13(1):35–39.74 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
 54. Gaspar M, Bo vaira M, Carrera-Hueso FJ, Querol M, Jiménez A, Moreno L. Efficacy of a 
topical treatment protocol with dimethyl sulfoxide 50% in type 1 complex regional pain 
syndrome. Farm Hosp . 2012;36(5):385–391. 55. Goris RJ. Treatment of reflex sympathetic dystrophy with hydroxyl radical scavengers. Unfallchirurg . 1985;88(7):330–332. 56. Zuurmond WW, Langendijk PN, Bezemer PD, Brink HE, de Lange JJ, van loenen AC. Treatment of acute reflex sympathetic dystrophy with DMSO 50% in a fatty cream. Acta 
Anaesthesiol Scand . 1996;40(3):364–367. 57.  v an Eijs F, Geurts JW, Van Zundert J, Faber CG, Kessels AG, Joosten EA, van Kleef M. 
Spinal cord stimulation in complex regional pain syndrome type I of less than 12-month duration. Neuromodulation. 2012;15(2):144–150. 58. Quisel A, Gill JM, Witherell P. Complex regional pain syndrome: Which treatments 
show promise? J Fam Pract . 2005;54(7):599–603. 59. Simon LS, Grierson LM, Naseer Z, Bookman AA, Zev Shainhouse J. Efficacy and 
safety of topical diclofenac containing dimethyl sulfoxide (DMSO) compared with those of topical placebo, DMSO vehicle and oral diclofenac for knee osteoarthritis. Pain. 2009;143(3):238–245. 60. Bookman AAM, Williams KSA, Shainhouse JZ. Effect of a topical diclofenac solution 
for relieving symptoms of primary osteoarthritis of the knee: A randomized controlled trial. CMAJ . 2004;171(4):333–338. 61. Barkin RL. Topical nonsteroidal anti-inflammatory drugs: The importance of drug, 
delivery, and therapeutic outcome. Am J Ther . February 22, 2012; Epub ahead of print. 62. Roth SH, Fuller P . Pooled safety analysis of diclofenac sodium topical solution 1.5% 
(w/w) in the treatment of osteoarthritis in patients aged 75 years or older. Clin Interv 
Aging. 2012;7:127–137. 63. Mostofi FK, Murph y GP, Mettlin C, Sesterhenn IA, Batsakis JG, Khaliq SU, Nadimpalli 
V , Tahan S, Siders DB, Kollin J. Pathology review in an early prostate cancer detec -
tion program: Results from the American Cancer Society-National Prostate Cancer Detection Project. Prostate. 1995;27(1):7–12. 64. Hoang BX, Le vine SA, Shaw DG, Tran DM, Tran HQ, Nguyen PM, Tran HD, Hoang C, 
Pham PT. Dimethyl sulfoxide as an excitatory modulator and its possible role in cancer pain management. Inflamm Allergy Drug Targets . 2010;9(4):306–312. 65. Hoang BX, Le BT , Tran HD, Hoang C, Tran HQ, Tran DM, Pham CQ et al. Dimethyl 
sulfoxide-sodium bicarbonate infusion for palliative care and pain relief in patients with metastatic prostate cancer. J Pain Palliat Care Pharmacother . 2011;25(4):350–355. 66. Moul JW , Civitelli K. Managing advanced prostate cancer with Viadur (leuprolide ace -
tate implant). Urol Nurs . 2001;21(6):385–388, 393–394. 67. Marks LS. Luteinizing hormone-releasing hormone agonists in the treatment of men 
with prostate cancer: Timing, alternatives, and the 1-year implant. Urology. 2003;62(6 Suppl 1):36–42. 68. F owler JE Jr; Viadur Study Group. Patient-reported experience with the Viadur 12-month 
leuprolide implant for prostate cancer. Urology. 2001;58(3):430–434. 69. Spruance SL, Ste wart JC, Freeman DJ, Brightman VJ, Cox JL, Wenerstrom G, McKeough 
MB, Rowe NH. Early application of topical 15% idoxuridine in dimethyl sulfoxide shortens the course of herpes simplex labialis: A multicenter placebo-controlled trial. J Infect Dis . 1990;161(2):191–197. 70. Aliag a A, Armijo M, Camacho F, Castro A, Cruces M, Díaz JL, Fernández JM, Iglesias 
L, Ledo A, Mascaró JM. A topical solution of 40% idoxuridine in dimethyl sulfoxide 
compared to oral acyclovir in the treatment of herpes zoster. A double-blind multicenter 
clinical trial. Med Clin (Barc) . 1992;98(7):245–249. 71. Elliott CS, Payne CK. Interstitial cystitis and the overlap with overactive bladder. Curr 
Urol Rep . 2012;13(5):319–326.75 DMSO Clinical Pharmacology
 72. Y ou S, Yang W, Anger JT, Freeman MR, Kim J. ‘Omics’ approaches to understanding 
interstitial cystitis/painful bladder syndrome/bladder pain syndrome. Int Neurourol J . 2012;16(4):159–168. 73. Quillin RB, Erickson DR. Management of interstitial cystitis/bladder pain syndrome: 
A urology perspective. Urol Clin North Am . 2012;39(3):389–396. 74. Shirle y SW, Stewart BH, Mirelman S. Dimethyl sulfoxide in treatment of inflammatory 
genitourinary disorders. Urology. 1978;11:215. 75. Ek A, Engberg A, Frödin L, Jönsson G. The use of dimethyl-sulfoxide (DMSO) in the 
treatment of interstitial cystitis. Scand J Urol Nephrol . 1978;12(2):129–131. 76. Perez-Marrero R, Emerson LE, Feltis JT. A controlled study of dimethyl sulfoxide in 
interstitial cystitis. J Urol . 1988;140(1):36–39. 77. Biggers RD. Self-administration of dimeth yl sulfoxide (DMSO) for interstitial cystitis. Urology. 1986;28(1):10–11. 78. P arkin J, Shea C, Sant GR. Intravesical dimethyl sulfoxide (DMSO) for interstitial cys -
titis—A practical approach. Urology. 1997;49:105–107. 79. Ste wart BH, Branson AC, Hewitt CB, Kiser WS, Straffon RA. The treatment of 
patients with interstitial cystitis, with special reference to intravesical DMSO. J Urol . 1972;107(3):377–380. 80. Shig a KI, Hirano K, Nishimura J, Niiro N, Naito S, Kanaide H.  Dimethyl sulphoxide 
relaxes rabbit detrusor muscle by decreasing the Ca2+ sensitivity of the contractile appa -
ratus. Br J Pharmacol . 2007;151(7):1014–1024. 81. Richter B, Hesse U, Hansen AB, Horn T, Mortensen SO, Nordling J. Bladder 
pain syndrome/interstitial cystitis in a Danish population: A study using the 2008 
criteria of the European Society for the Study of Interstitial Cystitis. BJU Int . 2010;105(5):660–667. 82. K ushner L, Chiu PY , Brettschneider N, Lipstein A, Eisenberg E, Rofeim O, Moldwin 
R. Urinary substance P concentration correlates with urinary frequency and urgency in interstitial cystitis patients treated with intravesical dimethyl sulfoxide and not intravesi -
cal anesthetic cocktail. Urology. 2001;57(6 Suppl 1):129. 83. Rossber ger J, Fall M, Peeker R. Critical appraisal of dimethyl sulfoxide treatment 
for interstitial cystitis: Discomfort, side-effects and treatment outcome. Scand J Urol 
Nephrol. 2005;39:73–77. 84. Sant GR. Intra vesical 50% dimethyl sulfoxide (Rimso-50) in treatment of interstitial 
cystitis. Urology. 1987;29(4 Suppl):17–21. 85. Ste wart BH, Shirley SW. Further experience with intravesical dimethyl sulfoxide in the 
treatment of interstitial cystitis. J Urol . 1976;116(1):36–38. 86. Ste wart BH, Persky L, Kiser WS. The use of dihyl sulfoxide (DMSO) in the treatment 
of interstitial cystitis. J Urol . 1967;98(6):671–672. 87. Ghoniem GM, McBride D, Sood OP , Lewis V . Clinical experience with multiagent 
intravesical therapy in interstitial cystitis patients unresponsive to single-agent therapy. World J Urol . 1993;11(3):178–182. 88. Hung MJ, Chen YT, Shen PS, Hsu ST, Chen GD, Ho ES. Risk factors that affect the 
treatment of interstitial cystitis using intravesical therapy with a dimethyl sulfoxide cocktail. Int Urogynecol J . 2012;23(11):1533–1539. 89. Amemori S, Iw akiri R, Endo H, Ootani A, Ogata S, Noda T, Tsunada S et al. Oral 
dimethyl sulfoxide for systemic amyloid A amyloidosis complication in chronic inflammatory disease: A retrospective patient chart review. J Gastroenterol . 2006;41(5):444–449. 90. Salim AS. Role of oxygen-derived free radical scavengers in the management of recur -
rent attacks of ulcerative colitis: A new approach. J Lab Clin Med . 1992;119(6):710–717. 91. Pestronk A, Drachman DB. Dimethyl sulphoxide reduces anti-receptor antibody titres in 
experimental myasthenia gravis. Nature . 1980;288(5792):733–734.76 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
 92. Pestronk A, Teoh R, Sims C, Drachman DB. Effects of dimethyl sulfoxide on humoral 
immune responses to acetylcholine receptors in the rat. Clin Immunol Immunopathol. 1985;37(2):172–178. 93. Kim R, Liu W, Chen X, Kreder KJ, Luo Y . Intravesical dimethyl sulfoxide inhibits acute 
and chronic bladder inflammation in transgenic experimental autoimmune cystitis mod -
els. J Biomed Biotechnol . 2011;2011:937061. 94. Lotz M, Villiger P, Hugli T, Koziol J, Zuraw BL. Interleukin-6 and interstitial cystitis. J Urol. 1994;152(3):869–873. 95.  de la Torre JC, Rowed DW. DMSO: A new respiratory stimulant? J Clin Pharmacol . 1974;14(7):345–353. 96.  de la Torre JC, Rowed DW, Kawanaga HM, Mullan S. Dimethyl sulfoxide in the treat -
ment of experimental brain compression. J Neurosurg . 1973;38(3):345–354. 97. Klein HA, Samant S, Herz B, Pearlman H. Dimeth yl sulfoxide in adult respiratory dis -
tress syndrome: Abstract of preliminary report. Ann N Y Acad Sci . 1983;411:389–390. 98. Mann A, Early GL. Acute respiratory distress syndrome. Missouri Med . 2012;109(5):371–375. 99. K yle RA, Greipp PR. Amyloidosis (AL). Clinical and laboratory features in 229 cases. Mayo Clin Proc . 1983;58(10):665–683. 100. Isobe T, Osserman EF. Effects of DMSO on Bence-Jones proteins, amyloid fibrils and 
casein-induced amyloidosis. In Amyloidosis, eds. O. Wagelius, A. Pasternak. Academic 
Press, London, U.K., 1976, p. 247. 101. Malek RS, Wahner-Roedler DL, Gertz MA, Kyle RA. Primary localized amy -
loidosis of the bladder: Experience with dimethyl sulfoxide therapy. J Urol . 2002;168(3):1018–1020. 102.  v an Rijswijk MH, Ruinen L, Donker AJ, de Blécourt JJ, Mandema E. Dimethyl sulfox -
ide in the treatment of AA amyloidosis. Ann N Y Acad Sci . 1983;411:67–83. 103. Iw asaki T, Hamano T, Aizawa K, Kobayashi K, Kakishita E. A case of pulmonary amy -
loidosis associated with multiple myeloma successfully treated with dimethyl  sulfoxide. Acta Haematol . 1994;91(2):91–94. 104. Sutani A, Tabe K, Nagata M, Kuramitsu K, Shimizu Y , Sakamoto Y . Treatment of pul -
monary amyloidosis with dimethyl sulfoxide—A case report. Nihon Kokyuki Gakkai 
Zasshi. 2004;42(9):825–830. 105. Ra vid M, Shapira J, Lang R, Kedar I. Prolonged dimethylsulphoxide treatment in 13 
patients with systemic amyloidosis. Ann Rheum Dis . 1982;41(6):587–592. 106. Hinchclif f M, Varga J. Systemic sclerosis/scleroderma: A treatable multisystem disease. Am Fam Physician. 2008;78(8):961–968. 107. Gries G, Bublitz G, Lindner J. The effect of dimethyl sulfoxide on the components 
of connective tissue. (Clinical and experimental investigations). Ann N Y Acad Sci. 1967;141(1):630–637. 108. Frommhold W, Bublitz G, Gries G. The use of DMSO for the treatment of postirradia -
tion subcutaneous plaques. Ann N Y Acad Sci . 1967;141(1):603–612. 109. Scherbel AL. The effect of percutaneous dimethyl sulfoxide on cutaneous manifesta -
tions of systemic sclerosis. Ann N Y Acad Sci . 1983;411:120–130. 110. W illiams HJ, Furst DE, Dahl SL, Steen VD, Marks C, Alpert EJ, Henderson AM, 
Samuelson CO Jr, Dreyfus JN, Weinstein A. Double-blind, multicenter controlled trial comparing topical dimethyl sulfoxide and normal saline for treatment of hand ulcers in patients with systemic sclerosis. Arthritis Rheum . 1985;28(3):308–314. 111. Corti R., Farkouh ME, Badimon, JJ. The vulnerable plaque and acute coronary syn -
dromes. Am J Med. 2002;113:668–680. 112. Gijsen F , van der Giessen A, van der Steen A, Wentzel J. Shear stress and advanced 
atherosclerosis in human coronary arteries. J Biomech. 2013;46(2):240–247.77 DMSO Clinical Pharmacology
 113. Da vi G, Pathono G. Platelet activation and atherothrombosis. N Engl J Med . 2007;357:2482–2494. 114. Pick er SM. Platelet function in ischemic heart disease. J Cardiovasc Pharmacol . 2013;61(2):166–174. 115. Pick er SM. Antiplatelet therapy in the prevention of coronary syndromes: Mode of 
action, benefits, drawbacks. J Cardiovasc Pharmacol . 2012;61(2):166–174. 116. Sibbing D, Orban M, Massber g S. Potent P2Y12 receptor inhibitors in patients with 
acute coronary syndrome. Agents, indications, issues to consider in clinical practice. Hamostaseologie . 2013;33(1):9–15. 117. Ruggeri ZM. Platelets in atherothrombosis. Nat Med. 2002;8:1227–1234. 118. Y uhki K, Kashiwagi H, Kojima F, Kawabe J, Ushikubi F. Roles of prostanoids in the 
pathogenesis of cardiovascular diseases. Int Angiol . 2010;29(2 Suppl):19–27. 119. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised tri -
als of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in highrisk patients. BMJ . 2002;324:71–86. 120. P atrono C, Garc Rodr  uez LA, Landolfi R, Baigent C. Low-dose aspirin for the preven -
tion of atherothrombosis. N Engl J Med . 2005;353:2373–2383. 121. Sa vi P, Herbert JM. Semin Thromb Hemost. Clopidogrel and ticlopidine: P2Y12 ade -
nosine diphosphate-receptor antagonists for the prevention of atherothrombosis. Semin 
Thromb Hemost. 2005;31(2):174–183. 122. Thomson RM, Anderson DC. Aspirin and clopidogrel for prevention of ischemic stroke. Curr Neurol Neurosci Rep . 2013;13(2):327. 123. Jør gensen L. ADP-induced platelet aggregation in the microcirculation of pig myocar -
dium and rabbit kidneys. J Thromb Haemost . 2005;3(6):1119–1124. 124. Ferreiro JL, Angiolillo DJ. Clopidogrel response variability: Current status and future 
directions. Thromb Haemost . 2009;102(1):7–14. 125. T renk D, Kristensen SD, Hochholzer W, Neumann FJ. High on-treatment platelet reac -
tivity and P2Y12 antagonists in clinical trials. Thromb Haemost. 2013;109(5):834–845. 126. Bates ER, Lau WC, Angiolillo DJ. Clopidogrel-drug interactions. Am Coll Cardiol . 2011;57(11):1251–1263. 127. The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med . 2001;345:494–502. 128. Markus HS, Droste D W, Kaps M, Larrue V , Lees KR, Siebler M, Ringelstein EB. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid steno -
sis evaluated using Doppler embolic signal detection: The Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation . 2005;111(17):2233–2240. 129. Kreutz RP , Nystrom P, Kreutz Y , Miao J, Kovacs R et al. Inhibition of platelet aggrega -
tion by prostaglandin E1 (PGE1) in diabetic patients during therapy with clopidogrel and aspirin. Platelets. 2013;24(2):145–150. 130. Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE, Cacoub P et  al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Eng J Med. 2006;354(16):1706–1717. 131. Jeong YH, Park Y , Kim IS, Yun SE, Kang MK, Hwang SJ, Kwak CH, Hwang JY . Enhanced 
platelet inhibition by adjunctive cilostazol to dual antiplatelet therapy after drug-eluting stent implantation for complex lesions. Thromb Haemost . 2010;104(6):1286–1289. 132. Ueno M, Ferreiro JL, Angiolillo DJ. Mechanism of action and clinical development of 
platelet thrombin receptor antagonists. Expert Rev Cardiovasc Ther. 2010;8(8):1191–200. 133. Y ang J, Xu K, Seiffert D. Challenges and promises of developing thrombin receptor 
antagonists. Recent Pat Cardiovasc Drug Discov . 2010;5(3):162–170.78 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
 134. Diener HC, Bogoussla vsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, Leys D, 
Matias-Guiu J, Rupprecht HJ; MATCH Investigators. Aspirin and clopidogrel com -
pared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack 
in high-risk patients (MATCH): Randomised, double-blind, placebo-controlled trial. Lancet. 2004;364(9431):331–337. 135. White JG. Platelet microtubules and microfilaments: Effects of cytochalasin B on struc -
ture and function. In Platelet Aggregation , ed. J. Caen. Masson, Paris, France, 1971, p. 30. 136. White JG, Rao GH, Gerrard JM. Ef fects of the ionophore A23187 on blood platelets I. Influence on aggregation and secretion. Am J Pathol . 1974;77(2):135–149. 137. Hynie S, Lanefelt F , Fredholm BB. Effects of ethanol on human lymphocyte levels of 
cyclic AMP. In vitro: Potentiation of the response to isoproterenol, prostaglandin E2 or 
adenosine stimulation. Acta Pharmacol Toxicol (Copenh) . 1980;47(1):58–65. 138. Görög P , Kovács IB. Antiarthritic and antithrombotic effects of topically applied 
dimethyl sulfoxide. Ann N Y Acad Sci . 1975;243:91–97. 139. P ace DG, Kovacs JL, Klevans LR. Dimethyl sulfoxide inhibits platelet aggregation in 
partially obstructed canine coronary vessels. Ann N Y Acad Sci . 1983;411:352–356. 140. Le vett JM, Johns LM, Grina NM, Mullan BF, Kramer JF, Mullan JF. Effects of dimethyl 
sulfoxide on systemic and cerebral hemodynamic variables in the ischemic canine myo-cardium. Crit Care Med . 1987;15(7):656–660. 141. Rogers KC, F aircloth JM, Finks SW. Use of cilostazol in percutaneous coronary inter -
ventions. Ann Pharmacother . 2012;46(6):839–850. 142. Y ang Y , Luo J, Kazumura K, Takeuchi K, Inui N, Hayashi H, Ohashi K, Watanabe H. 
Cilostazol suppresses adhesion of human neutrophils to HUVECs stimulated by FMLP and its mechanisms. Life Sci . 2006;79(7):629–636. 143. Gresele P , Momi S, Falcinelli E. Anti-platelet therapy: Phosphodiesterase inhibitors. Br J Clin Pharmacol . 2011;72(4):634–646. 144. Hidaka H, Asano T. Human blood platelet 3 ′:5′-cyclic nucleotide phosphodiester -
ase. Isolation of low-Km and high-Km phosphodiesterase. Biochim Biophys Acta . 1976;429:485–497. 145. Rondina MT , Weyrich AS. Targeting phosphodiesterases in anti-platelet therapy. Handb 
Exp Pharmacol . 2012;210:225–238. 146. Marcus AJ, Safier LB. Thromboregulation: Multicellular modulation of platelet reactiv -
ity in hemostasis and thrombosis. FASEB J . 1993;7(6):516–522. 147. V ane JR, Anggård EE, Botting RM. Regulatory functions of the vascular endothelium. N Engl J Med . 19905;323(1):27–36. 148. Moncada S, P almer RM, Higgs EA. Nitric oxide: Physiology, pathophysiology, and 
pharmacology. Pharmacol Rev. 1991;43(2):109–142. 149. LaHann TR, Horita A. Effects of dimethyl sulfoxide (DMSO) on prostaglandin synthe -
tase. Proc West Pharmacol Soc . 1975;18:81–82. 150. Dorn GW 2nd, Liel N, Trask JL, Mais DE, Assey ME, Halushka PV . Increased platelet 
thromboxane A2/prostaglandin H2 receptors in patients with acute myocardial infarc -
tion. Circulation . 1990;81(1):212–218. 151. Asmis L, Tanner FC, Sudano I, Luscher TF, Camici GG. DMSO inhibits human platelet 
activation through cyclooxygenase-1 inhibition. A novel agent for drug eluting stents? Biochem Biophys Res Commun. 2010;391:1629–1633. 152. T relle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM, Egger M, 
Jüni P. Cardiovascular safety of non-steroidal anti-inflammatory drugs: Network meta-
analysis. BMJ . 2011;342:c7086. 153. K earney PM, Baigent C, Godwin J, Halls H, Emberson JR, Patrono C. Do selective 
cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs 
increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ . 2006;332(7553):1302–1308.79 DMSO Clinical Pharmacology
 154. Martorell L, Martínez-González J, Rodríguez C, Gentile M, Calv ayrac O, Badimon 
L. Thrombin and protease-activated receptors (PARs) in atherothrombosis. Thromb 
Haemost. 2008;99(2):305–315. 155. Xiao Z, Theroux P. Platelet activation with unfractionated heparin at therapeutic con -
centrations and comparisons with a low-molecular-weight heparin and with a direct 
thrombin inhibitor. Circulation . 1998;97:251–256. 156. W instanley L, Chen R. New thrombin and factor Xa inhibitors for primary and secondary 
prevention of ischaemic stroke. CNS Neurol Disord Drug Targets . 2013;12(2):242–251. 157. Damman P , Woudstra P, Kuijt WJ, de Winter RJ, James SK. P2Y12 platelet inhibition in 
clinical practice. J Thromb Thrombolysis . 2012;33(2):143–153. 158. Sambrano GR, Weiss EJ, Zheng YW, Huang W, Coughlin SR. Role of thrombin signal -
ling in platelets in haemostasis and thrombosis. Nature . 2001;413(6851):74–78. 159. T oschi V , Gallo R, Lettino M, Fallon JT, Gertz SD, Fernandez OA, Chesebro JH, 
Badimon L, Nemerson Y , Fuster V . Tissue factor modulates the thrombogenicity of human atherosclerotic plaques. Circulation. 1997;95:594–599. 160. Moons AH, Levi M, Peters RJ. Tissue factor and coronary artery disease. Cardiovasc 
Res. 2002;53:313–325. 161. Owens AP 3rd, Mackman N. Role of tissue factor in atherothrombosis. Curr Atheroscler 
Rep. 2012;14(5):394–401. 162. Mackman N. Role of tissue f actor in hemostasis, thrombosis, and vascular development. Arterioscler Thromb Vasc Biol . 2004;24(6):1015–1022. 163. Mackman N. Role of tissue factor in hemostasis and thrombosis. Blood Cells Mol Dis . 2006;36(2):104–107. 164. W olberg AS, Mast AE. Tissue factor and factor VIIa—Hemostasis and beyond. Thromb 
Res. 2012;129(Suppl 2):S1–S4. 165. Jude B, Zawadzki C, Susen S, Corseaux D. Relevance of tissue factor in cardiovascular 
disease. Arch Mal Coeur Vaiss . 2005;98(6):667–671. 166. Libby P , Simon DI. Inflammation and thrombosis: The clot thickens. Circulation . 2001;103(13):1718–1720. 167. Camici GG, Stef fel J, Akhmedov A, Schafer N, Baldinger J, Schulz U, Shojaati K et al. Dimethyl sulfoxide inhibits tissue factor expression, thrombus formation, and vascular 
smooth muscle cell activation: A potential treatment strategy for drug-eluting stents. Circulation . 2006;114(14):1512–1521. 168. Gerthof fer WT. Mechanisms of vascular smooth muscle cell migration. Circ Res . 2007;100(5):607–621. 169. Bourne WM, Shearer DR, Nelson LR. Human corneal endothelial tolerance to glycerol, 
dimethylsulfoxide, 1,2-propanediol, and 2,3- butanediol. Cryobiology . 1994;31:1–9. 170. Stef fel J, Latini RA, Akhmedov A, Zimmermann D, Zimmerling P, Luscher TF, 
Tanner FC. Rapamycin, but not FK-506, increases endothelial tissue factor expression: 
Implications for drug-eluting stent design. Circulation . 2005;112:2002–2011. 171. Stahli BE, Camici GG, Stef fel J, Akhmedov A, Shoojati K, Graber M, Luscher TF, 
Tanner FC. Paclitaxel enhances thrombin-induced endothelial tissue factor expression via c-Jun terminal NH2 kinase activation. Circ Res. 2006;99:149–155. 172. Campbell CL, Smyth S, Montalescot G, Steinhubl SR. Aspirin dose for the prevention 
of cardiovascular disease: A systematic review. JAMA . 2007;297(18):2018–2024. 173. V ioli F, Ghiselli A, Iuliano L, Alessandri C, Cordova C, Balsano F. Influence of hydroxyl 
radical scavengers on platelet function. Haemostasis. 1988;18(2):91–98. 174. Nishimura H, Rosenblum WI, Nelson GH, Boynton S. Agents that modify EDRF forma -
tion alter antiplatelet properties of brain arteriolar endothelium in vivo. Am J Physiol . 1991;261(1 Pt 2):H15–H21. 175. Shirle y HH, Lundergan MK, Williams HJ, Spruance SL. Lack of ocular changes with 
dimethyl sulfoxide therapy of scleroderma. Pharmacotherapy . 1989;9(3):165–168.80 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
 176. Garcia CA. Ocular toxicology of dimeth yl sulfoxide and effects on retinitis pigmentosa. Ann N Y Acad Sci . 1983;411:48–51. 177. Rubin LF . Toxicologic update of dimethyl sulfoxide. Ann N Y Acad Sci . 1983;411:6–10. 178. Jacob SW , de la Torre JC. Pharmacology of dimethyl sulfoxide in cardiac and CNS dam -
age. Pharmacol Rep . 2009;61(2):225–235. 179. Santos NC, Figueira-Coelho J, Martins-Silv a J, Saldanha C. Multidisciplinary utiliza -
tion of dimethyl sulfoxide: Pharmacological, cellular, and molecular aspects. Biochem 
Pharmacol. 2003;65(7):1035–1041. 180. W aller FT, Tanabe CT, Paxton HD. Treatment of elevated intracranial pressure with 
dimethyl sulfoxide. Ann N Y Acad Sci . 1983;411:286–292. 181. Muther RS, Bennett WM. Effects of dimethyl sulfoxide on renal function in man. JAMA. 1980;244(18):2081–2083. 182. Sibert L, Khalaf A, Bugel H, Sfaxi M, Grise P. Intravesical dimethyl sulfoxide instilla -
tions can be useful in the symptomatic treatment of profuse hematuria due to eosino -
philic cystitis. J Urol . 2000;164(2):446. 183. Marshall LF , Camp PE, Bowers S. Dimethyl sulfoxide for the treatment of intracranial 
hypertension: A preliminary trial. Neurosurgery . 1984;4(6):659–663. 184. Karaca M, Bilgin U, Akar M, de la Torre JC. Dimethyl sulfoxide lowers ICP after closed 
head trauma. Eur J Clin Pharmacol. 1991;40:113–114. 185. K ulah A, Akar M, Baykut L. Dimethyl sulfoxide in the management of patients with 
brain swelling and increased intracranial pressure after severe closed head injury. Neurochirurgia . 1990;33:177–180. 186. Jacob SW , Herschler R. Pharmacology of DMSO. Cryobiology . 1986;23:14–27. 187. Smith ER, Hadidian Z, Mason MM. The single—and repeated—dose toxicity of 
dimethyl sulfoxide. Ann N Y Acad Sci . 1967;141(1):96–109. 188. W illhite CC, Katz PI. Toxicology updates. Dimethyl sulfoxide. J Appl Toxicol . 1984;4(3):155–160.81
4DMSO in Genetics
PROTECTION FROM IONIZING RADIATION
One of the most important biological properties of dimethyl sulfoxide (DMSO) is its 
ability to protect cells from radiation damage.1 DMSO has been used in a number of 
studies to repair radiation damage induced in a variety of mammalian models and in vitro  preparations. 2 Such radiation damage to mammalian cells generally involves 
injury to deoxyribonucleic acid (DNA). DNA molecules are double-stranded helices running in opposite directions to each other. In mammals, most of the DNA is stored inside the cell nucleus in a dense string-like fiber called chromatin. DNA is composed of building blocks called nucleotides that consist of a deoxy -
ribose sugar bound on one side and a phosphate group bound to the other side of four nitrogenous bases. The bases are composed of adenine (A), thymine (T), gua -
nine (G), and cytosine (C) (Figure 4.1). Phosphates and sugars that are adjacent to these nucleotides link to form a long polymer and the double helix, a process called transcription. The outside strands of DNA are made up of the sugar and phosphate portions 
of the nucleotides, while the middle parts are made of the nitrogenous bases. The nitrogenous bases on the two strands of DNA pair up, purine with pyrimidine (A always with T, G always with C), and are held together by weak hydrogen bonds. As the keeper of genetic information in each living cell, the integrity and stability of DNA are essential to life. In eukaryotic cells, when DNA is active, its code is copied to messenger RNA, 
which then carries the DNA information to the ribosomal factories within the cell cytoplasm in order to manufacture proteins. The proteins thus formed in the ribo -
some are made up of amino acids that are linked together to extend the growing protein chain, a process called translation. In humans, DNA strand breaks are a common daily occurrence arising at a 
frequency of tens of thousands per cell per day from direct attack by intracellular metabolites and from spontaneous DNA decay. 3 Despite this daily assault on DNA, 
strand breaks generally can be easily fixed by a collection of repair processes avail -
able to the cell. These lesions to the DNA structure are detected by damage sensors that initiate various response reactions. 4
These repair processes are vital to the integrity of its genome and to the  s urvival 
of the organism. Strand breaks can also result from mechanical stress, ionizing radi -
ation, and chemical damage, for example, from reactive oxygen species (ROS). Key experiments in the 1960s showed that the ratios of nitrogen bases A–T and 
G–C are constant in all living things.82 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
Damage to DNA can create a loss of genetic instructions for producing new cells and 
impair the well-functioning and development of every living organism. However, DNA 
is not inert, and like any other biological molecule, it is continually the target of dam -
age from the environment, which, if not repaired, can result in metabolic dysfunction, mutation, and potentially cell death. For this reason, all cells contain a range of repair pathways that have evolved to optimize their survival following damage to their DNA. One of these repair pathways that follow genomic DNA damage is the DNA 
 damage response, which coordinates DNA repair, cell cycle arrest, and ultimately 
cell death.5
This process is a complex signaling network involving cell cycle checkpoints 
and DNA repair/damage control pathways that work to minimize changes in normal metabolic function. The DNA damage response is affected by an assortment of cellular components and 
processes, which include chromatin structure, DNA replication, cell growth, and cell cycle status. When the DNA damage response fails, genomic instability and several 
human syndromes, particularly cancer, can appear. Paradoxically, DNA-damaging 
agents are sometimes used in cancer therapy, and drugs targeting DNA damage response proteins, cell cycle, and cancer differentiation therapy are presently an excit -
ing field being explored as potential new anticancer agents.Adenine
/T_hymine
Single-strand break
Guanine
Double-strand brea ks
Cytosine
Sugar phospha te
backbone
FIGURE 4.1  (See color insert.) Ionizing radiation can create two types of breaks: (1) in 
the sugar phosphate backbone or (2) in the base pairs of the DNA. These breaks can cause either  single (bolt) or double DNA strand breaks (bolts). Direct DNA damage occurs when  radiation particles physically break one or two strands of DNA. Indirect damage 
occurs when radiation creates harmful free radicals to damage DNA, a target of repair for 
DMSO. Single-strand DNA breaks are more prone to damage than double-strand DNA breaks 
because more toxic agents target single-strand DNA regions than double strands. Ionizing 
radiation of single-strand breaks are more easily repaired by the cell than cell repair of simi -
lar ionizing radiation of double-strand breaks, which can be lethal to the cell. Double-strand 
DNA breaks are the cause of many diseases, including various types of cancer.83 DMSO in Genetics
As reviewed later, DMSO has been shown to protect cells from genotoxic 
stress,  including free radical damage from excessive ROS and hydroxyl radical 
formation. DMSO can additionally accelerate DNA strand break repair or prevent damage to DNA from ionizing radiation. However, it remains a challenge to point to one property under the DMSO umbrella of activities that might broadly explain the extraordinary biological actions of this simple polar molecule in providing protection to cells exposed to harmful stimuli. DMSO PROTECTION OF SINGLE- AND DOUBLE-STRANDED 
DNA BREAKS
There is growing evidence that deficiencies in DNA damage signaling and repair 
pathways are fundamental to most, if not all, developing cancers in humans. The cell response to DNA damage is by activating the DNA damage response pathway, which involves cell cycle arrest and the transcriptional and posttranscriptional activation of a subset of genes associated with DNA repair. Transcriptional and posttranscrip -
tional activations involve the increased expression of a gene at the level of DNA–RNA (transcription) and at the level of RNA between transcription and translation (posttranscriptional). Cell cycle arrest occurs when DNA damage is inflicted and continues until the damage is repaired. If the damage cannot be repaired, the cell commits suicide by ordering apoptosis or programmed cell death. In a way, apopto -
sis is often a defense reaction that can keep other cells from dying. If the affected cells are unable to respond or repair DNA damage, genetic insta -
bility can result, which will increase the risk of disease, especially cancer develop -
ment. The most dangerous type of DNA damage that can develop in mammalian cells occurs when DNA double-strand breaks are induced. DNA double-strand breaks are potentially lethal lesions that can be created by ionizing radiation from x-rays and gamma rays
6 (Figure 4.1). Besides ionizing radiation, DNA double-
strand breaks can result from the excessive formation within the cell of free radi -
cals, such as ROS. ROS can target mitochondria by creating intracellular oxidative stress damage. 6
Although cells can adapt to mild forms of radiation damage, especially if only 
one strand of DNA is damaged, heavy doses of radiation can overwhelm the defen-sive process that cells possess to fix DNA from ionizing damage. However, cells have trouble fixing the DNA double-strand breaks due to the two DNA ends generated by the breaks becoming physically dissociated from one another, making the repair dif -
ficult to perform. Cells that cannot fix the DNA double-strand breaks by themselves and do not undergo apoptosis can become cancerous. Mammalian cells have two methods to repair DNA double-strand breaks, by 
homologous recombination or by nonhomologous end joining (NHEJ). The first method uses a duplicate set of DNA as a template to repair the damaged DNA, and 
the second method (NHEJ) is able to repair the break directly without outside influ -
ence. 7 The first method of DNA repair, homologous recombination, is more accurate 
than NHEJ because it uses the undamaged DNA strand from its template to make 
sure the repair is done correctly and no nucleotides are lost in the transaction as it 84 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
often happens with NHEJ. How the cell determines whether homologous recombina -
tion or NHEJ will be used to repair a break is not entirely clear. It is estimated that one DNA double-strand break in a key gene is enough to 
kill the cell outright or cause the cell to trigger the more complex process of 
apoptosis.8
The double-stranded DNA breaks can be repaired by the mammalian cell using 
powerful methods to repair this damage as soon as it happens.9 To understand how 
DMSO may help repair double-stranded DNA breaks, a review of the mammalian cell’s response to this type of genotoxic damage is in order. In the first place, the pathologic forms of double-stranded DNA breaks are repaired by NHEJ because they often occur when a nearby homology donor is not available. 10 Common causes 
of double-stranded DNA breaks are ionizing radiation (Figure 4.1) and ROS from an overactive oxidative metabolism. 11
Ionizing radiation from x-rays and gamma rays passes through human bodies 
every day at a rate of 300 million ionizing particles/h, and as they do, they create free radicals from water along their path. Radiation damage can strike DNA inside the living cell in two ways: first, by ionizing the DNA atoms and changing them to ions, and second, by ionizing water molecules to produce free radicals that can react with and damage DNA molecules. Free radicals formed in this manner can damage DNA by inducing single- and double-strand breaks. These breaks are easily fixed by the cells using NHEJ, which requires specific enzymes such as a nuclease to resect the damaged DNA, a polymerase to fill in new DNA, and a ligase to restore integrity to the DNA strands. 10 When these repair enzymes are unavailable, repair agents such 
as DMSO can be used with relative success, as discussed later. A second major cause of double-stranded DNA breaks occurs when ROS are 
formed. ROS can form from environmental pollutants such as polychlorinated biphenyls (PCBs), which are industrial chemicals used as dielectrics in capacitors, as lubricants, and as flame retardants in cooling fluids. 12
Despite the fact that PCB production in the United States was halted in the late 
1970s, it is estimated that more than a million tons of PCB particles have escaped into the environment worldwide where they persist and accumulate through the food chain in animal tissues, including humans. 13 Studies have reported a causal link 
between exposure to PCBs and non-Hodgkin lymphoma, a frequently fatal form of cancer
14 as well as other cancers, including liver and biliary cancer,15 breast cancer,16 
and skin cancer.17
Double-stranded DNA breaks have also been linked to malignant brain tumors 
such as gliomas, meningiomas, and medulloblastomas.18
These findings are of intense interest with respect to the properties DMSO is 
observed to exert as an agent that can help repair DNA double-strand breaks and its potential as a therapeutic and chemosuppressor of various forms of cancer arising primarily from DNA damage. The radioprotective properties of DMSO have been known for a long time and 
were first reported by Ashwood-Smith
19 in 1961 following the work on the ability of 
some sulfoxides to suppress the effect of irradiation. A series of other reports soon followed showing that the application of DMSO to newborn rat skin protected them from damage from x-ray exposure. 2085 DMSO in Genetics
A study on the fruit fly ( Drosophila melanogaster ) given DMSO via the abdomen 
showed a significant reduction of x-ray-induced mortalities and sex-linked recessive 
lethal mutations of male sperm.21 That report concluded that DMSO provided radio -
protection to the fruit fly at both the whole-body and genetic levels.21 However, that 
conclusion was at odds with another experiment that showed DMSO did not protect mouse testes subjected to x-irradiation. 22
A common malady among elderly people exposed to solar radiation was shown 
to have been completely prevented in mice after x-ray radiation (1000 radians) when DMSO was prophylactically applied topically to the eyes. 23
These early studies were rarely followed up by pharmaceutical firms or academic 
institutions with human trials even when the therapeutic potential to neutralize or 
lessen ionizing radiation damage from solar, nuclear reactions, radioactive  m aterials, 
x-rays, and other external sources of beta and gamma rays to human and animal body parts seemed not only obvious but also medically warranted. This was par -
ticularly baffling especially because the sources for radiation damage were strongly linked to many types of cancer even in the early 1950s following the nuclear bomb -
ings of Hiroshima and Nagasaki in 1945 and a study of the populations affected by this radiation exposure. To our knowledge and perplexity, the military forces in the United States, who 
would have an extra interest in protecting its more vulnerable personnel from radia -
tion exposure and damage from any source, never showed an interest in either funding extracurricular investigations with DMSO or employing its own research facilities to study radiation prevention and treatment. The exact explanation for the radioprotective effects of DMSO on tissue exposed 
to ionizing radiation remains unclear, but the effects are generally attributed to the suppression of DNA damage caused by the indirect action of radiation and the for -
mation of hydroxyl radicals, which DMSO is able to scavenge and neutralize. 1,2,20
However, this conclusion was questioned by more recent experiments on golden 
hamster embryo cells treated with DMSO after exposure to gamma rays. Although gamma ray damage to DNA single-strand breaks yielded hydroxyl radicals, the prin -
cipal protective effects of DMSO were observed to be not due to the scavenging of hydroxyl radicals, but rather due to the scavenging of H
+ atoms or other ions, which 
created protective DMSO radicals.24,25
The finding that DMSO may act to protect golden hamster embryonic cells from 
radiation damage by scavenging H+ ions does not negate that in other models, using 
other conditions to produce DNA strand breaks, DMSO can also be effective in its protection of DNA strand breaks through the inhibition of free radicals, includ -
ing those cytotoxic molecules known to damage DNA including ROS and hydroxyl radicals. Chinese hamster ovary (CHO) cells are a cell line derived from the ovary of the 
Chinese hamster used routinely in biological and medical research in genetic studies and gene expression. CHO are the preferred host cell lines in biological research and mutagenesis 
studies because of their rapid growth, ease of manipulation, and high production of recombinant therapeutic proteins such as monoclonal antibodies, growth factors, hormones, blood factors, interferons, and enzymes. 2686 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
Ionizing radiation-sensitive mutants of CHO cell lines that are deficient in DNA 
repair of single- and double-strand breaks are a preferred model to unravel the com -
plexities of DNA repair and to screen potential therapies that can aid in the DNA 
repair process. DMSO was tested for its protective effects against the induction and rejoining of 
DNA double-strand breaks and inactivation using CHO cells exposed to both high- and low-linear energy transfer (LET) radiations. 27 The cells were exposed under 
aerobic conditions as monolayers to either low-LET photons or high-LEt alpha par -
ticle radiation. Gamma irradiation in the presence of 0.5 mol/dm3 DMSO, 90%, was 
observed to be rejoined within a 3 h incubation. It was inferred that this action by DMSO was due to the scavenging of free radicals near the double-strand breaks after gamma radiation, but this was not the case after alpha particle radiation. 27 It seemed 
likely that the severity of damage reduced by DMSO was due to minimizing the formation of hydroxyl-induced sugar/base assault forming near the vicinity of the double-strand breaks. 27
The frequency of human chromosomal aberrations induced by irradiation was 
examined in the presence of 0.5 M DMSO.28 The number of aberrations of human 
chromosomes 1–4, 7, 11, and 12 in the presence of DMSO was found significantly reduced following irradiation as calculated by DNA content. 28
These studies suggest that DMSO may exert two viable protective mechanisms 
in repairing single and double DNA strand breaks by its ability to capture both the damaging H
+ ions and hydroxyl radicals formed after ionizing radiation. In a series of studies from Kyoto University in Japan, investigators tested different 
concentrations of DMSO on CHO cells irradiated with x-rays. At 1.28 mM DMSO, cells were treated for 2 h before and during irradiation. 29 These studies showed that 
DMSO was able to suppress some of the lethal consequences of irradiation such as chromosomal aberrations, but the DMSO dose was found to be toxic. 24,25 Further 
studies by this group found that the treatment of CHO cells with 64 mM DMSO for 1 h was nontoxic and suppressed bystander signal between irradiated and nonirradi -
ated cells. Bystander signals refer to the phenomenon in which unirradiated cells exhibit 
irradiated effects as a result of signals received from nearby irradiated cells. This blocking action on bystander signals by DMSO therefore suggested that DMSO sup -
pressed signal transduction in the irradiated cells since they did not appear to emit radiation to unirradiated neighboring cells in the vicinity. 30,31
DMSO has been used as a synchronizing agent in CHO cells, since there are 
few methods available that can arrest the cell cycle efficiently and reversibly in the CHO cell line. 32 The reason is that these cells show poor growth inhibition 
exerted by confluence. It has been shown that incubation with DMSO induces a G1 
cell cycle arrest in adherent Chinese hamster CHO K-1 cells33 (Figure 4.2). These 
results indicate that DMSO not only is able to arrest CHO cells in G1 cell cycle but 
also stimulates cell differentiation, inducing CHO cells to acquire some features 
of differentiated skin cells.32 DMSO exerts its induced growth arrest primarily by 
stimulating contact inhibition-dependent growth arrest, which is reported to be 
mediated by high levels of the cyclin-dependent kinase inhibitor p27.34 Transitions 87 DMSO in Genetics
between cell cycles are catalyzed by a family of cyclic-dependent kinases and 
inhibited by a host of proteins purified from arrested cells.34
A more recent study by Kashino and his Kyoto University colleagues revealed an 
elegant explanation of how DMSO may exert its radioprotective effects on irradiated CHO cells. 35 Their results put to question the general assumption that the radiopro -
tective effects of DMSO is due to the suppression of DNA damage induced by the indirect action of radiation. Indirect action of radiation can impair or damage cells by creating free radical molecules that are highly reactive due to the presence of unpaired electrons on the molecule. Free radicals that are thus formed are capable of creating chemical reactions within the cell that can induce damage to the genetic code. DNA strand breaks can then encode a mutated protein with oncogenic (cancer) potential. The mutation may be passed on during cell division, perhaps leading to a malignant cell or some other mutation. In some cases, a mutation may remain dor -
mant for years and even forever. 36
The recent findings by Kashino et al.35 concluded that DMSO appears to repair 
double-strand DNA breaks, first, by blocking hydroxyl radicals created by the radia -
tion from inhibiting NHEJ. Second, DMSO may protect from DNA double-strand breaks by affecting the conformational change of chromatin where DNA is stored, an action that would allow NHEJ to be activated for DNA repair. Activation of NHEJ is known to be the major repair pathway of DNA double-
strand breaks caused by irradiation, and any element that prevents the repair process will inhibit DNA repair. Although other mechanisms exist for DNA single-strand breaks, only homologous recombination and NHEJ are able to repair DNA double-strand breaks. This is critical because if genotoxic products generated by radiation can inhibit NHEJ, for example, unrepaired or misrepaired lesions lead to chromo -
somal aberrations and possible carcinogenesis. If DMSO can prevent the inhibition of NHEJ by genotoxic molecules such as 
hydroxyl radicals or by affecting chromatin conformational changes from blocking NHEJ, as the Kyoto studies suggest, the targeted cells stand a better chance of surviv -
ing from radiation damage and from possible mutagenesis leading to malignancies.Cancer stem cell sT umor re gressio n Cancer stem cell
differentiation by DMSOTheoretical treatment of cancer stem cells
by DMSO differentiation therap y
FIGURE 4.2  Cytodifferentiation of cancer stem cells converted to noncancerous growth 
by DMSO’s ability to arrest cell cycle at G1 phase. (From Fiore, M. et al., Mutagenesis , 17(5), 
419, September 2002; Chang, C.K. et al., J. Surg. Res ., 95, 181, 2001; Wang, C.C. et al., PLoS 
ONE, 7(4), e33772, 2012. )88 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
A deeper understanding of how DMSO aids DNA repair mechanisms could clar -
ify its potential value as a therapeutic agent in oncology where tumors with DNA 
repair defects are the rule. DMSO IN CELLULAR DIFFERENTIATION
Differentiated cells are distinguished from other cells in the same organism by the transition of a cell from one cell type to another, and in that sense, cells of one type never make the products characteristic of another type. Cancer cells, for example, generally synthesize proteins that are not characteristic of the tissue type they come from, and consequently when a tumor makes proteins, those proteins are not nor -
mally made by the tissue that the tumor has invaded. That means that cancer cells can give rise to disturbed patterns of protein synthesis, and some of these proteins can target DNA during replication and create mutagens, such as chemical carcinogens. In cytopathology, the level of cellular differentiation is used as a measure of cancer 
progression. Grade  is a marker of how differentiated a cell in a tumor has become. To understand how differentiated cancer cells differ from their normal counter -
part, four cellular dysfunctions need to be considered. First, whereas normal cell proliferation is strictly regulated, cancer cells are not. Second, the differentiation process is disturbed in cancer cells. Third, chromosomes are destabilized so that cancer cell growth is rapid and frequent. Fourth, apoptosis or regulated cell death does not work properly in cancer cells. A useful anticancer agent may target one or several of these cellular dysfunctions 
or the mechanisms that promote their disorganized behavior. There is now considerable evidence that the production of cancer cells is gener -
ally linked to lesions that generate abnormalities in protein synthesis or in nucleic acids that direct the course of protein synthesis and regulate all cell activities. Any genetic disease implies a defect in nucleic acids, and although some genetic dis -
eases are classified as protein abnormalities, there is always an inherent defect in the nucleotides that compose DNA and RNA. 37
It is at the treatment level of chemical carcinogens and mutagens that DMSO 
as shown preclinical usefulness as a potential anticancer agent. Many carcinogens including nitrosamines are known to react strongly with DNA to produce strand break lesions in the base pairs or sugar phosphate backbone
38 (Figure 4.1). In 1956, British scientists Peter Magee and John Barnes reported that dimethyl -
nitrosamine produced liver tumors in rats.39 Nitrosamines are considered to be muta -
gens, and of the more than 300 nitrosamines known, 90% of them have been found to be carcinogenic in a wide variety of experimental animals, a feature that suggests that they are also carcinogenic in humans. 40 Many nitrosamines are organ specific. For example, dimethylnitrosamine causes liver cancer in experimental animals as shown by Magee and Barnes,
40 whereas some of the tobacco-specific nitrosamines 
cause lung cancer.41
In the late 1970s, extensive attention was focused on the use of sodium nitrite 
as a preservative for cured meats due to their production of nitrosamines and the potential for inducing cancer. It was found that antioxidants such as ascorbic acid (vitamin C) could inhibit nitrosamine formation, and a law was passed that required 89 DMSO in Genetics
cured meat to be treated with ascorbic acid, or its isomer, erythorbic acid, a cheaper 
version of vitamin C. Other antioxidants, like vitamin E, were also found to inhibit nitrosamine formation in cured meats. It is not known whether DMSO, a powerful antioxidant, was considered as an additive to cured meats since its cost and safety would have been a keen attraction to meat manufacturers. The effect of DMSO in inhibiting nitrosamines is reviewed later. Animals exposed to cancer-producing nitrosamines and treated with several poly -
ene antimycotics combined with DMSO showed marked antineoplastic activity in animals treated with the carcinogenic agent diethyl nitrosoamine. The 5-month sur -
vival of the animals was 76% as compared to 35% with the untreated control group. 42
DMSO has been used to induce differentiation in a variety of human mesenchymal 
stem cells.43,44 In one recent study, DMSO was shown to differentiate cultured P19 
embryonic carcinoma cells into beating cardiomyocyte-like cells. The differentia -
tion by DMSO 1% was accelerated by a differentiation-inducing factor-1 (Br-DIF-1), 
which turned the cancer cells into spontaneously beating  ca rdiomyocyte-like cells, 
partly by enhancing the expression of the T-type Ca2+ channel gene.42 These results 
suggest that accelerating DMSO-induced differentiation of embryonic cancer cells by using Br-DIF-1 as a supplement is able to spontaneously change cancer cells into beating cardiomyocyte-like cells, while lowering the concentration of DMSO to safer levels. 45
A similar P19 embryonic carcinoma cell line derived from stem cells confirmed 
the ability of DMSO to differentiate these cells into cardiomyocytes. Experiments such as these suggest the possibility that differentiated cancer cells derived from stem cells are a promising intervention for cardiac repair and that DMSO may be a key agent in this transformation. 46
Just as important is the exciting possibility of induction by DMSO of cardiomyo -
cytes from embryonic stem cells that could be used for transplantation to repair the heart after a heart attack or in conditions where left ventricular failure impairs the heart’s pumping capacity. Although this clinical approach to a damaged heart is still in its research infancy, it raises optimism that one day it could become the great -
est revolution in cardiovascular medicine in a century. Work has already begun in attempting to make this heart repair a reality, and preliminary clinical findings have indicated the feasibility of this approach. The versatility of DMSO can be seen when other cancer cell differentiators 
are compared to DMSO. When oxytocin was used as a P19 cancer cell differen -
tiator, aggregated P19 cells could be differentiated into cardiomyocytes, but mono -
layer cells did not differentiate and express specific cardiac muscle marker genes. However, when DMSO was used instead of oxytocin, both aggregates and monolayer cells could be differentiated into cardiomyocytes. 47
A study explored the preventive effects of DMSO on experimental hepatic fibrosis 
induced by dimethylnitrosamine in rats.48 DMSO 2 mL/kg daily for 4 weeks was 
given orally in the drinking water, and at the end of the observation period, DMSO 
was seen to prevent the dimethylnitrosamine-induced body and liver weight loss 
with no major side effects. Significantly, DMSO also suppressed the induction of hepatic fibrosis and the expression of mRNA for type-1 collagen in the liver as deter -
mined by histological evaluation and reduced hepatic hydroxyproline. 48 This study 90 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
also determined that DMSO inhibited lipopolysaccharide-induced tumor necrosis 
factor-alpha (TNF-alpha) and nitric oxide production as reflected by reduced TNF-alpha mRNA levels. 48
TNF-alpha is a pro-inflammatory cytokine that can be produced by a wide vari -
ety of cells and is involved in an assortment of pathological processes and a wide spectrum of human diseases. TNF-alpha is associated with chronic inflammation and autoimmune disorders as well as malignant disease and tumor development. 49
TNF-alpha is often used experimentally to produce cell damage. This was the 
case in a study where TNF-alpha was added to human keratinocyte cultures to induce toxic production of metalloproteinase-9 and metalloproteinase-9 mRNA expression. 50 As metalloproteinases formed in the keratinocyte culture, an inflam -
matory environment was created that simulated impaired chronic wound healing. In situations where inflammation is allowed to continue, TNF-alpha and its product metalloproteinase-9 can persist in wounds and impede normal healing. Following DMSO 1% v/v administration to the inflammatory keratinocytic preparation, 
 metalloproteinase-9 was inhibited, and metalloproteinase-9 mRNA expression lev -
els were significantly  l owered.50 The results imply that DMSO blocked TNF-alpha 
induction of inflammatory metalloproteinase molecules possibly at the transcrip -
tion level.50
The pathological activities of TNF-alpha are not restricted to inflammation. Its 
association with many disorders is reflected by its correlation with an increased risk of morbidity and mortality. 51 However, much research has focused on inhibiting the 
effects of TNF-alpha in such diseases as rheumatoid arthritis and Crohn’s disease. For this reason, a number of anti-TNF-alpha inhibitors such as infliximab and 
adalimumab have been approved by the FDA for prescription use in the United States for the treatment of rheumatoid arthritis and Crohn’s disease, which constitute a billion-dollar industry despite their reported serious adverse effects that include non-Hodgkin’s lymphoma, heart failure, demyelinating disease, and systemic infec -
tions, including tuberculosis. 52,53
Curiously, despite its relative cost-effectiveness, safety, and efficacy as a TNF-
alpha blocker and powerful anti-inflammatory agent, DMSO has not yet been tested in clinical trials against these debilitating disorders. DMSO was studied as an anticancer agent by one of the great cell biologists of 
the twentieth century, Charlotte Friend. Among the many contributions to the field of cancer research made by Charlotte Friend, while working at Mt. Sinai Hospital in New York, was to isolate the first virus shown to cause leukemia in adult Swiss mice. Her original observations had an enormous impact on the growing field of leukemia and sarcoma tumor viruses. 54 The last 20 years of Friend’s career was spent studying 
cell differentiation induced by Friend leukemia virus made possible with the use of DMSO. The Friend leukemia virus was originally perceived as a disorder resulting from a 
defect in cell maturation. It was discovered that these leukemic cells were not subject 
to control by normal regulators such as erythropoietin or hemoglobin. Investigators 
using the Friend leukemia virus model reported that DMSO increased the infec -
tivity of some viruses, but when Friend tried to increase the virus infectivity with DMSO, she discovered instead that this solvent could induce differentiation of Friend 91 DMSO in Genetics
erythroleukemia cells with a loss of their malignant potential.55 This monumental 
discovery has led to the hope that less toxic forms of cancer therapy using DMSO or 
similar agents may be achieved based on the induction of cytodifferentiation. Friend and her coworkers published a series of papers showing induced cytodifferentia -
tion of Friend leukemia cells to normal erythrocyte maturation, thus confirming the role of DMSO in the differentiation process. 56,57 The experiments by Friend et al. were reproduced by others who reported erythroid cell–transforming spleen focus-forming virus exposed to DMSO-induced erythroid differentiation of these cells. 58,59
Treating malignant tumors through the induction of cell differentiation as shown 
in a number of experiments using DMSO thus became an attractive concept in onco -
logical research that still continues to this day. Friend speculated that the loss of malignancy potential for the leukemia cells 
might reflect a toxic action by DMSO, which could injure these cells so they were not able to replicate and grow malignant after a prolonged (96 h) exposure to 280 mM DMSO. 55 However, this assumption was never proven. Despite these 
encouraging in vitro  results, in vivo  experiments to test the chemotherapeutic 
potential of DMSO in infected Swiss mice using a 7% DMSO solution in the drinking water neither prolonged the life of the infected mice nor improved their disease course when compared to nontreated controls. 55 The 1975 study by 
Friend and Scher55 was a kiss of death for DMSO investigations as an anticancer 
agent for nearly a decade because after Friend’s negative DMSO findings, sci -
entists decided that this research avenue was not worth pursuing. On the other hand, the negative rodent findings by Friend and Scher
55 have not, to the best 
of our knowledge, been replicated. If another rat experiment using DMSO in 
the drinking water is attempted, a  m inimum 28% or higher solution of DMSO 
in the drinking water for several weeks may be a more realistic dose than a 7% solution as used by Friend in her study. 55 The reason is that DMSO is quickly 
excreted from the body after oral ingestion, and a cumulative therapeutic serum concentration is unlikely to result from a dose of 10% or less. The trick is to get rats to drink the same amount of water daily at a comparable rate to untreated controls using the bitter-tasting DMSO solution mixed into the drinking water. This was achieved using 28% DMSO in the drinking water to which several drops of an artificial sweetener had been added. Rats were observed to drink their daily 100 mL water ration for several months consistently in both DMSO and untreated controls. 60
This trick of neutralizing the bitter taste of DMSO in water may have been used in 
another experiment. For example, a study was done to determine whether DMSO is able to potentiate anticancer activity when given in conjunction with other antitumor drugs against a rodent tumor. 61 DMSO was given in the drinking water at nontoxic doses rang -
ing from 25% to 32% mixed with other anticancer agents. It was found that continuous DMSO ingestion from daily water drinking potentiated the antitumor agents’ ability to significantly reduce tumor growth and prolong the survival time of tumor-bearing rats. 61
Despite the initial setback in 1975, interest in DMSO as an anticancer agent 
resumed less than a decade later when it was reported that DMSO was seen to exert antiviral activity in a number of studies where it appeared to block viral replication
62 
(see also Chapter 5).92 Dimethyl Sulfoxide (DMSO) in Trauma and Disease
These tissue culture findings, whether positive or negative, point out the difficulty 
of bridging the gap between relatively simple in vitro culture preparations and com -
plex in vivo models that display a myriad of uncontrollable variables and permutated 
responses to chronic drug administration. Viewed from another angle, the basis for cytodifferentiation and growth arrest of 
erythroleukemia cells by DMSO developed by Friend has been used as a roadway 
map to develop other polar molecules similar in structure to DMSO for anticancer activity of solid tumors and blood cancers. 63
The use of DMSO as a differentiation-inducing agent in conjunction with conven -
tional chemotherapeutic agents or radiation therapy for the treatment of solid tumors needs to be clinically tested because such an approach could become a second- or third-line therapy in patients with advanced cancer. Another possible way DMSO could be used as a cell differentiation–inducing 
agent is by turning nonviral cancer tumors into nonaggressive growths. This concept has begun to receive attention for its simplicity and variety of cell differentiation–inducing agents presently available. CANCER STEM CELLS AND DIFFERENTIATION
Cancer stem cells are cancer cells found within tumors or blood cancers that possess characteristics associated with normal stem cells, specifically, the ability to gener -
ate all cell types found in a particular cancer sample. Cancer stem cells have been implicated in the formation of many cancers since they can self-propagate with more cancer cells and they can also differentiate into a variety of cell types. Studies have shown that populations of cancer stem cells have been isolated from solid tumors from such organs as brain, prostate, colorectum, pancreas, and lung. 64–68
Differentiation therapy is an attractive alternative to chemotherapy and radia -
tion, which can indiscriminately kill any cell whether cancerous or not. It is well known that chemotherapy often comes with side effects such as fatigue, hair loss, and extreme nausea. Currently, a new more serious side effect of long-term chemo -
therapy has been found that can alter brain function for years after posttreatment. Chemotherapy-induced cognitive impairment, or chemobrain , has been well estab -
lished in the literature. 69 Chemobrain is a common term used by cancer survivors 
to describe thinking and memory problems that can occur after cancer treatment. Chemobrain has also been called chemo fog or chemotherapy-related cognitive impairment.
Dimethyl_Sulfoxide_(DMSO)_in_Trauma_and_Disease_[2015].txt
Summarize the following text section accurately and concisely. Maintain specific details and numerical information, and use anti-repetition mechanisms:

        2006;22(3):235–239. 43. Birklein F, Schmelz M, Schifter S, Weber M. The important role of neuropeptides in 
complex regional pain syndrome. Neurology. 2001;57:2179–2184. 44. Oaklander AL, Rissmiller JG, Gelman LB, Zheng L, Chang Y, Gott R. Evidence of focal 
small-fiber axonal degeneration in complex regional pain syndrome-I (reflex sympa -
thetic dystrophy). Pain. 2006;120:235–243. 45. Cossins L, Okell RW, Cameron H, Simpson B, Poole HM, Goebel A. Treatment of com -
plex regional pain syndrome in adults: A systematic review of randomized controlled trials published from June 2000 to February 2012. Eur J Pain. 2013;17(2):158–173. 46. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent com -
plex regional pain syndrome in patients with wrist fractures. A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007;89(7):1424–1431. 47. Correll GE, Maleki J, Gracely EJ, Muir JJ, Harb ut RE. Subanesthetic ketamine infusion 
therapy: A retrospective analysis of a novel therapeutic approach to complex regional pain syndrome. Pain Med. 2004;5(3):263–275. 48. Collins S, Sigtermans MJ, Dahan A, Zuurmond WW, Perez RS. NMDA receptor antag -
onists for the treatment of neuropathic pain.
Not mentioned in the passage (the passage does not discuss complex regional pain syndrome).
What is one of the most important roles of neuropeptides in complex regional pain syndrome?
The passage does not mention the specific use of DMSO in interstitial cystitis, but it does discuss its potential in DNA repair and cancer treatment.
What is the purpose of dimethyl sulfoxide (DMSO) in interstitial cystitis?
The passage does not explicitly state the primary mechanism, but it discusses the scavenging of hydroxyl radicals and the inhibition of NHEJ.
What is the primary mechanism by which DMSO protects cells from DNA damage?
The passage does not discuss the specific study on CHO cells, but it highlights the potential of DMSO in DNA repair and its possible applications in cancer treatment.
What is the significance of the study on the effect of DMSO on DNA damage in CHO cells?
Chemobrain
What is the term used to describe the negative side effects of chemotherapy, particularly in cancer survivors?