What is Hesperidin

Hesperidin is a secondary plant metabolite and one of the principal bioflavonoids (flavanone glycoside, meaning it has a sugar molecule attached to its three-ringed flavonoid structure) of citrus fruits such as lemon, sweet orange (Citrus sinensis), and grapefruits ¹. Flavonoids are a large group of plant pigments sharing the same basic chemical structure, that is a three-ringed molecule with hydroxyl (OH) groups attached. In addition to the Citrus species, hesperidin could be isolated from other plant genera like legumes ², Papilionaceae ³, Betulaceae ⁴, Lamiaceae ⁵, Zanthoxylum species (Zanthoxylum avicennae and Zanthoxylum cuspidatum) ⁶ and Acanthopanax setchuenensis ⁷. Neohesperidin (as an isomer of hesperidin) is a bitter compound that is found in bitter orange (Citrus aurantium) ⁶. Lemons contain an amount of hesperidin (in mg/100 mL) comparable to that of oranges, but to drink a same volume of juice is more difficult. The flavonoid content of the red orange is mainly hesperidin (43.6 mg/100 mL), followed at a distance by narirutin (4.8 mg/100 mL) and dimidine (2.4 mg/100 mL) ⁸. According to a recent review, the content of hesperidin in 100 mL of juice is: orange 20–60 mg, tangerines 8–46 mg, lemon 4–41 mg, grapefruit 2–17 mg ⁹. This means that you can take about 100 mg of hesperidin, just in a large glass of orange juice. Based on these data, it can be said that the choice of the most suitable fruits for a better intake of hesperidin could be made between oranges, mandarins and clementines, according to individual preferences, and costs ⁹. Hesperidin is present mainly in the peel and in the white part (albedo) of citrus fruits, and consumption of the whole fruits may allow a greater intake than the juice ¹⁰. In fact, in fresh orange juice, the content of hesperidin is about 30 mg per 100 mL, and in commercial juice it can be a little higher ¹¹, probably because the industrial processing incorporates more peel.

Hesperidin has an aglycone (hesperitin) bonded to rutinose [6-O-(α-l-Rhamnopyranosyl)-d-glucopyranose] and/or [6-O-(α-l-Rhamnosyl)-d-glucose], as a disaccharide, in its structure (see Figure 1) ⁷. Thus, hesperidin (as a non-bitter flavonoid rutinoside) can be considered a beta-7-rutinoside of hesperetin ³. Both hesperidin and its aglycone hesperitin have been reported to possess a wide range of pharmacological properties ¹². Hesperidin has also been found in unripe sour oranges, Ponderosa lemon, Citrus unshiu, and calamansi ¹³.

Some tests have assessed the amount of hesperidin (or its metabolite hesperetin) in the blood of people drinking orange juice. Healthy volunteers drank orange juice in one intake (8 mL/kg) and blood and urine samples were collected between 0 and 24 hours after administration ¹⁴. The peak plasma concentration of hesperetin was 2.2 ± 1.6 micromol/L, with significant variations in different subjects. Elimination half-life ranged from 1.3 to 2.2 hours, indicating short-term kinetics. In another experiment ¹⁵, after a night fast, five healthy volunteers drank 0.5 or 1 L of commercial orange juice, containing 444 mg/L of hesperidin, along with a polyphenol-free breakfast. The flavanone metabolites appeared in the plasma 3 hours after the ingestion of the juice, peaked between 5 and 7 hours, then returned to the baseline value at 24 hours. The peak plasma concentration of hesperetin was 0.46 ± 0.07 micromol/L and 1.28 ± 0.13 micromol/L, after taking 0.5 and 1 L, respectively. The authors concluded that, in the case of moderate or high consumption of orange juice, flavanones represent an important part of the pool of total polyphenols in plasma ¹⁵. There is evidence that hesperidin and naringin are metabolized by intestinal bacteria, mainly in the proximal colon, with the formation of their aglycones, hesperetin and naringenin and various other small phenols ¹⁶. Studies have also shown that citrus flavanones and their metabolites are able to influence the composition and activity of the microbiota, and to exert beneficial effects on gastrointestinal function and health. Other bioavailability studies have calculated that, if the phenolic catabolites derived from the colon are added to the glucuronide and sulphate metabolites, the polyphenols derived from orange juice are much more abundant and available than previously thought ¹⁷.

Hesperidin is known for its valuable bioactivity and can act as an antioxidant ¹⁸, antibacterial ¹⁹, anti-inflammatory ²⁰, hypolipidemic ²¹, vasoprotective ²², ²³, anticancerogenic ²⁴ and anti-ageing properties ²⁵. Hesperidin, a flavonoid from citrus fruit, is known to improve vascular integrity and decrease capillary permeability ²⁶. A dietary deficiency in hesperidin has been linked to abnormal capillary leakiness, pain and weakness in the extremities, and nocturnal leg cramps ²⁷.

Recent animal studies have shown that hesperidin might have beneficial neuropharmacological effects including antidepressant, anticonvulsant, anti-inflammatory, and anticonvulsant properties, in addition to memory and locomotor enhancing ²⁸. Hesperidin can effectively protect neurons from damages induced by oxidative or nitrosative stress. Moreover, it enhances cognitive functions through various mechanisms such as elevating brain-derived neurotrophic factor (BDNF, a signaling molecule secreted from activated microglia that helps to support the survival of neurons) and reversing the disruptive effect of global cerebral ischemia and reperfusion on memory.

Hesperidin can be considered a potential candidate for the mitigation of oxidative stress, as well as for memory impairment of the Alzheimer’s disease type ²⁸. Furthermore, hesperidin showed antidepressant activities using mechanisms that differ from those of conventional antidepressant drugs. Clinical trials showed that hesperidin-enriched dietary supplements can significantly improve cerebral blood flow, cognition, and memory performance ²⁸. Despite the variety of in vivo (animal) mechanistic studies on the neuroprotective activity of hesperidin, the lack of clinical trials on the therapeutic effects of hesperidin is an important limitation that can be noted, deserving further research. Moreover, less is known about the clinical aspects of this compound, such as bioavailability, the appropriate dose, tolerability, and efficacy of hesperidin and its metabolites on neurodegenerative diseases ²⁸. These limitations deserve to be surmounted before expanding hesperidin treatment into humans. This can be accomplished by conducting well-designed clinical trials in patients with different types of neurodegenerative diseases. The almost published studies of the clinical efficacy of hesperidin has only been carried out on healthy participants. Studies on the role of hesperidin, either as therapeutic or as complementary supplement, on patients with neurodegenerative diseases should be a high priority ²⁸.

Table 1. Hesperidin content (mg/100 mL of fresh juice) in different citrus fruits

Fruit	Hesperidin Content (mg/100 mL Juice)
	mg	SD	Min.	Max.
Sweet orange (Citrus sinensis)	28.6	11.9	3.5	55.2
Red orange (Citrus sinensis)	43.6	17.9	18	66.5
Commercial sweet orange juice	37.5	19.2	4.45	76.3
Mandarin (Citrus reticulata)	24.3	18.2	0.81	45.8
Clementine (Citrus clementine)	39.9	29.4	5.21	86.1
Lemon (Citrus limon)	20.5	12.4	3.84	41
Lime (Citrus aurantifolia)	1.8	0.35	1.52	2
Grapefruit (Citrus paradisi)	0.9	0.58	0.25	1.8
Commercial grapefruit juice	2.8	3.9	0.2	16.4

[Sources ¹¹, ⁸ ]

Figure 1. Hesperidin chemical structure

Footnote: Chemical structure of hesperidin (2S)-5-hydroxy-2-(3-hydroxy-4-methoxyphenyl)-7-[(2S,3R,4S,5S,6R)-3,4,5-trihydroxy-6-[[(2R,3R,4R,5R,6S)-3,4,5-trihydroxy-6-methyloxan-2-yl]oxymethyl]oxan-2-yl]oxy-2,3-dihydrochromen-4-one)

[Source ²⁵ ]

Figure 2. Hesperitin chemical structure

[Source ²⁸ ]

Hesperidin benefits

Various biological and pharmacological effects have been reported for hesperidin. Hesperidin possesses the anti-oxidant, anti-inflammatory ²⁹ and anti-cancer activities ³⁰. Hesperidin exhibited significant mediatory effect on the extrinsic and intrinsic apoptosis of different cancerous cells ³¹. Hesperidin and its aglycon, hesperetin, were found to be effective on different types of cancers, including gastric cancer ³², colon cancer ³³, lung cancer ³⁴, liver cancer ³⁵, breast cancer ³⁶ and prostate cancer ³⁷. Along with the anti-cancer activity of hesperidin, the effect of isoflavone on inflammation associated with cancer has been proven. It exhibited the inhibitory effect on the inflammatory-mediated cancers by regulating the level of inflammatory components like TNF-α, IL-1β, cyclooxygenase-2 (COX-2), and iNOS ³⁸. Hesperidin was also found to have an anti-replicative activity against some viruses ³⁹.

The effect of hesperidin administration on blood vessel disorders such as edema, bleeding, pleurisy, Henoch-Schonlein purpura and tuberculosis was observed by decreasing the capillary permeability and enhancing the capillary resistance ³. Hesperidin also exerts the antihypercholesterolemic ⁴⁰, antihyperlipidaemic ⁴¹, antihypertensive, diuretic effect ⁴² and calcium channel blocker activity ⁴³. The in vivo (animal study) administration of phosphorylated hesperidin in rodents caused an anti-fertility effect ⁴⁴. Some other biological effects, such as immuno-modulatory activity, anti-depressant, anti-allergic effect, ultra-violet protective effect, platelet, and a cell aggregation inhibitory effect, have wound healing potential and have been attributed to hesperidin ⁴⁵. Apart from the aforementioned biological activities, hesperidin possesses considerable neuroprotective property in various neurodegenerative diseases, such as Alzheimer’s disease, Parkinson’s disease, stroke, and Huntington’s disease ⁴⁶.

Despite the various animal-based studies on the role of hesperidin in neurodegenerative diseases, there have not been enough clinical studies devoted to the administration of hesperidin for human neuroprotection ²⁸. Although a wealth of positive findings has been obtained in animal studies, the mechanism of function of hesperidin phytochemical in the human body remains to be elucidated.

In a placebo-controlled, randomized, and double-blinded clinical study, the effect of chronic administration (eight weeks) of orange juice on the cognition of 37 healthy adults (60–81 years of age) was examined ⁴⁷. A group of adults consumed a juice with 549 mg/L hesperidin and 60mg/L narirutin (as a flavanone); another group drunk a juice with 64 mg/L hesperidin and 10 mg/L narirutin, 250 mL twice a day ⁴⁷. At the baseline there was no significant alteration in the cognitive function of these two groups, but after eight weeks the cognitive function, executive function, and episodic memory of the group that consumed orange juice with higher hesperidin content was significantly better than the group that received a lower amount of hesperidin ⁴⁷.

The most significant effect of hesperidin-rich juice was observed in the immediate recall after the follow-up period of the Consortium to Establish a Registry for Alzheimer’s disease (CERAD) ⁴⁷. Besides these effects, the chronic consumption of hesperidin-rich juice significantly decreased the diastolic blood pressure. Their study clarified that hesperidin-rich dietary interventions could prevent cognitive decline in neurodegenerative patients ⁴⁷. The underlying mechanism reflecting these effects was not clear, but other studies have claimed that flavanone consumption causes increasing cerebral blood flow ⁴⁸. In order to examine the possibility of this mechanism, Lamport et al. ⁴⁹ carried out an acute, randomized, single-blind, placebo-controlled, clinical study on the role of citrus juice in the cognitive function and the cerebral blood flow of 44 healthy young adults (18–30 years of age). The subjects consumed 500 mL of citrus juice containing 42.15 mg hesperidin, while the control group consumed a drink containing 240 mL concentrate and 260 mL mineral water. A separate cohort of participants was chosen to examine the cerebral blood flow of functional MRI. After two hours of screening the participants, within a conscious resting state, a significant improvement was observed in the cerebral blood flow of the right frontal gyrus, as well as the Digit Symbol Substitution Test (DSST, which reflected the executive function) performance ⁴⁹. Although the citrus juice could enhance these parameters individually, no direct association was found between the improvement of behavioral parameters and an increase in cerebral blood flow. The region-specific alteration in the cerebral blood flow could be attributed to the test condition, which was carried out in the conscious resting state, in which the frontal gyrus was active ⁴⁹.

In another study that focused on the role of hesperidin-rich drinks in the cognitive function of healthy middle-aged men (30–65 years of age), 5.5 g of orange pomace fiber was added to 240 mL of orange juice containing 220.46 mg hesperidin ⁵⁰. The beverage was then administered to the treatment group. The placebo group received a drink with a similar taste and energy, but instead included a mixture of glucose, fructose, sucrose, and 0.67% citric acid in 240 mL water. Some tests corresponding to the cognitive battery were conducted to elucidate the role of drinking on the cognitive performance after a 6 h follow-up period, while only the Continuous Performance Task (CPT, which reflected the attention and executive cognitive function of participants) and finger tapping (a criterion for psychomotor speed) enhanced significantly 6 hours post drinking hesperidin reach juice, in comparison to the placebo ⁵⁰. The non-significant improvement of other cognitive measurements within 6 hours indicated that this medication could not significantly affect global performance. On the other hand, their findings revealed the role of hesperidin-rich juice on the development of objective and subjective cognitive functions and attenuating the decline of alertness ⁵⁰.

The clinical role of citrus consumption on dementia was also examined in a cohort study of 13,373 Japanese elderly participants ⁵¹. The incidence of dementia in participants was closely related to the consumption of citrus in a dose-response and reverse correlation. In the area where the authors carried out the clinical study, the flavonoid-rich citrus fruits were mostly consumed, which are rich in hesperidin, neohesperidin, and other flavonoids. The multivariate-adjusted hazard ratio (HR) for the incidence of dementia was found to be 0.97 for subjects with a ≤2 times/week citrus intake, while this value was 0.92 and 0.86 for subjects with a 3–4 times/week intake and almost every day citrus intake, respectivley ⁵¹. These results indicated the protective role of citrus flavonoid in incident dementia and possibility of lowering the risk of this disorder by frequent administration of citrus fruits.

Menopausal hot flashes

Some flavonoids demonstrate a very weak estrogenic effect, which maybe why regular use can alleviate symptoms associated with menopause ⁵². In one clinical study, 94 menopausal women with hot flashes were given a daily formula for one month containing 900 mg hesperidin, 300 mg hesperidin methyl chalcone and 1,200mg vitamin C ⁵³. After one month, symptoms of hot flashes were completely relieved in 53 percent and reduced in 34 percent of the women ⁵³. No signs of toxicity have been observed with the intake of hesperidin or related compounds.

Weight loss

Mounting evidence has demonstrated that hesperidin possesses inhibitory effect against obesity diseases ⁵⁴. Hesperidin regulates lipid metabolism ⁵⁵ and glucose metabolism by mediating AMP-activated protein kinase (AMPK) and peroxisome proliferator-activated receptor (PPAR) signaling pathways, directly regulates antioxidant index and anti-apoptosis, and indirectly mediates NF-κB signaling pathway to regulate inflammation to play a role in the treatment of obesity ⁵⁴. Hesperidin can also directly regulate the oxidation index, inhibit apoptosis, thereby protecting against damage caused by oxidative stress, and improving lipid peroxidation. In addition, hesperidin-enriched dietary supplements can significantly improve symptoms such as postprandial hyperglycemia and hyperlipidemia. Recent studies have shown that citrus flavonoids play an important role in the treatment of dyslipidemia, insulin resistance, hepatic steatosis, obesity and atherosclerosis ⁵⁴. Citrus flavonoids, including naringenin, hesperidin, nobiletin and hesperetin, have become promising therapeutic agents for the treatment of metabolic disorders ⁵⁶.

Hesperetin and hesperidin can stimulate the release of cholecystokinin (CCK), an appetite-regulating hormone, in enteroendocrine STC-1 cells, which is ultimately used to treat obesity by suppressing appetite ⁵⁷. Dietary bioflavonoid hesperidin can reduce cholesterol and triglyceride levels in broiler chicken serum and pectoral muscle, and positively improve fatty acid and lipid metabolism in broiler breasts in a dose-dependent manner ⁵⁸. The main types of hesperidin metabolism in rats are mainly hydrolysis, demethoxylation, dehydration, dehydrogenation, demethylation, glucuronide binding, sulfate binding and N-acetylcysteine binding ⁵⁹. Hesperidin can significantly increase the level of alpha-Klotho (α-KL) in serum, liver and kidney tissues of diabetic rats, and significantly reduce the levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), blood urea nitrogen (BUN) and creatinine in fibroblast growth factor-23 (FGF-23) in kidney tissues and serum samples ⁶⁰. High-dose hesperidin up-regulates adenosine 5ʹ-monophosphate (AMP)-activated protein kinase (AMPK) mRNA expression in mice with glycolipid metabolism disorder induced by high-fat diet, affecting insulin signaling pathway (insulin receptor, insulin receptor substrate 1 (IRS-1), GLUT2/4) and lipid metabolism-related genes (sterol regulatory element-binding protein 1c (SREBP1c) and FAS and acetyl-CoA carboxylase) gene expression also activates PPAR-α mRNA expression ⁶¹. In addition, hesperidin enhances the expression of genes encoding LDL receptors, which are some of the possible mechanisms by which hesperidin reduces blood lipids ⁶².

Although the hypoglycemic and lipid-lowering activities of hesperidin have been studied in some animals (such as rats) or cells, the lack of clinical trials on the therapeutic effect of hesperidin is a significant limitation that deserves further study ⁵⁴.

Table 2. The details on weight loss effect of hesperidin

Model	Dose And Treat Time	Described Effect	Weight Loss Mechanism	Reference
Sisolated perfused male wistar rats, ad libitum with a standard laboratory diet	300µM; 0–70min	Glycogenolysis and glycolysis in the liver↑; glucose phosphorylation catalysed by GK↓	G-6-Pase↓	63
Rats	1mL; 24h	Enzyme activities↓; production of pyruvate↓; hepatic gluconeogenes↓; α-ketoglutarate and the oxaloacetate↓	Liver ALT↓; liver AST↓	64
HIGH fat fed/streptozotocin- induced type 2 diabetic rats	50mg/kg; 4w	Serum glucose and glycosylated hemoglobin↓; vitamin C and vitamin E↑	NO↓; IL-6↓; TNF-α↓; serum INS↑; GSH↑; liver MDA↓; liver antioxidant enzymes↑	65
Male wistar rats, high-cholesterol diet	25g/d; 12w	Hepatic steatosis, adipose tissue and liver weights↓; serum TC ↓	RBP, H-FABP, C-FABP in liver and adipose tissue↓	66
Male wistar rats, high-fat/sucrose (western) diet	100mg/kg; 8w	Blood lipid profle↑; hepatic lipid accumulation↓; non-alcoholic steatohepatitis↓	SREBP1↓; PPAR-γ↓; SCD↓; FAS↓	67
Type 2 diabetic rats, high fat diet	50mg/kg; 4w	White blood cell count↓; neutrophils↓; monocytes↓; basophils↓	IL-6↓; adipose tissue ACDC↑	68
Streptozotocin-induced marginal type 1 diabetic rats	10g/kg; 4w	Blood glucose↓; TC↓	Serum ACDC↑; TG↓; G-6-Pase↓; GK↑; LDL-C↓; VLDL-C↓; HDL-C↑; serum INS↑;	62
Rats, high-cholesterol diet	8mg/d; 6–12w	Body and liverand adipose tissue weights↓; cholesterol synthesis and absorption↓	Lipid-related factors (RBP4, H-FABP and C-FABP)↓; ICAM-1↓; inflammatory-related factors (MCP1, CCR2 and TNF-α)↓	69
Goto-Kakizaki weanling rats with type 2 diabetes	0.01g/; 4w	Lipids in the serum and liver↓; blood glucose↓; HDL-C/TC↑	The genes coding for PPARs↑; HMG-CoA reductase↓; the expression of genes encoding LDL receptor↑; serum ACDC↑; TG↓; INS↑	70
Rats with diabetes induced by streptozotocin	100mg/kg; 2w	Strong positive effects on diabetic toxicity in the liver and kidneys	Liver, kidney and serum α-KL ↑; FGF-23↓; MDA↓	71
Rats subjected to isoproterenol- induced cardiotoxicity	200mg/kg; 7d	TC↓	LDL-C↓; TG↓; VLDL-C↓; FFA↓; plasma PL↓; HDL-C↑; PL in the heart and liver↑	72
Rats, high-cholesterol diet	100mg/kg; 5d	TC↓; HDL-C/TC↑; serum triglyceride levels↓	GSH in the liver↑; serum and liver MDA↓	73
Streptozotocin-induced hyperglycemic mice	200mg/kg; 14d	Blood glucose↓; lipid peroxidation and total nitrate/nitrite↓	Bad/Bcl-2↑; Bad/Bcl-XL↑; SOD↑; GSH↑	74
C57BL/6J mice, high-fat diet	100mg/kg/d; 4w	Serum total antioxidant capacity↑; liver TBARS levels↓; spleen mass↓; fat accumulation↓; liver damage↓	IL-6↓; MCP-1↓; hs-CRP↓; LDL-C↓	75
C57 mice, high-fat diet	100,200,400mg/kg/d; 16w	Body weight↓; body fat deposition↓; serum glucose↓; serum lipid↓; HOMA-IR index↓	mRNA of AMPK↑; serum INS↑; impact on signaling pathway genes↑ (INSR, IRS-1, GLUT2/4) and lipid metabolism pathway genes (SREBP1↓, FAS↓, ACC↓,PPAR-α↑)	61
Mice, high-fat diet	0.07mg/100g; 9w	Body weight and liver and adipose tissue weight↓	PPAR-γ↑	76
C2C12 cells	0.07mg/100g; 6h	Stimulated glucose↑	PPAR-γ↑
Pre-adipocytes of mesenchymal stem cells	1,10,25µM; 48h-8d	Anti-adipogenic and delipidating	C/EBPβ↓; SREBP1↓; perilipin↓;PPAR-γ↓	77
Mature adipocytes from mesenchymal stem cells	1,10,25µM; 48h-8d	Anti-adipogenic effect and delipidating	mRNA of ATGL↑; FAS↓;TG accumulation↓
3T3-L1 pre-adipocytes	1,10,25µM; 0-60h-8d	Lipid accumulation↓; riacylglycerol content in pre-adipocytes↓	SREBP1↓	78
3T3-L1 adipocytes	20µM; 8d	Lipid accumulation↓	ROS↓; PPAR-γ↓; C/EBPα↓; FABP4↓	79
3T3-L1 cells	0.5mg/mL; 24h	Induction of adipolytic activity↓; key adipogenic transcription factors↓	C/EBPα↓; PPAR-γ↓; SREBP1↓	80
3T3-L1 cells	10, 50, 100µM; 8d	Anti-lipogenic capacity↑	Binding affinity for the PPAR-γ rceptor↓; SCD↓; LPL↓	81
RAW264.7 and 3T3-L1 cells	1.8–8.3µM; 24h	Anti-inflammatory activity↑	ACDC↑; IL-6↓; TNF-α↓; NO↓	82
Enteroendocrine STC-1 cells	0.1,0.5,1.0µM; 60min	Appetite-regulating hormones↑; cholecystokinin release↑	Intracellular Ca(2+) concentrations↑	57
Retinal ganglial cells −5	12.5,25,50µmol/L; 6h	High glucose-mediated cell loss↓; mitochondrial function↑; Cell apoptosis↓	ROS, MDA and protein carbonyl↓; SOD↑; CAT↑; GSH↑; caspase-9, caspase-3 and Bax/Bcl-2↓	83
HepG2 cells	100ug/mL; 48h	Lipid accumulation↓	miR-122 and miR-33 expression↓; CPT1α↑; FAS↓	84
HepG-2 cells	50µM; 1min	Digestive enzyme activities↓; glycogen↑	GK activity↑; G-6-Pase↓	85
Porcine pancreas	100µM; 1min	Glucose consumption↑; glycogen↑; glucokinase activity↑	α-amylase activity↓; α-glucosidase activity↓
Caenorhaditis elegans	50µM,100µM; 0–35d	Fat accumulation↓; the ratio of oleic acid/stearic acid↓	SCD↓; FAT-6↓; FAT-7↓; POD-2↓; MDT-15↓; ACS-2↓; KAT-1↓	86
Broilers	20mg/kg; 42d	Plasma antioxidant parameters↑; TC↓; total antioxidant capacity↑	Total SOD↑; MDA↓; TG↓	58

Footnote: ↓indicates inhibition/reduction while ↑indicates increase/promotion

Abbreviations: ACDC = adiponectin; hs-CRP = High-sensitivity C-reactive protein; INSR = Insulin receptor; IRS-1 = Insulin receptor substrate 1; ATGL = adipose triacylglyceride lipase; PL =, phospholipids; FFA = free fatty acids; TG = triglycerides; HDL-C = high density lipoprotein-cholesterol; LDL-C = low density lipoprotein-cholesterol (“bad” cholesterol); VLDL-C = very low density lipoprotein-cholesterol; MDA = malondialdehyde; GSH = glutathione; G-6-Pase = glucose-6-phosphatase; HMG-CoA = 3-hydroxy-3-methyl-glutatyl coenzyme A; α-KL = α-Klotho; FGF-23 = fibroblast growth factor-23; RBP4 = retinol-binding protein 4; CCR2 = C-C chemokine receptor type 2; MCP1 = monocyte chemoattractant protein-1; TNF-α = tumor necrosis factor alpha; TBARS = thiobarbituric acid reactive substances; ROS = reactive oxygen species; CAT = catalase; GK = glucokinase; C/EBPβ = CCAAT/enhancer-binding protein beta; PPAR-γ = peroxisome proliferator-activated receptor gamma; SREBP1 = sterol regulatory element-binding protein 1; RBP = lipid metabolism–related proteins; H-FABP = heart fatty acid–binding protein; C-FABP = cutaneous fatty acid–binding protein; IL-6 = interleukin-6; NF-κB = nuclear factor kappa B; SCD = stearoyl-CoA desaturase; TC = Total cholesterol; ALT = alanine aminotransferase; AST = aspartate aminotransferase; CPT1α = carnitine palmitoyltransferase 1α; FAS = fatty acid synthase; LPL = lipoprotein lipase; FAT-6/7 = Fatty-acid desaturase 6/7; ACS-2 = acyl-CoA synthetase-2; KAT-1 = ketoacyl-CoA thiolase-1; POD-2 = acetyl-CoA carboxylase-2; MDT-15 = mediator subunit-15.

Use in cosmetics as anti-ageing active components

Hesperidin and hesperetin are the focus of intensive research for topical application. For example, sulfonated, acetylated, or phosphorylated hesperidin derivatives are potent inhibitors of hyaluronidase ²⁵. Moreover, hesperidin can also act on superoxide in electron transfer as well as proton transfer in vivo (animal study). Hesperidin might act as a topical UV-protective agent, by protecting phosphatidylcholine liposomes from UV irradiation-induced peroxidation. The neohesperidin, for example, demonstrates the capacity to extend yeast’s chronical lifespan, individually or in synergism with the hesperitin, for 10 different aging factors, such as scavenging ROS (reactive oxygen species) effects, regulation of stress-related enzymes, and maintaining pH cellular value, favorable for life extension of yeast cells ⁸⁷. Hesperidin was also proved as a potent anti-photoageing factor, through regulation of metalloproteinases MMP-9 via mitogen activation protein kinase (MAPK) signaling pathways ⁸⁸. In the same study, Lee and colleagues ⁸⁸ approved the positive effect of hesperidin on wrinkle depth on a mouse dorsal skin model and reduction in UVB-induced hydration changes and trans-epidermal water loss ⁸⁹. Different studies demonstrate accelerated cutaneous diabetic or venous wounds healing and ameliorate skin epidermal barrier function already after 7 days of Hesperidin application ⁸⁹. On the other hand, hesperitin was found to penetrate through the stratum corneum ⁹⁰ and assays conducted in vitro (test tube) showed that the presence of lecithin and d-limonene in formulations may aid towards faster hesperetin penetration into the skin ⁹¹. Additionally, in vitro studies of the stratum corneum have demonstrated that flavonoids show differences in penetration capacities, which depend in a large part on the ingredients/vehicles present in the formulation. Therefore, the penetration rate of flavonoids, such as catechin, rutin, quercetin, and others, is influenced by moisturizing ingredients (glycerol, glycols, polyglycols, ethoxylated methyl glucoside, and urea) and by the type of cosmetic formulation (hydrogel, emulsion, microemulsion, and micellar system) ⁹². For example, the water in oil microemulsion formulations significantly enhances quercetin skin penetration up to 12 hour after application ⁹³. Hesperidin-loaded nanostructured lipid vehicles show burst release in the beginning and further sustained bioflavonoid release from the lipid nanocarrier ⁹⁴. Despite their interesting and beneficial skin effects, bioflavonoids are very demanding for making effective formulations. In addition, their insolubility in water complicates their use in cosmetic products and influences greatly on their extraction from fruits and plants that is usually performed by the use of organic solvents ²⁵.

Parkinson’s disease

Parkinson’s disease is one of the neurodegenerative diseases associated with the loss of dopaminergic neurons. Oxidative stress is a prominent feature in pathogenesis of Parkinson’s disease; loss of dopaminergic neurons and the continued involvement of these features cause the appearance of non-motor symptoms of the disease (i.e., depression, mood and cognition impairment, sleep disturbance, impaired olfaction, etc.) ⁹⁵. This type of neurodegenerative disease is associated with the accumulation of ROS (reactive oxygen species). The suppressive mechanisms for minimizing free radical formation and oxidative stress could involve the regulation of antioxidant enzyme levels ⁹⁶. In addition to oxidative stress, the oxidative metabolism of cytosolic dopamine via interaction with monoamine oxidase (MAO) enzyme plays a prominent role in the progression of Parkinson’s disease ⁹⁷.

Hesperidin, as a potent antioxidant and biomembrane stabilizer, can cause several protective effects in Parkinson’s disease models via antioxidant and dopamine-enhancing mechanisms ²⁸. Furthermore, hesperidin exhibited modulatory activity upon kappa-opioid (κ-opioid) and serotonergic 5-HT1A receptors, leading to the reduction of depression symptoms ⁹⁸. Hesperidin was found to be effective in minimizing cognitive and depressive deficits in mice by modulating neurotransmitter systems. Moreover, it potentially inhibited the depletion of dopamine and its metabolites 3,4-dihydroxyphenylacetic acid and homovanillic acid, as well as its exertion of antioxidant activity by modulating glutathione (GSH) levels, glutathione-peroxidase (GPx) and catalase (CAT) activities, inhibiting ROS formation, and attenuating glutathione reductase activity ⁹⁸. Additionally, hesperidin enhanced the locomotion efficiency, inhibited the lipid peroxidation in Parkinson’s disease models (by decreasing malondialdehyde content), attenuated hypercholesterolemia (by diminishing the total cholesterol and triglycerides in plasma level), and ameliorated DNA damage (by decreasing the levels of 8-hydroxydeoxyguanosine) in Chlorpyrifos-induced models of Parkinson’s disease ⁹⁹. The neuroprotective mechanism of hesperidin in Parkinson’s disease could also be due to regulation of other neurotransmitters, such as norepinephrine, serotonin, and epinephrine ¹⁰⁰. Hesperidin consumption also can be effective on Parkinson’s disease models via down-regulating the level of proinflammatory cytokines such as TNF-α, IL-1β, IL-6, IL-4, and IL-10, as well as affecting glial fibrillary acidic protein (GFAP), iNOS, and COX-2 levels ¹⁰¹.

Hesperidin was found even more effective than the current drug, l-Dopa (levodopa). L-DOPA is the precursor to the neurotransmitters dopamine, norepinephrine (noradrenaline), and epinephrine (adrenaline), which are collectively known as catecholamines. Coadministration of hesperidin with l-Dopa increased the bioavailability of this drug in the 6-hydroxydopamine (6-OHDA) rat model of Parkinson’s disease ¹⁰⁰ and inhibited degeneration of cytoplasmic vacuolation mediated by 6-hydroxydopamine (6-OHDA) in the striatal and mid-brain ¹⁰². The synergetic interaction of these two Parkinson’s disease medicaments caused a suppressive effect on gene expressions of synuclein alpha (SNCA, as a ubiquitously expressed protein affecting the regulation of dopamine release) and Leucine-rich repeat kinase 2 (LRRK2), as an enzyme containing kinase and GTPase function, which its mutation is the most frequent genetic cause of Parkinson’s disease ²⁸. This combination also potentiated the expressions of parkin (a protein involved in the pathogenesis of autosomal recessive juvenile parkinsonism) and PTEN induced putative kinase1 (PINK1, a mitochondrial kinase phosphorylates parkin) ¹⁰³. This combination of hesperidin with Sinemet (as one of the most common therapeutics for Parkinson’s disease) decreased the side effect of this drug in Chlorpyrifos-induced Parkinson’s disease models ⁹⁹.

Dementia and Alzheimer’s disease

Alzheimer’s disease is a neurodegenerative disorder in the central nervous system (brain and spinal cord) with progressive cognitive decline and memory impairment. Alzheimer’s disease is considered the most important cause of dementia ¹⁰⁴. However, there is no definite cause for Alzheimer’s disease, even though it has been well-established that its pathogenesis is closely related to cholinergic dysfunction, mitochondrial abnormalities, and oxidative stress ⁶. Due to the strong memory enhancing and antioxidant effects of hesperidin, it can be considered as a potential medicament for Alzheimer’s disease and dementia ²⁸.

The ability of hesperidin in increasing the anti-oxidative defense might be one of the mechanisms by which hesperidin improves cognitive function. Administration of hesperidin for 16 weeks helped improve learning and memory function by enhancing recognition index in the APPswe/PS1dE9 transgenic mouse model ²⁸. It corrected the amyloid beta (Aβ)-induced mitochondrial abnormalities by reducing malondialdehyde (MDA) and hydrogen peroxide (H2O2) levels, as well as restoring depleting GSH levels and total antioxidant capacity. The mitochondrial enzyme activities were also restored by elevating the mitochondrial complex I–IV enzymes activities ¹⁰⁵. Glycogen synthase kinase-3β (GSK-3β) is a protein kinase possesses prominent role in the mitochondrial functions and in Alzheimer’s disease. It closely affects the tau protein hyperphosphorylation and mitochondrial target ¹⁰⁶. Activation of this protein kinase causes increasing the oxidative damage. Hesperidin potentially rescued cognitive deficits and demonstrated mitochondrial neuroprotection effect by inhibiting restoration of this kinase. It was the possible mechanism by which hesperidin decreased the level of Aβ1–40 ¹⁰⁵. Hesperidin also inhibited learning and memory impairments resultant from Aluminum chloride (AlCl3)—induced Alzheimer’s disease, acting as an acetylcholinesterase (AChE) inhibitor. Hesperidin attenuated amyloid precursor protein expression via NF-κB dependent pathway and suppressed the levels of Aβ1–40 and β- and γ-secretases (which both modulate the cleavage of amyloid precursor protein) in the hippocampus and the cortex of the brain of rats ⁴⁶. In another study, the role of hesperidin on cognitive deterioration in rats with Alzheimer’s disease induced by AlCl3. Alzheimer’s disease was found to reverse the cognitive dysfunctions. By up-regulating B-cell lymphoma 2 (Bcl2) and down-regulating Bcl2-associated X proteins (Bax), expressions were included in the neuroprotective mechanism of hesperidin ¹⁰⁷.

Beside the cognitive deficits, Alzheimer’s disease is also associated with non-cognitive and behavioral impairments. Aggregation, deposition, and neuro-inflammation of amyloid beta (Aβ) are all possible reasons for behavioral and cognitive manifestations. In addition to cognitive deficits, hesperidin was found effective in restoring the behavioral manifestation associated with Alzheimer’s disease. In a study on the amyloid precursor protein (APP)/PS1 mice model of Alzheimer’s disease, hesperidin blocked the inflammatory process, rescued amyloid precursor proteins (APPs) production and deposition of amyloid beta (Aβ) peptides in the cortex and hippocampus of the animals, and consequently enhanced the nesting ability and social interactions of the transgenic mice ¹⁰⁸. The anti-inflammatory effect of hesperidin was found to be related to the mechanism, in which this herbal compound down-regulated the level of the transforming growth factor β1 (TGF-β1) immunoreactivity and NF-κB (which are known to be involved in the progression of Alzheimer’s disease) in the brain cortical region ¹⁰⁹. The role of TGF-β1 in stimulating the amyloid precursor protein (APP) production and Aβ peptides deposition has been reported in a previous study conducted by Gray et al. ¹¹⁰.

Dementia is also a progressive dysfunction with a stepwise deterioration of memory, learning, and motor functions. The neuroprotective effect of hesperidin on the intracerebroventricular streptozotocin-induced animal model of sporadic dementia of Alzheimer’s type (SDAT) was corroborated by testing its efficacy on spatial learning, memory, and cholinergic dysfunctions. Morris water maze escape and probe tests revealed the dose-dependent effect of hesperidin to decrease escape latency and enhance memory consolidation. The decrease of acetylcholinesterase activity and lipid peroxidation (by decreasing the content of thiobarbituric acid reactive substances), enhancement of gangliosides level, and blocking inflammatory process (by inhibiting NF-κB, COX-2, and iNOS) after administration of hesperidin exhibited the promising role of this flavonoid in alleviating symptoms of sporadic dementia of Alzheimer’s type (SDAT) ¹¹¹. Moreover, hesperidin exerted the protective effect on vascular dementia in the rat model of l-methionine-induced hyperhomocysteinemia (HHcy). Endothelial dysfunction in addition to cognitive deteriorates, mediated by hyperhomocysteinemia, was attenuated by hesperidin via a dose-dependent mechanism, in which nitrite and serum Hcy levels with MDA levels were decreased, acetylcholinesterase activity was inhibited, and the levels of GSH, SOD, and CAT were increased ¹¹². Similar results were also achieved after coadministration of hesperidin and donepezil in the scopolamine induced amnesia model, corroborating the prominent role of hesperidin in ameliorating dementia and cognitive deficits of Alzheimer’s disease ¹¹³.

Huntington’s disease

Huntington’s disease is a progressive and fatal neurodegenerative disorder that is associated with a spectrum of abnormalities, such as involuntary movements, motor impairment, cognitive and memory manifestations, personality changes, neuro-psychiatric disturbances, and dementia ¹¹⁴. A known and well-established phenotypic Huntington’s disease inducer in both human and animal studies is 3-Nitropropionic acid (3-NP), which was used to investigate Huntington’s disease neuro-psychiatric symptoms. 3-NP intoxication was accompanied by oxidative damage, body weight deficit, mitochondrial, locomotor, and grip impairments in striatum. Hesperidin treatment necessitates overcoming these impairments and enhancing locomotor and grip strength. Hesperidin’s enhancement of striatal oxidative defense and its effect on the cellular energy stores were found to be due to the modulatory effect on nitric oxide pathway ¹¹⁵.

To ensure the promising role of hesperidin in attenuating nitric oxide synthase expression, scientists compared the expressions of iNOS before and after hesperidin administration to the 3-NP-intoxicated animal models of Huntington’s disease. The significant role of hesperidin in suppression of iNOS level in cortical, striatal, and hippocampal regions corroborated its nitric oxide-related mechanism of effect on the Huntington’s disease models ¹¹⁶. In addition to these effects, the role of hesperidin on reduction of malondialdehyde (MDA) level, enhancement of CAT activity, and prevention of prepulse inhibition of the startle response provided a strong indication that it had a beneficial role in the treatment of Huntington’s disease ¹¹⁶. Interestingly, a microglial pathway was found to likely be involved in the protective effect of hesperidin on Huntington’s disease ⁴⁵. Coadministration of minocycline (as a microglial inhibitor) with hesperidin in rat models of quinolinic acid mediated Huntington’s disease, significantly potentiated the effect of hesperidin on excitotoxicity induced by quinolinic acid. The quinolinic acid-mediated apoptosis (increased level of caspase-3 activity), the quinolinic acid-mediated reduction of brain-derived neurotrophic factor (BDNF, a signaling molecule secreted from activated microglia that helps to support the survival of neurons) level ¹¹⁷ and the quinolinic acid-mediated elevation of TNF-α level were inhibited by minocycline and hesperidin ¹¹⁸. These results altogether suggest that the inhibitory effect of hesperidin on the activation of microglial cells and involvement of the microglial pathway in its neuroprotective effects against Huntington’s disease ²⁸.

Multiple sclerosis

Multiple sclerosis (MS) is a chronic and complex neuro-inflammatory demyelinating disease of the central nervous system, which is the major cause of neurological disability ¹¹⁹. This type of neuro-inflammatory disease is commonly accompanied by axonal loss and glial scaring, in addition to the secretion of inflammatory cytokines ¹²⁰. The pathogenesis of these types of central nervous system disorders include the invasion and proliferation of the CD4+ T-cells, T-cells and macrophage infiltration, and nitric oxide (NO) production in the cerebral spinal fluid (CSF) ¹²¹. The anti-inflammatory effect of flavonoids (i.e., hesperidin) and their inhibitory effect on the pro-inflammatory cytokines, together with their potential in attenuating proliferation of T-cells, makes them a promising agent in ameliorating MS. Hesperidin dose-dependently diminished demyelination in the central nervous system and ameliorated the clinical abnormalities in the myelin oligodendrocyte glycoprotein-induced C57BL/6 mice model of MS. These abnormalities include excretion of pro-inflammatory cytokines such as IL-6, IL-17, IL-23, TNF-α, and Th17 cells transcription factor (ROR-γt, retinoic acid receptor-related orphan nuclear receptor gamma) and the reduction of Treg related cytokines (IL-10 and TGF-β), as well as the FoxP3 transcription factor ¹²².

Other than the aforementioned abnormalities, MS models demonstrated the lipid peroxidation (elevated thiobarbituric acid reactive substances (TBARS) level) and suppression of enzymatic and non-enzymatic antioxidants. Hesperidin treatment was found beneficial to alleviate these manifestations and reversed oxidative damage and histological changes of cerebral cortex caused by experimental allergic encephalomyelitis ¹²³. The anti-apoptotic effect of hesperidin on the neurons of a C57BL/J6 mouse model was also corroborated via down-regulating caspase3-like immunoreactivity ¹²³.

Diabetes mellitus associated neurotoxicity

Diabetes is among the many independent risk factors of neurodegenerative diseases like Alzheimer’s disease and dementia ¹²⁴. Diabetes causes vascular and neurodegenerative effects on patients, leading to the fast cognitive decline; insulin resistance causes potentiating amyloid beta (Aβ) production ¹²⁵. Protein glycation and glucose autoxidation are the main reasons for damaged cell structures and disrupted cellular integrity in diabetic patients. Several studies have provided insights on the role of flavonoids as potent antioxidants with hypoglycemic and anti-inflammatory effects, in hyperglycemia of diabetes mellitus, and the incidence and progression of diabetes-induced neuro-complications ¹²⁶. Hesperidin exhibited antihyperglycemic and antidyslipidemic activities in streptozotocin induced diabetes mellitus (STZ-diabetes mellitus) models and successfully attenuated the overproduction of ROS by restoring the enzymatic (glutathione-S-transferase (GST) and glutathione reductase (GR); nonenzymatic endogenous antioxidants, GSH, and Nonprotein bound thiol). Consequently, there was also the depletion of lipid peroxidation levels in a STZ diabetic rat brain ¹²⁷. Furthermore, it reduces the activities of cytochrome oxidase and aldose reductase, as well as sorbitol dehydrogenase ¹²⁸. The formation of xanthine oxidase (XO) in the brain of diabetic patients is included in the major pathogenesis of diabetes mellitus; hesperidin was found as one of the medicaments capable of suppressing XO levels in the diabetic brain ¹²⁷. The activity of neurotoxicity markers such as AChE and Na+/K+ ATPase were also significantly affected by hesperidin treatment. This therapeutic process possessed the ability to attenuate the diabetic neurotoxicity by controlling the sodium and potassium gradients ¹²⁹. These studies strongly suggest that hesperidin, as a medicament with dual anti-diabetic and Alzheimer’s disease treating attributes, is effective when targeting diabetes-induced Alzheimer’s disease.

Diabetic neuropathy is one of the most troublesome long-term complications of diabetes mellitus. Clinically, it can be distinguished by an increase in a nociceptive response with abnormal electrophysiological conduction ¹³⁰. The neuroprotective effect of hesperidin against STZ-induced diabetic neuropathic pain in rats has shown that hesperidin, in conjunction with insulin, reduces the diabetic condition and reverses neuropathic pain through control over hyperglycemia and hyperlipidemia, which down-regulates ROS production, releases pro-inflammatory cytokines, and elevates membrane bound enzymes ¹²⁹ . The antihyperglycemic activity of hesperidin against diabetic neuropathy is attributed to its effect on mitigating the elevated level of glycated hemoglobin (HbA1c) and overcoming the insulin resistance by increasing the level of insulin ¹²⁹. In the STZ-induced diabetic neuropathy, the overproduction of TNF-α and IL-1β increase the hyperalgesia effect of polyneuropathy’s progress and maintenance ¹³¹, which could be attenuated after hesperidin treatment ¹²⁹. Furthermore, hesperidin possesses a restorative effect on normal secretome and hippocampal proteome profiles in the diabetic brain ¹²⁶. Interestingly, hesperidin was found to be a potent medicament for diabetic neuropathy, which is highly related to both its anti-diabetic and neuroprotective effects ²⁸.

Diosmin and hesperidin

Diosmin is a naturally occurring flavonoid glycoside (diosmetin 7-rutinoside) that can be isolated from various plant sources but is contained mainly in citrus or derived from the flavonoid hesperidin ¹³². Diosmin differs molecularly from hesperidin by the presence of a double bond between two carbon atoms in diosmin’s central carbon ring (see Figure 3). Diosmin can be manufactured by extracting hesperidin from citrus rinds, followed by conversion of hesperidin to diosmin. Diosmin shows antihyperglycemic ¹³³ and anticancer effects ¹³⁴, in addition to anti-inflammatory and antioxidant-like actions ¹³⁵. In type-2 diabetic animals, diosmin attenuated hyperglycemia and increased insulin secretion ¹³⁶. Diosmin is considered to be a vascular-protecting agent used to treat chronic venous insufficiency, hemorrhoids, lymphedema and varicose veins ¹³⁷. Diosmin has been used for more than 30 years as a phlebotonic and vascular-protecting agent and has recently begun to be investigated for other therapeutic purposes, including cancer, premenstrual syndrome, colitis, and diabetes. As a flavonoid, diosmin also exhibits anti-inflammatory, free-radical scavenging, and antimutagenic properties.

Diosmin’s mechanisms of action include improvement of venous tone, increased lymphatic drainage, protection of capillary bed microcirculation, inhibition of inflammatory reactions, and reduced capillary permeability ¹³⁸, ¹³⁹. Certain flavonoids, including diosmin, are potent inhibitors of prostaglandin E2 (PGE2)and thromboxane A2 (TxA2)7 as well as being inhibitors of leukocyte activation, migration, and adhesion. Diosmin causes a significant decrease in plasma levels of endothelial adhesion molecules and reduces neutrophil activation, thus providing protection against microcirculatory damage ¹⁴⁰.

Studies have also investigated the use ofdiosmin for stasis dermatitis ¹³⁸, wound healing ¹⁴¹, premenstrual syndrome ¹⁴², mastodynia ¹⁴³, dermatofibrosclerosis ¹³⁸, viral infections ¹⁴⁴ and colitis ¹⁴⁵.

Pharmacokinetic investigations have shown diosmin is rapidly transformed by intestinal flora to its aglycone form, diosmetin. Diosmetin is absorbed and rapidly distributed throughout the body with a plasma half-life of 26-43 hours. Diosmetin is degraded to phenolic acids or their glycine-conjugated derivatives and eliminated through the urine. Diosmin or diosmetin not absorbed is eliminated in the feces ¹⁴⁶. In vitro experiments have reported that only diosmetin is more effective than diosmin ¹⁴⁷

Figure 3. Diosmin chemical structure

Diosmin benefits

Diosmin has been widely used as a vasoprotective agent for venous vascular diseases, such as venous leg ulcers ¹⁴⁸ and hemorrhoids ¹⁴⁹. Diosmin also shows anti-hyperglycemic ¹³³, anti-diabetic ¹⁵⁰, anti-gastric ulcer ¹⁵¹, anti-cancer ¹⁵², anti-inflammatory, and anti-oxidant-like actions ¹³⁵. These effects are achieved via decreasing the levels of hydroxyl free radicals, increasing the free thiol (SH-) group concentration and the natural scavenger capacity ¹⁵³. In addition, since Diosmin has a strong anti-cancer effect, many researchers consider it as an alternative treatment for various cancers that occur in the liver, colon, and urinary system ¹⁵⁴.

Diosmin is broken down into its aglycone, diosmetin, by enzymes in the gut bacteria before it is absorbed from the gastrointestinal tract ¹⁵⁵. Diosmetin also has antiallergic activity due to its inhibitory effect on the release of beta-hexosaminidase, which induces an inflammatory response from RBL-2H3 cells and inhibits the production of IgE receptor-mediated IL-4 in in vitro experiments ¹⁵⁶.

Varicose veins and chronic venous insufficiency

Chronic venous insufficiency is characterized by pain, leg heaviness, a sensation of swelling, and cramps, and is correlated with varicose veins. A multicenter international trial, carried out in 23 countries over two years, in which 5,052 symptomatic patients were enrolled, evaluated theefficacy of flavonoids in the treatment of chronic venous insufficiency ¹⁵⁷. Patients were treated with 450 mg diosmin and 50 mg hesperidin daily for six months. Continuous clinical improvement was found throughout the study, as well as improvements in quality of life scores for participants ¹⁵⁷.

Diosmin-containing flavonoid mixtures have also been effective in treating severe stages of chronic venous insufficiency, including venous ulceration and delayed healing ¹⁵⁸, ¹³⁹. In a randomized multicenter trial, 900 mg diosmin and 100 mg hesperidin plus standard venous ulcer management was compared with standard venous ulcer management alone ¹⁵⁹. Standard ulcer management included cleaning, compression therapy, and skincare of the adjacent skin. Forty-seven percent of patients in the treatment group compared to 28 percent in the standard management group experienced complete healing of ulcers less than 10 cm in diameter ¹⁵⁹.

Hemorrhoids

Several large clinical trials have demonstrated diosmin to be effective in the treatment of acute and chronic symptoms of hemorrhoids. A double-blind, placebo-controlled study of 120 patients showed improvement of pain, pruritis, discharge, edema, erythema, and bleeding on examination ¹⁶⁰. The treatment group was given a flavonoid mixture (90% diosmin and 10% hesperidin) at a dose of two 500-mg tablets daily for two months ¹⁶⁰.

The use of diosmin in the treatment of hemorrhoids associated with pregnancy did not adversely affect pregnancy, fetal development, birth weight, infant growth, or infant feeding. Pregnant women suffering from acute hemorrhoids were treated eight weeks before delivery and four weeks after delivery ¹⁶¹. More than half of the women participating in the study reported relief from symptoms by the fourth day ¹⁶¹. Diosmin is non-mutagenic and does not have any significant effect on reproductive function ¹⁶².

Lymphedema

Diosmin acts on the lymphatic system by increasing lymph flow and lymph oncotic pressure ¹⁶³. A flavonoid mixture containing diosmin was used to treat upper limb lymphedema secondary to conventional therapy for breast cancer. Results showed improvement of symptoms and limb volume; the mean decrease in volume of the swollen limb reached 6.8 percent ¹⁶⁴. In addition, lymphatic functional parameters assessed with scintigraphy were significantly improved. Animal studies of high-protein lymphedema, such as in burns and lung contusions, showed significant improvement with diosmin ¹⁶⁵.

Diabetes

Diosmin has been shown to improve factors associated with diabetic complications. Blood parameters of glycation and oxidative stress were measured in type 1 diabetic patients before and after intervention with a diosmin-containing flavonoid mixture ¹⁶⁶. A decrease in hemoglobin A1c (HbA1c) was accompanied by an increase in glutathione peroxidase, demonstrating long-term decreased blood glucose levels and increased antioxidant activity ¹⁶⁶.

Diosmin can normalize capillary filtration rate and prevent ischemia in diabetics. Rheological studies of type 1 diabetics show diosmin can facilitate hemorheological improvements due to decreased red blood cell aggregation, which decreases blood flow resistance, resulting in reduction of both stasis and ischemia ¹⁶⁷.

Cancer

Diosmin has been investigated in a number of animal models and human cancer cell lines and has been found to be chemopreventive and antiproliferative ¹⁶⁸. More clinically oriented research in this area is warranted to determine effective dosages and protocols.

Diosmin dosage

The standard dose of diosmin is 500 mg twice daily. For acute dosing, a loading dose of 1,000 mg three times daily for four days is recommended, followed by 1,000 mg twice daily for three days, and a maintenance dose of 500 mg twice daily for two months ¹⁶⁹.

Diosmin hesperidin side effects

One of the advantages of hesperidin–therapy is attributed to its safety, non-accumulative nature, and limited adverse effect, even during the pregnancy period ²⁸. Hesperidin has been administered at doses up to 5% with no mutagenic, toxic, and carcinogenic effects on mice, even after 13 weeks ³. Diosmin is considered to have no mutagenic activity, embryo toxicity, nor any significant effect on reproductive function. Transplacental migration and passage into breast milk are minimal ¹⁷⁰. Human studies have long shown the safety and good tolerability of hesperidin up to very high doses ⁹. Results from oral toxicity studies showed the absence of adverse side effects after oral hesperidin ingestion of more than 2 g /kg body weight ¹⁷¹. Furthermore, the oral administration of hesperidin to human caused minor adverse effects in only 10% of the patients ¹⁷². Although hesperidin is a safe phytochemical, possible interactions of this phytochemical should be considered. Coadministration of hesperidin with vincristine causes an increase in the drug uptake of this drug, in addition to hesperidin interacting with daunomycin ³. In animal studies, hesperidin showed a good safety profile, with a median lethal dose (LD50) of 4837.5 mg/kg, and in chronic administration up top, 500 mg/kg of the flavanone did not induce any abnormalities in body weight, clinical signs and symptoms and blood parameters ¹⁷³. LD50 (Lethal dose 50) is the amount of an ingested substance that kills 50 percent of a test sample. It is expressed in mg/kg, or milligrams of substance per kilogram of body weight.

Daflon 500 mg is a marketed tablet dosage form containing a micronized flavonoid mixture of 50 mg of hesperidin (10% hesperidin) and 450 mg of diosmin (90% diosmin) which used as vasoprotective venotonic agent ¹⁷¹. Continues oral administration for hesperidin mixture to rats for 13 and 26 weeks, using a very high dose of 35-fold of the daily dosage showed no toxicity with a high LD50 value of more than 3 g/kg body weight (ie, 180 times the daily therapeutic dose). Clinical trials used more than 2850 patients treated with the hesperidin mixture for a period of 6 weeks to 1 year showed normal hematological parameters, hepatic and renal functions with no signs of toxicity ¹⁷⁴.

Drug interactions

Diosmin can cause a decrease in red blood cell aggregation and blood viscosity ¹⁷⁵. There are no documented cases of adverse interactions between diosmin and prescription medications, but caution should be taken when combining diosmin with aspirin or other blood-thinning medications.

Data suggest that diosmin has an inhibitory effect on cytochrome P450-mediated metabolism in healthy volunteers, which may alter the pharmacokinetics of drugs taken concomitantly. Patients given metronidazole after nine days of pretreatment with 450 mg diosmin demonstrated changes in serum concentrations of metronidazole, as well as changes in urinary concentrations of metronidazole and its metabolites compared to controls ¹⁷⁶.

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