DAO Activity in the Monitoring of Diverse Diseases: Comparison
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Please note this is a comparison between Version 2 by Dean Liu and Version 1 by Yingwei Ou.

The serum level of diamine oxidase (DAO) reflects the integrity and maturation of the small intestinal mucosa. This measure is important in diagnosing various diseases, including chronic urticaria tachyphylaxis, multiple organ dysfunction syndrome, preterm abortion, and migraine.

  • histamine
  • diamine oxidase
  • molecular mechanisms

1. Role of DAO in Detecting Various Gastrointestinal Diseases

Several human and animal experiments have confirmed that plasma DAO level is a key marker for assessing the function of the intestinal mucosal barrier [5][1]. The crucial role of DAO level in monitoring intestinal mucosal damage has also been validated in various clinical scenarios [6,7,8,9][2][3][4][5]. Injury to the intestinal mucosal barrier increases epithelial cell permeability, which consequently triggers an inflammatory response that is closely associated with inflammatory bowel diseases, especially Crohn’s disease [10,11][6][7]. Elevated plasma DAO level indicates the repair of intestinal damage, and it can be used as a sensitive and precise marker in monitoring Crohn’s disease activity [12,13][8][9]. DAO is a useful molecular parameter for the early and accurate diagnosis and identification of small bowel obstruction. Clinically, an increase in serum DAO level (twice the basal level) may be a useful marker to diagnose simple to strangulated intestinal obstruction. An animal study showed that serum DAO level significantly increases in simple intestinal obstruction but progressively decreases in strangulated intestinal obstruction [14][10]. This result can be attributed to reduced blood flow caused by strangulated intestinal obstruction. Additionally, an increasing number of animal experiments have demonstrated the value of DAO in the early diagnosis of acute mesenteric ischemia and superior mesenteric artery occlusion [15,16][11][12]. Another study specified that DAO = 29.81 U/L can be used as an early diagnostic criterion for diagnosing superior mesenteric artery occlusion [17][13]; however, this criterion is insufficient for clinical diagnosis, and extensive clinical studies in humans are needed.

2. DAO and Migraine

Migraine is a common neurological disorder and the third most common disorder, affecting up to 1 billion people worldwide [18,19][14][15]. HIT arises from a deficiency of DAO, and headache is one of the most documented of the several multifaceted symptoms associated with HIT. In a single clinical study [20][16], 198 volunteers were divided into migraine and control groups, and DAO level was measured using ELISA. The mean DAO level was significantly lower in patients with migraine than in the healthy volunteers. Moreover, DAO deficiency was more prevalent in patients with migraine (87%) than in healthy volunteers. Another RCT by Joan et al. [21][17] verified that 1 month of oral DAO enzyme supplementation reduces pain duration by 1.4 h in patients with episodic migraine; however, this treatment exerts no significant effect on migraine attack frequency or pain intensity.
Regarding the mechanisms underlying the association between DAO and migraine, a recent genetic study of 22 genome-wide association studies found that 38 genes are susceptibility loci for migraine [22][18]. Another study reported that the frequency of mutations caused by C2029G DAO single-nucleotide polymorphisms (SNPs) is significantly higher in patients with migraine than in healthy controls and that the C314T mutant allele of HNMT and the C2029G polymorphism of DAO interact to increase the risk and impact of migraine [23][19]. Another study examining alleles and the frequency of their allelic variants in patients with migraine found that the DAO SNP rs10156191 is associated with reduced DAO activity and is related to the risk of migraine onset, particularly in women [24][20]. These results suggest that the risk of migraine is associated with the SNP rs10156191 and sex.
However, a recent study exploring the relationship between serum DAO and histamine levels and three polymorphisms in the DAO gene (rs10156191, rs1049742, and rs1049793) found similar frequencies of DAO genes and allelic variants in patients with migraine and controls [25][21]. Surprisingly, serum DAO levels were significantly higher in the patients with migraine than in the controls. The opposite conclusion may stem from differences in the methods used to measure DAO level, whether age- and sex-matched subgroups were used, and variations in the inclusion criteria.

3. DAO in Pregnancy Monitoring

DAO can be generated in large quantities by the placenta and is thought to be a paracrine signal during endometrial shedding and embryonic implantation [26][22], serving as a metabolic barrier against the excessive passage of active histamine from the placenta into the maternal or fetal circulation [27][23]. The balance between histamine and its degrading enzyme DAO plays an essential role in pregnancy [28][24]. Serum DAO activity has significant sex differences, with females showing greater fluctuations in serum DAO levels than males [29][25]. Hamada et al. [30][26] found that serum DAO levels vary with the menstrual cycle, with markedly lower plasma DAO levels in the follicular phase than in the luteal phase. DAO is synthesized by placental and trophoblast cells, explaining the high plasma DAO level during pregnancy [31][27]. The maternal plasma DAO level exponentially increases during the first 20 weeks of pregnancy by up to even 1000 times the pre-gestational level [28][24], which consequently decreases plasma and urinary histamine levels in the maternal circulation. In abnormal pregnancies, compared to normal pregnancies, the maternal plasma DAO level ceases to rise and the circulating histamine level increases, which significantly increases the risk of threatened abortion, pre-eclampsia, and spontaneous abortion [31,32,33][27][28][29]. Moreover, this level drops to pre-pregnancy values within 10–15 days after delivery [34][30]. Low DAO levels can also be used as a diagnostic tool for trophoblastic diseases. In pregnant females with trophoblastic diseases, such as choriocarcinoma and hydatid mole, DAO levels remain low despite high titers of human chorionic gonadotropin. In molar pregnancies, DAO levels are equal to those in normal pregnancies in early gestation but decline after 15 weeks of gestation. In addition, a sharp drop in the DAO curve is a sign of fetal distress or intrauterine death [27][23].

4. DAO as a Predictor of the Gastrointestinal (GI) Tract Toxicity of Drugs

In rats, the DAO level in blood significantly correlates with the level in small intestinal mucosal villi and with the severity of intestinal toxicity caused by anticancer drugs such as 5-fluorouracil (FT) [35][31]. Tsutomu et al. [36][32] measured serum DAO levels in 20 patients with gastric cancer during adjuvant chemotherapy with oral FT anticancer drugs and found that antitumor drug treatment decreased DAO levels and health status positively correlated with DAO levels in these patients. A recent prospective cohort study involving 50 patients with esophageal cancer treated with docetaxel + cisplatin + 5-FT reported that plasma DAO level reflects the ability of the intestine to absorb amino acids and thus can be used as an indicator of the efficacy of chemotherapy in patients with esophageal cancer [37][33]. Serum DAO activity decreases gradually over the course of anticancer drug treatment, and the percentage decrease in DAO activity correlates closely with the severity of gastrointestinal toxicity [38][34]. This result indicates that plasma DAO levels can be used to monitor and evaluate the GI toxicity response to chemotherapy in patients with cancer [38,39][34][35]. Colchicine increases gut permeability, alters the intestinal microbiota, exacerbates flora displacement, and inhibits inflammatory response in mice, which may increase toxic load in the mouse intestine. Thus, the serum levels of DAO and lipopolysaccharide are increased [40][36]. Plasma DAO level is an important measure in conducting drug/food therapy studies of anticancer drug-induced gastrointestinal toxicity and monitoring intestinal integrity and related complications in gastric, esophageal, liver, colorectal, breast, head, and neck cancers [41,42,43,44,45,46][37][38][39][40][41][42].
Table 1. Serum DAO in different diseases.
Disease Origin Change of Serum DAO * Comments Refs.
gastrointestinal diseases rats, mice, humans increased More clinical studies are needed to support the diagnostic value of DAO. [12,15,16,[11][1217][8]][13]
migraine humans decreased/increased Oral DAO supplementation might be a new therapy for migraines. [18,19,20,21][14][15][16][17]
pregnancy humans increased Serum DAO has a role in pregnancy confirmation and screening for trophoblast diseases. [23,25,26][19][21][22]
gastrointestinal tract toxicity humans, rats, mice decreased/increased The precision of DAO levels reflecting toxicity needs further study. [28,29,30,31][24][25][26][27]
liver disease humans increased DAO might be a potential biomarker in patients with liver and intestinal dysfunction. [32,33,35][28][29][31]
histamine intolerance humans increased The role of DAO in the diagnosis of histamine intolerance and its treatment has been clarified. [38,39,40,41][34][35][36][37]
* DAO expressed differently in a variety of diseases, suggesting the respective direction of future research.

5. DAO in Hepatitis and Post-Hepatitis Cirrhosis

Plasma DAO level has also been associated with the development and prognosis of many liver disorders, such as hepatitis, cirrhosis, and orthotopic liver transplantation. Li et al. [47][43] conducted a 1-month follow-up study of 106 patients newly diagnosed with acute-on-chronic hepatitis B liver failure (ACHBLF) and found that plasma DAO level reflects the severity of ACHBLF and is an independent risk factor for 1-month mortality. Furthermore, DAO level is more sensitive than the conventional model for end-stage liver disease, with a plasma DAO level of 15.2 ng/mL as the cut-off point. As for patients with hepatitis B virus-associated decompensated cirrhosis, plasma DAO levels > 19.7 ng/mL have been associated with high 6-month readmission rates [48][44]. Considering the connection between DAO level and intestinal mucosal condition, a previous study measured serum DAO and endotoxin levels in patients with liver cirrhosis and found that DAO level is significantly higher in patients with liver cirrhosis than in healthy individuals [49][45]. This result suggests that DAO level is a sensitive marker for the early diagnosis of gut failure in liver cirrhosis.
Recent studies on serum DAO levels have extended their focus to liver transplantation. The only curative procedure for patients with end-stage liver disease is orthotopic liver transplantation (OLT). To assess the role of histamine and plasma DAO in OLT, an RCT of 22 liver transplant patients and 22 healthy adults as controls found that the baseline levels of histamine and plasma DAO were markedly elevated in patients undergoing OLT; however, the concentration of histamine decreased and DAO increased significantly during OLT [50][46]. This result can be attributed to the intraoperative use of norepinephrine. As mentioned in these studies, serum DAO mainly reflects the function of the intestine rather than the liver.

6. DAO and HIT

HIT is a disturbance in histamine homeostasis caused by reduced intestinal degradation of histamine due to DAO deficiency [51][47]. DAO deficiency may be a major cause of HIT, in which alterations in histamine homeostasis lead to a decrease in intestinal degradation and a subsequent increase in plasma [52][48]. DAO deficiency may be congenitally caused by genetic mutations in DAO genes or alterations in protein coding resulting in decreased DAO levels; it may also be acquired from lesions that reduce DAO secretion, particularly in inflammatory or degenerative bowel diseases [53][49]. The multifaceted clinical symptoms associated with HIT include headache, gastrointestinal disturbances (such as abdominal pain, diarrhea, and flatulence), urticaria, pruritus, nausea and sneezing, runny nose, cardiac arrhythmias, hypotension, and muscle pain [21][17].
HIT is a disease characterized by a disequilibrium between accumulated histamine and histamine degradability. The degradation of histamine in the intestine decreases with reduced DAO activity, resulting in the accumulation of histamine in the blood plasma and adverse reactions [54[50][51],55], which mainly originate in the gut [56][52]. Impaired histamine degradation due to reduced DAO activity and subsequent histamine overload may lead to symptoms similar to those of allergic reactions [3][53]. In patients with HIT, ingestion of histamine-rich foods, alcohol, or drugs that either release histamine or block DAO may induce diarrhea, headache, respiratory allergies (e.g., atopic asthma and allergic rhinitis) [57][54], hypotension, cardiac arrhythmias, urticaria [58][55], pruritus, flushing, and other conditions. This finding indicates that serum DAO level is valuable in the diagnosis of HIT [59][56], and symptom severity is associated with DAO deficiency.
A recent questionnaire follow-up study of 133 outpatients with HIT (serum DAO values < 10 U/mL) with onset symptoms (primarily gastrointestinal, cardiovascular, respiratory, and skin complaints) was conducted to explore the onset of non-specific GI and extraintestinal symptoms arising from the distribution of the four histamine receptors in different organs and tissues of the body. Results of this study showed that patients with HIT predominantly had gastrointestinal manifestations, with abdominal distention being the most common symptom (92%), followed by cardiovascular symptoms and, finally, respiratory and skin complaints [3,60,61,62][53][57][58][59]. Another study showed that in patients with low DAO levels (<40 HDU/mL), the clinical symptoms typical of HIT disappear, and serum DAO levels significantly increase after the introduction of a histamine-free diet [63][60]. Similar effects can be exerted by oral DAO supplementation in patients with HIT [64][61]. Cucca et al. found that patients with DAO values of 3–10 U/mL exhibit the most complicated clinical presentation but also respond best to treatment with a low-histamine diet and/or DAO supplementation [65][62]. The prevailing consensus is that incorporating a histamine-reduced diet and/or oral microbial DAO capsules into a targeted dietary intervention can help alleviate HIT-related symptoms [66,67][63][64]. HIT has been a hot research topic for almost a decade, but evidence-based, double-blind, placebo-controlled, and crossover in vivo studies are still necessary to understand the effects of oral DAO supplementation and provide a basis for further investigations on HIT.

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