Liquid Mobile Guide to: NAD+ Injections 

Table of Contents

• NAD+ Injections Intro
• Liquid Mobile Program
• NAD+ Need to Know
• How to Store
• How to Administer Injections

Welcome to NAD+ with Liquid Mobile!
Congratulations on taking this step on your NAD+ (nicotinamide adenine dinucleotide) wellness journey. We are excited to support you! Be sure to include your primary care and medical teams on your NAD+ decision and plan. Consultations are required every 3 months to ensure your wellness is on track. Medications are non-refundable.

About NAD+ Injections
Nicotinamide Adenine Dinucleotide (NAD+) is a prevalent cellular electron transporter, coenzyme, and signaling molecule found in all cells of the body and is vital for cell function and viability.^[1][2] Its reduced (NADH) and phosphorylated forms (NADP+ and NADPH) are as important as NAD+.^[1][2] Each step of cellular respiration—glycolysis in the cytoplasm, the Krebs cycle, and the electron transport chain in the mitochondria—requires the presence of NAD+ and NADH, their redox partner.

The manufacture of cholesterol and nucleic acids, elongation of fatty acids, and regeneration of glutathione, a vital antioxidant in the body, are just a few anabolic processes that frequently require NADP+ and NADPH.^[3] NAD+-dependent/-consuming enzymes modify proteins post-translationally in various cellular processes using NAD+ and its other forms as substrates.^[1][2] NAD+ also acts as a precursor for cyclic ADP ribose, an essential component of calcium signaling and a secondary messenger molecule.^[4]

The amino acid tryptophan and the vitamin precursors nicotinic acid and nicotinamide, often known as vitamin B3 or niacin, are used by the body to naturally produce NAD+. It can also be produced from biosynthetic intermediates including nicotinamide mononucleotide and nicotinamide riboside.^[2][3] NAD+ is continuously recycled within cells as it transitions between its many forms through salvage mechanisms.^[3] Mammalian cells may be able to take up extracellular NAD+, according to studies on cell culture.^[5]

The highest NAD+ levels are found in neonates, and they gradually decrease with increasing chronological age.^[6] They are around half of what they are in younger persons after age 50.^[6] Model organisms have been used to study the subject of why NAD+ levels fall with aging.^[7][8] However, during other metabolic activities, NAD+ is consumed by NAD+-dependent enzymes and may subsequently become depleted over time, contributing to increased DNA damage, age-related illnesses and diseases, and mitochondrial malfunction. During redox reactions, NAD+ and NADH are not consumed but rather continually regenerated.^[2][6] Views of aging and senescence frequently highlight a deterioration in mitochondrial health and function with age, and investigations of NAD+ depletion and the associated oxidative stress and damage corroborate these theories.^[1][2]

The age-related drop in NAD+ levels is caused by rising levels of CD38, a membrane-bound NADase that degrades both NAD+ and its precursor nicotinamide mononucleotide, according to a 2016 study in mice, which exhibit age-related declines in NAD+ levels similar to those seen in humans.^[7] The study also demonstrated that human adipose tissue from older adults (mean age, 61 years) expresses the CD38 gene at higher levels than that of younger adults (mean age, 34 years).^[7] Other research in mice, however, has shown that oxidative stress and inflammation brought on by aging lower NAD+ production.^[8] Therefore, it is likely that a number of mechanisms work together to cause individuals to lose NAD+ as they age.

When it was recognized that pellagra, a condition marked by diarrhea, dermatitis, dementia, and mortality, could be treated with foods containing NAD+ precursors, particularly vitamin B3, the clinical significance of maintaining NAD+ levels was established in the early 1900s.^[9] Notably, the skin does not flush with NAD+ injection, in contrast to vitamin B3 (niacin) intake, which also causes this negative effect.^[10] Low NAD+ levels have recently been associated with a variety of age-related ailments and diseases linked to increased oxidative/free radical damage, including diabetes, heart disease, vascular dysfunction, ischemic brain injury, Alzheimer’s disease, and vision loss.^{[11][8][12][13][14][15][16][17]}

Since a 1961 report by Paul O’Hollaren, MD, of Shadel Hospital in Seattle, Washington, NAD+ IV infusion has been widely utilized for the treatment of addiction.^[18][19][20] In more than 100 instances, Dr. O’Hollaren detailed the effective use of IV-infused NAD+ for the prevention, relief, or treatment of acute and chronic symptoms of addiction to a range of substances, including alcohol, heroin, opium extract, morphine, dihydromorphine, meperidine, codeine, cocaine, amphetamines, barbiturates, and tranquilizers.^[18] The security and effectiveness of NAD+ treatment for addiction, however, have not yet been assessed in clinical trials.

NAD+-replacement therapy may encourage optimal mitochondrial function and homeostasis, genomic stability, neuroprotection, long life, and may help with addiction treatment.^{[1][2][3][20]} Clinical trials assessing these effects in humans receiving NAD+ injection have not yet been published; nevertheless, many clinical trials assessing the effectiveness and safety of NAD+-replacement therapy or augmentation in the context of human disease and aging have recently been completed, and many more are currently underway.

Mechanism of Action
Unknown are the precise mechanisms of NAD+ repair or enhancement for potential health benefits, such as supporting healthy aging and treating age-related illnesses, metabolic and mitochondrial diseases, and addiction.^{[1][2][3][20]}

Contraindications, Precautions & Interactions
At the time of writing, there were no other reported contraindications/precautions/Interactions for NAD+ injection. Individuals with known allergy to NAD+ injection should not use this product.

Adverse Reactions & Side Effects
Injection of NAD+ seems to be secure and well-tolerated.^[10] The injection of NAD+ may cause adverse reactions and side effects, such as headache, shortness of breath, constipation, increased plasma bilirubin, and decreased levels of gamma glutamyl transferase, lactate dehydrogenase, and aspartate aminotransferase.^[18][10]

Case studies of the use of NAD+ to treat drug addiction offered early information on side effects and safety.^[18][19] According to a 1961 study, patients with addiction who got NAD+ at a moderate IV drip rate (no more than 35 drops per minute) reported “no distress” but those who received it at a quicker drip rate complained of headache and shortness of breath.^[18] In this study, the dosage was 500–1000 mg per day for 4 days, then two injections every week for a month, and then one injection every two months as a maintenance dose. One of the two patients who had therapy reported experiencing constipation.^[18]

In a 2019 study, a cohort of healthy male participants (n=11; NAD+ n = 8 and Control n = 3) aged 30-55 years had their safety of IV infusion of NAD+ evaluated using liver function tests (serum, total bilirubin, alkaline phosphatase, alanine aminotransferase, gamma glutamyl transferase, lactate dehydrogenase, and aspartate aminotransfer.^[10] Neither the NAD+ cohort nor the placebo (saline) cohort experienced any negative side effects throughout the 6 hour infusion.^[10] At 8 hours following the start of the NAD+ infusion, it was shown that the NAD+ group had significant declines in the liver function enzymes gamma glutamyl transferase, lactate dehydrogenase, and aspartate aminotransferase as well as a large increase in plasma bilirubin.^[10] The modifications, however, were not regarded as clinically important. Because of the limited sample sizes, notably for the control group, which are acknowledged by the authors, these results should be evaluated with care.^[10]

Pregnancy & Breastfeeding
The safety of NAD+ injection has not been evaluated in pregnant women. Due to this lack of safety data, pregnant women should avoid NAD+ injection. The safety of NAD+ injection has not been evaluated in women who are breastfeeding or children. Due to this lack of safety data, women who are breastfeeding and children should avoid NAD+ injection

Storage
Store dry powder at 68°F to 77°F (20°C to 25°C) and away from heat, moisture and light. Once reconstituted keep this medicine in a refrigerator between 36°F to 46°F (2°C to 8°C). Keep all medicine out of the reach of children. Throw away any unused medicine after the beyond-use date. Do not flush unused medications or pour down a sink or drain.

Recommended Labs
It is recommended that you manage your labs directly with your primary medical provider and your medical team. Labs often recommended by primary care teams include:

• A1C: High levels of blood glucose or a consistently high A1c can harm your heart, blood vessels, kidneys, feet, and eyes. As you shed extra pounds, the insulin in your body lowers your blood sugar levels more efficiently, which will cause your A1c levels to drop over time. Taking steps to get your A1c in a healthy range lowers your risk of complications such as nerve damage, eye problems, and heart disease.
• Complete Metabolic Panel: The panel also includes tests that measure kidney and liver function. These vital organs filter out proteins and waste products produced during the metabolizing process. Fluids, electrolytes, and minerals in the blood are also measured. If the body is low on fluids or electrolytes, the metabolic function slows down, leading to potential weight gain or trouble losing weight.
• DHEA Sulfate: DHEA is involved in lipid (fat) breakdown and building lean muscle. Like other hormones, we tend to produce less of it with age, with the production of DHEA peaking around age 25 – 30.
• Estradiol – Estradiol regulates body weight by decreasing appetite and increasing feelings of satiety. This could be particularly important for women whose estradiol levels are abnormal, perhaps as a result of ovarian dysfunction, or whose estradiol levels drop, as part of the normal estradiol decline during menopause.
• Progesterone: A hormone imbalance, such as low progesterone, could potentially lead to weight gain as imbalances between estrogen and progesterone are one of the emerging causes of obesity. Healthy levels of progesterone support the thyroid, which produces hormones to regulate your metabolism or how quickly food is used for energy.
• PSA – Men with obesity have been found to have lower serum levels of prostate specific antigen (PSA) than non-obese men of the same age. This has potential implications for the use of PSA for prostate cancer detection in obese men.
• Testosterone: Being an overweight man can have a harmful effect on testosterone, while higher levels of testosterone in women can hinder losing weight.
• Thyroid Panel – Losing weight can be challenging for many living with low thyroid hormone levels. Researchers have shown that a slight change in your thyroid hormone levels can lead to weight gain or even make it hard for you to lose weight.

Guest should always notify their primary care and all specialists of their NAD+ plan, related information, issues and recommendations.

What are the benefits of using NAD+?
NAD+ is a naturally occurring co-enzyme that has a central role in the metabolism and energy production of every single cell in the body.  Nicotinamide adenine dinucleotide (NAD) is one of the most important and interesting molecules in the body. It controls hundreds of critical processes from energy metabolism to cell survival. Above all, it may allow us to lead healthier and longer lives. Benefits may include:

• Boosts energy and mental clarity
• Supports brain health and function
• Improves mood and reduces anxiety
• Supports cellular repair and longevity
• Enhances detoxification and healing
• Reduce brain fog
• Protects and repairs DNA, reducing DNA mutations which contribute to atherosclerosis, cancer, immunodeficiency, rheumatoid arthritis, and much more
• Lowers cholesterol
• Lowers blood pressure
• Strengthens the immune system
• Stimulates production of dopamine, serotonin, and noradrenaline, thereby improving moods
• Stimulates nitric oxide production, thereby improving blood flow in the body

NAD+ and Anti-Aging
Probably the most significant and least avoidable. By age 60, a person’s NAD levels are approximately half of what they were in their 40s. This is simply because our cells make NAD, and as we age our bodies can’t replace the cells that die as quickly with new ones.

NAD+ and Fat
One of NAD’s most essential functions is energy metabolism. Our cells use NAD to turn the food (and drinks) we consume into the energy we need to stay healthy. NAD does this by turning into the hydrogen-carrying version of itself (NADH) which aids in burning fats and proteins in the cell.

NAD+ and Muscles
Strenuous exercise requires NAD for muscle recovery, studies suggest that moderate or light exercise can actually increase NAD levels.

NAD+ and Heart
Helps produce ATP, which is fuel for the heart to beat.

Will this medication interact with my other medication?
These injections may interact other medications. Be sure to consult your healthcare provider and provide a complete list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also, tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

What should I report before taking this medicine?
Your Liquid Mobile care team should be notified of any of the following conditions:

• Endocrine tumors (MEN 2) or if someone in your family had these tumors
• Eye disease, vision problems
• Gallbladder disease
• History of depression or mental health disease
• History of pancreatitis
• Kidney disease
• Stomach or intestine problems
• Suicidal thoughts, plans, or attempt; a previous suicide attempt by you or a family member
• Thyroid cancer or if someone in your family had thyroid cancer
• Pregnant or trying to get pregnant
• Breast-feeding

Please note this list may not include all potential contraindications or precautions. Please consult your primary care physician or pharmacist for a list of all contraindications and precautions.

Side effects that you should report to your primary care physician as soon as possible:

• Allergic reactions—skin rash, itching, hives, swelling of the face, lips, tongue, or throat
• Change in vision
• Dehydration—increased thirst, dry mouth, feeling faint or lightheaded, headache, dark yellow or brown urine
• Gallbladder problems—severe stomach pain, nausea, vomiting, fever
• Heart palpitations—rapid, pounding, or irregular heartbeat
• Kidney injury—decrease in the amount of urine, swelling of the ankles, hands, or feet
• Pancreatitis—severe stomach pain that spreads to your back or gets worse after eating or when touched, fever, nausea, vomiting
• Thoughts of suicide or self-harm, worsening mood, feelings of depression
• Concerns for thyroid cancer – new mass or lump in the neck, pain or trouble swallowing, trouble breathing, hoarseness
• Concerns for pancreatitis—severe stomach pain that spreads to your back or gets worse after eating or when touched, fever, nausea, vomiting

This list may not describe all possible side effects. Call your doctor for medical advice about side effects.

How will I receive my medications?
You may receive your injections in one of our local clinics, provided by a physician, nurse practitioner or registered nurse. Injection clinic visits are for medication administration only and are not to be used for follow-up visits. Please book an appointment in the clinic or via telehealth for follow-ups, refills, and questions regarding your response to the current weight loss plan.

You may also elect to self-administer your injections at home. The medication will be shipped to your home.

What is my starting dosage? 
Your prescription is unique to you. Be sure to read the front of the prescription so you understand your starting dose. Most will start with the following and only increase if advised and approved by your clinical team:

• Week 1 to 4 = 25 units once to three times a week.
• Week 5 to 8 = 50 units once to three times a week
• Week 9+ = 100 units once to three times a week

How do mix (reconstitute) my NAD+? 
Reconstitute your NAD+ with Bacteriostatic Water provided. Follow instructions below.

• 500mg Vial of NAD+:  Add 5mL of Bacteriostatic Water
• 1,000mg Vial of NAD+:  Add 10mL of Bacteriostatic Water

* Refrigerate you NAD+ vial once it is reconstituted.
How do I Reconstitute Video

How do I receive refills?
It is highly encouraged that you request a refill 2 weeks in advance to your medication running out. Visit www.LiquidMobileIV.com , click Telehealth, then Refill to schedule a call for a refill or call 855.954.7843. Increases in dosages will require a telehealth visit with a provider and will only be allowed after 4 weeks of being on current dosage.

How to do I store these medications?
Keep out of the reach of children and pets.  Once you receive it, store it in the refrigerator in-between doses.

Dispose of needles in a sharps containers available at your retail pharmacy. If not assessable, place needles in a hard, closed container, such as a sealable detergent bottle.

Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. You should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA’s Safe Disposal of Medicines website for more information.

How do I draw up my medicine? 
It is important to draw up your medication correctly. We recommend calling, stopping by the clinic or scheduling a telehealth visit for assistance, especially on your initial injections. If you have a friend or family member that is a clinician, they may be able to assist. Clean top of vial with alcohol, insert needle in the center, then turn vial upside down. Make sure the medicine covers the tip of the needle, then pull back the plunger to the line on your syringe for your dose. Remove the needle from the vial.

Drawing Up a Syringe Video

What dose will I inject?
Dosages will depend on each individual, as you may titrate up about every 4 weeks at the discretion of the Liquid Mobile care team. .

How do I inject these medications? 
For subcutaneous injections, the belly can be an easy location to start. Target at least 2 inches from the belly button, laterally and inject at a 45 to 90 degree angle once site is cleaned with alcohol. See your guide or video for complete instructions.

Injecting Subcutaneous Tissue Video

1. Gather your supplies:

• Medication vial
• Syringe
• Alcohol wipe

2. Wash your hands and prepare injection site.

3. Clean the injection site with alcohol wipe, and let the skin dry.

4. Draw up medication

• Remove the seal on the top of the vial and wipe with alcohol
• Remove the cap off the needle
• Hold the syringe like you hold a pen or a dart, inserting the needle into the middle of the rubber stopper perpendicular, so the needle does not bend.
• Together, turn the vial and syringe upside down.
• Make sure the tip of the needle is in the liquid.
• Pull the plunger down, past the dosage prescribed. Then, push up to the prescribed dosage, as this will remove all air bubbles.
• Once you have the correct amount of liquid, pull the entire syringe out of the vial.

5. Inject into subcutaneous tissue. Subcutaneous injections will be very little pain because it is only injected directly under the skin. It can be injected into the stomach, thighs, and back of the upper arm.

• Pinch the injection site to create a firm surface. Alternate injection sites between either side of the stomach, back of the arm, or thigh.
• Inject two inches from the belly button on either side.
• Insert the needle into the skin between the index finger and thumb at 90 degrees.
• Using a slow and constant pressure, push the plunger rod until it reaches the bottom.
• Gently pull the syringe out of the skin.
• Discard of the needle in a sharps container.

Additional Suggestions
It is recommended that you work closely with your primary physician and medical team, along with a wellness consultant, fitness trainer and nutritionist, to best round out your wellness journey and to build good habits.