Can you safely take Bumetanide or Acetazolamide (Diamox) if you have a Sulfonamide allergy?

I was contacted by a reader in Italy whose child with autism may respond to bumetanide, but has a sulfonamide allergy and got a skin reaction (hives). She had to stop giving the drug, but wanted to know how she could re-start bumetanide.

Other readers have pointed out how they dare not try bumetanide because they know their child has a sulfonamide allergy. I think our longtime reader Tanya is one example.

 

Key Point to Note

Most people discover their sulfonamide after being giving an antibiotic in early childhood.

It is now well established that many (but not all) people with an allergy to sulfonamide antibiotics can safely take a sulfonamide diuretic like Bumetanide or Diamox/Acetazolamide. This is presented in case studies later in this post.

 

Sulfonamide Drugs

Many common drugs are “sulfonamides”. Their chemical structure includes a sulfonyl (–SO2) group attached to an amine group (–NH2). They include common antibiotics, like erythromycin, many diuretics (bumetanide, furosemide, acetazolamide (Diamox), some anticonvulsants (zonisamide) and some anti-inflammatory drugs (sulfasalazine).

 

Sulfonamide Allergy

Many parents discover early in their child’s life that their child has a sulfonamide allergy. Sometimes this is abbreviated to a “sulfa allergy.”

The symptoms of a sulfonamide allergy can vary but may include:

• Skin reactions (rash, hives, or itching)
• Fever
• Swelling
• Respiratory issues (shortness of breath)
• Anaphylaxis (in severe cases)

Usually the symptoms are minor, but once diagnosed the parents usually take note never to give their child any sulfonamide drug.

 

If you have the allergy must you avoid all sulfonamide drugs?

The standard assumption has been that if you have a sulfonamide allergy you cannot take Bumetanide or Acetazolamide (Diamox).

Upon further investigation in the research, this may not always be true.

 

What happens when there is no alternative drug?

When treating ion channel/transporter dysfunctions there may not be a non-sulfonamide alternative.

Acetazolamide (Diamox) is documented in the literature as a case in point. Bumetanide has not yet made it to the literature.

Furosemide fortunately has been researched and a safe desensitization protocol exists. Furosemide is a very similar drug to bumetanide.

 

Desensitization strategies

I did recently write about enzyme potentiated desensitization, which is an old, mostly overlooked, technique to overcome allergic reactions. I was interested in pollen allergy.

The best-known kinds of desensitization are allergy shots and more recently overcoming nut allergies, which gets media attention. 

Oral immunotherapy for peanut allergy in young children

The study also found that the youngest children and those who started the trial with lower levels of peanut-specific antibodies were most likely to achieve remission. 

“The landmark results of the trial suggest a window of opportunity in early childhood to induce remission of peanut allergy through oral immunotherapy,” says NIAID Director Dr. Anthony Fauci. “It is our hope that these study findings will inform the development of treatment modalities that reduce the burden of peanut allergy in children.”

 

I did wonder that if it works for nuts then why not bumetanide.

It turns out that I am not the first to consider desensitization to a drug allergy. The best known method is rapid drug desensitization (RDD), usually intravenous, which opens a window to be able to start taking a drug you are allergic to. Once you stop taking the drug, you then again become allergic to it.

The other approach is more like dealing with nut allergies, it is called slow drug desensitization (SDD) and involves taking a tiny initial dose and then slowly increasing it over weeks and months.

Drug desensitization is normally done in hospital as part of some therapy when you absolutely must have a drug that you are allergic to.

The paper below contains information on a very large number of common drugs where drug desensitization has been successfully carried out.

 

Desensitization for the prevention of drug hypersensitivity reactions

Drug desensitization is the temporary induction of tolerance to a sensitized drug by administering slow increments of the drug, starting from a very small amount to a full therapeutic dose. It can be used as a therapeutic strategy for patients with drug hypersensitivity when no comparable alternatives are available. Desensitization has been recommended for immunoglobulin E (IgE)-mediated immediate hypersensitivity; however, its indications have recently been expanded to include non-IgE-mediated, non-immunological, or delayed T cell-mediated reactions. Currently, the mechanism of desensitization is not fully understood. However, the attenuation of various intracellular signals in target cells is an area of active research, such as high-affinity IgE receptor (FcɛRI) internalization, anti-drug IgG4 blocking antibody, altered signaling pathways in mast cells and basophils, and reduced Ca²⁺ influx. Agents commonly requiring desensitization include antineoplastic agents, antibiotics, antituberculous agents, and aspirin/nonsteroidal anti-inflammatory drugs. Various desensitization protocols (rapid or slow, multi-bag or one-bag, with different target doses) have been proposed for each drug. An appropriate protocol should be selected with the appropriate concentration, dosage, dosing interval, and route of administration. In addition, the protocol should be adjusted with consideration of the severity of the initial reaction, the characteristics of the drug itself, as well as the frequency, pattern, and degree of breakthrough reactions.

Two categories of desensitization protocols are currently available: RDD and slow drug desensitization (SDD). RDD is recommended for immediate reactions, both allergic and nonallergic. The most widely used RDD protocol is doubling the dosage every 15 minutes until the therapeutic dose is achieved. SDD is recommended for type IV delayed hypersensitivity reactions with T cell involvement, and can be performed both orally and intravenously. There is as yet no consensus on SDD protocols, including the initial dose, dose increments between steps, and dosing interval. Further clinical experience and research are required to establish the role and efficacy of desensitization for delayed reactions.

H1 blockers, H2 blockers, and glucocorticoids can be used as premedication. Aspirin and montelukast block the end products of the arachidonic acid cascade and decrease the incidence and severity of BTRs. NSAIDs can help to control the symptoms of cytokine release syndrome. Glucocorticoids alone are not recommended because they cannot prevent the initial degranulation of mast cells. 

The desensitization process is known to be antigen-specific, as the level of drug-specific immunoglobulin E (IgE) decreases but the levels of other allergen-specific IgE remain consistent throughout the treatment period. However, the cellular and molecular mechanisms underlying drug desensitization are not yet fully understood.

Aspirin/NSAID desensitization is considered for patients with cardiovascular or musculoskeletal diseases who require aspirin or NSAID administration for prolonged periods.

The temporary tolerance to aspirin/NSAIDs lasts 48 to 72 hours after desensitization. Therefore, hypersensitivity reactions can recur 2 to 5 days after discontinuation if the therapeutic dose is not continued.

 

DHR to β-lactams, such as penicillin or cephalosporin, is more common than that to non-β-lactams. Desensitization can be performed for both immediate and delayed hypersensitivity reactions. The protocol should be selected based on patient characteristics, hospital capacity, and physician preferences. It is generally started with 1/1,000 of the therapeutic dose and then increased by 2 to 3-fold every 15 minutes to 5 hours. Oral administration is preferred due to its ease, safety, and effectiveness. Desensitization to penicillin and cephalosporins has been well established. Successful desensitization has also been reported for other β-lactams, such as carbapenem and monobactam, and non-β-lactams, such as vancomycin, clindamycin, metronidazole, macrolides, aminoglycosides, tetracycline, and ciprofloxacin.

Successful desensitization to other antimicrobials has also been reported for antifungals, such as amphotericin B, fluconazole, itraconazole, voriconazole, and micafungin, and for antivirals, such as acyclovir, valganciclovir, ribavirin, and nevirapine.

 

Furosemide desensitization

There is no literature specific to bumetanide but there is on the very similar drug furosemide.

 

RAPID ORAL DESENSITIZATION TO FUROSEMIDE

Furosemide is a commonly used loop diuretic that contains a sulfonamide group. Although there are rare reports of hypersensitivity to furosemide, severe reactions, including anaphylaxis, have been reported. Ethacrynic acid, the only loop diuretic without a sulfonamide moiety, is no longer available in oral formulation, thus posing a dilemma in the outpatient treatment of patients with furosemide allergy.

Published protocols for furosemide desensitization include rapid intravenous administration and oral protocols lasting 3 to 10 days.3–5 The oral protocols were performed in patients with non–type I hypersensitivity reactions. We present a rapid, oral protocol for desensitization in a patient with presumed type 1 furosemide allergy manifesting as urticaria.

 

Desensitization to sulfonamide-containing antibiotics has been extensively used, but desensitization to furosemide is uncommon. The oral protocols previously described took 3 to 10 days and were performed in patients with non–type I hypersensitivity reactions, one with pancytopenia and the other with pancreatitis. The patient with a type I hypersensitivity reaction underwent an intravenous desensitization protocol. Rapid oral desensitization to a loop diuretic has not been previously described. The potential advantages of oral desensitization are that it is probably safer than intravenous desensitization, it may be more cost-effective in terms of monitoring and staff requirements, and it may be possible to perform in an outpatient setting. We propose our protocol as a novel approach to furosemide desensitization therapy for patients with non–life threatening reactions to furosemide. Further progress in the diagnosis and treatment of hypersensitivity to sulfonamide drugs will require identification of the major antigenic determinant and standardization of skin testing and specific IgE testing.

I think we should say good work to Dr Naureen Alim, then at Baylor College of Medicine Houston, Texas.

If anyone wants to desensitize to a bumetanide allergy I think she is the one to contact for advice. She is easy to find via Google. 

Here is another case example. 

Desensitization therapy in a patient with furosemide allergy

Allergy to furosemide is a rare phenomenon. Desensitization to this sulfa-containing drug has not been frequently performed. We describe a patient with severe congestive heart failure and type I allergy to furosemide. Because of the severity of her condition, we decided to use a rapid intravenous desensitization protocol. Following the desensitization, the patient was treated with intravenous and oral furosemide with a dramatic improvement in her clinical state. We suggest that rapid desensitization may be a safe and effective way of introducing furosemide to allergic patients for whom loop diuretics are urgently indicated.

 

In the case of Acetazolamide, here is one published desensitization method:

  

Desensitization to acetazolamide in a patient with previous antimicrobial sulfonamide allergy

Acetazolamide is a carbonic anhydrase inhibitor that is frequently used in the management of idiopathic intracranial hypertension. Acetazolamide is a sulfonamide agent; specifically, it is a non sulfonylarylamine, which lacks the amine moiety found at the N4 position that is seen in sulfa antibiotics. 

Sulfonamide antibiotics contain a substituted ring at the N1 position that is thought to be the driving factor in immediate hypersensitivity reactions.  

Although sulfa allergies are commonly reported, there is no evidence to suggest cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics. However, patients can report a history of allergy to both categories of drugs. We present a rapid desensitization protocol to acetazolamide in a patient with history of immediate hypersensitivity reactions to both a sulfonamide antibiotic and acetazolamide. 

We formulated a 12-step intravenous protocol that was performed in the intensive care unit setting (Table 1). Informed consent was provided by the patient, and she tolerated the procedure well without any adverse reactions. The desensitization procedure took 395 minutes or approximately 6.5 hours. She was monitored overnight in the hospital and was observed the following morning after taking 500 mg of acetazolamide orally to ensure tolerance. She was thereafter able to continue her recommended dose of acetazolamide without any issues to date.

 

Allergy to a sulfonamide antibiotic does not always mean you will be allergic to the non-antibiotic sulfonamide drugs.

  

Use of Acetazolamide in Sulfonamide-Allergic Patients With Neurologic Channelopathies

The 3 patients had been considered for carbonic anhydrase inhibitor treatment but a pharmacist had refused to fill a prescription for acetazolamide for 1 patient and the other 2 patients were denied treatment because of the allergy history. All 3 patients were prescribed acetazolamide and had no adverse reaction. Two patients improved substantially and are continuing treatment. A review of the pharmacology literature suggests that cross-reactivity between antibiotic and nonantibiotic carbonic anhydrase inhibitors is unlikely. Moreover, a review of case reports does not suggest cross-reactivity. Previous reports in the ophthalmology literature also indicate that acetazolamide can be administered to patients with a history of antibiotic sulfonamide allergic reaction.

Conclusions

These 3 cases confirm that the carbonic anhydrase inhibitor acetazolamide can be given to patients with a history of allergic skin rash with antibiotic sulfonamide.

 

Acetazolamide has been used for the treatment of episodic ataxia type 2, with benefit in 50% to 75% of patients. In episodic ataxia type 1, acetazolamide was also effective in decreasing attack frequency. Acetazolamide is also effective in the periodic paralyses. Carbonic anhydrase inhibitors have been used to prevent altitude sickness, to lower intraocular pressure in open-angle glaucoma, and to treat refractory absence, myoclonic, and catamenial epilepsy as part of multidrug regimens. Acetazolamide has recently been used for hemiplegic migraine and idiopathic intracranial hypertension. 

The lack of available clinical or pharmacological evidence to support cross-reactivity between sulfonamide antibiotics and acetazolamide lends supports to the use of acetazolamide to treat patients with episodic ataxia and periodic paralysis. Of our 3 sulfonamide-allergic patients, 2 improved in symptoms after treatment with acetazolamide and none of the 3 had a hypersensitivity reaction. We conclude that a sulfonamide allergy should not be a contraindication to treatment with acetazolamide in patients with neurologic channelopathies. 

 

Acetazolamide and sulfonamide allergy: a not so simple story

 Allergies and adverse reactions to sulfonamide medications are quite common. Two distinct categories of drugs are classified as sulfonamides: antibiotics and nonantibiotics. The two groups differ in their chemical structure, use, and the rate at which adverse reactions occur. Cross-reactivity between the two groups has been implied in the past, but is suspect. Acetazolamide, from the nonantibiotic group, is routinely used in the prevention and treatment of high altitude issues and may not need to be avoided in individuals with a history of sulfonamide allergy. This review addresses the differences between the groups and the propensity for intergroup and intragroup adverse reactions based on the available literature. We also examine the different clinical presentations of allergy and adverse reactions, from simple cutaneous reactions with no sequelae through Stevens-Johnson syndrome and anaphylaxis, with risk for significant morbidity and mortality. We offer a systematic approach to determine whether acetazolamide is a safe option for those with a history of allergy to sulfonamides.

Sulfonamide-containing antibiotics are the second most frequent cause of allergic drug reactions, after the b-lactams (penicillins and cephalosporins). In one large study, the incidence of reactions to trimethoprim–sulfamethoxazole (TMPSMX) was 3% of patients exposed, compared with 5% for amoxicillin. The incidence of reactions to nonantibiotic sulfonamides is not well established; it is clearly less than with antibiotics.

 

There are several approaches to the use of sulfonamide drugs (specifically acetazolamide) in patients with past reactions to this class of medications. The choice of strategy depends on the type and severity of the previous reaction, as well as the class of drug (antibiotic versus non antibiotic) and the risk–benefit profile for the patient. However, regardless of the approach, the risks of subsequent reactions cannot be completely eliminated, and a thorough discussion between the medical provider and the patient should include this point so that an informed decision regarding the use of acetazolamide can be made. The safest approach for the patient with any prior reaction to a sulfa drug, multiple drug allergies, or penicillin allergy would be to avoid all drugs in the sulfonamide group, including acetazolamide.

 

Avoidance of the entire sulfonamide drug group is warranted for individuals whose previous reaction included a serious and/or life-threatening condition such as anaphylaxis, SJS, and TEN. Any form of reexposure to the precipitating drug or a sulfonamide in the same group is strictly contraindicated. Published evidence has shown that SJS/TEN can recur with even minor reexposures and may be more severe in the second episode. Even though SJS/TEN reactions are so far not associated with nonantibiotic sulfonamides, because of the severity and life-threatening nature of these reactions, a safe practice is to avoid all sulfonamides in patients with past SJS or TEN from sulfonamide containing medications.

 

This paper was published in a journal on high altitude medicine. That is why the suggested alternatives are staged ascents of the mountain and oxygen.

  

Conclusion

The first key point is that you can have an allergy to sulfonamide antibiotics and have absolutely no negative reaction to sulfonamide drugs like bumetanide and acetazolamide (Diamox).

If you do have a mild allergic reaction to a sulfonamide drug, there are desensitization strategies that are proven to work in many people.

It looks like rapid oral desensitization to bumetanide and acetazolamide is likely possible, based on what has been shown possible with furosemide and a wide variety of other drugs.

Clearly the level of sensitivity and hence the nature of the allergic reaction can vary massively from person to person, this is why rapid desensitization usually takes place in hospital.

If you opt for the slower process, much less is known, because it is not generally used. If you did it in hospital it would require a very long stay and so would be hugely expensive.

It is suggested that slow drug desensitization (SDD) should be much more long lasting and hopefully might become permanent – as is the hope for nut allergy treatment.

When posed the initial question by our reader wanting to use bumetanide, I was thinking along the lines of slow drug desensitization (SDD), because this is how you would treat a pollen allergy. If rapid oral desensitization will work for taking bumetanide once a day that would be great. To maintain the protection from allergy it might be safer to take a small second daily dose.

 

Here is a quick overview of desensitization options for sulfonamide allergy:

• Rapid Desensitization (RDD):
• Faster process (hours)
• Temporary tolerance achieved
• May be repeated if needed
• Slow Desensitization (SDD):
• Slower process (days, weeks, or months)
• Might offer a greater chance of longer-lasting
• Still requires close monitoring

Important Considerations:

• Always consult your doctor: They can assess your allergy severity, treatment options, and the suitability of desensitization if necessary.
• Desensitization is not without risks: It requires careful monitoring.

 

I for one found this an interesting investigation and with promise for parents of those with severe autism who have been unable to trial Bumetanide due to a sulfonamide allergy. 

Hopefully our reader Dr Antonucci will follow up on this and make a bumetanide desensitization protocol for those people with autism and a sulfonamide allergy. Maybe he has already done it. It looks very achievable.

Tardive Dyskinesia (TD) - Amino Acids, VMAT2, Diamox, B6 etc

Today’s post is about Tardive Dyskinesia which is a side effect eventually experienced by about 30% of people taking antipsychotic drugs, like risperidone, widely prescribed in both autism and schizophrenia.

Enough money for your lifetime supply of a VMAT2 inhibitor?

Tardive Dyskinesia (TD) is a disorder resulting in involuntary, repetitive body movements, which might think of as tics or grimaces.

It appears that the longer the drug is taken the greater the chance of developing Tardive Dyskinesia.

Predicting the long-term risk of tardive dyskinesia in outpatients maintained on neuroleptic medications.

Tics are quite common in autism and not just in those taking psychiatric drugs.

Tourette’s syndrome is a well-known tic disorder that does overlap with autism, it used to be considered rare, but now 1% of children are thought to be affected.  Some common Tourette’s tics are eye blinking, coughing, throat clearing, sniffing, and facial movements.

People diagnosed with Tourette’s might also be diagnosed with ADHD, OCD or indeed autism.  

We saw in some Italian research that young children with Tourette’s type autism have a fair chance of seeing their symptoms of autism substantially fade away. It was called Dysmaturational Syndrome.

Inflammatory Response to GAS (Group A Strep) and Dysmaturational Syndrome (Tourette’s Syndrome with Autism “Recovery” by 6 Years Old)

The part of the brain that is thought to be affected in  Tardive Dyskinesia is that same part suspected in Tourette’s and indeed PANDAS/PANS; it is the basal ganglia.  

Avoiding Tardive Dyskinesia

The best way to avoid Tardive Dyskinesia is not to use antipsychotic/ neuroleptic drugs.

It appears that high doses of melatonin and other antioxidants may give a protective effect from developing Tardive Dyskinesia. 

Treating Tardive Dyskinesia

Much is written about treating Tardive Dyskinesia (TD), because nobody yet has found a cure for it, nonetheless there is a long list of partially effective therapies.

Given that the underlying basis of TD may very likely to overlap to some extent with Tourette’s and PANDAS/PANS it is over broader interest.  

A Review of off-label Treatments  for Tardive Dyskinesia 

The Spanish study below gives a good overview of most therapies, but exclude the very recent therapies based on VMAT2. 

Treatment of tardive dyskinesia: A systematic review (1997-2011)

  

All of the studies in the review were small, but you can see that some therapies did seem to help, including:-

·        Vitamin E

·        Vitamin B6

·        Acetazolamide/Diamox

·        Amino Acids

·        Piracetam

I proposed Acetazolamide/Diamox to potentially treat some autism a while back and some readers of this blog do find it effective.

Piracetam is the world’s first cognitive enhancing (nootropic) drug.  It was discovered by mistake when trying to make a cure for motion sickness.

Amino acids may look an odd choice, but in males, and only males, branched chain  amino acids (BCAAs) valine, isoleucine, and leucine in a 3:3:4 ratio appears to be beneficial.  Another amino acid called Phenylalanine is associated with tardive dyskinesia in men but not in women. It is an established fact that an increase in BCAAs will cause a reduction in phenylalanine in the brain, among a range of other effects.

Phenylalanine is a precursor for dopamine (as well as  tyrosine, norepinephrine, and epinephrine). 

One theory is that tardive dyskinesia results primarily from neuroleptic-induced dopamine supersensitivity. So if the BCAAs reduce the amount of dopamine produced, this might explain their effect.

VMAT2

VMAT2 transports monoamines - particularly neurotransmitters such as dopamine, norepinephrine, serotonin, and histamine - from cellular cytosol into synaptic vesicles. Inhibiting VMAT2 will reduce the release of dopamine. 

In some circumstances VMAT2 is necessary for the release of the neurotransmitter GABA. 

Drugs that inhibit VMAT2 appear to help treat Tardive Dyskinesia and one drug Valbenazine/Ingrezza was FDA approved for this purpose in April 2017. Not surprisingly, it is now being investigated to treat Tourette’s syndrome. 

Valbenazine is known to cause a reversible reduction of dopamine release by selectively inhibiting VMAT2. 

Conclusion

Since our regular reader Valentina is dealing with Tardive Dyskinesia, she will probably be very interested in Valbenazine.

The problem is the price. The drug will apparently cost $60,000 a year in the US.

So for the time being it is best to work through the list of very cheap interventions that do seem to be partially effective, at least in some people.

Enhancing the effect of Bumetanide in Autism

Many readers of this blog, and some of those who leave comments, are using the Bumetanide therapy proposed by Ben-Ari and Lemonnier.

At some point it should become an approved autism drug and Ben Ari has already patented it for use in Down Syndrome, so I guess that will come later on.

I have been developing my own add-on therapies that might help people for whom a high level of intracellular chloride is part of their autism, or indeed Down Sydrome.  If Bumetanide has a profound impact on your autism, this is almost certainly you.

Monty, aged 13 with ASD

After 4 years of Bumetanide, it continues to be effective and if Monty stops taking it there is a gradual cognitive decline over a few days, presumably as chloride concentration gradually increases.

In spite of an odd temporary Tourette’s type verbal tic that developed after an infection before Christmas, I have been getting plenty of feedback that Monty has got cleverer in 2017.  So it looks like some bumetanide add-on does indeed work.

The Colosseum

Monty’s big brother continues to be a fan of Lego and indeed Nanoblocks from Japan.  Nanoblocks is like extremely small Lego.

Having completed the Colossuem, his latest Nanoblocks model, he asked Monty “where is it?”.

Back came the answer, unprompted, “Italy”.

This was a big surprise.

That was not the answer big brother expected, he expected no answer or a silly answer like “over there”.

Add-ons

The first is potassium bromide (KBr) which was the original epilepsy therapy 150 years ago.  One of its effects is that the bromide (Br^-) part competes with chloride (Cl-) to enter neurons and bromide is known to be faster.  As a result some of the chloride inside cells is replaced by bromide.  Bromide is extremely similar to chloride, but is not reactive; this is why it can be used with any anti-epileptic drug (AED) without fear of negative interactions.

KBr has an extremely long half-life, meaning that if you take it every day it will take 4-6 weeks to reach its stable level in your body.

KBr is used for pediatric epilepsy in Germany and Austria and for epilepsy in pet dogs all over the world.  

A dose of 8mg/kg is far below the dose used for epilepsy, but does have a bumetanide enhancing effect in one 50kg boy.

The even more recent add-on is based on the experience of our reader Petra’s son with Asperger’s, who found that taking his bumetanide with Greek coffee seemed to make it more effective.

It turns out that dopamine is known to increase the effect of diuretics on the chloride cotransport NKCC2 in your kidneys.  There is a myth that coffee is a diuretic, but it is clear where this myth has come from.  Coffee will increase diuresis and so does caffeine.

In the brain it is the chloride cotransporter NKCC1 that is also blocked by bumetanide.  So it would be plausible that dopamine/coffee/caffeine it might have the same effect on NKCC1 as it does on the very similar NKCC2.

The cheap and widely available 50mg caffeine tablets do seem to serve as a proxy for a steaming cup of Greek coffee.  Indeed 50mg of caffeine is more like a weak cup of instant coffee.

I did much earlier propose the use of Diamox/ Acetazolamide to reduce chloride.  It seems that in some neurons 2/3 of the chloride enters via NKCC1 and 1/3 via the exchanger AE3.  Diamox/ Acetazolamide works via AE3.

Diamox has some other ion channel effects, making it useful in some epilepsy.

Some readers of this blog use Diamox, but in Monty it seems to cause reflux.

Caffeine is a very simple add-on to try.

Neuroligins, Estradiol and Male Autism

Today’s post looks deeper into the biology of those people who respond to the drug bumetanide, which means a large sub-group of those with autism, likely those with Down Syndrome and likely some with schizophrenia.

It is a rather narrow area of science, but other than bumetanide treatment, there appears to be no research interest in further translating science into therapy.    So it looks like this blog is the only place to develop such ideas.

I did not expect this post would lead to a practical intervention, but perhaps it does. As you will discover, the goal would be to restore a hormone called estradiol to its natural higher level, perhaps by increasing an enzyme called aromatase, which appears to be commonly downregulated in autism.  This should increase expression of neuroligin 2, which should increase expression of the ion transporter KCC2; this will lower intracellular chloride and boost cognition.

It seems that those people using Atorvastatin may have already started this process, since this statin increases IGF-1 and insulin is one of the few things that increases the aromatise enzyme. 

This process is known as the testosterone-estradiol shunt.  In effect, by becoming slightly less male, you may be able to correct one of the key dysfunctions underlying autism. Options would include insulin, IGF-1, estradiol and a promoter of aromatase.




The testosterone – estradiol shunt

It would seem that this sub-group of autism is currently a little bit too male, which might be seen as early puberty and in other features. In this group the balance between testosterone and estradiol is affected not just in the brain, which is actually a good thing.  This should be measurable, if it is not visible.

  

NKCC1, KCC2 and AE3

As we have seen in earlier posts, some people with autism have too little of a transporter called KCC2 that takes chloride out of neurons and too much of NKCC1 that lets chloride in.  The result is an abnormally high level of chloride, which changes the way the GABA neurotransmitter functions.  This reduces cognitive function and increases the chance of seizures.

It is likely that a group may exist that has mis-expression of an ion exchanger called AE3. Potentially some have just an AE3 dysfunction and some may have AE3, KCC2 and NKCC1 mis-expression.  I will come back to this in a later post, but in case I forget, here is the link:

NKCC1 and AE3 Appear to Accumulate Chloride in Embryonic Motoneurons

“NKCC1 seems to be responsible for approximately two thirds of the steady-state chloride accumulation, whereas AE3 is responsible for the remaining third”

Genetic dysfunction of AE3 is not surprisingly associated with seizures and should respond to treatment with Diamox/Acetazolamide.

Block NKCC1 with Bumetanide and/or increase KCC2 expression

I was recently updating the Bumetanide researchers about my son’s near four years of therapy with their drug and my ideas to take things further.

My plan is to apply other methods to reduce intracellular chloride levels.  I think that over time, blocking NKCC1 with bumetanide may trigger a feedback loop that leads to a further increase in NKCC1 expression.  So bumetanide continues to work, but the effect is reduced. One way to further reduce intracellular chloride levels is to increase expression of KCC2, the transport that takes chloride out of neurons.

The best way to do this would be to understand why KCC2 is down regulated in the first place. I have touched on this in earlier posts, where I introduced neuroligin 2.

Today’s post will look at neuroligins in autism and how they are connected to the female hormone Estradiol.  We will also look at how estrogen receptor expression may help explain why more males have autism. Taken together this suggests that an  estrogen receptor agonist might be an effective autism therapy in this sub-group.

The difficulty with hormones is that, due to evolution, each one performs numerous different functions in different parts of the body and they react with each other.  So a little extra estradiol/estrogen might indeed increase neuroligin 2 expression and hence increase KCC2 expression in the brain, but it would have other effects elsewhere.  In female hormone replacement therapy care is usually taken to direct estradiol/estrogen to where it is needed, rather than sending it everywhere.

I suspect that in this subgroup of autism the lack of estradiol is body-wide, not just in the brain.  If not you would either need an estrogen receptor agonist that is cleverly developed to be brain specific, or take the much easier route of delivering an existing agonist direct to the brain, which may also be possible.

In the paper below NL2 and neuroligin-2 mean the same thing. 

An unexpected role of neuroligin-2 in regulating KCC2 and GABA functional switch

Background

GABA_A receptors are ligand-gated Cl^- channels, and the intracellular Cl^- concentration governs whether GABA function is excitatory or inhibitory. During early brain development, GABA undergoes functional switch from excitation to inhibition: GABA depolarizes immature neurons but hyperpolarizes mature neurons due to a developmental decrease of intracellular Cl^- concentration. This GABA functional switch is mainly mediated by the up-regulation of KCC2, a potassium-chloride cotransporter that pumps Cl^- outside neurons. However, the upstream factor that regulates KCC2 expression is unclear.

Results

We report here that KCC2 is unexpectedly regulated by neuroligin-2 (NL2), a cell adhesion molecule specifically localized at GABAergic synapses. The expression of NL2 precedes that of KCC2 in early postnatal development. Upon knockdown of NL2, the expression level of KCC2 is significantly decreased, and GABA functional switch is significantly delayed during early development. Overexpression of shRNA-proof NL2 rescues both KCC2 reduction and delayed GABA functional switch induced by NL2 shRNAs. Moreover, NL2 appears to be required to maintain GABA inhibitory function even in mature neurons, because knockdown NL2 reverses GABA action to excitatory. Gramicidin-perforated patch clamp recordings confirm that NL2 directly regulates the GABA equilibrium potential. We further demonstrate that knockdown of NL2 decreases dendritic spines through down-regulating KCC2.

Conclusions

Our data suggest that in addition to its conventional role as a cell adhesion molecule to regulate GABAergic synaptogenesis, NL2 also regulates KCC2 to modulate GABA functional switch and even glutamatergic synapses. Therefore, NL2 may serve as a master regulator in balancing excitation and inhibition in the brain.

  

Neuroligins and Neurexins

The following paper has an excellent explanation of neuroligins, neurexins and their role in autism.  It does get complicated.

Neuroligins and Neurexins Link Synaptic Function to Cognitive Disease

Neurexins (Nrxns) and neuroligins (Nlgns) are arguably the best characterized synaptic cell-adhesion molecules, and the only ones for which a specifically synaptic function was established^8,9. In the present review, we will describe the role of Nrxns and Nlgns as synaptic cell-adhesion molecules that act in an heretofore unanticipated fashion. We will show that they are required for synapse function, not synapse formation; that they affect trans-synaptic activation of synaptic transmission, but are not essential for synaptic cohesion of the pre- and postsynaptic specializations; and that their dysfunction impairs the properties of synapses and disrupts neural networks without completely abolishing synaptic transmission as^10–12. As cell-adhesion molecules, Nrxns and Nlgns probably function by binding to each other and by interacting with intracellular proteins, most prominently PDZ-domain proteins, but the precise mechanisms involved and their relation to synaptic transmission remain unclear. The importance of Nrxns and Nlgns for synaptic function is evident from the dramatic deficits in synaptic transmission in mice lacking Nrxns or Nlgns.

As we will describe, the role of Nrxns and Nlgns in synaptic function almost predestines them for a role in cognitive diseases, such as schizophrenia and autism spectrum disorders (ASDs), that have been resistant to our understanding. One reason for the difficulties in understanding cognitive diseaseas is that they may arise from subtle changes in a subset of synapses in a neural circuit, as opposed to a general impairment of all synapses in all circuits. As a result, the same molecular alteration may produce different circuit changes and neurological symptoms that are then classified as distinct cognitive diseases. Indeed, recent studies have identified mutations in the genes encoding Nrxns and Nlgns as a cause for ASDs, Tourette syndrome, mental retardation, and schizophrenia, sometimes in patients with the same mutation in the same family^13–27. Viewed as a whole, current results thus identify Nrxns and Nlgns as trans-synaptic cell-adhesion molecules that mediate essential signaling between pre- and postsynaptic specializations, signaling that performs a central role in the brain’s ability to process information and that is a key target in the pathogenesis of cognitive diseases.

Neuroligins and neurexins in autism

ASDs are common and enigmatic diseases. ASDs comprise classical idiopathic autism, Asperger’s syndrome, Rett syndrome, and pervasive developmental disorder not otherwise specified^73,74. Moreover, several other genetic disorders, such as Down syndrome, Fragile-X Mental Retardation, and tuberous sclerosis, are frequently associated with autism. Such syndromic forms of autism and Rett syndrome are usually more severe due to the nature of the underlying diseases. The key features of ASDs are difficulties in social interactions and communication, language impairments, a restricted pattern of interests, and/or stereotypic and repetitive behaviors. Mental retardation (~70% of cases) and epilepsy (~30% of cases) are frequently observed; in fact, the observation of epilepsy in patients with ASDs has fueled speculation that autism may be caused by an imbalance of excitatory vs. inhibitory synaptic transmission. In rare instances, idiopathic autism is associated with specialized abilities, for example in music, mathematics, or memory. The relation of ASDs to other cognitive diseases such as schizophrenia and Tourette’s syndrome is unclear. As we will see below with the phenotypes caused by mutations in Nlgns and Nrxns, the boundaries between the various disorders may not be as real as the clinical manifestations suggest.

A key feature of ASDs is that they typically develop before 2–3 years of age^73,74. ASDs thus affect brain development relatively late, during the time of human synapse formation and maturation. Consistent with this time course, few anatomical changes are associated with ASDs⁷⁵. An increase in brain size was repeatedly reported⁷⁶, but is not generally agreed upon⁷⁵. Thus, similar to other cognitive diseases, ASDs are not a disorder of brain structure but of brain function. Among cognitive diseases, ASDs are the most heritable (~ 80%), suggesting that they are largely determined by genes and not the environment. ASDs exhibit a male:female ratio of approximately 4:1, indicating that ASDs involve the X-chromosome directly, or that the penetrance of pathogenic genes is facilitated in males^73,74.

Mutations in many genes have been associated with familial ASDs. A consistent observation emerging from recent studies is the discovery of mutations in the genes encoding Nrxn1, Nlgn3, and Nlgn4. Specifically, seven point mutations, two distinct translocation events, and four different large-scale deletions in the Nrxn1 gene were detected in autistic patients^13–18. Ten different mutations in the Nlgn4 gene were observed (2 frameshifts, 5 missense mutations, and 3 internal deletions), and a single mutation in the Nlgn3 gene (the R451C substitution)^21–24. Besides these mutations, five different larger deletions of X-chromosomal DNA that includes the Nlgn4 locus (referred to as copy-number variations) were detected in autism patients^18,25–27.

In addition to the Nrxn/Nlgn complex, mutations in the gene encoding Shank3 – an intracellular scaffolding protein that binds indirectly to Nlgns via PSD-95 and GKAP (Fig. 1)⁶⁶ – may also be a relatively frequent occurrence in ASDs. An astounding 18 point mutations were detected in the Shank3 gene in autistic patients, in addition to several cases containing CNVs that cover the gene^18,77–82. Indeed, the so-called terminal 22q deletion syndrome is a relatively frequent occurrence that exhibits autistic features, which have been correlated with the absence of the Shank3 gene normally localized to this chromosome section. Shank3 is particularly interesting because it not only indirectly interacts with Nlgns, but also directly binds to CIRL/Latrophilins which in turn constitute α-latrotoxin receptors similar to Nrxns, suggesting a potential functional connection between Shank3 and Nrxns⁸³.

Overall, the description of the various mutations in the Nrxn/Nlgn/Shank3 complex appears to provide overwhelming evidence for a role of this complex in ASDs, given the fact that in total, these mutations account for a significant proportion of autism patients. It should be noted, however, that two issues give rise to skepticism to the role of this complex in ASDs.

First, at least for some of the mutations in this complex, non-symptomatic carriers were detected in the same families in which the patients with the mutations were found. Whereas the Nlgn3 and Nlgn4 mutations appear to be almost always penetrant in males, and even female carriers with these mutations often have a phenotype, the Shank3 point mutations in particular were often observed in non-symptomatic siblings^77,78. Thus, these mutations may only increase the chance of autism, but not actually cause autism.

Second, the same mutations can be associated with quite different phenotypes in different people. For example, a microdeletion in Nlgn4 was found to cause severe autism in one brother, but Tourette’s syndrome in the other²⁶. This raises the issue whether the ‘autism’ observed in patients with mutations in these genes is actually autism, an issue that could also be rephrased as the question of whether autism is qualitatively distinct from other cognitive diseases, as opposed to a continuum of cognitive disorders. In support of the latter idea, two different deletions of Nrxn1α have also been observed in families with schizophrenia^19,20, indicating that there is a continuum of disorders that involves dysfunctions in synaptic cell adhesion and manifests in different ways. Conversely, very different molecular changes may produce a similar syndrome, as exemplified by the quite different mutations that are associated with ASDs⁸⁴.

At present, the relation between the Nrxn/Nlgn synaptic cell-adhesion complex and ASDs is tenuous. On one hand, many of the mutations observed in familial ASD are clearly not polymorphisms but deleterious, as evidenced by the effect of these mutations on the structure or expression of the corresponding genes, and by the severe autism-like phenotypes observed in Nlgn3 and Nlgn4 mutant mice^85–87. On the other hand, the nonlinear genotype/phenotype relationship in humans, evident from the only 70–80% heritability and from the occasional presence of mutations in non-symptomatic individuals, requires explanation. Elucidating the underlying mechanisms for this incomplete genotype/phenotype relationship is a promising avenue to insight into the genesis of autism. Furthermore, in addition to the link of Nrxn1α mutations to schizophrenia^19,20, linkage studies have connected Nrxn3 to different types of addiction^88,89. It is possible that because of the nature of their function, mutations in genes encoding Nrxns and Nlgns constitute hotspots for human cognitive diseases.

  

As you will have seen from the above paper, whose author seems to be very well informed of the broader picture (a continuum of disorders that involves dysfunctions in synaptic cell adhesion, and even the link to addiction), neuroligins and neurexins are very relevant to autism and other cognitive disease.

Let’s get back on subject and focus on Neuroligin 2 

The very recent paper below mentions sensory processing defects and NLG2 alongside what we already have figured out so far.

Neuroligin 2 nonsense variant associated with anxiety, autism, intellectual disability, hyperphagia, and obesity

Abstract

Neuroligins are post-synaptic, cellular adhesion molecules implicated in synaptic formation and function. NLGN2 is strongly linked to inhibitory, GABAergic signaling and is crucial for maintaining the excitation-inhibition balance in the brain. Disruption of the excitation-inhibition balance is associated with neuropsychiatric disease. In animal models, altered NLGN2 expression causes anxiety, developmental delay, motor discoordination, social impairment, aggression, and sensory processing defects. In humans, mutations in NLGN3 and NLGN4 are linked to autism and schizophrenia; NLGN2 missense variants are implicated in schizophrenia. Copy number variants encompassing NLGN2 on 17p13.1 are associated with autism, intellectual disability, metabolic syndrome, diabetes, and dysmorphic features, but an isolated NLGN2 nonsense variant has not yet been described in humans. Here, we describe a 15-year-old male with severe anxiety, obsessive-compulsive behaviors, developmental delay, autism, obesity, macrocephaly, and some dysmorphic features. Exome sequencing identified a heterozygous, de novo, c.441C>A p.(Tyr147Ter) variant in NLGN2 that is predicted to cause loss of normal protein function. This is the first report of an NLGN2 nonsense variant in humans, adding to the accumulating evidence that links synaptic proteins with a spectrum of neurodevelopmental phenotypes

After some investigation I learned that both estradiol/estrogen and progesterone increase expression of neuroligin 2, at least in rats.

Increasing neuroligin 2/NLGN2/NL2 looks a promising strategy.

Gene expression analysis of the pro-oestrous-stage rat uterus reveals neuroligin 2 as a novel steroid-regulated gene

In addition, neuroligin 2 mRNA levels were increased by both 17beta-oestradiol (E(2)) and P(4), although P(4) administration upregulated gene expression to a greater extent than injection of E(2). These results indicate that neuroligin 2 gene expression in the rat uterus is under the control of both E(2) and P(4), which are secreted periodically during the oestrous cycle.[1]

So a female steroid-regulated gene is down-regulated in male-dominated autism.  Another example of the protective nature of female hormones?  I think it is.

Estrogens Suppress a Behavioral Phenotype in Zebrafish Mutants of the Autism Risk Gene, CNTNAP2

Highlights

·         Zebrafish mutants of the autism risk gene cntnap2 have GABAergic neuron deficits

·         High-throughput behavioral profiling identifies nighttime hyperactivity in mutants

·         cntnap2 mutants exhibit altered responses to GABAergic and glutamatergic compounds

·         Estrogenic compounds suppress the cntnap2 mutant behavioral phenotype

Summary

Autism spectrum disorders (ASDs) are a group of devastating neurodevelopmental syndromes that affect up to 1 in 68 children. Despite advances in the identification of ASD risk genes, the mechanisms underlying ASDs remain unknown. Homozygous loss-of-function mutations in Contactin Associated Protein-like 2 (CNTNAP2) are strongly linked to ASDs. Here we investigate the function of Cntnap2 and undertake pharmacological screens to identify phenotypic suppressors. We find that zebrafish cntnap2 mutants display GABAergic deficits, particularly in the forebrain, and sensitivity to drug-induced seizures. High-throughput behavioral profiling identifies nighttime hyperactivity in cntnap2 mutants, while pharmacological testing reveals dysregulation of GABAergic and glutamatergic systems. Finally, we find that estrogen receptor agonists elicit a behavioral fingerprint anti-correlative to that of cntnap2 mutants and show that the phytoestrogen biochanin A specifically reverses the mutant behavioral phenotype. These results identify estrogenic compounds as phenotypic suppressors and illuminate novel pharmacological pathways with relevance to autism.

Estrogen receptor expression may help explain why more males have autism

Estrogen is known to help protect premenopausal women from maladies such as stroke and impaired cognition. Exposure to high levels of the male hormone testosterone during early development has been linked to autism, which is five times more common in males than females.

The new findings of reduced expression of estrogen receptor beta as well as that of an enzyme that converts testosterone to estrogen could help explain the high testosterone levels in autistic individuals and higher autism rates in males, Pillai said.

It was the 5-to-1 male-to-female ratio along with the testosterone hypothesis that led Pillai and his colleagues to pursue whether estrogen might help explain the significant gender disparity and possibly point toward a new treatment.

"The testosterone hypothesis is already there, but nobody had investigated whether it had anything to do with the female hormone in the brain," Pillai said. "Estrogen is known to be neuroprotective, but nobody has looked at whether its function is impaired in the brain of individuals with autism. We found that the children with autism didn't have sufficient estrogen receptor beta expression to mediate the protective benefits of estrogen."

Comparing the brains of 13 children with and 13 children without autism spectrum disorder, the researchers found a 35 percent decrease in estrogen receptor beta expression as well as a 38 percent reduction in the amount of aromatase, the enzyme that converts testosterone to estrogen.

Levels of estrogen receptor beta proteins, the active molecules that result from gene expression and enable functions like brain protection, were similarly low. There was no discernable change in expression levels of estrogen receptor alpha, which mediates sexual behavior.

Estrogen receptor expression may help explain why more males have autism

The new findings of reduced expression of estrogen receptor beta as well as that of an enzyme that converts testosterone to estrogen could help explain the high testosterone levels in autistic individuals and higher autism rates in males

They also plan to give an estrogen receptor beta agonist -- which should increase receptor function -- to a mouse with generalized inflammation and signs of autism to see if it mitigates those signs. Inflammation is a factor in many diseases of the brain and body, and estrogen receptor beta agonists already are in clinical trials for schizophrenia.

The following trial was run by a psychiatrist; when I looked at why he thought estrogen might improve schizophrenia, there was no biological explanation.  He is trying to avoid the possible side effects by using of a selective estrogen receptor agonist.  I hope the trial successful.  The question is whether his subjects are starting out as extreme male or just male.

The Efficacy and Safety of a Selective Estrogen Receptor Beta Agonist (LY500307) for Negative Symptoms and Cognitive Impairment Associated With Schizophrenia (Beta)

http://grantome.com/grant/NIH/UH2-TR000955-01

Several lines of investigation have supported the potential therapeutic effects of estrogen for negative and cognitive symptoms in schizophrenia. However, estrogen has had limited therapeutic application for male and premenopausal patients with schizophrenia because of tolerability concerns including uterine cancer liability, and heart disease and feminization effects in men. Selective Estrogen Receptor Beta (ER beta) agonists are a new class of treatments that are relatively free of estrogen's primary side effects and yet have demonstrated estrogen-like effects in brain including improvement in cognitive performance and an association to extremes in social behavior. Thus, these agents may have a therapeutic role for cognitive and negative symptoms in schizophrenia. The primary objectives of this application are to determine if the selective ER beta agonist LY500307 significantly improves negative and cognitive symptoms in patients with schizophrenia. Secondary aims include assessing LY500307 effects on cerebral blood flow during working and episodic memory tasks with fMRI, and electrophysiological indices of auditory sensory processing and working memory. A single seamless phase 1b/2a adaptive design will be used to evaluate two LY500307 doses (25 mg/day and 75 mg/day) in the first stage of the trial (year 1 of the application) to determine which dose should be advanced to stage 2 (years 2and 3 of the application) or if the trial should be discontinued.

More generally:-

Learning and memory: Steroids and epigenetics

Highlights

Steroid hormones exert a considerable influence on several aspect of cognition.

Estrogens and androgens exert positive effects on cognitive functions.

Progesterone and allopregnanolone have variable effects on cognitive functions.

Glucocorticoids act to encode and store information of the emotional events.

Epigenetic modifications are a powerful mechanism of memory regulation.

Conclusion

More female hormones and less male hormones? Seems a good idea.

More of the aromatase enzyme ?  There are numerous drugs to reduce/inhibit aromatase but not specifically to increase it.

Insulin does increase aromatase, as does alcohol and being overweight.

The clever thing to do would be to just correct the reduced level of aromatase, or wait for a selective estrogen receptor beta agonist like LY500307 to come to the market.

In those who are extreme male, a little estradiol might be the simple solution, but not the amount that is currently taken by those that abuse it.  Yes people abuse estradiol – males who want to be females.

Antonio Hardan at Stanford did trial high dose pregnenolone, another hormone mainly found in females, that should increase progesterone.

Brief report: an open-label study of the neurosteroid pregnenolone in adults with autism spectrum disorder.

Overall, pregnenolone was modestly effective and well-tolerated in individuals with ASD.

This steroid should increase the level of progesterone and so might be expected to cause some side effects in males. You would expect it to have an effect on anxiety, but as we saw in an earlier post it should be quite dose specific.

Why Low Doses can work differently, or “Biphasic, U-shaped actions at the GABAa receptor”

So Hardan may have just picked the "wrong dose".

If he would like to trial 0.3mg of oral estradiol in adults with autism, I think he might find a positive response.