Low dose Clonazepam for MIA Autism, Ponstan and TRPM3 in Intellectual Disability, Clemastine to restore myelination in Pitt Hopkins, Improving Oxytocin therapy with Maca, Lamotrigine for some autism

 

Monty in Ginza, Tokyo

Today’s post comes from Tokyo and looks at 5 therapies already discussed in previous posts and follows up on recent coverage in the research. They all came up in recent conversations I have been having.

·      Low dose Clonazepam  – Maternal Immune Activation model of autism

·      Ponstan – TRPM3 causing intellectual disability  (ID/MR)

·      Clemastine – improving myelination in Pitt Hopkins syndrome model

·      Oxytocin – Maca supplement to boost effect

·      Lamotrigine (an anti-epilepsy drug) to moderate autism

The good news is that many of same therapies keep coming up.

Ponstan and TRPM3 caused ID/MR

There is a lot in this blog about improving cognition, which is how I called treating ID/MR.  There are very many causes of ID and some of them are treatable.

ID/MR was always a part of classic autism and in the new jargon is part of what they want to call profound autism.

I was recently sent a paper showing how the cheap pain reliever Ponstan blocks the TRMP3 channel and that this channel when mutated can lead to intellectual disability and epilepsy.

Mefenamic acid selectively inhibits TRPM3-mediated calcium entry.

My own research has established that mefenamic acid seems to improve speech and cognition, as well as sound sensitivity.  The latter effect I am putting down to its effect on potassium channels. 

De novo substitutions of TRPM3 cause intellectual disability and epilepsy

The developmental and epileptic encephalopathies (DEE) are a heterogeneous group of chronic encephalopathies frequently associated with rare de novo nonsynonymous coding variants in neuronally expressed genes. Here, we describe eight probands with a DEE phenotype comprising intellectual disability, epilepsy, and hypotonia. Exome trio analysis showed de novo variants in TRPM3, encoding a brain-expressed transient receptor potential channel, in each. Seven probands were identically heterozygous for a recurrent substitution, p.(Val837Met), in TRPM3’s S4–S5 linker region, a conserved domain proposed to undergo conformational change during gated channel opening. The eighth individual was heterozygous for a proline substitution, p.(Pro937Gln), at the boundary between TRPM3’s flexible pore-forming loop and an adjacent alpha-helix. General-population truncating variants and microdeletions occur throughout TRPM3, suggesting a pathomechanism other than simple haploinsufficiency. We conclude that de novo variants in TRPM3 are a cause of intellectual disability and epilepsy.

 

Fenamates as TRP channel blockers: mefenamic acid selectively blocks TRPM3

This study reveals that mefenamic acid selectively inhibits TRPM3-mediated calcium entry. This selectivity was further confirmed using insulin-secreting cells. K_ATP channel-dependent increases in cytosolic Ca²⁺ and insulin secretion were not blocked by mefenamic acid, but the selective stimulation of TRPM3-dependent Ca²⁺ entry and insulin secretion induced by pregnenolone sulphate were inhibited. However, the physiological regulator of TRPM3 in insulin-secreting cells remains to be elucidated, as well as the conditions under which the inhibition of TRPM3 can impair pancreatic β-cell function. Our results strongly suggest mefenamic acid is the most selective fenamate to interfere with TRPM3 function. 

Here, we examined the inhibitory effect of several available fenamates (DCDPC, flufenamic acid, mefenamic acid, meclofenamic acid, niflumic acid, S645648, tolfenamic acid) on the TRPM3 and TRPV4 channels using fluorescence-based FLIPR Ca²⁺ measurements. To further substantiate the selectivity, we tested the potencies of these fenamates on two other TRP channels from different subfamilies, TRPC6 and TRPM2. In addition, single-cell Ca²⁺ imaging, whole-cell voltage clamp and insulin secretion experiments revealed mefenamic acid as a selective blocker of TRPM3.

  

Oxytocin

 Oxytocin does increase how emotional you feel; the difficulty is how to administer it in a way that provides a long lasting effect.  The half-life of oxytocin is a just minutes. The traditional method uses a nose spray.

I favour the use of a gut bacteria that stimulates the release of oxytocin in the brain.  The effect should be much longer lasting. Even then the effect is more cute than dramatic.

The supplement Maca does not itself produce oxytocin, but “it restores social recognition impairments by augmenting the oxytocinergic neuronal pathways”.

So Maca looks like an interesting potential add-on therapy to boost the effect of oxytocin.

One reader wrote to me with a positive report on using Maca by itself, without any oxytocin.

 

Oral Supplementation with Maca Improves Social Recognition Deficits in the Valproic Acid Animal Model of Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a congenital, lifelong neurodevelopmental disorder whose main symptom is impaired social communication and interaction. However, no drug can treat social deficits in patients with ASD, and treatments to alleviate social behavioral deficits are sorely needed. Here, we examined the effect of oral supplementation of maca (Lepidium meyenii) on social deficits of in utero-exposed valproic acid (VPA) mice, widely used as an ASD model. Although maca is widely consumed as a fertility enhancer and aphrodisiac, it possesses multiple beneficial activities. Additionally, it benefits learning and memory in experimental animal models. Therefore, the effect of maca supplementation on the social behavioral deficit of VPA mice was assessed using a social interaction test, a three-stage open field test, and a five-trial social memory test. The oral supplementation of maca attenuated social interaction behavior deficit and social memory impairment. The number of c-Fos-positive cells and the percentage of c-Fos-positive oxytocin neurons increased in supraoptic and paraventricular neurons of maca-treated VPA mice. These results reveal for the first time that maca is beneficial to social memory and that it restores social recognition impairments by augmenting the oxytocinergic neuronal pathways, which play an essential role in diverse social behaviors.

Maca (Lepidium meyenii) belongs to the cruciferous family and grows at high altitudes in Peru. In 2002, it was transplanted from Peru to the Yunnan Province of China. It is rich in dietary fiber; has many essential amino acids and nutrients including vitamin C, copper, and iron; and its root contains bioactive compounds. It is globally consumed and is popularly used as a fertility enhancer and aphrodisiac. On the other hand, with its potential to possess multi-nutritious components, it is reported to have diverse functions, including immunomodulation, antioxidant, antidepressant, antirheumatic, UV radiation protection, hepatoprotective, anti-fatigue, and neuroprotective effects. Interestingly, although the mechanism of the neuronal effect of maca is unclear, the uptake of maca extract improves learning and memory in memory-impaired model mice induced by either ethanol, ovariectomy, or scopolamine. However, the effects of maca on social memory impairment in neurodevelopmental disorders, including ASD, have not yet been tested.

In this study, the effects of maca on ASD animal models, in utero VPA-exposed mice, were investigated. The effect on social recognition by maca uptake with gavage was assessed using the social interaction test, a three-stage open field test, and the five-trail social recognition test. We also explored whether maca intake affects oxytocinergic signaling pathways, which play an important role in various social behaviors.

In this study, we showed that maca uptake rescues the deficits of social behavior and social recognition memory in VPA mice, a mouse model of autism. The c-Fos immunoreactivity of oxytocinergic neurons in SON and PVN increased significantly after maca treatment in VPA mice. Following previous studies indicating that OT administration ameliorates the impairment of social behavior in VPA mice, maca may also have improving effects on the deficit of social behavior and social recognition memory of VPA mice, probably by activating the OT neuronal pathway. Previous studies showed that maca could improve cognitive function in the mice model of impaired cognitive memory induced by either ovariectomy, ethanol, or scopolamine. Further studies are necessary to elucidate the potential link between maca and OT and to determine which components are involved in improving social recognition memory.

We have shown that maca improves the impairment of social memory and social behavioral deficits through oxytocinergic system modulation in this study. Although maca may not have an immediate effect on social behavioral deficits and takes days or weeks to demonstrate the effects, behavioral improvements, were visible regardless of the time of oral intake. The time between the very last oral intake of maca and the start of the social behavioral experiments in this study was more than 16 h. The duration of the maca’s effect on social behavioral deficits after the supplementation period is being investigated in our follow-up experiments. The possibility of the persistent effect of maca is very appealing, given that OT does not have a sustained effect due to its rapid metabolism, despite its immediate effects. Therefore, taking maca as a supplement while also receiving repeated OT treatment may have a synergistic, sustainable effect on improving social impairment in patients with ASD. Maca is already being used as a dietary supplement worldwide and has a high potential for practical applications.

 

This study showed for the first time that maca supplementation improves the impairment of social recognition memory in ASD model mice. We added the mechanism that social memory improvement may occur through the upregulation of oxytocinergic pathways. Maca highlights the possibility of treating social deficits sustainably in individuals with ASDs.

 

Low dose clonazepam

Professor Catterall was the brains behind low dose clonazepam for mice, I just translated it across to humans. It is one way to modify the E/I (excitatory/inhibitory) imbalance in autism.

I found that it gave a boost to cognition. Not as big as bumetanide, but worth having nonetheless.

I do not believe you have to be a bumetanide responder to respond well to low dose clonazepam.

Several people have written to me recently to say it works for their child.

Our reader Tanya is interested in the Maternal Immune Activation (MIA) trigger to autism. She highlighted a recent study showing how and why clonazepam can reverse autism in the MIA mouse model of autism. 

Clonazepam attenuates neurobehavioral abnormalities in offspring exposed to maternal immune activation by enhancing GABAergic neurotransmission

Ample evidence indicates that maternal immune activation (MIA) during gestation is linked to an increased risk for neurodevelopmental and psychiatric disorders, such as autism spectrum disorder (ASD), anxiety and depression, in offspring. However, the underlying mechanism for such a link remains largely elusive. Here, we performed RNA sequencing (RNA-seq) to examine the transcriptional profiles changes in mice in response to MIA and identified that the expression of Scn1a gene, encoding the pore-forming α-subunit of the brain voltage-gated sodium channel type-1 (Na_V1.1) primarily in fast-spiking inhibitory interneurons, was significantly decreased in the medial prefrontal cortex (mPFC) of juvenile offspring after MIA. Moreover, diminished excitatory drive onto interneurons causes reduction of spontaneous gamma-aminobutyric acid (GABA)ergic neurotransmission in the mPFC of MIA offspring, leading to hyperactivity in this brain region. Remarkably, treatment with low-dose benzodiazepines clonazepam, an agonist of GABA_A receptors, completely prevented the behavioral abnormalities, including stereotypies, social deficits, anxiety- and depression-like behavior, via increasing inhibitory neurotransmission as well as decreasing neural activity in the mPFC of MIA offspring. Our results demonstrate that decreased expression of Na_V1.1 in the mPFC leads to abnormalities in maternal inflammation-related behaviors and provides a potential therapeutic strategy for the abnormal behavioral phenotypes observed in the offspring exposed to MIA.

 

Pitt Hopkins – Clemastine and Sobetirome

Poor myelination is a feature of much autism and is a known problem in Pitt Hopkins syndrome.

I did cover a paper a while back where the Pitt Hopkins researchers showed that genes involved in myelination are down-regulated not only in Pitt Hopkins, but in several other popular models of autism.

From the multiple sclerosis (MS) research we have assembled a long list of therapies to improve different processes involved in myelination. Today we can add to that list sobetirome (and the related Sob-AM2). Sobetirome shares some of its effects with thyroid hormone (TH), it is a thyroid hormone receptor isoform beta-1 (THRβ-1) liver-selective analog.

Some people do use thyroid hormones to treat autism, and indeed US psychiatrists have long used T3 to treat depression.

The problem with giving T3 or T4 hormones is that it has body-wide effects and if you give too much the thyroid gland will just produce less.

One proposed mechanism I wrote about long ago is central hypothyroidism, that is a lack of the active T3 hormone just within the brain. One possible cause proposed was that oxidative stress reduces the enzyme D2 that is used to convert circulating prohormone T4 to T3. The result is that your blood test says your thyoid function is great, but in your brain you lack T3.

It looks like using sobetirome you can spice up myelination in the brain, without causing any negative effects to your thyroid gland.

Rather surprisingly, sobetirome is already sold as a supplement, but it is not cheap like Clemastine, the other drug used in the successful study below.

 

Promyelinating drugs promote functional recovery in an autism spectrum disorder mouse model of Pitt–Hopkins syndrome

Pitt–Hopkins syndrome is an autism spectrum disorder caused by autosomal dominant mutations in the human transcription factor 4 gene (TCF4). One pathobiological process caused by murine Tcf4 mutation is a cell autonomous reduction in oligodendrocytes and myelination. In this study, we show that the promyelinating compounds, clemastine, sobetirome and Sob-AM2 are effective at restoring myelination defects in a Pitt–Hopkins syndrome mouse model. In vitro, clemastine treatment reduced excess oligodendrocyte precursor cells and normalized oligodendrocyte density. In vivo, 2-week intraperitoneal administration of clemastine also normalized oligodendrocyte precursor cell and oligodendrocyte density in the cortex of Tcf4 mutant mice and appeared to increase the number of axons undergoing myelination, as EM imaging of the corpus callosum showed a significant increase in the proportion of uncompacted myelin and an overall reduction in the g-ratio. Importantly, this treatment paradigm resulted in functional rescue by improving electrophysiology and behaviour. To confirm behavioural rescue was achieved via enhancing myelination, we show that treatment with the thyroid hormone receptor agonist sobetirome or its brain penetrating prodrug Sob-AM2, was also effective at normalizing oligodendrocyte precursor cell and oligodendrocyte densities and behaviour in the Pitt–Hopkins syndrome mouse model. Together, these results provide preclinical evidence that promyelinating therapies may be beneficial in Pitt–Hopkins syndrome and potentially other neurodevelopmental disorders characterized by dysmyelination.

 

Sobetirome  (also called GC-1)

Sobetirome is a thyroid hormone receptor isoform beta-1 (THRβ-1) liver-selective analog.

In humans, sobetirome lowers plasma LDL cholesterol and reduced plasma triglycerides, while its liver-selective activity helped avoid the side effects seen with many other thyromimetic agents.

 

Myelin repair stimulated by CNS-selective thyroid hormone action

Oligodendrocyte processes wrap axons to form neuroprotective myelin sheaths, and damage to myelin in disorders, such as multiple sclerosis (MS), leads to neurodegeneration and disability. There are currently no approved treatments for MS that stimulate myelin repair. During development, thyroid hormone (TH) promotes myelination through enhancing oligodendrocyte differentiation; however, TH itself is unsuitable as a remyelination therapy due to adverse systemic effects. This problem is overcome with selective TH agonists, sobetirome and a CNS-selective prodrug of sobetirome called Sob-AM2. We show here that TH and sobetirome stimulated remyelination in standard gliotoxin models of demyelination. We then utilized a genetic mouse model of demyelination and remyelination, in which we employed motor function tests, histology, and MRI to demonstrate that chronic treatment with sobetirome or Sob-AM2 leads to significant improvement in both clinical signs and remyelination. In contrast, chronic treatment with TH in this model inhibited the endogenous myelin repair and exacerbated disease. These results support the clinical investigation of selective CNS-penetrating TH agonists, but not TH, for myelin repair.

 

Compound protects myelin, nerve fibers

 

Research could be important in treating, preventing progression of multiple sclerosis, other neurodegenerative diseases

A compound appears to protect nerve fibers and the fatty sheath, called myelin, that covers nerve cells in the brain and spinal cord. The new research in a mouse model advances earlier work to develop the compound - known as sobetirome - that has already showed promise in stimulating the repair of myelin.

Lead author Priya Chaudhary, M.D., assistant professor of neurology in the OHSU School of Medicine who is focused on developing therapies for neurodegenerative diseases, said that the technique is a common step in drug discovery.

"It is important to show the effectiveness of potential drugs in a model that is most commonly used for developing new therapies," Chaudhary said.

The researchers discovered that they were able to prevent damage to myelin and nerve fibers from occurring, by stimulating a protective response in the cells that make and maintain myelin. They also reduced the activity of migroglia, a type of inflammatory cell in the brain and spinal cord that's involved in causing damage in multiple sclerosis and other diseases.

"The effects are impressive and are at least in part consistent with a neuroprotective effect with particular inhibition of myelin and axon degeneration, and oligodendrocyte loss," the authors write.

The discovery, if proven in clinical trials involving people, could be especially useful for people who are diagnosed with multiple sclerosis early in the disease's progression.

"The drug could protect the nervous system from damage and reduce the severity of the disease," Bourdette said.

 

Does Lamotrigine have the potential to 'cure' Autism?

Recently headlines appeared like this one:-

Scientists 'CURE autism' in mice using $3 epilepsy drug

It referred to the use of the epilepsy drug Lamotrigine to treat a mouse model of autism, caused by reduced expression of the gene MYT1L.

What the tabloid journalists failed to notice was that there has already been a human trial of Lamotrigine in autism.  That trial was viewed as unsuccessful by the clinicians, although the parents did not agree.

There were many comments in the media from parents whose child already takes this drug for their epilepsy and they saw no reduction in autism. There were some who found it made autism worse.

 

MYT1L haploinsufficiency in human neurons and mice causes autism-associated phenotypes that can be reversed by genetic and pharmacologic intervention

 

Lamotrigine therapy for autistic disorder: a randomized, double-blind, placebo-controlled trial

In autism, glutamate may be increased or its receptors up-regulated as part of an excitotoxic process that damages neural networks and subsequently contributes to behavioral and cognitive deficits seen in the disorder. This was a double-blind, placebo-controlled, parallel group study of lamotrigine, an agent that modulates glutamate release. Twenty-eight children (27 boys) ages 3 to 11 years (M = 5.8) with a primary diagnosis of autistic disorder received either placebo or lamotrigine twice daily. In children on lamotrigine, the drug was titrated upward over 8 weeks to reach a mean maintenance dose of 5.0 mg/kg per day. This dose was then maintained for 4 weeks. Following maintenance evaluations, the drug was tapered down over 2 weeks. The trial ended with a 4-week drug-free period. Outcome measures included improvements in severity and behavioral features of autistic disorder (stereotypies, lethargy, irritability, hyperactivity, emotional reciprocity, sharing pleasures) and improvements in language and communication, socialization, and daily living skills noted after 12 weeks (the end of a 4-week maintenance phase). We did not find any significant differences in improvements between lamotrigine or placebo groups on the Autism Behavior Checklist, the Aberrant Behavior Checklist, the Vineland Adaptive Behavior scales, the PL-ADOS, or the CARS. Parent rating scales showed marked improvements, presumably due to expectations of benefits.

One reader of this blog who heard all about the news and was sceptical, since after all it is a mouse model. Her 8 year old non-verbal child was not happy taking the drug Keppra and was already scheduled to try Lamotrigine. 

“Within a week his teacher called to say he was saying his ABCs, the next week he was counting out loud, the following month he’s attempting to repeat words of interest and this week he’s spelling animals by memory, dolphin, duck, wolf, chicken, pig, etc.

We are 2 months in and at 50mg, our target dose is 100mg bid. Obviously with our success, I’ve been working with his doctor and will continue to.”

 

Conclusion

Even though every day new autism research is published, there is so much already in this blog that not much appearing is totally new to regular readers.

We saw several years ago that low dose clonazepam should be beneficial to some people with autism, in particular Dravet syndrome. Today we learnt a little more about why Nav1.1 might be disturbed beyond those with Dravet syndrome. In the maternal immune activation model it seems to be a winner. It seems to benefit many of those who have trialed it.

Treating myelination deficits has been well covered in this blog. In previous posts we saw how Pitt Hopkins syndrome researchers showed how myelination gene expression was disturbed in a wide range of autisms. Today we saw evidence to support such therapy and we discovered a new drug.

Oxytocin does help some people with autism, but not as much as you might expect. Today we learnt of a potential add on therapy, a supplement called Maca.

The idea that anti-epilepsy drugs might help some autism has been well covered. From low dose valproate to low dose phenytoin from Dr Philip Bird in Australia.

Treatment of Autism with low-dose Phenytoin, yet another AED

Recent research suggested that Lamotrigine should help some with autism and today you learned that it really does help in one case. The fact that a tiny study a few years ago suggested no responders just tells us that only a small subgroup are likely to benefit.

We already know that some people's autism is made worse by their epilepsy therapy. This is just what you would expect. Time to find a different epilepsy therapy.

My favorite new therapy, low dose mefenemic acid / ponstan has numerous effects. One reader without autism, but with an unusual visual dysfunction (visual snow syndrome) and a sound sensitivity problem contacted me a while to see if NKCC1 might be the root of his problem. I suggested he try Ponstan, which did actually work for him and is easy to buy where he lives. Now he sends me research into all its possible modes of action. One mode of action relates to a cause of intellectual disability (ID/MR). Is this a factor in why Ponstan seems to improve speech and cognition in some autism? I really don't mind why it works - I just got lucky again, that is how I look at it. The more I read the luckier I seem to get.

Repurposing Autism Drugs to treat Alzheimer’s – Bumetanide for APOE4 Alzheimer’s and Clemastine for all Alzheimer’s

The Gladstone Center for Translational Advancement was formed in 2017, and focuses on drug repositioning; repurposing already-approved drugs for new uses and clinical trials, to speed up (and lower the cost of) drug development.

 

Our neurologist reader Eszter commented recently on the overlap between experimental therapies for Alzheimer’s and those for autism. She was mentioning GHK-Cu, which is a naturally occurring peptide in our bodies that looks interesting in the research on both Alzheimer’s and Parkinson’s.  There will be post on GHK-Cu, but this is a potential therapy that would require injections, so it has a big drawback

In the early days of this blog we looked at the repurposing of Alzheimer’s drugs like Memantine, Donepezil and Galantamine for some autism.

Roll forward a few years and we now have quite a handful of autism drugs in the portfolio. Today we look again at how some of these autism drugs can be repurposed for Alzheimer’s.

We have come full circle.

In a previous post we saw that Fenamate NSAIDs, like Ponstan, reduce the incidence of Alzheimer’s.  Only a low dose seems to be required for Alzheimer's and this drug is extremely cheap in countries like Greece. A low dose seems to have a broad effect on autism.  All in all very interesting, I believe.

We saw that Agmatine improves cognitive dysfunction and prevents cell death in a Streptozotocin-Induced Alzheimer rat model.

We saw that the ketone BHB inhibits inflammasome activation to attenuate Alzheimer's disease pathology.

I have mentioned the interest to repurpose Verapamil to treat Huntington’s disease, via its effect on autophagy, but there is also interest to use it in Alzheimer’s.

Repurposing verapamil for prevention of cognitive decline in sporadic Alzheimer’s disease

Today we will look at why Bumetanide and Clemastine may be beneficial in Alzheimer’s. 

 

A quick summary of Alzheimer’s Disease 

Alzheimer’s disease features prominently plaques (amyloid plaques) and fibers (tau tangles) that are visible within the brain.

It is thought that inhibiting the aggregation and accumulation of amyloid plaques and tau in the brain is the key to treating Alzheimer’s Disease.

We did see that that the red pigment in beetroot has been shown to block the formation of amyloid plaques and no prescription is required for that superfood.

In addition, we know that there is reduced glucose uptake across the blood brain barrier via the GLUT1 and GLUT3 transporters.  In effect the brain is left starving. There is also impaired insulin signalling within the brain, this led to the idea of intranasal insulin as a treatment.  The insulin dependent glucose transporter GLUT4 plays a central role in hippocampal memory processes, and reduced activation of this transporter may underpin the cognitive impairments seen in Alzheimer’s disease and more generally in those who develop insulin resistance. (more insulin inside the brain, please)

We also did look at the recently discovered lymphatic drainage system of the brain. It was seen that this waste clearing system is impaired in Alzheimer’s and perhaps some autism. This then takes us back to the autophagy process within the brain, where cellular waste is collected. It is thought that autophagy itself is impaired in autism. Collecting and disposing of brain garbage does not function as it should.

Over a decade or so, the brain gradually shrinks away and loses functions.  I think in reality Alzheimer’s initially develops slowly, years before diagnosis.

The currently prescribed drugs do not alter the course of the disease and often provide only minimal benefit. Donepezil increases acetylcholine concentrations at cholinergic synapses and upregulates nicotinic receptors. Memantine blocks NMDA receptors.  Much more appears to be possible.

This is an autism blog so let’s be aware of the research on the overlaps with Alzheimer’s. 

Alzheimer’s protein turns up as potential target for autism treatments 

Lowering the levels of a protein called tau, best known for its involvement in Alzheimer’s disease, eases autism-like traits in mice, according to a study published today in Neuron.

Tau regulates a gene called PTEN, according to a 2017 study4. PTEN accounts for 2 to 5 percent of autism cases and is known to modulate the PI3K pathway; without it, the pathway becomes overactive, in some cases leading to autism.

Mucke’s team found that knocking out PTEN in neurons blocks the effect of lowering tau on the mice’s behaviors. 

Proteomics of autism and Alzheimer’s mouse models reveal common alterations in mTOR signaling pathway

 Bumetanide for APOE4 Alzheimer’s?

Certain genes can increase the risk of developing dementia, including Alzheimer’s disease. One of the most significant genetic risk factors is a form of the apolipoprotein E gene called APOE4. About 25% of people carry one copy of APOE4, and 2 to 3% carry two copies. APOE4 is the strongest risk factor gene for Alzheimer’s disease, although inheriting APOE4 does not mean a person will definitely develop the disease.

The APOE gene comes in several different forms, or alleles. APOE3 is the most common and not believed to affect Alzheimer’s risk. APOE2 is relatively rare and may provide some protection against Alzheimer’s disease.

The reason APOE4 increases Alzheimer’s risk is not well understood. The APOE protein helps carry cholesterol and other types of fat in the bloodstream. Recent studies suggest that problems with brain cells’ ability to process fats, or lipids, may play a key role in Alzheimer’s and related diseases.

Regular readers of this blog will be familiar of the remarkable effects of statin drugs. So from the mention of cholesterol we take a brief diversion to see how people who start taking statins before older age get yet another benefit.

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5830056/#:~:text=Additionally%2C%20statins%20could%20reduce%20dementia,in%20Alzheimer's%20disease%20%5B70%5D.

 

"Additionally, statins could reduce dementia risk by directly affecting Alzheimer’s disease pathology. A study in transgenic mice models of Alzheimer’s disease found that atorvastatin reduced Aβ formation [69], and atorvastatin can attenuate some the damage from neuroinflammation in Alzheimer’s disease [70].

Much of the evidence supporting statins in the prevention of dementia and AD are in persons exposed to statins at mid-life as opposed to late life. This suggests that statins benefits may be limited to the vascular prevention stage of AD and dementia. "

 

Back to Bumetanide.

 

The easy to read article:-

 

Can an Already Approved Drug Treat Alzheimer’s Disease?  

An Alternative Approach to Drug Discovery 

Developing new, targeted drugs for complex conditions like Alzheimer’s disease is a notoriously long and expensive process. In 2017, with the goal of bringing safe treatments to patients more quickly, Huang launched the Gladstone Center for Translational Advancement to repurpose FDA-approved drugs for new uses.

 

Huang’s approach centers around the idea that patients with Alzheimer’s disease may have different underlying causes of neurodegeneration, and therefore, the efficacy of specific treatments may differ among patients—a strategy called precision medicine. However, in the large clinical trials required for new drugs, it can be hard to pinpoint whether a drug is effective in only a subpopulation of the patients.

 

Therefore, the research team used a computational approach to identify unique gene expression profiles (or the level to which genes are turned on or off) associated with Alzheimer’s disease in brain tissues from specific subgroups of patients. They then screened a database of existing drugs to find the ones most likely to reverse the altered gene expression profiles in each subgroup.

 

In the new study, the researchers first analyzed a publicly available database of 213 brain samples from people with and without Alzheimer’s disease, including people with different versions of a gene called APOE, the major genetic risk factor for the disease.

The team identified nearly 2,000 altered gene expressions in the brains of people with Alzheimer’s disease. While roughly 6 percent of the altered genes were similar between people with different APOE versions, the vast majority of them were unique to people with specific combinations of the APOE3 or APOE4 versions, the latter conferring the highest genetic risk of Alzheimer’s disease.

The researchers next queried a database of more than 1,300 existing drugs to look for those able to change the altered gene expressions they had identified for subgroups of Alzheimer’s patients. They zeroed in on the top five drugs that might reverse the altered gene expressions found in Alzheimer’s patients carrying two copies of the high-risk APOE4 version.

 

“This unbiased approach allowed us to find which drugs might be able to flip the altered gene expression associated with APOE4-related Alzheimer’s disease back to the normal state,” says Alice Taubes, PhD, lead author of the study and former graduate student in Huang’s lab at Gladstone and co-mentored by Marina Sirota at UCSF. “It gave us important clues in solving the puzzle of which drugs could be effective against APOE4-related Alzheimer’s disease.”

 

After looking at the known mechanisms and previous data on the drugs in their top-five list, the researchers homed in on bumetanide, a diuretic that reduces extra fluid in the body caused by heart failure, liver disease, and kidney disease. Bumetanide is known to work by changing how cells absorb sodium and chloride—both important not only for maintaining appropriate levels of water throughout the body, but also for electrical signaling of neurons in the brain.

 

Huang and his team tested the effect of bumetanide on mice genetically engineered to have human APOE genes. Mice with two copies of the human APOE4 version typically develop learning and memory deficits around 15 months of age—the equivalent of roughly 60 years in humans. But when the researchers treated the mice with bumetanide, they no longer developed such deficits. In addition, the drug rescued alterations in electrical brain activity that can underlie these cognitive deficits.

 

The scientists also studied a second mouse model of Alzheimer’s disease, in which two copies of APOE4 coexist with amyloid plaques—a major pathological sign of Alzheimer’s disease in the brain. In these mice, bumetanide treatment decreased the number of amyloid plaques and restored normal brain activity.

 

Lastly, when the researchers studied the effect of the drug on human neurons derived from skin cells of Alzheimer’s patients carrying the APOE4 gene, they found that bumetanide reversed the gene expression changes associated with the disease.

 

… the researchers evaluated two large electronic health record databases—one from UCSF containing information on 1.3 million patients seen from 2012 through 2019, and another from the Mount Sinai Health System covering 3.9 million patients seen from 2003 through 2020. They narrowed in on more than 3,700 patients who had taken bumetanide and were over the age of 65, and compared them to patients of similar age and health who had taken different diuretic drugs. Strikingly, the patients who had taken bumetanide were 35 to 75 percent less likely to be diagnosed with Alzheimer’s disease.

 

 

 

The full paper:-

 

It gets a bit heavy, so just skip through it.

 

Experimental and real-world evidence supporting the computational repurposing of bumetanide for APOE4-related Alzheimer’s disease

 

The evident genetic, pathological and clinical heterogeneity of Alzheimer’s disease (AD) poses challenges for traditional drug development. We conducted a computational drug-repurposing screen for drugs to treat apolipoprotein E4 (APOE4)-related AD. We first established APOE genotype-dependent transcriptomic signatures of AD by analyzing publicly available human brain databases. We then queried these signatures against the Connectivity Map database, which contains transcriptomic perturbations of more than 1,300 drugs, to identify those that best reverse APOE genotype-specific AD signatures. Bumetanide was identified as a top drug for APOE4-related AD. Treatment of APOE4-knock-in mice without or with amyloid β (Aβ) accumulation using bumetanide rescued electrophysiological, pathological or cognitive deficits. Single-nucleus RNA sequencing revealed transcriptomic reversal of AD signatures in specific cell types in these mice, a finding confirmed in APOE4 induced pluripotent stem cell (iPSC)-derived neurons. In humans, bumetanide exposure was associated with a significantly lower AD prevalence in individuals over the age of 65 years in two electronic health record databases, suggesting the effectiveness of bumetanide in preventing AD. 

Bumetanide exposure is associated with a significantly lower AD prevalence in individuals over the age of 65. We hypothesized that, if bumetanide is efficacious against AD, we would observe a lower prevalence of AD diagnosis in individuals exposed to bumetanide than in a matched control cohort of individuals over the age of 65 years. To test this hypothesis in humans, we analyzed two independent EHR databases (Fig. 7a). One is an EHR database from the University of California at San Francisco (UCSF), which contains complete medical records for 1.3 million patients from outpatient, inpatient and emergency room encounters as part of clinical operations from June 2012 to November 2019. The UCSF EHR database was filtered using the medication order table for patients on the drug of interest, and we found 5,526 patients who had used bumetanide (other names, Bumex or Burinex). Among them, 1,850 patients (1,059 men (57.2%) and 791 women (42.8%)) were over the age of 65. The other EHR database was from the Mount Sinai Health

 

Fig. 7 | Bumetanide exposure is associated with a significantly lower AD prevalence in individuals over the age of 65 in two independent EHR databases.

Bootstrapped χ2 tests40 confirmed a significantly lower AD prevalence in bumetanideexposed individuals than that in non-bumetanide-exposed individuals in both EHR databases (Fig. 7b,c). Together, these data suggest that bumetanide may be effective in preventing AD in individuals over the age of 65 years, warranting further tests in prospective human clinical trials.

 

Discussion 

This study represents an attempt to apply a precision medicine approach to computational drug repurposing for AD in an APOE genotype-directed manner. The efficacy of a top predicted drug, bumetanide, for APOE4 AD was validated in vivo in both aged APOE4-KI (without Aβ accumulation) and J20/E4-KI (with Aβ accumulation) mouse models of AD for rescue of electrophysiological, pathological or behavioral deficits. Importantly, by leveraging real-world data, bumetanide exposure was associated with a significantly lower AD prevalence in individuals over the age of 65 years in two independent EHR databases, suggesting the potential effectiveness of bumetanide in preventing AD in humans.

Bumetanide exposure is associated with a significantly lower AD prevalence in individuals over the age of 65 in two independent EHR databases.

 

Clemastine for Alzheimer’s 

The research suggests multiple possible benefits from the use of the cheap antihistamine Clemastine in Alzheimer’s.

 

Clemastine Attenuates AD-like Pathology in an AD Model Mouse via Enhancing mTOR-Mediated Autophagy

Background: Alzheimer’s disease (AD) is a neurodegenerative disorder with limited available drugs for treatment. Enhancing autophagy attenuates AD pathology in various AD model mice. Thus, development of potential drugs enhancing autophagy may bring beneficial effects in AD therapy. Methods: In the present study, we showed clemastine, a first-generation histamine H1R antagonist and being originally marketed for the treatment of allergic rhinitis, ameliorates AD pathogenesis in APP/PS1 transgenic mice. Chronic treatment with clemastine orally reduced amyloid-β (Aβ) load, neuroinflammation and cognitive deficits of APP/PS1 transgenic mice as shown by immunohistochemistry and behavioral analysis. We further analyzed the mechanisms underlying the beneficial effects of clemastine with using the combination of both in vivo and in vitro experiments. We observed that clemastine decreased Aβ generation via reducing the levels of BACE1, CTFs of APP. Clemastine enhanced autophagy concomitant with a suppression of mTOR signaling. Conclusion: Therefore, we propose that clemastine attenuates AD pathology via enhancing mTORmediated autophagy.

 

Clemastine Ameliorates Myelin Deficits via Preventing Senescence of Oligodendrocytes Precursor Cells in Alzheimer’s Disease Model Mouse 

Disrupted myelin and impaired myelin repair have been observed in the brains of patients and various mouse models of Alzheimer’s disease (AD). Clemastine, an H1-antihistamine, shows the capability to induce oligodendrocyte precursor cell (OPC) differentiation and myelin formation under different neuropathological conditions featuring demyelination via the antagonism of M1 muscarinic receptor. In this study, we investigated if aged APPSwe/PS1dE9 mice, a model of AD, can benefit from chronic clemastine treatment. We found the treatment reduced brain amyloid-beta deposition and rescued the short-term memory deficit of the mice. The densities of OPCs, oligodendrocytes, and myelin were enhanced upon the treatment, whereas the levels of degraded MBP were reduced, a marker for degenerated myelin. In addition, we also suggest the role of clemastine in preventing OPCs from entering the state of cellular senescence, which was shown recently as an essential causal factor in AD pathogenesis. Thus, clemastine exhibits therapeutic potential in AD via preventing senescence of OPCs.

  

Reversing Alzheimer's disease dementia with clemastine, fingolimod, or rolipram, plus anti‐amyloid therapy

A few anti‐amyloid trials offer a slight possibility of preventing progression of cognitive loss, but none has reversed the process. A possible reason is that amyloid may be necessary but insufficient in the pathogenesis of AD, and other causal factors may need addressing in addition to amyloid. It is argued here that drugs addressing myelination and synaptogenesis are the optimum partners for anti‐amyloid drugs, since there is much evidence that early in the process that leads to AD, both neural circuits and synaptic activity are dysfunctional. Evidence to support this argument is presented. Evidence is also presented that clemastine, fingolimod, and rolipram, benefit both myelination and synaptogenesis. It is suggested that a regimen that includes one of them plus an anti‐amyloid drug, could reverse AD. 

Note that Rolipram is a selective PDE4 inhibitor that never made it to use in humans. Roflumilast is very similar and counts as an autism drug in this blog, alongside Pentoxifylline, which is a non-selective PDE inhibitor (if affects more than just PDE4). 

Conclusion

It looks like if you were an enlightened neurologist treating autism you would have the drugs needed to make a fair crack at treating, or preventing, Alzheimer’s.  Unfortunately, once they are established, you are not going to cure either disease; nonetheless, fully treating autism will carry forward the person further than their ABA therapist would ever have dreamed possible. Treating Alzheimer's successfully will depend on when you start, best to start as soon as the signs appear on an MRI or CT scan, not a few years later.

Prevention is better than cure; indeed an older person’s multipurpose Polypill looks to be in order. This could go beyond the usual cardiovascular concerns and include prevention/mitigation of dementia and diabetes (e.g. statin, low dose ponstan, verapamil and a mix of betanin, spermidine, agmatine with ALA or NAC)

Just because you might carry the APO4 gene does not mean you will develop Alzheimer’s, but it is a good reason to take steps to prevent it.

There is a long list of factors that increase the incidence/severity of autism, so there are is an equal number of steps that can be taken to reduce it.

The gene expression study showed that Bumetanide has wide ranging effects within the brain that counter the defects found in APO4 mice and humans who have developed Alzheimer’s.  This suggests that bumetanide’s effects go well beyond blocking the NKCC1 cotransporter.  This may explain why some bumetanide responders with autism have a paradoxical reaction to GABA agonists, like benzodiazepines, and some people do not. They are receiving different beneficial effects.

We will look at the anti-inflammatory benefits of bumetanide suggested in very recent Chinese research in the next post.  This might provide biomarkers for likely responders. 

You might have thought that clemastine would not be good for dementia, because it is anticholinergic, as are many antihistamines and even drugs commonly given to older people like Nexium. The neurotransmitter acetylcholine is good for cognition and it has been suggested that depleting it might lead to dementia.

It looks like our off-label MS drugs, clemastine, Ibudilast and Roflumilast are going to be good for dementia, not to forget our new reader Bob and his Pentoxifylline.

It is notable that Gladstone Center for Translational Advancement exists. There are clearly very many existing drugs that can be repurposed to treat all kinds of medical issues. I keep discovering more, which is good for me. Bob discovered Pentoxifylline, which is good for him and his patients.  Other people are free to make their own choices.